A friend re-posted this meme and the list of questions below recently, and I want to clarify at the outset that they were interested in a response from their friends in the medical field, not trying to perpetuate the misinformation, nonsense, and deliberate misrepresentations the original author is promoting. While it takes only a sentence or two to ask a nonsensical or disingenuous question or blast some ridiculous health misinformation, a careful and satisfactory answer will probably take a bit longer. Because of this, I’ve decided to tackle these one question at a time over the next few weeks, and will update this blog post with my responses as I go.
One last preliminary; we should recognize two things about the comic above, besides the fact that it’s pretty standard COVID-19 misinformation (“ooh they want you to wear a mask but nobody will tell you to be healthy! No medical expert has ever recommended people exercise before!”). First, it has pretty much nothing to do with the rest of the post. Second, it’s a riff off of the comic below from Mike Baldwin, author of the Cornered single-panel newspaper comic.
Mr. Baldwin is an apolitical cartoonist, and I can’t find anything in his writings that would give me the impression he would endorse this list of complaints about doctors; but of course I can’t find anything to disprove it either. There is one comic where a doctor had removed someone’s entire intestine because his “stomach was all tied up in knots,” so take from that what you will. Still, if the original author is going to start this whole thing off with a stolen and poorly revised comic strip, best to give some credit to the actual cartoonist (whose original comic was more poignant anyway).
“We Have Questions”
12/6/2020: Why don’t doctors tell you to take magnesium instead of stool softeners (which dehydrates the bowel)?
Before I even dive into these, I have the definite sense that the number of “Wait, What?!” moments I encounter in responding to this post is going to be extremely high. In fact, with just a cursory glance at this long list of “questions,” I’m really not sure whether the “Wait, What?!’s” are going to outnumber the “Um… We Do’s”. I think I’ll keep score.
This post is a good example of both.
Um… We Do
First, let’s be clear what they mean when they say ‘why don’t doctors tell you to take magnesium?’ Surely they mean a laxative compound like Magnesium Citrate or Magnesium Oxide, the active ingredient in Milk of Magnesia. These are commonly used over-the-counter laxatives, and I think we can give the benefit of the doubt that the original author is not here advocating for anything like high doses of magnesium salts like Mag Gluconate or Mag Chloride, typically used to treat magnesium deficiency, as a first line treatment for constipation. Your kidneys will thank you if you don’t overdose on magnesium supplements.
And assuming that this is indeed the form of magnesium they are discussing for constipation, of course we recommend this to patients- when it is indicated. When a patient comes to me with complaints of constipation, the first thing I do is listen to the history of their constipation, including what they’ve already tried for it and whether it was helpful. This helps me both to diagnose whether their constipation is actually due to an underlying medical condition that will need additional work-up, and to make sure that I am not recommending treatment options that they have already tried and found to be ineffective. In general, here are my recommendations for constipation, and usually in this order:
- Increased water intake, increased exercise and walking, dietary changes.
- Increased dietary fiber, including either food sources or fiber supplementation.
- Stool softeners including colace, which are more gentle than laxatives but generally less effective.
- Laxatives, ranging from dietary options that include sorbitol (prunes and prune juices) to polyethylene glycol and milk of magnesia or mag citrate.
- Combination stool-softener/pro-motility agents like sennosides.
- Finally rectal suppositories and enemas, not because they are a worse option than the others but because the patient will pretty much only try these if they have already tried everything else and are now truly desperate.
Because my patients’ time is valuable and I trust them to make good healthcare choices with appropriate advice, we usually briefly discuss the risks and benefits, potential side effects, and stepwise strategy for all of these types of agents; I don’t tell them to drink more water and do some lunges and see me in two weeks if they still haven’t pooped. So it’s fair to say that while Milk of Magnesia or Mag Citrate are not by any means my go-to medications for constipation, I do talk about it as an option with patients very regularly (ha, ‘regularly’. Get it?) If these medications are both readily available OTC medications that you can buy at your local pharmacy and are commonly discussed with patients, why did the OP decide to focus in on it as the one hidden, secret treatment for constipation that doctors won’t tell you about? I don’t really know, but probably because it sounds more natural to invoke an element like ‘magnesium’ than “Sodium 1,4-bis(2-ethylhexoxy)-1,4-dioxobutane-2-sulfonate”… Though I usually shorten this to ‘docusate’ and in fact (in the spirit of full disclosure) had to google that chemical formula (obviously). And in the alternative health world, unfortunately, sounding natural and crunchy is too often more important than the actual efficacy, side effect profile, and safety of the treatments being recommended. One should ask, why didn’t the author complain that doctors recommend magnesium laxatives and stool softeners instead of increased water intake and yoga, both of which have been proven to help with constipation?
Before we move on, we should also address this “dehydrates the bowel” aspect of the post. Because of the beautiful and very intricate fluid homeostasis the body maintains, there’s really no such thing as ‘gut dehydration’ outside of two situations; total body dehydration, which is of course associated with constipation but also a whole host of temporary and potentially chronic problems resulting from poor blood flow and oxygen delivery to vital organs; and medical conditions that result in dysfunction of the normal transport of fluid and ions into the intestinal lumen, such as in Cystic Fibrosis where deficiency and dysfunction of the cystic fibrosis transmembrane conductance regulator (CFTR) protein results in decreased free fluid (and bicarbonate) in the gut and thus accumulation and alteration of intestinal mucous and eventual obstruction. So what are they talking about here?
As best I can tell, they must be referring to the fact that some medications commonly used for constipation work by drawing free fluid into the lumen of the gut from the intracellular space by changing the osmotic gradient of the intestines. While it’s true that this could lead to total body dehydration if the fluid is not replaced with oral hydration, most people who are taking medications for constipation (and all that are following their doctor’s advice and don’t have contraindications) will be increasing their fluid intake as well. The more likely risk is diarrhea, abdominal cramping, and bloating. Which medications do this? The ones that contain magnesium, among others. But not all agents work that way; some actually work by increasing the peristalsis of the intestines (similar to how exercise helps constipation), while others help the thickened, firm stool mix better with the free fluid and fats that are already in the intestinal lumen, which is exactly what that fluid is there for in the first place. Here’s a handy chart so you can see how each of these agents works:
So if you are going to complain that anything that mixes stool and fluid together in order to ease bowel movements “dehydrates the guts,” you are going to be complaining about some of the gentlest, safest, and most natural approaches to constipation, including things like upping your fiber intake and cooking with olive oil. If you wanted to go the pulling-fluid-into-the-intestinal-lumen-through-osmotic-changes route, you could definitely go with the magnesium citrate or the magnesium hydroxide the original author is talking about; but let’s not pretend like they are the crunchiest or most natural options available when you had to walk past all of those sorbitol rich prunes, pears, and apricots in the produce section on your way to the pharmacy to buy them.