In this article, we explore the many causes of constipation and how nutrition, lifestyle and functional medicine can help to alleviate constipation and associated symptoms. We explore the role of lab testing looking for underlying causes as well as supplements and other lifestyle changes you can make to help overcome constipation symptomatically and with a root cause focus.
Constipation is a common disorder of the gastrointestinal system generally impacting females more than males and is thought to affect about 20% of the population (Roque & Bouras, 2015).
It’s mainly characterised by; failed or lengthy attempts to pass a stool, excessive straining, a sense of incomplete evacuation and by a low number of bowel movements per week. It is also reported that there is about a 30% increased prevalence of constipation in the non-white population vs the white population (Diaz et al, 2022).
The causes behind constipation are diverse with over 20 different subtypes being listed, many of them overlapping which is why fixating on finding just one can be a slightly narrow-minded objective.
Common factors behind constipation include a low fibre diet, excessive caffeine and alcohol consumption, inadequate water intake, certain medications, hypothyroidism, specific imbalances in the gut microbiome, poor digestion, stress, neurotransmitter imbalances and also behavioural and psychological factors.
As you can see, the slowing of stool movement through the colon is not only impacted by our diets and level of physical activity (which are the usual suspects) but by a myriad of components which requires a holistic approach.
Our nervous system controls the muscles that are responsible for the movement of the contents of our gut and a lack of nervous system activity could be partially responsible for sluggish bowels. More on this later.
Other associated causes include a history of voluntary stool retention and a history of eating disorders such as anorexia nervosa or bulimia both seeming to impact the optimal functioning of the bowels. (Chiarioni et al, 2000).
With the causes of constipation being so wide and varied, it’s important that a professional spends some time with you looking at the ‘surface level’ side of constipation to narrow down all possible contributing factors towards your symptoms.
Optimising your dietary habits and perhaps using therapeutic diets and food to support your health is a significant pillar when taking a functional medicine approach.
The two main components of diet for constipation are water / fluid intake and fibre intake.
An adequate amount of water intake is needed to promote the softening of stools and to help push the stools along the digestive tract.
Many studies have shown that being mildly dehydrated can increase constipation and we should aim to have roughly 1.5-2.5L per day depending on your individual activity levels (Arnaud, 2003).
Despite dietary fibre being one of the first things we might think of when it comes to healthy bowel movements, there are mixed findings when it comes to studies using dietary fibre to improve constipation. In some cases, it may even make matters worse.
We know that adequate fibre intake is essential to the normal functioning of the bowels by adding water to the stools, softening the consistency of it and increasing the time taken for stools to move through the colon but studies have shown that it isn’t as black and white as this.
A study of 149 patients with chronic constipation showed poor results for 80% of them when dietary fibre was increased perhaps suggesting that while dietary fibre is essential for healthy subjects with normal colonic transit time, it does not seem to be as effective when chronic constipation is already present. (Voderholzer et al, 1997).
However, in clinical practice, we know that soluble fibre containing fruits like kiwi-fruits, papaya and prunes are great additions to the diet to help alleviate constipation by softening the stools proving that constipation is a complex condition and especially if under part of the wider IBS umbrella. Equally, some of these foods contain specific polyphenols which have been shown to alleviate constipation. So, sometimes you have to look beyond the fibre and consider other compounds that make up that food.
Just to add more confusion to an already complex topic, certain types of carbohydrates and fibres may actually do more harm than good for individuals with SIBO (small intestinal bacterial overgrowth). A condition that is associated with IBS and is expressed as constipation in some cases (Achufusi et al, 2020).
In any case, dietary fibre and the favourable health benefits that we garner from it i.e. blood sugar regulation and cardiovascular benefits as well as the feeding of beneficial bacteria in our intestines to produce vitamins means that it is still something we should be striving to include on a daily basis.
Working with a nutritionist will help you recognise whether dietary fibre could be a solution for you and if so, what type to include and avoid.
As a rule of thumb, we should be aiming for roughly 25g for females and 38g for males per day or 14g per 1000 kcal of food intake (Abdullah et al, 2005).
It is somewhat unclear as to whether alcohol consumption has a direct negative impact on constipation as generally speaking, frequent alcohol users may also have other aggravating lifestyle factors such as smoking and eating out with a mixture of certain trigger foods.
Perhaps there’s an indirect correlation between alcohol consumption and constipation as alcohol increases intestinal permeability which is associated with IBS (Dunlop et al, 2006).
Outside of lifestyle modification, laxative usage is the most common form of treatment for constipation.
There are several different types with different modes of inducing a bowel movement. Some will add bulk to the stools and are called bulk forming laxatives (psyllium being a common natural one) whereas other stimulant laxatives will invoke a bowel movement within several hours.
Whilst on the whole laxatives are safe to use, with occasional bloating and abdominal discomfort being the most commonly reported side effects, users often report high dissatisfaction rates with outcomes.
One consideration to make with magnesium based laxative usage are for those with renal or cardiac impairments as an overload of magnesium-based laxatives can cause metabolic disturbances (Xing et al, 2001). Some magnesium chelates are more gentle than others and can be considered to support chronic constipation. However, it has to be noted that this does little to address the underlying cause in most cases.
Our team of clinicians will be able to provide advice on the use of magnesium, what type and whether it would be of benefit in the short and long term.
It is now clear and unanimous that psychological stress can impact the way that our guts function. The connection between our brain and our gut is governed by the longest nerve in our body, the vagus nerve. Kind of like the M1 motorway which allows passengers to travel north and south of England, the vagus nerve connects and carries hormones, chemical messengers, and neurotransmitters between these two sites and we can see the impact that they have on each other.
The release of inflammatory cytokines (a type of immune cell) during periods of stress has been shown to impact gut motility which we know is a contributor towards constipation. The consequent increase in inflammation also weakens our gut lining and perpetuates intestinal permeability which also has a detrimental impact on gut function.
With more and more studies emerging in the field of the gut microbiome, it also seems that the gut flora can be influenced and disturbed by stress which ultimately mediates IBS symptoms like constipation (Chang et al, 2014).
In todays world, it’s almost impossible to avoid stress which is why effective stress relieving techniques should be explored as part of a therapeutic strategy. Stress is in the eye of the beholder; therefore, it can be as much about changing our perception of stress as it is about unloading certain stressors.
There is a strong association between IBS patients suffering with mental health comorbidities like depression or anxiety and although the exact mechanism is unclear, mindfulness-based practices like meditation, clinical hypnotherapy and CBT have both shown great efficacy in the management of both conditions. (Mudyanadzo et al, 2018).
In a study of 16 IBS patients undergoing a 6 week program of 15 minute meditation sessions twice a day and saw favourable outcomes in bloating, flatulence, belching and constipation (Keefer & Blanchard, 2001).
Laboratory testing can be very useful in helping to determine underlying reasons why you may be constipated.
Stool tests can be used to assess immune and inflammatory issues in the bowel, gut permeability and infections or imbalances in the bugs within your gut.
Certain bugs or families of bugs in your gut have been linked with constipation. Increased levels of the archaea, Methanobrevibacter smithii increases gut methane levels which directly inhibits gastrointestinal motility and results in clinical symptoms of constipation (Ghoshal et al, 2016).
Equally, you can look for evidence of low levels of bacteria associated to healthy bowels and supporting motility.
Other testing considerations might be for SIBO, typically done as a breath test. This test provides evidence of excess hydrogen and methane production, with the later being more associated with constipation symptoms as mentioned previously.
There is some evidence that food allergies and sensitivities could be a factor in constipation. Unfortunately testing in this area remains controversial and the standardisation from one lab to another is not there. The gold standard for discovering sensitivities continues to be an elimination-provocation diet, however, with the right lab there may still be some benefit in blood tests for allergies and sensitivities to foods.
Serotonin is an important neurotransmitter commonly known as the ‘happy hormone’. It’s role in mediating our feelings of happiness and satisfaction is often well documented however it’s true ‘unsung’ role is how it works with the brain to regulate our bowel movements.
Primarily located in the gut (95% of all serotonin in the body) it plays a pivotal role in gut motility and emerging research is showing that constipation based IBS sufferers may have a reduced ability to produce this important hormone (Dunlop et al, 2005).
It is also no coincidence that depression has been associated with serotonin dysregulation for many years (Cowen & Browning, 2015).
An interesting association is also that of sex hormones and serotonin. Research has shown that drops in the hormone estrogen, can lead to reductions in serotonin. This may be why females are more prone to constipation at certain points in their cycle as well as when they are entering into perimenopause and post-menopausal phases of their life.
The use of probiotics has become somewhat of a health craze as of late, with companies hailing them as the new panacea to a wide range of health problems.
Taking probiotics for the treatment of constipation should in theory be a smart move as the gut microflora in IBS patients tends to be altered. Heavy alcohol consumption, a history of antibiotic usage and a low fibre diet are all correlated with IBS however the results of probiotics are varied.
Emerging research is showing that when it comes to using probiotic supplementation to support the human gut ecosystem, being strain specific with the bacteria species is absolutely imperative. It is estimated that the human body is made up of over 30 trillion bacteria cells made up of 10,000 different species and so understanding which strain will be beneficial in what way is important.
The lactobacillus & bifidobacterium strain have shown good effectiveness and therefore must be present in the right amount when choosing a probiotic for constipation (Miller etc al, 2017).
Other natural supplements used but more for a laxative type effect include, magnesium chelates such as magnesium citrate and hydroxide, triphala an Ayurvedic herbal blend, aloe vera, senna and psyllium husk. Short term use in response to temporary constipation may be of benefit, however, relying on these usually provides little longer term benefit, especially as the effectiveness tends to wain.
Other potentially useful supplements include papaya extract, 5HTP and vitamin B6 to boost serotonin levels.
Before embarking on taking supplements, we recommending working with a professional to determine if and what is going to be most effective given your symptoms and the circumstances that lead to the onset of constipation for you.
Structured exercise and daily movement can be a very useful tool in combating constipation. The more sedentary you are, the higher the risk of developing constipation.
Bounding movements have been shown to be useful for constipation. This might include things like walking, running, and using a rebounder (mini trampoline).
Yoga has also been shown to be useful, with specific poses providing benefit. The increased focus on diaphragmatic breathing as part of yoga practice may also be of benefit. Diaphragmatic breathing encourages the diaphragm to massage gently against the bowel and helps to stimulate the parasympathetic nervous system at the same time. This is the branch of the nervous system known as the ‘Rest & Digest” branch.
Targeted pelvic floor exercises may also be useful. The pelvic floor is a layer of muscle at the bottom of the pelvis, and it interacts with the bladder and bowel. Strengthening these may help you to push stool through the colon more effectively, resulting in more successful and complete bowel movements.
To conclude, constipation is a common multifactorial disorder which can significantly reduce quality of life. The standard first line approach of conventional medicine is to use laxatives which may be necessary in the short term but does not seem to produce satisfactory results or addresses the root cause.
Addressing diet and lifestyle by ensuring adequate fibre and water intake is being met and a reasonable amount of physical movement is also being achieved to support gut motility should be the first port of call in the management of constipation.
Understanding that constipation almost always stems from an imbalance to the nervous system and how stress can impact gut motility will be key to form part of the therapeutic strategy.
Meditation and mindfulness-based practices have both shown good effectiveness for constipation as has incorporating regular movement.
Supporting the gut with supplements that support serotonin and probiotics to encourage a more ‘normal’ gut transit time may be necessary as constipation sufferers may have altered levels in these two areas.
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The above article was contributed by
Danny
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