It's been exactly a year since my big book about bloating, "The Bloated Belly Whisperer," was published, and I've since had the occasion to hear from hundreds of readers across the U.S. and Canada about what diagnostic journeys my book has inspired for them.
The one finding that seems to have surprised the greatest number of readers was realizing that they were literally full of stool -- or FOS, as I like to call it -- without even knowing it. In other words: They were constipated, even though they were having bowel movements on a daily basis. Clinically, we refer to being FOS as having a high stool burden.
Symptoms of Constipation with a High Stool Burden
The story of someone who is FOS often sounds something like this:
You wake up every day with as flat a belly as you're going to have for the day -- which is to say, it may actually even be a little bit distended on waking, but it will certainly get worse from here. You move your bowels in the morning -- sometimes even more than once -- and get on with your healthy breakfast. The belly is status quo after breakfast, but after lunch is when the trouble sets in.
Your belly becomes visibly distended, and often you start farting up a storm, no matter what you eat. Things get progressively worse after dinner, and you wind up going to bed bloated, gassy and uncomfortable each and every night.
Clue No. 1: The bloating is bad no matter what you eat, but it's definitely more severe after higher fiber meals like salads and less severe after lower fiber ones like sushi or eggs.
Clue No. 2: You gave up gluten and dairy, but there was only a modest change -- if any at all. You tried a low FODMAP diet, but the improvement was so minor that it wasn't even worth the effort. You've tried keto, paleo, Whole30 -- but no diet has solved the problem for you.
Clue No. 3: A visit to the gastroenterologist landed you with a bunch of tests -- and all came back normal. The bloating was temporarily improved after doing a colon cleanse in preparation for your colonoscopy, but it returned within a couple of days.
Clue No. 4: If there were imaging studies of any kind done, the radiologist may have noted a substantial amount of stool in the image -- or perhaps that the visuals were obscured by a large amount of gas or stool present in the colon.
Clue No. 5: If your doctor ordered a breath test to rule out small intestinal bacterial overgrowth (SIBO), the baseline levels of methane gas were so high that the test was read as positive even though the numbers didn't really budge. Still, one or more courses of antibiotics did nothing to alleviate your symptoms.
Finally, after a clean colonoscopy, normal stool tests, nothing amiss in your bloodwork, and your symptoms' failure to respond to diet change or antibiotics, your doctor lands on a diagnosis of irritable bowel syndrome (or IBS) and sends you on your way.
Frustrated, you land in a naturopath's or integrative/functional medicine practitioner's office, where you are given a bunch of expensive stool tests and told you have some combination of "dysbiosis," "leaky gut" and/or " candida overgrowth."
You're told to go gluten free, sugar free and sold hundreds of dollars worth of dietary supplements that purport to "heal your gut."
Clue No. 6: After taking dozens of pills per day, you're still no better -- unless one of those pills happens to contain high-dose magnesium that has a laxative effect, which makes your symptoms somewhat less severe. But you're still nowhere near feeling good.
Too Much Fiber?
If any of this sounds familiar, you may be simply full of stool, literally. And you're not going to feel better until you can reduce the amount of poop you're carrying around in that colon of yours. It's not a bacterial imbalance, it's not a leaking gut, it's not a food sensitivity, it's not "inflammation" and it may not even be IBS. It's a simple case of more fiber going in than is going out.
In my nutrition practice -- which is embedded in a gastroenterologist's office -- I estimate that a good 40% of my bloated patients suffer from constipation -- often completely unbeknownst to them. People who move their bowels every day -- and sometimes even more than once per day -- never fathom that they could be constipated, or at least insufficiently emptying their bowels. It's often the case that these patients consume extremely healthy, very high fiber diets precisely so as to prevent constipation.
But here's the thing about fiber: It's indigestible by definition. So whatever goes in your mouth, must eventually come out of your bowels. If you take in a tremendous amount of fiber in from your flaxseed-and-berry-studded oatmeal, your lunch salad, your fruit and nut snacks, your high fiber/low carb protein bar and your dinnertime sweet potato vegetable harvest bowl, then a tremendous amount of poop is going to need to make its way out to prevent a -- pardon my word choice -- backlog.
If you only move your bowels once or even twice per day in the setting of a very high fiber diet, it may simply not be enough.
[READ: Causes of Chronic Constipation.]
Treatment for a High Stool Burden
If you and your doctor suspect you may indeed be FOS, easing up on the amount of bulky fiber you consume -- especially from raw vegetables, nuts and popcorn -- can be a helpful immediate term measure until you can get things flowing better. A simple X-ray to observe your "stool burden" can confirm the diagnosis.
Exploring an effective pooping support regimen -- whether from gentle over-the-counter remedies like magnesium or polyethylene glycol or from more assertive prescription options -- is the next step. But if you don't respond adequately to laxatives, ask your doctor about tests that evaluate your pelvic floor muscle function.
Pelvic floor dysfunction is an under-recognized cause of chronic constipation. It often responds better to physical therapy, biofeedback or other interventions aimed at correcting muscle coordination among the various muscles involved in defecation than it does to laxatives.