Toilet Training And Constipation

Adam is an adorable two-year-old boy with an awesome, loving, supportive family.  He is the middle child of three, and is just beginning to show interest in using the toilet.  He handles “number one” like a champ and gets lots of kudos and high-fives from his parents and older brother for using the potty.  However, he initially refused to poop on the toilet.

With lots of encouragement, he finally manages to move his bowels while sitting on the commode.  After that event (and it WAS an event, with much praise and fanfare), he refuses an encore, with tears and tantrums.  Worse, his normal bowel habit of daily or twice-daily stools changes.  He starts going several days between stools and then begins complaining of tummyaches and wetting his training briefs again.

What’s going on?  Why all of a sudden is he taking two steps back in his toilet training progress?  Is there a link between toilet training and constipation?

Yes, there is.  Constipation and stool withholding are commonly seen during the toilet-training process.  More commonly seen in boys than girls, it’s felt that stool withholding is a form of assertion of control.  Toddlers in the two-to-three-year-old age range are in the control-and-competency developmental stage which I affectionately call the “terrible threes.”

Broken down to its basics, three-year-olds are learning that they can have control over themselves and their environment.  It is a very important developmental task and is often difficult for parents.  This is where I counsel parents to pick their battles and cheerfully load their toddlers up with age-appropriate choices (red shirt versus blue shirt, toast vs waffles for breakfast, book before nap or straight to nap, bath before or after bedtime snack, etc).  Here’s a great book on navigating this age and stage.

Toilet training is the ultimate struggle for control.  This is one where the toddler holds all the cards.  He CAN choose and he WILL choose whether he wants to pass urine and stool into the commode or into his diaper/briefs.

Working backwards with Adam’s worried Mom, we figured that what probably happened was that when he pooped on the commode the sound and the splash startled and scared him.  Put yourself in his place, right?  If you’re not expecting it, that echoing depth-charge sound from deep inside this big cold white thing, coupled with a sudden splash of cold water on his bottom, were probably pretty scary!

After that experience, although he got positive reinforcement from his family, he wouldn’t really be eager for a repeat performance.  Feeling pushed into doing something again that was scary to him would have triggered every control urge in his three-year-old heart.  Digging in his heels in typical toddler fashion, he took that control and ran with it.

Not only did he not want to poop on the commode, now he didn’t want to poop AT ALL.  After withholding stool for a day or two, the stool would have become hard and possibly painful to pass.  That would have negatively reinforced the experience of pooping which will make the process worse.

Constipation (whether or not it’s caused by stool withholding) causes lower abdominal pain and can interfere with urinary urge and control as well, so he starts having trouble staying dry.  Poor Adam, and poor Mom and Dad!  Everything seems to be falling apart.

I’m so happy Adam’s mom brought him to see me (and Dr. Ted, who was very helpful).  A quick check showed Adam was very healthy and had no signs of illness.

Our plan for Adam started with a full stop on toilet training.  If Adam wanted to use the toilet, by all means go for it, but no pressure.  He was in control.

Next we needed to relieve his constipation which required him to unlearn the “pooping hurts” conditioning.  To do that, we used mineral oil, one teaspoon in yogurt or pudding every morning.  Plenty of fresh fruit and water to drink.  Mom would gradually increase the mineral oil every few days until he’s back to one or two soft stools daily.  Mineral oil softens and lubricates the stool so that it’s difficult to withhold and easy to pass.  (Don’t give mineral oil alone, always mix it in creamy food.)

After the tummyaches and constipation were gone, I suggested Mom and Dad take Adam shopping for a potty chair of his own.  With no water in the potty chair, there’s no splash to bother him.  Letting him pick it out helps him take ownership and control of the toilet training process.

Once he was able to move his bowels sitting on the potty chair, he would empty it himself. Dumping his poop in the commode would get him accustomed to the sound and splash it makes in a funny and non-threatening way.

Toilet training is tough for both parents and toddlers.  Beyond the bodily control required (which is a milestone of physical development), toddlers and parents must negotiate the minefield of personal control that is part of the larger developmental stage.

In the larger scheme of things, I encourage parents to relax and take the long view.  If you make toilet training is a battle, you won’t win.  Your child holds all the ammunition, and pushing too hard can set your kiddo up for some health consequences.  She will learn to use the commode at her own pace, and I promise she won’t go to college still wearing pull-ups.

Talk to your child’s doctor if you’re having trouble with toilet training and constipation.  The sooner it’s addressed, the less it will disrupt your efforts to guide your child through this important learning process.

QUESTION: Did your child have trouble with toilet training and constipation?  What worked for you?

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Fasting For Health And Weight Loss

A patient of mine asked me a really good question the other day.  She is obese and knows she needs to lose weight.  She mentioned that she is able to control her food intake during the day without too much trouble but has a HUGE problem with snacking in the evening.

Now, another doctor might have just said “Well just don’t snack.”  As you might have guessed by now, I’m not just another doctor, LOL!  I recommended she consider a trial of intermittent fasting.

What’s intermittent fasting, you ask?  Intermittent fasting, or IF, is a newer method of calorie restriction where you reduce or avoid eating SOME of the time.  This is contrasted with calorie restriction, or CR, where you reduce calorie intake every day.

For instance, what I suggested to my patient is that she confine her calorie intake to 12 hours per day.  She doesn’t need to necessarily reduce her calorie intake drastically.  If snacking in the evening is a problem for her, I suggested she make a 2-week commitment to not eat between 7 PM and 7 AM.  Water and tea are fine to take in.

After a 12-hour overnight fast most people are pretty hungry.  That’s good!  She’ll be able to eat a good breakfast which will get her prepped for the day and give her metabolism a boost.

There are lots of intermittent-fasting diets out there.  A quick Google search yielded a LOT of confusing websites.  Some of them are pretty intense and seem like they would be hard to incorporate into real life.  Some are a bit simpler.

Is going without food worth the hassle?  I did a search on PubMed which yielded a lot of research information.  After a light skim of a number of articles it seemed there is evidence that intermittent fasting is as effective as calorie restriction for weight loss and may be better for prevention of diabetes in people with insulin resistance.

I have been experimenting on myself with different types of intermittent fasting and have found that it’s not as hard as I thought it would be.  Sure I’m hungry when I’m fasting, but that’s to be expected, and knowing you’re going to be able to eat in a few hours makes it easier to handle.

A few words of caution for anyone who may be interested in trying intermittent fasting for weight loss.  Check with your doctor to see if there’s any reason prolonged fasting may be dangerous for you.  For instance, diabetics who take insulin or some oral medication should pay close attention to their blood sugar and be on the lookout for hypoglycemia.

Anyone who is limiting their calorie intake with the goal of losing weight should pay close attention to their nutrition.  Eating real food (not processed food) or using meal replacements that don’t have chemicals and artificial ingredients is important.  Take a high-quality, well-absorbed multivitamin to fill in any gaps in your nutritional intake.

Intermittent fasting is an attractive weight loss method because of its simplicity.  Simply confining your food intake to a certain number of hours per day or restricting your food intake a few days per week can be a very effective way to gradually lose body fat.

QUESTION:  Have you tried fasting before?  How did it go?  Is it something you’d be interested in trying in the future?

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Afraid Of The Doctor?

Over the last few weeks, I’ve had several patients come in who were clearly TERRIFIED to be in the doctor’s office.  Huh?!  Why would anybody be scared to come see me?  Why would anybody be afraid of the doctor?

On further reflection, I guess it’s not so hard to understand.  Thinking back to doctor’s office visits when I was a kid, it always seemed like they ended with being jabbed with something sharp.  We doctors do seem to want to do mildly painful things to patients (with the best of intentions, of course).

The most common reason for patients to be afraid of the doctor, though, isn’t about the doctor (or pointy things) at all.  Patients are afraid the doctor is going to find something wrong.

High blood pressure, diabetes, high cholesterol, and some much scarier things have no symptoms in their early stages.  That’s why we do screening tests, to find them early. Sometimes that seemingly minor, annoying symptom actually is a sign of something serious.  Patients are usually very aware of this and it’s frightening.

If you come see me in the office there’s a chance I might find something wrong.  Something that needs medication or further testing or other management of some sort.  However, whether or not I found the high blood pressure or diabetes or whatever it is, it was THERE before I found it.  If it’s there, much better to KNOW it’s there, because if we know it’s there we can address it.

There is one more big reason patients don’t like to go to the doctor.  They’re afraid the doctor will tell them they shouldn’t be doing something they aren’t ready to stop doing.  Smoking, drinking alcohol, eating junk food, avoiding exercise, avoiding thinking about or dealing with a stressful job or abusive spouse.

For those of you who are afraid of the doctor, I have a few words of advice.  First of all, it’s important to see the doctor as an ally, a friend and advisor who has your best interests at heart.  I’m outside of my personal area of expertise when I meet with my attorney or take my car to the shop.  I rely on them for their best advice, but I’m not afraid of my lawyer or my auto mechanic.

If you’re scared to see the doctor, it might be time to think about getting a new doctor.  Think about whether your doctor listens to you, answers your questions, and puts you at ease.  Do you have confidence that if something IS wrong your doctor is the right partner to help you handle it?

One more thing to remember is that you have some responsibility as well.  If something is worrying or scaring you, you have to tell your doctor about it.  Remember, we don’t read minds!  I can’t reassure you if I don’t know what’s bothering you.

Also, if I haven’t done a good job of answering your questions or explaining things I need you to tell me so.  A good doctor will explain things again in a different way, as many times as is needed so you understand.

As far as not wanting to be told to change your behavior, that one I can’t help you with.  It’s my responsibility to point out things that are destructive to your health.  Whether or not you take my advice is up to you.  I’ll keep reminding you until you ARE ready to address it 🙂

I don’t want anybody to be scared to come see me.  You might be sick or hurt, you might be worried about something, but my goal is for everyone to feel better when they walk out of the office than they did when they walked in.

QUESTION:  Does seeing your doctor scare you?  Why?

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Diabetes And Glycemic Index

Betty and Judy are two women I know well who are both recently diagnosed with diabetes.  You know what that means, right?  New medicine, new worries and fears, and above all, new Google searches.  No, I’m not joking, I know perfectly well that my invisible partner in caring for my patients is the infamous Dr. Google.

The biggest change both these ladies are going through, though, is a changing relationship with food.  This can be so confusing!  Everybody knows that eating sugar is bad for diabetics, but is that ALL they need to know?

Of course not.  What to put in your mouth is the single biggest decision you will make on a daily basis that impacts your health.  So how do you learn new ways of eating that don’t make you completely frustrated?

Today I’d like to introduce you to a (maybe) new concept called the Glycemic Index.  This is a measure of how eating a certain food impacts your blood sugar.   High-glycemic-index foods make the blood sugar go up a lot, and low-glycemic-index foods don’t.

This is a rough “average” measure and everyone’s body is different, but it gives new diabetics (and some “older” diabetics who are looking to get serious about diet) a place to start with meal planning and food choices.

The American Diabetic Association has more information about the glycemic index of certain foods and there are TONS of websites with glycemic index information.  I don’t want to give you an exhaustive list since that’s easily available.

Helping you understand how to use this information is much more important.  In general, if you’re diabetic or concerned about obesity or diabetes, you will want to generally choose lower-GI foods for most of your meals and snacks.

It’s also important to understand how individual foods impact your own body.  That’s where your glucometer comes in handy.  If you are eating a food and aren’t sure how your body reacts to it, you’ll check your blood sugar 2 hours after eating it.  If your sugar is higher than expected, that means that, FOR YOU, that food may have a higher glycemic index than average.

Here’s an example.  Suppose you’re planning to have grilled chicken, roast potatoes and salad with vinaigrette dressing for dinner.  You’re not quite sure how the potatoes are going to affect your blood sugar, so you check 2 hours after dinner and find your sugar is much higher than expected.  Oops!  What happened?

The potatoes had a bigger impact on your sugar than expected.  We can assume it’s the potatoes since chicken and salad don’t affect the sugar much at all.  Does this mean you can never have potatoes again?  Of course not.

The other concept to understand is the glycemic IMPACT.  This is a combination of glycemic index and portion size.  If you eat a small amount of a higher-GI food, it has less IMPACT on your sugar than if you eat a larger portion.  So if you are planning to eat a food that you know tends to raise your blood sugar, eating just a small portion will minimize its impact.

What about just eating meat and cheese and eggs?  Low-carb diets have been recommended for those who are diabetic or who are trying to lose weight.  The problem with low-carbohydrate diets is that they have no fiber, which is essential for proper bowel function and the health of digestive bacteria.  Just adding a psyllium fiber supplement isn’t good enough, your body needs whole grains, beans and other sources of healthy plant fiber.

Your body is unique, and I can’t tell you exactly how any individual food will treat you.  However, with information about glycemic index, proper portions, and your trusty glucometer, you will be able to create meals and snacks you love that don’t throw your blood sugar out of whack.

Check here to see my favorite low-glycemic-impact weight loss program that has helped a number of my diabetic patients lose weight and get their sugars under better control.

QUESTION:  Are you diabetic or trying to lose weight?  Have you used glycemic index information to help in meal planning?  Do you think it would be useful for you?

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