Constipation

constipation

how to keep things moving

We are a constipated nation. In fact, NICE (the National Institute for Health and Care Excellence) suggest that it is something that affects as many as 20% of the UK population. As a doctor, it would not surprise me if the number was even more! 

Constipation has a much greater impact on our health than you may imagine. Conventional medicine defines ‘being constipated’ as going for a poo less than twice a week. However, our new evidence-based understanding of the importance of gut microbiomes show that a daily poo is actually a good marker of someone’s long-term health. 

Constipation is your body’s way of telling you that you need to improve your diet and nutrition. Good gut health does not just affect our toileting habits, but can also play a major role in other illnesses and medical conditions. You will rarely make it out the door of a consultation with a practitioner of functional or traditional Chinese medicine without being asked about your toilet habits!

From a medical perspective, if you are newly suffering from constipation, or seeing a slowing down in frequency of your usual poo routine, but have not made any major changes to your life, then it is important to speak to your healthcare provider. A change in your normal digestive pattern can be a sign of a more serious digestive problem, so a check-up is necessary. Don’t be shy or feel like it can wait (no pun intended). Doctors deal with poo problems every day and it is nothing to be embarrassed about.  

Although there are many reasons for experiencing an onset of constipation, it is important to remember our gut is often the primary and most direct way for our body to rid itself of toxins and unwanted waste. If our gut is blocked or inactive, these waste products can be reabsorbed, cause irritation or haemorrhoids and can cause us to feel generally unwell. It can also make our body more prone to inflammation. It’s logical that if our gut is blocked, then our body will try to detoxify itself through one of our other mechanisms, such as the skin, which is why many integrative and functional medicine practitioners work successfully on this link between skin problems and a blocked gut. 

The good news is that in most cases, our Gut Health & Digestion Toolkit can help remedy many of the issues faced by constipation sufferers. You may also wish to consider how you sit when trying to use the loo and consider changing position or even squatting.

stool chart

what is constipation?

Constipation is defined as being unable to go to the loo regularly for a poo. It can mean that when you do try to go, you find it a strain. If it becomes an ongoing issue that lasts three weeks or more, it is called chronic constipation. 

Quite often, conventional medicine may struggle to find a reason for constipation, which is why functional medicine that looks at other possible causes and the overall gut health can be extremely beneficial, particularly for those who find that medication only offers a short-term fix. 

Doctors often use something called ‘The Bristol Stool Chart’,1 to define different types of bowel movement. Using a scale of one to six, where one is severe constipation, characterised by small, hard lumps of poo, to type six, which is very soft diarrhoea-like poo.

Constipation can also cause haemorrhoids, which are congested pads of inflamed soft tissue around the anus, which can be painful and sometimes bleed. It can also be a cause of diverticulitis, which are pockets and bulges in the lining of the intestine. These pockets form from the pressure of constipation as the bowel strains to push the poo along. Diverticulitis can cause abdominal pain, bleeding and hard lumps in the lower stomach. Chronic constipation can also indicate an increased risk of bowel cancer, which is why seeking treatment is important, rather than simply suffering in silence or using over the counter laxatives. 

The most common causes of constipation are a side effect from taking antibiotics or painkillers, poor diet, food allergies or intolerances, a lack of exercise or stress. Long-term use of laxatives can also cause constipation, when overused. 

Less common causes may be either hypothyroidism (underactive thyroid gland) or  hypercalcaemia (raised calcium levels). If your doctor suspects either of these is the cause, they may run tests to check that your endocrine system is fully functioning and working as it should be. In rare cases, constipation could be an indicator of cancer, however, this is extremely unlikely and should not be the first conclusion when attempting self-diagnosis – this is why it is important to speak to a healthcare professional if your constipation symptoms continue.

symptoms and signs

  •       A decrease in the frequency of  regular bowel movements
  •       General abdominal discomfort
  •       Lack of appetite
  •       A feeling of fullness and bloating
  •       Haemorrhoids
  •       Small, hard poos when you are able to go
  •       Dehydration and thirst
  •       Overflow diarrhoea. Sometimes in cases of severe constipation, poo can block the bowel and only liquid can get past 

how do you diagnose constipation? 

  •       Irregular or infrequent bowel movements (less than three times a week)
  •       Small, hard poos
  •       Trouble going to the loo
  •       Stomach examination to look for inflammation, swelling and impacted intestines

 If your doctor is looking for further confirmation or if your symptoms are chronic (long term), your doctor may advise an x-ray, colonoscopy, or an MRI scan to check for any obvious issues, such as a blockage in your digestive system. In older people, constipation can occur higher up in the intestine (rather than near the bottom end) and this can only be seen using medical imaging techniques. 

how is it usually treated?

You may assume that doctors will simply prescribe a course of laxatives to treat constipation, but this is not correct. Your doctor will most likely first begin to look for any underlying cause of your constipation and their first suggestion will almost inevitably be to increase the fibre in your diet, either through gel fibre supplement drinks, or ideally, by discussing ways in which you can add more fibre to your diet through healthy eating. Aim to consume 30g of fibre per day. Look for: 

  •       Whole grains, products such as flax and chia seeds, brown bread and brown rice are ideal.
  •       Lots of fresh vegetables. Artichokes are a particularly good source of dietary fibre. 
  •       Fruit is also high in fibre, particularly raspberries and stewed apple. Do not overindulge though, as a lot of fruit contains too much sugar, which can make  constipation symptoms worse
  •       Legumes of all kinds, from kidney beans to white beans and lentils
  •       Nuts and seeds 

You will also be advised to increase the amount of fluid you drink. Aim to consume two litres of water per day. If you don’t like water, choose herbal teas instead. And be sure to move more. A bout of activity, from yoga to a walk in the park can help to get things moving. 

If this does not remedy the situation, your doctor may consider using a short course of laxatives, like Movicol, to remedy the situation. If your case of constipation is severe, they may use an enema to flush your intestine and help loosen any blockage. 

If with your constipation you find yourself in severe pain and are unable to also pass wind (fart), then seek immediate medical attention as this could indicate an obstruction in your bowel or intestine. 

other perspectives on constipation 

Examining the root causes of constipation, we start primarily with gut health and possible inflammation, food sensitivities and intolerances, leaky gut and dysbiosis (poor balance or lack of diversity of the microbiome). Diet is a big part of constipation management. On average, we consume 2kg of food each day, most of which is in direct contact with our gut wall and feeds the vast and complex gut microbiome

If we are dehydrated (when we are dry, our poo is dry!) or our food is full of sugar, white flour, inflammatory fats or oils, we can become constipated. Fibre content from things like vegetables and meat collagen (not just whole grains and cereals) in our diet has dramatically decreased over the last 50 years and while we used to eat fermented foods regularly, despite the rise in popularity of kefir and kombucha, they are much less widely consumed today. Many of us notice during celebrations or festive periods when we eat more processed or rich foods, that our bowel habits change for the worse. We also become more tired, low in mood and sluggish as a consequence. 

You don’t need to eat a perfect diet to fix your gut and resolve constipation (though for quick results, you may want to try our refresh programme. Adding simple natural supports (see below) and dietary adjustments can really help – you may even find them life-changing!

Although gut health is the number one area to focus on, do not forget about the impact of stress – diarrhoea before an exam, interview or big event shows just how much power stress hormones can have on your gut. Equally, when stressed, our body diverts resources away from our gut (in case we need to run away or fight). A long-term stress reaction can cause some big changes in our gut environment and lead to a number of digestive issues. Visit our brain function & mental health toolkit, for help with managing stress and trauma.

Our gut heroes and villains article can help you to understand the things that can potentially damage your gut, and the best natural supports for gut health. 

In traditional Chinese medicine, constipation is often due to heat (other signs may be thirst, hunger, feeling flushed or hot) or dryness and deficiency (feeling tired, dry skin and hair, chronic constipation). TCM uses herbs to promote and stimulate healthy bowel movement, reduce heat and nourish and calm the gut.  

Well-known constipation formulas include Mai Zi Ren with the chief herb Huo Ma Ren (hemp seed, which you can easily buy and eat) and other herbs like Da Huang – Rheum palmatum (rhubarb root)2 – to be used only in small amounts and not whilst pregnant or breastfeeding. Dr. Jess has found this formula brilliant in practice, as well as the formula Tong Bian Pian which has main herbs He Shou Wu, Yi Yi Ren (Job’s tears – here’s a great recipe), Tao Ren (Peach Kernel Seed) and Da Huang. 

Zhi shi (bitter orange peel) can be great to counteract an over-indulgence of food, if that is causing your constipation. There is some clinical trial evidence for the benefits of Chinese herbal medicine in constipation,3 particularly Mai Zi Ren.4

Acupuncture, moxibustion, electroacupuncture, massage and Chinese cupping have some trial evidence that shows they may be of benefit5 and many patients find these therapies work for them. You can also try these acupressure points at home, massaging them in turn for 2-3 minutes, which may also help.

  •     Triple energizer 6

  •     Spleen 6

  •     Stomach 25

  •     Stomach 36

  •     Conception Vessel 12

  •     Large Intestine 4

  •     Bladder 57 

 

In Ayurvedic medicine, constipation is often seen as a disturbance of Vata (cold, hard and dry). Patients are encouraged to stay away from cold food and drinks, dried fruit and beans. Triphala6 is a commonly used excellent herbal formula for digestive complaints, containing Emblica officinalis, Terminalia chebula and Terminalia belerica. It is considered safe and has been shown to aid constipation and help the growth of beneficial bacteria.7 It can be bought as a supplement – Pukka and Fushi are great organic brands. 

Ayurvedic medicine also encourages 1-2tsp of freshly crushed fennel seeds in warm water, or fennel tea. Another traditional Ayurvedic remedy is to dissolve a teaspoon of ghee in warm milk, to support the digestion.

Meanwhile, the western herbal approach to constipation includes mucilaginous herbs traditionally used to make the stool move through the bowel more easily, such as Althea officinalis (marshmallow) and slippery elm (slippery elm enjoys an endangered status, so should be purchased from a reputable provider). Both are gentle on the gut and help increase the moisture and mucus in the gut to help get things moving.  More traditional anti-inflammatory herbs like Calendula officinalis have been shown to help regulate bowel spasms8 and digestive herbs like dandelion root and liquorice can also help to relieve constipation symptoms.

A well-known group of constipation herbs are called ‘bitters,’ which help stimulate digestive secretions and support regular bowel movements. A famous Austrian herbalist called Maria Treben used a 15th Century herbal blend, Swedish bitters;9  a combination of digestive herbs that remains a well-used digestive aid, loved by many herbalists. As its name suggests, it is bitter, but a small amount of tincture (in water if necessary) with meals can be a great support for many digestive issues, particularly constipation. 

Senna is also well known, but Jess would caution against regular use, as it can irritate the gut lining and regular use can make it as damaging as continued use of prescribed laxatives. 

In homoeopathy,10 remedies like nux vom 30c11 for constipation from overindulgence of food, or opium 30c12 for stubborn, unmoving constipation can be helpful, taken up to twice a day. If the problem persists, look at constitutional treatment from a good homoeopath. They may suggest remedies such as Lycopodium, Alumina, Bowel nodoses, Bryonia and Silica. To find a good homoeopath, click here.

natural supports for constipation 

diet:

  • Aim to drink two litres of water, herbal teas or hot lemon daily. Why not try our digestive drink of 2 slices fresh ginger, 1 dsp apple cider vinegar and ½ tsp honey in hot water.
  • Eat whole, unprocessed and unrefined foods that are high in prebiotic-soluble and insoluble fibre, low in sugar and low in inflammatory fats and oils (see the refresh programme)
  • Fermented foods, such as kefir, sauerkraut or kimchi are all a very important part of a healthy gut. Raw, whole-milk kefir is a wonderful gut tonic. 
  • Have C8 MCT oil in a hot drink in the morning (start at 1tsp and work up to 1tbsp). This is a great digestive support, loved by the Paleo/Keto communities. Jess finds this very useful in practice.
  • Lots of vegetables, preferably cooked (steamed, roasted or slow-cooked), soups and stews
  • Organic bone broth or buy ready-made from companies like Osius
  • Avoid too much sugary fruit, which can ferment in the stomach and cause further digestive issues. Instead, choose naturally low-sugar fruit from the UK e.g. apples (great as our stewed apple dessert), pears, berries and cherries
  • For infants or children, consider eliminating cow’s milk for four weeks (if you are currently feeding your child formula, we recommend Holle’s goat’s milk formula as an excellent alternative). Childhood allergies to cow’s milk can be a cause of constipation.13
  • Figs soaked in warm water and prune juice14 are excellent, gentle constipation aids and are safe for children.

nutrients

Magnesium – magnesium citrate can aid digestion and help improve constipation.15 it has a mild laxative effect, acting by softening stools and helping to relax muscles. Starting at 200mg daily, you can increase gradually to up to 400mg until constipation is relieved. 

Probiotics and Prebiotic fibre.16 Inflammation and constipation are heavily influenced by our gut microbiome. These supports are shown to restore and rebalance the microbiome, particularly after antibiotics. 

herbal supports

Aloe Vera gel. Traditionally used to soothe and heal the gut lining, for IBS and constipation. Cytoplan sells an excellent aloe leaf, take one dessertspoon daily

Swedish bitters (herbal tincture blend). A wonderful digestive aid, traditionally used to help improve digestive function and aid constipation. Take daily with meals. 

Psyllium husk (Organic) – this is one of the most beneficial supports we have found in practice, it can be taken as a supplement, but we prefer to add 1tsp of psyllium husk to a kefir smoothie. Psyllium husk features in several of our recipes in the refresh programme. 

Rheum palmatum (rhubarb root). This is a well-known traditional Chinese herb for constipation, it is relatively strong and not to be used continuously without consulting a TCM practitioner, but it can bring great relief. 

Triphala. A brilliant Ayurvedic digestive aid that can support a healthy gut and has gentle laxative action. Consider Pukka or Fushi supplements taken daily.

Fennel tea. Can help with bloating and digestive discomfort. Make it yourself, using the seeds in hot water. Gentle and safe, even in pregnancy and breastfeeding. 

other ways to relieve constipation

Give yourself time and space for bowel movements – listen to the call of nature! For most people, this is in the morning. Give yourself time to listen to the signals your body is sending, rather than repressing them because you are too busy. 

Squatting – get in the right position to poo! Sitting on the loo in a throne-like position,  leaning back with our legs down is not the position nature intended for us to open our bowels. This position actually tightens the muscles around the rectum and makes things more difficult.

In countries where squatting toilets are the norm, the position you crouch in provides a much better alignment, helping to prevent over-straining and haemorrhoids. Squatting actually relaxes the muscles around our bottom and pubic bones and straightens the rectum. To mimic this at home, use a small stool or step under your feet (to bring your knees up higher) and sit forwards . This is also a good position to prevent and help relieve haemorrhoids. Studies show that a simple footstool improved bowel habits in 71% of patients.17

Prolapses. Rectal and vaginal prolapses can make it difficult to poo. Manually supporting the wall of the bowel (by gently pressing against the back of the vaginal canal with a clean or gloved finger) and improving your toilet position as above can help. Consider working on core posture, to help support prolapses.

Exercise. Many people find that the act of moving and exercising improves the regularity of their digestion. Abdominal and core muscle contraction can support a healthy gut, benefit the gut microbiome and reduce stress, all of which can affect our toilet habits. 

Stress management. Breathwork, meditation and mindfulness are all proven to improve stress and therefore benefit the gut. Following the traditional philosophies of moving, energy exercise like yoga and tai chi would also be a good choice to help relieve constipation symptoms. 

To find a functional medicine practitioner who can support diet, nutrition and gut health and help you consider further stool testing, gut health, nutritional testing and genetic factors click here. 

q&a with dr jess

I tried increasing my fibre intake, but it only made things worse. Why is that?

There are several reasons why you could be having problems with fibre, firstly you may be using a prebiotic fibre that doesn’t suit you, like a cereal or grain-based fibre. Instead, try increasing vegetable fibre and nuts. Make sure that you are using a probiotic with your fibre like kefir, or if this doesn’t suit you, try an over-the-counter probiotic. Visit our gut health and digestion toolkit, to learn about the best prebiotics and probiotics. Our refresh programme will help you change your diet to gut-nourishing and digestion supporting foods. 

If you have long term digestive problems, it may be worth being tested for a condition called SIBO (Small Intestinal Bacterial Overgrowth). This can be tested with a simple breath test. In this condition, bacteria from the large intestine migrate into the small intestine and because these bacteria are in the wrong place, you can experience increased symptoms with foods that would normally be good for the gut, like fibre or fermented foods.

In some cases, people who have inadequate stomach acid or digestive enzymes can struggle to break down fibre. Trialling a good betaine and pepsin supplement or digestive enzymes (both available from Cytoplan) could improve your symptoms if this is an issue. If you are not finding relief from the tips above, seek out a good functional medicine practitioner, naturopath or herbalist for further investigations and remedies.

references

  1.  Bristol stool scale
  2. Wei L, Luo Y, Zhang X, Liu Y, Gasser M, Tang F, Ouyang WW, Wei H, Lu S, Yang Z, Waaga-Gasser AM, Deng C, Lin M. Topical therapy with rhubarb navel plasters in patients with chronic constipation: Results from a prospective randomized multicenter study J Ethnopharmacol. 2021 Jan 10;264:113096. doi: 10.1016/j.jep.2020.113096. Epub 2020 Jul 18. PMID: 32693116.
  3. Li DY, Dai YK, Zhang YZ, Huang MX, Li RL, Ou-Yang J, Chen WJ, Hu L. Systematic review and meta-analysis of traditional Chinese medicine in the treatment of constipation-predominant irritable bowel syndrome PLoS One. 2017 Dec 18;12(12):e0189491. doi: 10.1371/journal.pone.0189491. PMID: 29253850; PMCID: PMC5734785.
  4. Cheng CW, Bian ZX, Zhu LX, Wu JC, Sung JJ. Efficacy of a Chinese herbal proprietary medicine (Hemp Seed Pill) for functional constipation Am J Gastroenterol. 2011 Jan;106(1):120-9. doi: 10.1038/ajg.2010.305. Epub 2010 Nov 2. PMID: 21045817.
  5. Liu Z, Yan S, Wu J, He L, Li N, Dong G, Fang J, Fu W, Fu L, Sun J, Wang L, Wang S, Yang J, Zhang H, Zhang J, Zhao J, Zhou W, Zhou Z, Ai Y, Zhou K, Liu J, Xu H, Cai Y, Liu B. Acupuncture for Chronic Severe Functional Constipation: A Randomized Trial Ann Intern Med. 2016 Dec 6;165(11):761-769. doi: 10.7326/M15-3118. Epub 2016 Sep 13. PMID: 27618593.
  6. Tarasiuk A, Mosińska P, Fichna J. Triphala: current applications and new perspectives on the treatment of functional gastrointestinal disorders Chin Med. 2018 Jul 18;13:39. doi: 10.1186/s13020-018-0197-6. PMID: 30034512; PMCID: PMC6052535.
  7. Peterson CT, Denniston K, Chopra D. Therapeutic Uses of Triphala in Ayurvedic Medicine J Altern Complement Med. 2017 Aug;23(8):607-614. doi: 10.1089/acm.2017.0083. Epub 2017 Jul 11. PMID: 28696777; PMCID: PMC5567597.
  8. Bashir S, Janbaz KH, Jabeen Q, Gilani AH. Studies on spasmogenic and spasmolytic activities of Calendula officinalis flowers Phytother Res. 2006 Oct;20(10):906-10. doi: 10.1002/ptr.1980. PMID: 16906636.
  9. Swedish Bitters | London’s Oldest Herbalist
  10. About homoeopathy
  11. Nux vomica
  12. Opium
  13. Miceli Sopo S, Arena R, Greco M, Bergamini M, Monaco S. Constipation and cow’s milk allergy: a review of the literature Int Arch Allergy Immunol. 2014;164(1):40-5. doi: 10.1159/000362365. Epub 2014 May 17. PMID: 24853450.
  14. Stacewicz-Sapuntzakis M. Dried plums and their products: composition and health effects–an updated review Crit Rev Food Sci Nutr. 2013;53(12):1277-302. doi: 10.1080/10408398.2011.563880. PMID: 24090144.
  15. Mori S, Tomita T, Fujimura K, Asano H, Ogawa T, Yamasaki T, Kondo T, Kono T, Tozawa K, Oshima T, Fukui H, Kimura T, Watari J, Miwa H. A Randomized Double-blind Placebo-controlled Trial on the Effect of Magnesium Oxide in Patients With Chronic Constipation J Neurogastroenterol Motil. 2019 Oct 30;25(4):563-575. doi: 10.5056/jnm18194. PMID: 31587548; PMCID: PMC6786451.
  16. Naseer M, Poola S, Uraz S, Tahan V. Therapeutic Effects of Prebiotics on Constipation: A Schematic Review Curr Clin Pharmacol. 2020;15(3):207-215. doi: 10.2174/1574884715666200212125035. PMID: 32048977.
  17. Modi RM, Hinton A, Pinkhas D, et al. Implementation of a Defecation Posture Modification Device  J Clin Gastroenterol. 2019;53(3):216-219. doi:10.1097/MCG.0000000000001143

 

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