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Are prunes better for constipation than psyllium?

My mother’s mother, who had lived with us, passed away when I was still quite young, so I don’t remember too much about her. But I do remember the prunes.

Every morning, my Bubbeh (grandmother in Yiddish), would have a handful of prunes with her breakfast. I had a vague sense that it was to help her in the bathroom and it was something that older people just happened to eat regularly—like soup. I’m not sure where these ideas came from, but I suppose I must have seen other older people eating prunes while discussing their digestion. At some point, I had also decided that they were somehow not delicious and politely declined prune-containing desserts when they were infrequently offered to me.

So, you can imagine my surprise when one day, desperate for Hamentashen (Jewish holiday cookies) and finding only prune-filled ones remaining, I decided to go for it and eat the geriatric flavor which turned out to be my new favorite. You can further imagine my surprise when I discovered that prunes are not only delicious, but actually magical.

“a serving of prunes a day helps with constipation more than a similar amount of psyllium fiber”

While doing some reading on constipation for the book I am currently working on, I fell down a rabbit hole of research, with one article leading me to look up another and that article leading me to look up yet another. This path ended at a well-done study published in an obscure journal called “Alimentary Pharmacology and Therapeutics” which showed that a serving of prunes a day helps with constipation more than a similar amount of psyllium fiber (the stuff most often recommended for constipation). The authors of the study were gastroenterologists from the University of Iowa who carefully selected their patients to make sure they didn’t have other diseases and then did something called a “cross over” so that the same people switched and got the same treatments separated by a week. It is a way to compare like to like and probably the best way to do a study where you can’t keep the treatment a secret (called blinding).

Even if the prunes had worked just as well, it should have been big news. But they had actually worked a bit better. Here’s a truly natural and fairly inexpensive way to help with constipation—a problem about 20% of people are thought to suffer with. And yet, ten years on, I hadn’t heard about this miracle cure. Perhaps I had been lacking in my keeping up to date with guidelines? So, I looked up the American Gastroenterological Association guidelines on constipation. Nope. No mention of prunes. Then I went to their website geared towards the lay-person. Surely they would suggest that people pop a couple prunes (more like 12 to be consistent with the aforementioned study) before bringing out the medications. Also no!

Are the authorities on the GI system as biased against prunes as I once was? It would seem so.

This isn’t to say that prunes will work for everyone. The study, while well done, was small in size with only 40 participants, and people who haven’t discussed their constipation with their doctors may need a medical work up to make sure there isn’t a more serious condition underlying the slow stools.

But for now, I’ll be keeping a bag of prunes in my pantry. Just like my Bubbeh did.

 

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NOVA – A New Way of Thinking About Food

In the past decade, we have learned that the more ultra-processed food you eat, the higher your risk of obesity, heart disease, cancer, gastrointestinal maladies, and maybe even dementia. The problem is, these so-called foods are getting harder and harder to avoid. A recent JAMA (Journal of the American Medical Association) article notes that kids’ consumption of a substance called ultra-processed foods has increased significantly in the past 20 years, going from about 61% to 67% or what is now two-thirds of their diets.

Kids’ consumption of ultra-processed foods has increased to 67% of their diets.

Why are ultra-processed foods so hard to avoid?

The reason these substances are hard to avoid is that they’ve been manufactured and marketed to look like real, actual food, but perhaps a bit cheaper and flashier. Take pizza, for example. My husband likes to make pizza. He makes a dough from scratch with the following ingredients: wheat flour, water, yeast, salt. He makes his sauce from scratch too with tomatoes, salt, pepper, a little bit of sugar, garlic, basil, oregano. The cheese, he buys, but it contains only milk, cultures, and salt. Compare that to the ingredients of a frozen supermarket pizza (which may not be any better, ingredient-wise than the take-out pizza you get from your local chain). Can you picture what all the individual ingredients in my husband’s pizza look like in your mind’s eye? Now can you picture what all the ingredients listed on the frozen pizza look like? I can’t.

I’m not arguing that my husband’s pizza is health food. It isn’t. It’s a processed food. It’s not a banana or an apple or kale for that matter, but it’s still recognizable as food to our bodies. The stuff that we are all now consuming, and our kids are consuming at an alarming rate, isn’t. Your mind can’t picture what some of the ingredients widely used in 67% of kids’ diets look like and your body isn’t quite sure what to do with some of them either. They are more than just processed. They are ultra-processed.

A New Nutrition Classification

That’s why in 2009, a new nutrition classification system, called NOVA, put ultra-processed foods into its own category.

We have to be able to name a thing as a first step in figuring out what to do about it, so NOVA groups foods into four categories:

  • Category 1 is made up of foods that are unprocessed or minimally processed. Unprocessed foods are eaten as nature gives them to you—an apple, banana, or kale. If you take the kale and bake it into chips, you’ve processed it, but minimally (it’s still basically kale).
  • Category 2 is made up of what are called processed culinary ingredients like oil or salt. Nature does not give us oil or salt directly. We have to make them from basic starting points (pressing olives in the case of oil and grinding whatever it is that salt comes from—rocks? The sea?). They should be used sparingly to enhance the flavor of Category 1 foods.
  • Category 3 foods are processed foods. It generally is how we have historically preserved food to last a bit longer. Bread and pasta are processed. Real cheese and yogurt are processed. The ingredients used to make them have to go through a few steps to get to their final stage, but they are essentially still wheat or milk.

Category 4 are the ultra-processed foods. NOVA says these are made up of: substances that are of “rare” or of “no culinary use” or are “additives whose function is to make the final product sellable, palatable and often hyper-palatable. Food substances of no or rare culinary use, employed in the manufacture of ultra-processed foods, include varieties of sugars (fructose, high-fructose corn syrup, ‘fruit juice concentrates’, invert sugar, maltodextrin, dextrose, lactose), modified oils (hydrogenated or interesterified oils) and sources of protein (hydrolysed proteins, soya protein isolate, gluten, casein, whey protein, and ‘mechanically separated meat’). Classes of additives used only in the manufacture of ultra-processed foods, are flavours, flavour enhancers, colours, emulsifiers, emulsifying salts, artificial sweeteners, thickeners, and foaming, anti-foaming, bulking, carbonating, gelling and glazing agents.”

Category 4 foods are the culprit in many diet-related diseases…

Here’s what I want to communicate clearly—Category 1 foods are best, but Category 2 and 3 foods are fine as long as we don’t go crazy with them. Category 4 foods are the culprit in many diet-related diseases and now we can identify them (at least when we have access to the list of ingredients).

What’s the next step?

Well, according to the JAMA study, in the past 20 years, there was a notable DECREASE in the consumption of sugary beverages by kids. This is probably due to numerous campaigns to steer kids away from sodas. So, we know how to make our diets healthier and it’s not just about avoiding fast food. Ultra-processed foods are in pricier restaurants too. They are in our school cafeterias and in our homes, though the JAMA article notes that the more we eat at home, the less ultra-processed foods we tend to eat. If we can put them in, we can take them out. We didn’t always eat ultra-processed foods. They are a relatively recent invention. Like sodas, we can learn to limit them or cut them out entirely. NOVA means “new” in Portuguese and it’s a good, new way to think about what we eat this year.

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What is Trashy Food? (And Why You’ll Want to Steer Clear)

What makes something trashy?

Urban Dictionary tells us that “trashy people contribute little or nothing to society.” They are flashy, but don’t have much substance. No one wants to be called “trashy.” And we shouldn’t call people “trashy”—everyone deserves respect. Some food, on the other hand, deserves no respect. There is definitely some trashy food out there.

 Similar to a celebrity who hires a publicist to make sure he is photographed at a soup kitchen, so that no one is paying attention to his sexual harassment charges[AG2] , trashy foods cover themselves in clever packaging that hails them as “organic” or “high in fiber.”

Dr. Carlos Monteiro, M.D., Ph.D., professor and chair of the Center for Epidemiological Studies in Health and Nutrition at the University of São Paulo in Brazil, calls this trashy food, “ultra-processed” because he’s classier than I am.

Dr. Monteiro developed the NOVA food classification system, defining the ultra-processed stuff as, “made mostly or entirely from substances derived from foods and additives, with little if any intact (whole) foods.” This makes a lot of sense to me. However, when nutrition professionals were asked to place food into one of his four NOVA categories (ultra-processed being the 4th one), there wasn’t much consistency in where ultra-processed stuff should go.1[AG3]  

Which begs the question—why can’t we agree on what an ultra-processed (trashy) food is?

 

I’m not big into conspiracy theories, but in this case, I’m going to have to go with the possibility that the ultra-processed food industry has been working for decades on muddying the waters of what an ultra-processed food vs. a processed food vs. even what a whole food is. [AG4] If the celebrity has a publicist, trashy foods have an army of them.

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A Trip to Italy Changed How I Treat My Patients

italy-changed-my-life

 I went to Italy where I ate only whole foods. My years-long symptoms of irritable bowels went away—completely gone—in two days. I came back to the U.S. and my IBS was back within a day of returning.

So, I started removing different emulsifiers and thickeners (used in over 50% of what we eat in the U.S.) from my diet and my gut felt and acted exactly like it did in Italy. I advised friends and patients to do likewise and they improved too. It wasn’t hard. It just took some careful label-reading at first. And a bit more cooking, which I like to do anyway (don’t ask me about cleaning—try to get someone else to do this).

“This happened!!!” I wanted to shout from every rooftop and started to.

“That’s not possible,” I was told by some other physicians.

And maybe I would have started to think that I was wrong except for my very practical physician husband having been there for the whole thing.

“You are right,” he would insist (I told him he should say that about other things I do too, but I digress).

It seems weird that I would start to doubt my own experience. But then I recalled the idea of scientific paradigms that I learned about in college. Basically, frameworks for ideas get set up and everything that follows needs to fit into that framework. If it doesn’t fit, it gets rejected.

And dietary emulsifiers causing some bowel disease, and contributing to other diseases, doesn’t fit with the current food and gastrointestinal paradigm which says that if a substance is derived from natural sources, it is safe for us to consume. In order for a paradigm to change or shift, enough evidence has to build up and not fit into the paradigm to convince people to create a new paradigm.

And that’s happening here. But slowly. Too slowly. For the past decade researchers have been showing that certain substances added to food to make it softer, thicker, and more shelf-stable, alter our gut microbiomes and gut lining. Diets are being developed for the sufferers of the most severe bowel ailments, called inflammatory bowel disease, that eliminates these additives.

One of the biggest known offenders, carrageenan, was slated to be decertified from products marketed as “organic” in 2018 by the USDA upon the suggestion of groups that advise the regulatory agency. Instead, the USDA rejected the advice of consumer health and safety groups and kept carrageenan, not only in our food supply, but in the foods that are marketed as somehow being better for us.

And so, it seems, we are on our own here. That’s the bad news. The good news is that it isn’t hard to cut out emulsifiers and thickeners from our diet and see what happens for a week. Just eat food that doesn’t come from a package, or if it does, make sure that you read the ingredient list and you can create a mental image of what that ingredient would look like if you were to go and get it from nature. Can’t? Don’t buy it or eat it. Or, use the list I’ve made. Since we mostly don’t know what they are putting in our food (in general) in restaurants, just skip eating out for that week.

See how you feel.

If skipping the additives for a week gets you feeling better, see if you can keep doing it. It gets easier and easier the more you eat real food. There is a saying that we need to create the change we want to see. In this case, change begins with a single meal.

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