Level 3

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KEY POINTS:

• Accidental or intentional gluten exposure is one of the main causes of constipation in people with celiac disease.

• If you are constipated, take a close look at your diet. Have you added a new food? Re-read labels? Have you checked your medications and supplements? Did you examine your kitchen for potential cross-contamination? Consider where you dine out and how safely your meals are being prepared.
• If you have any questions about whether or not a product or a restaurant meal is gluten-free, talk to the manufacturer or the restaurant manager.
• Do not hesitate to talk to your doctor or dietitian about your concerns.

Dietary fiber comes in two forms: soluble and insoluble fiber.

• Soluble fiber dissolves in water in the gut to become a smooth, slimy gel that passes slowly through the gastrointestinal tract.
• Insoluble fiber absorbs water but retains its rough texture, which scrapes old cells off the intestinal lining as it moves through.
• Water helps ensure that the stool, while bulky from fiber, is soft enough to easily pass out. ¹
• It is best to get your fiber from food. People with celiac disease can meet the recommended daily intake for fiber with fruits, vegetables, dried beans and legumes, gluten-free whole grains, nuts and seeds.

Visit Healthy Eating on the Gluten-Free Diet sections for more information on fiber.

IDEAS TO ADD GLUTEN-FREE FIBER TO LUNCH OR DINNER:

• Brown rice and beans with chunky salsa, guacamole and your favorite mixed greens salad
• Cook 1/2 portion of your regular rice with 1/2 portion of labeled gluten-free quinoa, amaranth, or millet. Add enough water for all the grains.
• Add cooked dried beans to your own soups, salads, or casseroles, or cut the meat portion in your chili by half and replace it with beans
• Quinoa salad: cooked quinoa (labeled gluten-free) with plain pumpkin or sunflower seeds, almonds or walnuts, and a light dressing
• Be sure to drink liquid at each meal and snack and eat plenty of fresh or frozen fruit

Reference: Adapted from Higgins, L. Whole Grains = Nutritional Gold. In Real Life with Celiac Disease: Troubleshooting and Thriving Gluten-Free . Eds. Dennis M, Leffler D. AGA Press. Bethesda, MD, 2010.

• If you cannot get all of the fiber you need from your diet, you can talk to your doctor or dietitian about adding a gluten-free fiber supplement.

  FIBER SUPPLEMENTS*
  Product	Gluten Free?	Manufacturer/Contact Information
  Metamucil Capsules Powders and singles Wafers	Yes Yes No	Proctor & Gamble www.metamucil.com 800-983-4237
  Fibersure Powders Soft chews Capsules	Yes Yes Yes	Proctor & Gamble www.fibersure.com 800-525-2855
  Citrucel Powders Caplets	Yes Yes	GlaxoSmithKline www.citrucel.com 800-897-6081
  FiberChoice All products	Yes	GlaxoSmithKline www.fiberchoice.com 877-553-4237
  Konsyl Powders Caplets	Yes Yes	Konsly Pharmaceutical, Inc. www.konsyl.com 800-356-6795
  Fibercon No gluten in ingredients but will not guarantee raw ingredients have not been in contact with gluten.	N/A	Wyeth Consumer Healthcare www.fibercon.com 800-282-8805
  Resource Benefiber	Yes	Nestle Nutrition www.nestlenutritionstore.com 888-240-2713
  Benefiber All products contain wheat dextrin but test to 10 parts per million of gluten, which is considered gluten free.	Yes	Novaris www.benefiber.com 800-452-0051

  Reference: Adapted with permission from Gluten-free status of commercial fiber supplements. Pract Gastroenterol 2009;XXXIII(1):54. 
  
  Updated October 2011

• Modest physical activity, such as daily walks, may help you overcome mild constipation, although it is not likely to help you improve severe constipation. ²

• Other causes of constipation can be*:
  • Certain medications including pain medications, diuretics and those used to treat Parkinson's disease, high blood pressure and depression,³ "pain medications (especially narcotics), antacids that contain aluminum and calcium, blood pressure medications (calcium channel blockers), antiparkinson drugs, antispasmodics, antidepressants, iron supplements, diuretics, and anticonvulsants" ⁴
  • Certain supplements including calcium and iron
  • A sign of another medical disorder such as thyroid disease, endocrine disorders, neurological disorders, structural abnormalities, or intestinal motility disorders, ¹such as constipation predominant irritable bowel syndrome
  • Hormonal changes, such as underactive thyroid
  • Changes in lifestyle or routine, such as pregnancy, travel and aging ³
  • Food intolerances - such as lactose intolerance ⁵

TAKE HOME MESSAGES:

• To help with constipation, increase your dietary fiber gradually, as tolerated, until you see an improvement in your stool. Drink 6-8 glasses of fluids throughout each day and participate in regular physical exercise.
• Add gluten-free whole grain side dishes, higher fiber gluten-free flours, plain nuts and seeds, legumes such as beans and peas, and more fruits and vegetables to your diet.
• If your constipation does not resolve with simple dietary changes, speak to your doctor about starting a fiber supplement or medication to treat the constipation,1 or possible other causes.
• Not everyone's body can tolerate moderate or high-fiber diets. Speak to your doctor if you feel this is you!

*This list is not comprehensive.

References:

1. Simpson, S. Constipation. In Real Life with Celiac Disease: Troubleshooting and Thriving Gluten-Free . Eds. Dennis M, Leffer D, eds. AGA Press. Bethesda, MD, 2010.
2. Meshkinpour H. et al. Effects of regular exercise in management of chronic idiopathic constipation. Dig Dis Sci 1998;43:2379-83.
3. Mayo Clinic. Constipation: Causes http://www.mayoclinic.org/diseases-conditions/constipation/symptoms-causes/dxc-20252715 . Accessed April 20, 2011.
4. National Digestive Diseases Information Clearinghouse: Constipation. Accessed April 20, 2011.
5. Campbell AK, Matthews SB, Vassel N, Cox CD, Naseem R, Chaichi J, Holland IB, Green J, Wann KT.Bacterial metabolic 'toxins': a new mechanism for lactose and food intolerance, and irritable bowel syndrome . Toxicology. 2010 Dec 30;278(3):268-76.

Revision Date: 8-23-12 
Author: Melinda Dennis, MS, RD, LDN 
Editors: Suzanne Simpson, RD and Rupa Mukherjee, MD

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