Hemorrhoids and CRAN

by Ben Best

Does the practice of CRAN (Caloric Restriction with Adequate Nutrition) lead to hemorrhoids? Until I got hemorrhoids I had no reason to believe so. Then I received a private email message from a CRAN enthusiast who had noticed his stools getting harder when he began his dietary regimen -- and he got subsequently got hemorrhoids. He told me that he had a conversation with Dr. Roy Walford at the 1996 American Academy of Anti-Aging Medicine Conference, and Roy spontaneously told him that Caloric Restriction causes hemorrhoids. I think this is overstating the matter, because I practiced CRAN for 2.5 years, occasionally with very hard, stools (on the rare occasions that I wasn't eating lots of cereal), without getting hemorrhoids. I think it would be more accurate to say that people who practice CRAN may be more vulnerable to hemorrhoids because reduced caloric intake may lead to smaller, harder stools -- and more straining at the toilet.

I believe that the proximate cause was my decision to eliminate cereal altogether from my diet, beginning in January 1997. Cereal has been a major source of my calories, and also a major impetus for binging. Although I do eat large quantities of vegetables, the loss of dietary fiber in cereal may have been critical (my stools became hard). Also, I am a very impatient person who habitually strains at his stools. Furthermore, I am a computer programmer by profession, and most of my working day is spent in the sitting position. If I would concede anything it would be the idea that the way CRAN is practiced may lead to hemorrhoids. In particular: "Reduce calories without reducing fiber". Or even: "Reduce calories without reducing adequate nutrition and increase fiber to compensate for a drop in colonic volume".

Surgery can completely cure hemorrhoids, but it often requires several days of hospitalization and weeks of recovery. (The Battle of Waterloo might have had a different outcome had not Napoleon been suffering from such painful hemorrhoids that he couldn't get out of bed -- much less sit on a horse).

The vascular system evolved in animals that walked on 4 legs -- and the venous system around the anus is not well-evolved to handle the gravitational stresses of standing upright. People who spend most of their time sitting or standing (rather than walking or reclining) are more vulnerable to hemorrhoids. Lifting weights while holding your breath puts pressure from the diaphragm onto the viscera below -- right down to the anus. Long periods on the toilet reading a newspaper can also increase pressure in the anal veins leading to the ballooning of hemorrhoids. This creates something of a dilemma, because the cause of hemorrhoids most frequently cited is straining at stools. (Straining at stools is also the single most frequent trigger of sudden cardiac death.) The solution is to have soft, wet stools that pass quickly & easily without straining -- reducing the time required for defecation.

A study of 70 consecutive patients with hemorrhoids found that all 70 had a diet of less than 3 grams of fiber per day [HAEMORRHOIDS, Clive Wood, Editor (1979), page 29]. The average American consumes 11 grams per day, and most dietary authorities recommend several times that amount. Five surgeons agreed that the use of dietary bran markedly reduces hemorrhoids [Wood, page 33].

In the past it was thought that hemorrhoids, like diverticulosis (diverticula of the intestine), was aggravated by too much "roughage". This is now known to be untrue. An article entitled "Dietary Fiber and Gastrointestinal Disease" [from SURGERY, GYNECOLOGY & OBSTETRICS 177(2):209-214 (1993)], contains the following passages concerning diverticulosis:

"Until the early 1970s, diverticular disease had been treated with low fiber diets, the concern being that coarse high fiber dietary residue would lodge in diverticula and predispose to stasis, inflammation and perforation. In 1972, dramatic improvement of diverticular symptoms in 62 patients treated with high fiber diet during a period of 22 months was reported (33). Other prospective clinical trials have confirmed the beneficial effects of high fiber diets in alleviating the symptoms of diverticulosis (30, 34, 35) and results in surgical treatment being performed less frequently for complications of diverticular disease (3)."

The following table [from SURGERY, GYNECOLOGY AND OBSTETRICS 177(2): 209-214 (1993)] shows some of the highest sources of dietary fiber (I included bread & rice for contrast). "NCP" stands for NonCellulose Polysaccharide (hemicellulose, pectins, gums, mucilages).

                          [ GRAMS / 100 GRAMS DRY MATTER]

White Rice         0.16        0.16         0.35       0.67
Brown Rice         0.70        0.14         1.18       2.02
White Bread        0.13        1.19         0.59       2.63
Oatmeal            0.40        3.93         2.96       7.29
Whole Wheat Bread  1.61        2.67         5.63       9.91
All Bran           4.38        3.94         5.54       10.41
Shredded Wheat     1.70        2.33         6.70       10.73
Iceburg Lettuce    7.17        9.35         2.72       19.24
Raw Cabbage        9.86       13.53         4.21       27.60
Wheat Bran         8.17        4.25        28.60       41.06
Corn Bran         16.7         6.57        55.21       78.48

Most of the cereals I had been eating were very high in carbohydrates -- in contrast to vegetables, which (along with sandwiches) are the staple of my diet. I had been eating BRAN BUDS primarily for the good mix of fibers, but at the cost of a whopping 8 grams of sugar per 30 grams of cereal. FIBRE ONE cereal, by contrast, is composed primarily of wheat bran & corn bran -- and is sweetened with aspartame. (Unfortunately, FIBRE ONE contains 1% of the daily RDA for iron per gram of cereal -- so I limit myself to 30 grams per day.) Jean Pennington's book FOOD VALUES lists the calorie content of FIBRE ONE as half that shown on the package (in agreement with what I calculate based on the stated protein, fat, sugar and starch content), but I believe the true value lies between (based on calories released due to bacterial fermentation of fiber in the colon).

Insoluble fiber increases fecal bulk by absorbing water, and reduces colon carcinogenesis by absorbing carcinogens. Colon/rectal cancer as a cause of cancer death is second only to lung cancer. (Although skin, breast and prostate cancer are more common, they are more frequently cured.) A diet of 8% wheat bran (insoluble fiber) or 8% psyllium (soluble fiber) has been shown to halve the incidence of colon tumors in rats [CANCER LETTERS 75:53-58 (1993)], but a diet of 4% wheat bran & 4% psyllium halved it yet again (to one-quarter the incidence of controls). Wheat bran and psyllium are powerful complements.

Insoluble fiber is the preferred treatment for hemorrhoids, not soluble fiber -- as attested by the recommendations for wheat bran by so many surgeons. In fact, one good review of dietary fiber states "Water-soluble fibers, such as pectin and gums, have little effect on stool weight and hence are not appropriate treatment for patients with constipation." [JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION 87(9):1164-1171 (1987)] Psyllium, however, is the most effective of soluble fibers, and is the best to use for increasing stool bulk and preventing hemorrhoids.

Oat bran is over-rated, and the soluble fiber it contains is primarily gum -- of some use in lowering cholesterol and reducing blood glucose, but marginally (barely measurable, in fact -- see the above reference). At nearly 4 calories per gram, oatmeal is very high in fat.

Psyllium has the highest level of soluble fiber known. Ispaghula husk (from another plantain in the Plantago genus) attracts 40 times its own weight in water [Wood, page 22]. One study showed that 18 grams of ispaghula (divided into two daily doses of 9 grams each) nearly doubles the daily fecal wet weight [GUT 35(10):1747-1752 (1994)].

For these reasons I have now added a noon "lunch" to my daily diet. I mix 9 grams (1 tablespoonful = 15 ml) of sugar-free generic Metamucil (psyllium hydrophilic mucilloid) with water, and then pour the slurry onto 30 grams of FIBRE ONE in a bowl. This 90-calorie meal is quite filling (making the practice of CRAN easier), and has reduced the hardness of my stools considerably. This is the one "meal" I do not eat with supplements -- because fiber is known to reduce absorption of vitamins & minerals.

My hemorrhoids have shrunken (they may have done so anyway), but I have hope that my new dietary policies will prevent their reappearance. And I hope others find the lessons I have learned to be of personal value to them.