Chronic Constipation: What You Should Know To Help You Go

If your intestines are chronically miserable, it is time to stop suffering and get some help.

If your intestines are chronically miserable, it is time to stop suffering and get some help.

Please note: This article discusses an uncomfortable topic, but if you suffer from this condition you need to know that help is available. This article is geared toward adults and does not address children with chronic constipation. If you have a child with this issue you need to see a pediatrician and pediatric nutritionist. This article is not a replacement for medical care. See your physician if you have frequent constipation.

Chronic Constipation Should Be Taken Seriously

Chronic constipation can be so distressing, embarrassing, and debilitating for some people that they may begin to socially isolate themselves, and feel unable to live a full life. If you have this condition, then you know that traditional remedies such as using a fiber supplement, taking a laxative, drinking more water and exercising don’t necessarily work.

The number of people going to the emergency room for constipation increased by 42% between 2006 and 2011. Infants and the elderly (over age 65) are more likely to end up in the emergency room.  There can be a multitude of causes for this condition, and to successfully tackle this you may need to assemble a team of health care professionals. Please read on to understand some of the possible causes of chronic constipation and how you can get help.

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Do You Have Constipation?

According to the American Society of Colon and Rectal Surgeons, bowel movements should occur AT LEAST every third day, if not more. If a bowel movement requires great effort to expel, or does not satisfactorily empty, a person would be considered to have constipation even if they are having “normal frequency” of bowel movements.

But if a bowel movement occurs every third day, is normal and formed, and does not require great effort to expel and the feeling of complete emptying occurs this is considered normal.  Holistic practitioners advocate for a daily bowel movement for overall health and detoxification purposes, but if this can’t happen without overuse of laxatives then expectations need to be changed.

Chronic Constipation Often Occurs With Other Symptoms

I my practice, I see chronic constipation occurring with other issues such as anxiety, depression, difficulty concentrating, headaches, insomnia, bladder pain, dry eyes and sometimes even all over achiness. Food allergies, gas, bloating, reflux, and nausea may also be part of the picture. These other symptoms can provide clues as to what is causing the chronic constipation.

Some Possible Causes of Chronic Constipation

A Diet Low in Fiber and Fluids. Most people with chronic constipation are told to eat more fiber and drink more fluids. This is a good commonsense strategy to try first as sometimes it works. The type of fiber you choose is important.

Eating fiber keeps the muscles in gastrointestinal tract strong, just like lifting weights keeps our skeletal muscles strong. Fiber may help strengthen the wave of peristalsis that moves food through our gastrointestinal tract. Fiber also helps to prevent hemorrhoids.

High fiber foods include unprocessed foods such as beans and lentils, fruit, vegetables, nuts, and wholegrains. In other words: unprocessed food from plants. Not all of these foods may be appropriate for people with chronic constipation.

A Diet Too High in Fiber. Sometimes people are recommended to use a fiber supplement or to start eating lots of high fiber grains such as oatmeal and quinoa for chronic constipation. This can make matters worse. Too much fiber, or suddenly greatly increasing the amount of fiber you are consuming, can cause constipation.

This sounds counter-intuitive to most people. However, a study was done in 2012 on individuals with chronic constipation. The researchers observed that typically people with chronic constipation are self-treating with too much fiber. This bulks the stool, making it harder to pass, slows down gut transit time and therefore, causes trapped gas and worsens the symptoms of gas, bloating, constipation.

If the person has an overgrowth of bacteria or yeast in the small intestine, the fiber may serve as a food source for these organisms thus worsening their GI symptoms.

In the study they put people with chronic constipation on a no fiber diet for two weeks, followed by a low fiber diet, or what felt an acceptable level of fiber. Those on the low fiber diet had complete resolution of symptoms, those who resumed a high fiber diet had a return of all symptoms.  

If you are given a fiber supplement by your doctor, start very slow, such as ¼ teaspoon in water, instead of a whole serving which could be 2 tablespoons. Don’t increase the amount by over ½ teaspoon per week.

The Wrong Type of Fiber--- Fiber that is high in FODMAPs. FODMAP foods are high in fermentable carbohydrates called Fructans, Oligosaccharides, Disaccharides, Monosaccharides, and Polyols or, “FODMAP” foods for short. The carbohydrate in these foods ferment in the GI tract and can make gas, bloating and constipation worse.

Examples of these foods include apples, pears, cauliflower, pistachios, beans, lentils, whole wheat, wheat bran…. In other words, foods that we often think of consuming for constipation. There are tons of high fiber foods that are low in FODMAPS and may really be helpful for constipation without causing gas, bloating and intestinal pain. These foods are in a table at the end of this article.

Irritable Bowel Syndrome (IBS). Irritable bowel syndrome is considered a functional motility disorder where the motility of the gastrointestinal (GI) tract can be uncoordinated. There is IBS-C (constipation) or IBS-D (diarrhea). IBS may involve low grade inflammation, poor muscle coordination of the GI tract, food sensitivities, and bi-directional communication between the gut and brain.

IBS is associated with abdominal pain, irregular bowel movements and typically the pain is relieved by having a bowel movement. Many people with chronic constipation have IBS. Your physician can diagnosis IBS.

Food Allergies/Intolerances/Sensitivities. Gluten intolerance (Celiac’s disease), corn, oats and diary or other individual food sensitivities may be correlated with constipation.

Certain medications. Always speak with your doctor and pharmacist about any medications you are taking that may be causing constipation. Examples include opoids, anti-cholinergic medications, antispasmodic medications, some psychotropic medications such as tricyclic anti-depressants, calcium channel blockers, NSAIDs like ibuprofen and aleve, and antihistamines like Claritin or Zyrtec. Certain iron supplements may also cause constipation.

Neurotransmitter Production

Low Serotonin Production. Serotonin is a neurotransmitter that many people associate with a happy, calm mood. We make about 70% of our serotonin in our GI tract. Serotonin helps with peristalsis or the movement of food through the gastrointestinal tract (motility). Certain supplements can help to boost the production of serotonin which may be helpful for some people to improve peristalsis and thus constipation.

Low acetylcholine production. Some people may genetically underproduce acetylcholine, or may be taking a medication that blocks acetylcholine production. Some symptoms of low acetylcholine production may include slow gut transit time, difficulty emptying the bladder, difficulty with memory and learning, lack of deep REM sleep, facial flushing, dry eyes, and mood instability.

If you can check the box on these symptoms, lack of acetylcholine may be an issue for you. Certain supplements can help boost the production of acetylcholine. Lack of acetylcholine production may also have to do with vagus nerve dysfunction.

 Vagus Nerve Dysfunction. The connection with the vagus nerve and constipation is still being researched. The vagus nerve is a cranial nerve that starts in the brainstem and runs through the chest all the way to the colon. It serves as a communication highway between the gut and the brain.

The vagus nerve is an important part of our autonomic nervous system, which is responsible for things our bodies do automatically such as breathe and digest food. The vagus nerve releases acetylcholine when it is stimulated. When the vagus nerve is not stimulated enough you may experience brain fog, slow gastric emptying and constipation, anxiety, panic attacks, tinnitus, depression.

To stimulate the vagus nerve you can try deep belly breathing, splashing cold water on your face, massaging your feet or gargling forcefully several times per day. Acupuncture and cranial sacral therapy may also stimulate the vagus nerve. Meditation is another option to explore on a daily basis.

Hyperparathyroidism.  Hyperparathyroidism can be another cause of chronic constipation. This condition is diagnosed by a physician. The parathyroid gland is situated behind the thyroid gland in the neck. When your parathyroid is over active (hyperparathyroidism) it can cause constipation as well as bone loss and calcification of soft tissues.

You can have primary hyperparathyroidism (often due to a benign tumor) or secondary hyperparathryoidism due to malabsorption of calcium and Vitamin D (common in malabsorption disease, gastric bypass surgery, and celiac’s disease). You can ask your doctor to run a blood test to measure parathyroid hormone (PTH) level.

 Hypothyroidism or a sluggish thyroid. Whether or not you receive a true diagnosis of hypothyroidism, you may have a sluggish thyroid contributing to chronic constipation. As nutritionists, we work to improve the function of the thyroid by making sure you have enough of the nutrients that support thyroid function. Removing foods that contribute to hypothyroidism and inflammation is part of the answer as well.

 When we help people with thyroid issues, we work on gut healing which also improves constipation. Asking your doctor to run a thorough thyroid panel can be helpful in determining if this is contributing to constipation. Your physician can diagnose hypothyroidism.

Lifestyle Factors

  • Too much sitting and not enough exercise to “get things moving.”

  • Not drinking enough water can result in a hard stool that is difficult to pass.

  • Suppressing the urge “to go.” Peristalsis is the wave of muscle contraction that sweeps through our intestinal tract and allows us to have a bowel movement. Typically it happens in the morning, after a meal or a hot beverage. Some people are in a hurry and don’t wake up in time to eat and relax; and therefore don’t allow that “wave” to happen in the morning. And then when the “wave” does happen later, they can’t get away to use the restroom so it is suppressed.

  • Chronic stress and not enough time to relax.

 If the “urge to to” is suppressed on a regular basis it can result in lack of movement in the GI tract and things get backed up. School aged kids often don’t want to “go” at school, and then this can be compounded by after school activities where they don’t get to come home and “relax” to have a bowel movement.

Adhesions or scarring after abdominal surgery .Think of C sections, hysterectomies, tummy tucks, hernia repair and other abdominal surgeries. Adhesions or scar tissue as a result of surgery can build up over time and block the intestine. Pelvic floor physical therapy specialists can help with adhesions and other mechanical reasons for chronic constipation.

Anesthesia used during any surgery, even if it is not abdominal surgery, can slow the GI tract and result in small intestinal bacterial overgrowth (SIBO) which can in turn result in chronic constipation.  Gastro-intestinal tract function after surgery should be managed to prevent constipation. If you have a surgery coming up, make sure you speak to your surgeon in advance to prevent constipation after surgery.

Small intestinal bacterial overgrowth (SIBO). Small intestinal bacterial overgrowth (SIBO) or small intestinal fungal overgrowth (SIFO) is a condition where bacteria or yeast is overgrowing in the small intestine. This condition can slow the “migrating motor complex” that stimulates peristalsis in the small intestinal tract, thus slowing down transit time of the whole intestine. In order to correct SIBO, the underlying functional motility issue must be addressed. There are supplements that can act as “pro-kinetics” and help restore functional motility of the gut. Sometimes SIBO can take a few years to get under control so patience, persistence, and a positive attitude (easier said than done), are helpful here. This condition is diagnosed by a physician.

Dysbiosis. Dysbiosis in the GI tract (imbalance, overgrowth, or low amount of normally occurring friendly bacteria) can occur from antibiotics, artificial sweetners, lack of fiber from plant foods, and just too much sugar and junk food. Nutritionists help you rebalance the gut bacteria with healthy diet, probiotics and certain herbs.

Intestinal Inflammation. Intestinal inflammation can be caused by a variety of reasons such as bacterial or yeast overgrowth, too little beneficial bacteria, celiac’s disease, NSAID (ibuprofen) or aspirin use, crohn’s disease or ulcerative colitis. Intestinal inflammation may be a culprit in chronic constipation. Inflammation can be seen by gastroenterologists through certain diagnostic tests.

Lack of moisture in the intestinal tract. The person may constitutionally have dry mucous membranes all over, such as eyes, mouth, GI tract or sinuses. For these folks, not only water, but also essential fats can help with dryness all over the body. Flax seed oil, olive oil, fish oil, avocado and sources of gamma linoleic acid (GLA) oil such as evening primrose oil or black current seed oil are examples essential fats.

Pelvic floor dysfunction.The causes of pelvic floor dysfunction are many. When these muscles spasm or function with poor coordination, it can certainly lead to colon and bladder irregularities as well as back pain. Physical therapists that specialize in the pelvic floor muscles can help you correct the underlying dysfunction.

Neurogenic bowel. (lack of nervous system control). This can occur from diabetes, multiple sclerosis, spinal injury, etc. This is a serious situation and can require many interventions to manage. This is diagnosed by a physician.

Anatomical Reasons:. Enterocele, sigmoidocele, rectocele, and rectal prolapse. These conditions are diagnosed by a physician.

Colonic stricture or narrowing. This can occur from inflammatory bowel disease, diverticulitis, radiation, etc. This is diagnosed by a physician.

Where to Start?

I suggest starting with your physician and a nutritionist. All of these scenarios should be discussed with your physician so you can start investigating the cause and start finding a solution. I recommend putting together a team of professionals that can include a gastroenterologist, a functional medicine dietitian/nutritionist, homeopath, physical therapist and even an acupuncturist. Most people have multiple issues going on and that is why their condition is so serious. For instance, abdominal surgery, pelvic floor dysfunction, sluggish thyroid, SIBO, food sensitivities, and insufficient acetylcholine production can all occur together, feeding into one another.

How to Improve your Diet to Help Your Gut

The number one way to improve the healthy bacteria in your gut is by eating plants: Fruits, vegetables, nuts, and possibly beans and whole grains. Cut down on white carbohydrate foods (sugar, flour, pasta, tortillas, bread, chips, baked goods). Don’t overdo fat or protein. You can shift the bacterial balance toward a more friendly population in 24 hours. Fermented foods such as kim cheese, sauerkraut, yogurt and kefir may or may not be helpful. These may make gas and bloating worse, or conversely make everything better. Working with a nutritionist to sort this out will be beneficial.

To improve the balance of healthy bacteria in your gut, eat lots of plants.

To improve the balance of healthy bacteria in your gut, eat lots of plants.

Should You Take Supplements?

There are a number supplements that your functional medicine nutritionist can recommend that augment diet and lifestyle changes to help address slow GI motility, low serotonin, low acetylcholine, inflammation of the GI tract, low mucin production, excessive mast cell production, food allergies, gut healing, and probiotic bacteria and the right type of fiber for your circumstance. Do it yourself supplement programs may not always be a wise idea. It is best if supplements are discussed with an expert in the use of supplements for gastrointestinal dysfunction.

Summary of Solutions for Chronic Constipation

  • Set up a routine with daily exercise, plenty of fluid, stress reduction and a sleep/ wake cycle that allows plenty of time in the morning to have a bowel movement.

  • Work with a nutrition professional to identify foods that may be worsening constipation, foods that may help constipation, and supplements that may help constipation. Seek out sources of fiber that are low in FODMAPS.

  • Have your functional medicine nutritionist or doctor help you with integrative lab work, such as stool cultures, to identify dysbiosis that may be causing inflammation in the intestinal tract.

  • Work with your doctor to identify medications such as antihistamines or NSAIDs; or medical conditions such as hypothyroidism or hyperparathyroidism that may be worsening constipation.

  • Visit with a physical therapist who specializes in pelvic floor therapy.

  • ·Work with a homeopath. Homeopathic remedies that look at your whole constitution can be very helpful in correcting chronic constipation.

  • Consider buying a “squatty potty.”

Simple Recipes to Help With Constipation

Pureed Prunes:

You can just eat straight prunes or turn it into a dessert with some hemp or chia seeds sprinkled on top.

Process ½ cup of prunes and ½ cup of water, in a food processor. This makes 2 servings.  Prunes are high FODMAP but have a laxative effect that can be helpful. I suggest eating this at night so you can “go” in the morning.

 Smoothie:

12 oz water

1 - 1 1/2 cups frozen or fresh fruit that can be helpful with digestion including berries, pineapple, kiwi, papaya.

Option: ½ cup Low lactose Greek yogurt

Fiber option: Ground flax seeds or chia seeds (start small like ¼ teaspoon),

2-3 teaspoons of flax seed oil to sooth the intestinal tract

Options to add creaminess: avocado or nut butter.

Vegetable Option:  ½ cup spinach or kale.

*Beware that protein powders and collagen may sit like a lump and make constipation worse. Aloe vera juice is often recommended to be added to smoothies  for constipation but it may ferment, irritate, and bloat.

Flavored water to encourage fluids:

Water with slices of lemon, lime, cucumber, strawberries. The better it tastes the more likely you are to drink it.

Low FODMAP Food Sources of Fiber

  • Fruit: Berries, kiwis, pineapple, grapes, melon (not watermelon), citrus fruit.

  • Non Starchy Veggies: Aim for about 2 cups of non-starchy vegetables a day. Choose from broccoli florets, bok choy, kale, arugula, celeriac, carrots, green cabbage, red bell peppers, eggplant, zucchini. A simple trick to get a variety of vegetables is to saute 7-10 different types of veggies and eat those throughout the week. Avoid cauliflower, celery, onion, garlic, shallots, mushrooms, asparagus, snow peas if you have IBS symptoms.

  • Parsnips: Roast or boil and mash parsnips with olive oil and broth with little sprinkle of nutmeg are delicious. You can eat about ½ cup per day. Mash them as you would make mashed potatoes (but use low lactose milk).

  • Winter Squash: Roasted acorn, delicata, kabocha, and spaghetti squash are excellent sources of fiber and can replace pasta, rice and other low fiber grains. (Butternut squash and sweet potatoes are high in FODMAPS and may be irritating).

  • Gluten Free Grains: Quinoa, oats, millet, teff, brown rice are three examples of high fiber grain replacements (quinoa is a seed). These can work wonders for people with constipation or conversely, can cause inflammation and intestinal distress. Try small portions of these and see how you do.

  • Lentils and Beans: If tolerated, lentils and beans can be helpful with constipation. Beans contain fermentable carbohydrates as well as a protein called lectin that might irritate the GI tract lining, so they really may cause distress in certain people.  Beans are often NOT well tolerated with IBS. If you are eating beans it may be best to choose canned beans that have been cooked in a pressure cooker to destroy lectins, or soak them overnight and cook them in a pressure cooker yourself.

  • Nuts: Keep nuts to about ¼-1/3 cup per day or about 2 -4 Tablespoons of nut butter. Some good choices include macademia nuts, walnuts, sunflower seeds, pumpkin seeds. Chia seeds and flax seeds are used in much smaller amounts, start at ¼ teaspoon and slowly increase to 1-2 Tablespoons if tolerated. Be careful with pistachios, cashews as these are high in FODMAPS and can worsen intestinal distress in people with a FODMAP intolerance. Too many nuts in general can worsen IBS.

  • Make Healthier Baked Goods: You can add pureed prunes (baby food prunes), psyllium and ground flax seed, chia seeds in baked goods to help with constipation.

  • Fiber Supplements: Psyllium, ground flax seed and chia seed are Low FODMAP sources of fiber that are NOT prone to fermentation by bacteria in the small intestine and may be tolerated easier by people. You must start with a very low dose such as 1/8-1/4 teaspoon in water and very, very slowly build up.

Don’t increase the amount of these fibers by more than ½-1 teaspoon per week. Some people cannot tolerate very much of these at all. It may take up to 4 weeks for these to consistently help with constipation.

You may hit a threshold where you are taking too much fiber and it will cause constipation and slow transit time. Some people cannot tolerate over a ½ teaspoon/day of any of these. I typically start people on straight psyllium powder rather than flax or chia seed. Do not give these to small children, instead, work with your pediatrician and a pediatric nutritionist for simple solutions. Children can respond quickly to very simple interventions.

For more about low FODMAP diet visit this link: https://www.monash.edu/medicine/ccs/gastroenterology/fodmap

Summary

Chronic constipation can be a lifelong health condition that has to be managed. Learning effective strategies to manage this condition may greatly improve your quality of life. Chronic use of laxatives is NOT a safe option, so if you are using laxatives regularly it is time to seek professional help.

Resources:

https://www.fascrs.org/patients/disease-condition/constipation-expanded-version

https://www.medscape.com/viewarticle/805517_6

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3389673/

https://www.ncbi.nlm.nih.gov/pubmed/?term=HO+ks+fiber

https://www.todaysdietitian.com/newarchives/0816p34.shtml