Constipation is a common issue, but often goes untreated or ignored, as people get used to their level of ‘normal’. Chronic constipation impacts quality of life and can also exacerbate other health conditions, so it’s important to get to the root cause for overall health.
WHAT IS CONSTIPATION?
Constipation is when you have difficulty passing stools, need to strain when going to the toilet, or have infrequent bowel movements. The Rome IV criteria defines constipation as fewer than 3 bowel movements per week for at least 3 months.
The prevalence of constipation is 15% in the general population with a higher female to male ratio and a higher prevalence in the elderly especially over 65 years. The reason females are more likely to get constipation is due to hormonal changes, as gastric emptying is slowed during the luteal phase.
ROME IV criteria for functional constipation (must have at least 2 of 6):
• Fewer than 3 bowel movement per week
• Straining during >25% of the time
• Lumpy or hard stools > 25% of the time
• Sensation of anorectal obstruction > 25% of the time
• Sensation of incomplete evacuation > 25% of the time
• Manual maneuvers required to aid defecation > 25% of the time
In addition to the above, the following three criteria should also be met to diagnose functional constipation:
(1) Loose stools should rarely be present without the use of laxatives
(2) Insufficient criteria for IBS
(3) Present for at least 3 months during a period of 6 months.
In reality, ideally we are moving our bowels every day. Our digestive tract is one of the main channels of elimination for clearing toxins and waste products. If we aren’t moving our bowels regularly, these waste products sit stagnant in the bowel, causing inflammation and excess fermentation (cue gas & bloating).
Additionally, waste products can be reabsorbed via the bowel and enter circulation all over again, causing an increased toxic burden on the body and load on the liver.
SYMPTOMS OF CONSTIPATION
- Hard stools
- Straining or extended periods of time sitting on the toilet
- Incomplete evacuation
- Abdominal discomfort, bloating and gas
WHAT CAUSES CONSTIPATION?
Inadequate water intake
Adequate water is what keeps the stools soft enough to move through the digestive tract efficiently. Without enough liquid, stools end up being dry and hard, which slows down their transit in the bowel.
Low fibre diet
Fibre comes in soluble and insoluble forms, and is found in foods such as vegetables, fruits, seeds and legumes. Soluble fibre can dissolve in water and creates a soft, gel-like material as it passes through the digestive system. Insoluble fibre retains most of its structure as it goes through the digestive system. Both forms of fibre join with stool creating ‘bulk’, increasing its weight and size while also softening it. Having sufficient bulk in the stool triggers the gut to rhythmically contract (also known as peristalsis), moving the stool through the digestive tract ready for excretion. Examples of fibre and other gut loving foods can be found here.
Low physical activity
Exercise helps relieve constipation because it stimulates the nervous system and helps the muscles and nerves in the gut to work better.
High stress levels
When we are stressed the body activates our fight or flight response. In this state our body downregulates digestion, instead directing energy and resources to survival of the perceived threat. For some people with constant levels of high stress, this can result in constipation.
Medications and supplements
Medications including pain-killers, antidepressants, diuretics, and antacids may increase the occurrence of constipation. Laxative abuse can also cause this, as the bowel becomes reliant on laxatives in order to move. Nutritional supplements such as iron and calcium may also contribute to constipation.
Dysbiosis refers to an imbalance of beneficial and opportunistic bacteria within the digestive tract. A certain type of bacteria that produce methane as a byproduct, have been found to contribute to constipation. A healthy bacteria balance produces good levels of serotonin, our happy hormone, which plays an important role in peristalsis. Inadequate peristalsis leads to slow movement through the digestive tract, resulting in constipation.
A number of biological factors can continue to constipation including, metabolic conditions (diabetes), hormone imbalance, hypothyroid, neurological disorders, myopathic disorders (Parkinson’s disease, multiple sclerosis), abnormalities in the gastrointestinal tract (IBS, food intolerance, coeliac disease, cow milk protein allergy, IBD, colonic motility dysfunction), and genetic predisposition.
An increase in progesterone during pregnancy causes a relaxation of your body’s muscles, including your intestines. Unfortunately slower moving intestines can lead to constipation.
Caffeine abuse (this is a diuretic meaning it dehydrates the body), and ignoring the urge to pass stools can both result in constipation.
WHAT ARE THE CONSEQUENCES OF CONSTIPATION?
Fecal impaction is a large, hard mass of stool that gets stuck in your colon or rectum. Symptoms of fecal impaction include abdominal pain, low appetite, and stool leakage.
Haemorrhoids are swollen veins located around the anus or in the lower rectum, that occur due to straining when using your bowels.
Not only can dysbiosis contribute to constipation, but it can also be the result of constipation. Slower transit can cause a rise in pH levels, meaning a more alkaline environment, which allows opportunistic bacteria to grow.
Enterohepatic recycling occurs when stool sits in the colon for too long, and the body begins to reabsorb waste products that are meant to be eliminated. A common issue is the reabsorption of oestrogen that was bound up and ready for elimination. This can result in an excess of oestrogen (also known as oestrogen dominance), and cause PMS symptoms such as breast tenderness, hormonal breakouts, and mood changes. Other waste products can also be reabsorbed, causing a load on the liver and symptoms such as fatigue and headaches.
WAYS TO SUPPORT CONSTIPATION
FIRST LINE TREATMENT
Hydration levels to aim for are 33 ml of liquid per kg of body weight, plus 500ml per hour of exercise. Sparkling water, herbal teas and broths all count towards the goal, but black tea/coffee detract as these are dehydrating.
Increase your fibre intake
As a general rule, aim for around 25g and 38g per day for women and men respectively. Include soluble and insoluble fibre-rich foods via a variety of fruits & vegetables, legumes, nuts, seeds and whole grains.
Some examples of high fibre foods are:1 large pear with skin (7 grams)1 cup fresh raspberries (8 grams)½ medium avocado (5 grams)30g almonds (3.5 grams)½ cup cooked black beans (7.5 grams)1 cup cooked brown rice (3.5 grams)
To specifically resolve constipation, increase insoluble fiber, as this draws water into and adds bulk to your stool, helping the stool pass more quickly through the intestines. Start slowly when increasing fibre, and ensure you maintain adequate hydration at the same time. Insoluble fibre-rice foods include: wheat bran, rice bran, brown rice, legumes, vegetables, chia seed & flaxseed.
Crowd out low fibre foods
Reduce your intake of low-fibre foods such as refined carbohydrates & sugars. This includes white bread, white pasta, cakes, biscuits, and other packages ‘white foods’. Also reassess high amounts of meat & dairy. This makes room for more high fibre foods, as above.
Daily physical activity
Aim for 30 minutes of moderate exercise at least 5 days per week. Try walking, swimming, or cycling.
Use your bowels whenever you feel the urge. Don’t hold it.
When using the bathroom, allow yourself plenty of time, and aim to be in a relaxed state.
Try sitting on the toilet for 10 minutes each morning after breakfast, to give your bowels an opportunity to regulate.
Raising your knees or using a footstool puts your body in the optimum position for easy bowel motions. You want to be in a squatting type of position.
Eat bitter foods
Bitter foods help to stimulate digestion, and can assist in the overall digestive process. Try having a bitter salad with your main meal rocket, witlof & radicchio. Alternatively have lemon juice or ACV in warm water before meals.
Happy Belly + Tea
The Hälsa Health Happy Belly + Tea is a lovely blend of cinnamon, dill, chamomile, licorice, calendula & cascara. Designed as a gentle treatment for constipation, have 1 teaspoon steeped in hot water twice daily.
Prebiotic foods feed the beneficial bacteria that help to promote regular bowel motions. Incorporate foods such as garlic, onion, leek, asparagus, legumes, oats, banana & berries.
Lactulose is an indigestible sugar that acts as a prebiotic. Despite being marketed as a laxative, it works on osmotic based mechanisms, therefore will not create issues with dependence as other laxatives can. Try Actilax from the chemist, starting at 5ml daily.
Partially hydrolysed guar gum (PHGG) this is a low gas producing prebiotic which helps to regulate bowels. Consume 4g in water daily.
Probiotic foods to consider include sauerkraut, kimchi, kefir, miso, kombucha and yoghurt.
Specific probiotic supplement strains can also be beneficial in constipation. See your health practitioner for prescribing advice.
Magnesium citrate may help with constipation, as it can stimulate the intestines to draw water into the bowels, promoting softer stools that are easier to pass. Start with 300 mg daily.
If dietary and lifestyle strategies haven’t worked, herbal medicine can be a useful adjunct. The exact herbs used depends on what is causing constipation for you, so consider the following and see your health practitioner for guidance (especially if pregnant): dandelion leaf, dandelion root, gentian, globe artichoke, licorice, marshmallow root, slippery elm, St Mary’s Thistle and yellow dock.
Rule out biological causes of constipation
If your constipation doesn’t resolve with dietary & lifestyle changes, see your health practitioner to rule out diabetes, hypothyroid, cow protein allergy, and coeliac disease, to name a few.
If you are experiencing digestive symptoms and would like individualised support, please get in touch by booking in a Base Chat or Simplify Session here.
Brooke is a qualified naturopath with a focus on digestive health, hormones, and adrenal conditions.