Chronic Constipation: What You Need to Know to Go
Article by Dr. Margo Gasta, DCN, RDN, CCH
*Please Note: This article is aimed at adults. If you have small children with chronic constipation, I recommend that you work with a pediatric nutritionist AND a pediatrician as some of these recommendations will not be appropriate.
Chronic constipation can be distressing, and some people suffer immensely. 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.
What is 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 a “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.
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 chronic constipation.
Click here to schedule a free discovery call if you are suffering from chronic constipation
Some of the Causes of Chronic Constipation May Include:
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 the 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 whole grains. In other words: unprocessed food from plants.
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, and 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 like an acceptable level of fiber. Those on the low-fiber diet had complete resolution of symptoms, and 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 1/4 serving in water instead of a whole serving which could be 2 tablespoons. Don’t increase the amount by over a teaspoon or so per week.
The Wrong Type of Fiber--- Fermentable Fiber . FODMAP foods are high in fermentable carbohydrates called Fructans, Oligosaccharides, Disaccharides, Monosaccharides, and Polyols, or, “FODMAP” foods for short. The carbohydrates 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, and wheat bran…. In other words, foods that we often think of consuming for constipation. There are plenty of high-fiber foods that are low in FODMAPS and will likely be helpful for constipation without causing gas, bloating, and intestinal pain. These foods are on a table at the end of this article. Hopefully, after working with a functional dietitian to improve the health of your gastrointestinal tract, you will start to be able to tolerate all forms of fiber.
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 and irregular bowel movements, and typically the pain is relieved by having a bowel movement.
Food Allergies/Intolerances/Sensitivities. Gluten intolerance (Celiac disease), corn, oats, dairy, 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 opioids, 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.
Click here to schedule a free discovery call if you are suffering from chronic 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.
Vagus Nerve Dysfunction. 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 breathing and digesting 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, and 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 overactive (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 disease). You can ask your doctor to run a blood test to measure your parathyroid hormone (PTH-intact) level.
Hypothyroidism or a sluggish thyroid. You may have a clinical diagnosis of hypothyroidism, you may have sub-clinical or 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. This initial thyroid screen should include TSH, total and free T3, and T4 at a minimum.
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; 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 go” is regularly suppressed, it can result in a 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. Gastrointestinal tract function after surgery should be managed to prevent constipation. If you have 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 may be caused by prior food-borne illness episodes. This condition can slow the “migrating motor complex” that stimulates peristalsis in the small intestinal tract, thus slowing down the transit time of the whole intestine. In order to correct SIBO, the underlying functional motility issue must be addressed. 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.
Dysbiosis. Dysbiosis in the GI tract (imbalance, overgrowth, or low amount of normally occurring friendly bacteria) can occur from antibiotics, artificial sweeteners, lack of fiber from plant foods, and just too much sugar and junk food. Nutritionists help you rebalance the gut bacteria with a 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 few beneficial bacteria, Celiac disease, NSAID (ibuprofen) or aspirin use, Crohn’s disease, or Ulcerative Colitis. Intestinal inflammation may be a culprit in chronic constipation.
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 of 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 who 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.
Anatomical Reasons-enterocele, sigmoidocele, rectocele, and rectal prolapse.
Colonic stricture or narrowing-This can occur from inflammatory bowel disease, diverticulitis, radiation, etc.
Click here to schedule a free discovery call if you are suffering from chronic constipation
So How Should You Tackle This?
The purpose of listing all of these causes is to empower my clients so they can start searching for a solution. All of these possibilities should be discussed with your physician so you can start to get relief. Many people with chronic constipation have several 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
Remember that the number one way to increase your healthy bacteria is by eating plants: Fruits and vegetables are a top priority. Cut down on white carbohydrate foods (sugar, flour, pasta, tortillas, bread, chips, baked goods). You can shift the bacterial balance toward a more friendly population in 24 hours. Fermented foods such as Kimchee, 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.
Should You Take Supplements?
There are a number of supplements that your functional medicine nutritionist can recommend that augment diet and lifestyle changes to help address slow GI motility, inflammation of the GI tract, low mucin production, excessive histamine, food allergies, gut healing, and probiotic bacteria and the right type of fiber for your circumstance. 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 in the beginning.
Have your functional medicine nutritionist or doctor help you with integrative lab work such as stool cultures to identify dysbiosis or SIBO 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.
Work with a homeopath. Homeopathic remedies that look at your whole constitution can be very helpful in correcting chronic constipation.
Simple Recipes:
Pureed Prunes:
You can just eat straight prunes or turn it into a dessert with some hemp or chia seeds sprinkled on top.
Process 1/2 cup of prunes and 1/2 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 1/2 cups frozen or fresh fruit including any mix of berries, pineapple, kiwi, papaya, less ripe banana.
Option: 1/2 cup lactose-free greek yogurt
Fiber option: Ground flax seeds or chia seeds (start small like 1/4 teaspoon),
2-3 teaspoons of flaxseed oil to soothe the intestinal tract
Options to add creaminess: avocado or nut butter.
Vegetable Option: 1/2 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, and strawberries. The better it tastes the more likely you are to drink it.
Low FODMAP Food Sources of Fiber
Berries, kiwis, pineapple, grapes, melon (not watermelon), citrus fruit.
Veggies: Aim for about 2 -3 cups of non-starchy vegetables a day. Choose from broccoli florets, bok choy, kale, arugula, celeriac, carrots, green cabbage, red bell peppers, eggplant, and 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. Temporarily limit cauliflower, celery, onion, garlic, shallots, mushrooms, asparagus, and snow peas to see if IBS symptoms improve.
Parsnips. Roast or boil and mash parsnips with olive oil and broth with little sprinkle of nutmeg are delicious. You can eat about 1/2 cup per day. Mash them as you would make mashed potatoes (but use lactose-free 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 if you have too much).
Gluten-Free Whole Grains. Caution: These high-fiber grains may make exacerbate your symptoms if you have SIBO. These include Quinoa, oats, millet, teff, brown rice, and buckwheat. These foods may work wonders for people with constipation or conversely, can cause inflammation and intestinal distress. Try small portions of these and see how you do.
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 1/4 - 1/3 cup per day or about 2 -4 Tablespoons of nut butter. Some good choices include macadamia nuts, walnuts, sunflower seeds, and pumpkin seeds. Chia seeds and flax seeds are used in much smaller amounts, start at 1/4 teaspoon and slowly increasing to 1-2 Tablespoons if tolerated. Be careful with pistachios, and 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.
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 1/2 - 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 much of any of these. 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.
Apples, pears, prunes, and cherries are High FODMAP foods. For some people these foods may be helpful for occasional constipation but realize that chronic constipation may have more of an IBS component and these foods might really cause uncomfortable GI symptoms.
For more about low FODMAP diet visit this link: https://www.monash.edu/medicine/ccs/gastroenterology/fodmap
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.
Click here to schedule a free discovery call if you are suffering from chronic constipation
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3389673/
Fichna J, Storr MA. Brain-Gut Interactions in IBS. Front Pharmacol. 2012;3:127. Published 2012 Jul 5. doi:10.3389/fphar.2012.00127
https://pubmed.ncbi.nlm.nih.gov/22969234/
Ho KS, Tan CY, Mohd Daud MA, Seow-Choen F. Stopping or reducing dietary fiber intake reduces constipation and its associated symptoms. World J Gastroenterol. 2012 Sep 7;18(33):4593-6. doi: 10.3748/wjg.v18.i33.4593. PMID: 22969234; PMCID: PMC3435786.
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Fiber & Irritable Bowel Syndrome — Strategies for Counseling Patients
Judith C. Thalheimer, RD, LDN
Today's Dietitian
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