The number of people living with constipation increases in China[1] and affects anywhere from three to twenty-seven per cent of people in Europe[2] and the USA[3].
Whilst constipation affects mainly females and progresses with age, many children are also affected, with a quarter of visits to a paediatrician looking to address constipation without an explanation.[4]
For those living with a chronic version of constipation, the physical and mental burden interferes with daily quality of life. The hundreds of millions spent on laxatives alone demonstrate the extent of those looking to gain some form of relief.[5]
In this article, I will look into some of the potential causes and solutions for constipation you might not have tried and even look at ways to test if some of these causes are appropriate for you.
Are you constipated or just having a challenging bowel experience?
Most people living with constipation describe the symptoms as straining, incomplete evacuation, a sensation of blockage, and decreased stool frequency.[6] In contrast, the modern medical definition concentrates more on frequency, with constipation defined as having three or fewer bowel motions a week.[7]
Associated symptoms that I see in the clinic are bloating and abdominal pain, especially after missing a few days. Compounding this, fatigue, brain fog and poor sleep follow quickly.
This overlap of symptoms is where the definitions count. For most, missing three days is relatively standard, and for some, up to five days can be extreme but possible. How about you?
As you might have read in other articles, personalising what’s going on is always important, not just in mental health but also in these long-standing digestive cases.
For this article, we will be looking at chronic idiopathic or functional constipation that follows the definition above and constipation as part of irritable bowel syndrome. A condition typically referred to as IBS-C.
Changing your iron supplement to one that’s better tolerated could be one of the quick ways to solve your constipation.
The causes of constipation, most of the time, can be down to a sedentary lifestyle, dehydration, and a less than desirable diet (think low fibre). [8]
These side effects can be remedied, especially in a selection of cases where medication is the cause.
One study had around thirty per cent of the drugs prescribed to an elderly population with the potential to cause constipation.[9]
Popular pharmaceutical medications that can cause constipation are as follows:[10]
- Pain killers such as non-steroidal anti-inflammatories (think Panadol and Neurofen),
- Antidepressants and antipsychotics
- Blood pressure medications such as calcium channel blockers (ask your practitioner if you are not sure what you are taking)
- Diuretic drugs
- Iron supplements.
I think I’d like to comment on the iron supplement side. With the use of an iron bis-glycinate formula, I find that ninety-nine per cent (an estimate from me, not a study) had zero symptoms, especially the typical ones, nausea, bloating, and constipation.
A small study assessing thirty-eight people has compared iron bis-glycinate with a common form of iron, ferrous sulfate. While only a small amount of people, most of them found the former better tolerated.[11]
Not getting enough nutrients in your diet is a key cause and solution for constipation.
Within natural medicine clinics, including my own, subclinical micronutrient deficiencies in the diet, primarily magnesium, can be a significant cause. Two studies on young women in Japan[12] and preschool children in Hong Kong[13] found that diets deficient in magnesium were associated with increased levels of functional constipation. For the preschool children in Hong Kong, this was a common issue. Not enough plants in the diet.
More extensive studies are required to confirm this, but the number of successful prescriptions of magnesium I’ve used to solve functional constipation counts for something.
Magnesium oxide, specifically, has some promising research behind it as a stool softener and laxative.
In east Asian countries such as Japan, China and Taiwan, it has been one of the laxatives of choice since its introduction from the west in the nineteenth century.[14]
One particular study conducted in Japan found that magnesium oxide assisted with overall symptom improvement, better spontaneous bowel movements, stool form, abdominal symptoms and the associated quality of life that would come with those improvements. One of the most positive parts of this study was that seventy per cent of the participants experienced these improvements.[15]
Magnesium oxide’s performance has also made it a candidate for improving constipation associated with taking pain killers. Sometimes, the use of PPI and antacid drugs alongside the painkillers can diminish the effectiveness of magnesium oxide,[16] although we’ll need some quality studies to confirm this. So, keep this in mind or consult your healthcare practitioner if you feel as if you want to try it.
Low fibre is a significant cause of functional constipation.
I’ve written an entire article about why fibre is potentially the most significant blind spot in the western diet. Some statistics have fibre consumption in western diets, such as in the United States, as low as fifty per cent below the recommended daily intake.[17]
Further, a review of a collection of studies pooled data from countries including Australia, the US, and countries in Europe, found that none of the countries hit their daily recommended intake. Out of the studied countries, Australia had the highest average amount of fibre daily.[18]
So, where does this leave us when looking to solve constipation?
A key place to start when assessing how fibre can help with constipation is understanding the two primary different forms of fibre: soluble and insoluble fibre.
Soluble fibre turns into a gel when it interacts with water, and insoluble fibre is resistant to water and goes through the digestive system unchallenged. For a more in-depth definition of how these different forms of fibre can help, check out the article here or the Free and Inspired Radio episode on fibre here.
I’ve mentioned fibre’s relationship with water because, believe it or not, the consistency of stool is very closely related to its water content. In fact, even minimal changes can affect consistency.[19]
Normal stool contains around seventy-four per cent of water, hard stool has less than seventy-two per cent, and soft stool has at least seventy six per cent. Based on these numbers, a variation in water content of stool by as little as two per cent can make a difference in whether your stool is hard or not and how quickly it travels through to the toilet.[20]
Guess what increases the water content of your stool?
Yep, it’s our friend, fibre. Both soluble and insoluble fibre sources are beneficial for chronic constipation, especially regarding stool frequency.[21] Unfortunately, many of the studies into this have floored methodologies or small amounts of people, making it difficult to get a sense of how much fibre helps and how long it will take to solve the problem in the long term.
Despite this, I can say that patients who have increased their fibre content through food, even by a small amount of five to ten grams daily, have seen some positive changes in their symptoms, especially with their stool frequency.
Interestingly, I came across a study suggesting that adding a probiotic, specifically Bifidobacterium bifidum, improved stool frequency and water content in animals.
Ok, so we don’t get too excited by animal studies, but probiotics can help increase stool frequency.
Remember we discussed how vital frequency is when defining if you have constipation or not?
A meta-analysis (where they pool the results of similar studies to get a broader, more reliable conclusion) found that multi-species probiotic formulas (classified as formulas with more than two species) improved three main components of chronic constipation. These three were the time it takes for food to travel through your body, frequency, and stool consistency.[22]
What if you’ve tried all of this, and you haven’t been able to solve your constipation?
It’s time to consult your healthcare practitioner about whether some further testing might be more appropriate. The first place to start would be to test for small intestinal bacterial overgrowth (SIBO). If you are new to SIBO, then it’s defined as the presence of excess bacteria in the small intestine.[23]
The symptoms of SIBO can vary from person to person but include abdominal pain, burping, bloating, fullness, flatulence and indigestion, and either diarrhoea or constipation.[24]
Multiple studies have investigated the connection between SIBO and IBS, and if you want to know more about it, you can read the article I’ve created here.
One of the key characteristics of some of the studies done to date is the presence of methane-producing bacteria in IBS-C cases.[25] These same studies have proven that people living with constipation have higher levels of this bacteria when tested for SIBO.
Interestingly, the causation of SIBO and constipation can overlap also. One critical characteristic of both conditions is the journey your food takes from your plate to the toilet. A journey referred to as motility. Both SIBO and functional constipation’s origins are from slow motility.[26]
Correcting SIBO to solve constipation is an emerging field. I can tell you that my constipation patients, who have tried everything, often find relief via the clearance of the methane-based bacteria resolving their constipation.
Now, this doesn’t happen overnight and can require the confirmation of the bacterial overgrowth via a breath test and the associated dietary and herbal treatment. This process, for most, can take around ten to twelve weeks. No easy process. But worth looking into if you’re one of the people living with constipation who wonders if you’ll ever be able to solve it.
Before rushing to do a SIBO test, increasing your fibre intake and trying a magnesium supplement may save you time!
The recommendations we’ve looked at around fibre and magnesium are low hanging fruit and straightforward to get started! If you are yet to try them, I suggest you start as soon as possible.
Getting some advice from a healthcare professional is always a good place to start if you are unsure. However, your situation presents itself; I hope this article has reassured you that the problem you’re living with is not insurmountable.
Hope this helps.
References
[1] Chen Z, Peng Y, Shi Q, et al. Prevalence and Risk Factors of Functional Constipation According to the Rome Criteria in China: A Systematic Review and Meta-Analysis. Front Med (Lausanne). 2022;9:815156. Published 2022 Feb 16. doi:10.3389/fmed.2022.815156
[2] Hungin AP. Chronic Constipation in Adults: The Primary Care Approach. Dig Dis. 2022;40(2):142-146. doi:10.1159/000516489
[3] Lacy BE, Shea EP, Manuel M, Abel JL, Jiang H, Taylor DCA. Lessons learned: Chronic idiopathic constipation patient experiences with over-the-counter medications. PLoS One. 2021;16(1):e0243318. Published 2021 Jan 11. doi:10.1371/journal.pone.0243318
[4] Wallace C, Sinopoulou V, Gordon M, et al. Probiotics for treatment of chronic constipation in children. Cochrane Database Syst Rev. 2022;3(3):CD014257. Published 2022 Mar 29. doi:10.1002/14651858.CD014257.pub2
[5] Sanchez MI, Bercik P. Epidemiology and burden of chronic constipation. Can J Gastroenterol. 2011;25 Suppl B(Suppl B):11B-15B. doi:10.1155/2011/974573
[6] Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology. 2020;158(5):1232-1249.e3. doi:10.1053/j.gastro.2019.12.034
[7] https://medlineplus.gov/constipation.html, viewed 17th May 2022.
[8] Diaz S, Bittar K, Mendez MD. Constipation. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513291/
[9] Al Khaja KAJ, James H, Veeramuthu S, Tayem YI, Sridharan K, Sequeira RP. Prevalence of drugs with constipation-inducing potential and laxatives in community-dwelling older adults in Bahrain: therapeutic implications. Int J Pharm Pract. 2020;28(5):466-472. doi:10.1111/ijpp.12636
[10] Jani B, Marsicano E. Constipation: Evaluation and Management. Mo Med. 2018;115(3):236-240.
[11] Coplin M, Schuette S, Leichtmann G, Lashner B. Tolerability of iron: a comparison of bis-glycino iron II and ferrous sulfate. Clin Ther. 1991;13(5):606-612.
[12] Murakami K, Sasaki S, Okubo H, et al. Association between dietary fiber, water and magnesium intake and functional constipation among young Japanese women. Eur J Clin Nutr. 2007;61(5):616-622. doi:10.1038/sj.ejcn.1602573
[13] Lee WT, Ip KS, Chan JS, Lui NW, Young BW. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant foods: A community-based study. J Paediatr Child Health. 2008;44(4):170-175. doi:10.1111/j.1440-1754.2007.01212.x
[14] Mori H, Tack J, Suzuki H. Magnesium Oxide in Constipation. Nutrients. 2021;13(2):421. Published 2021 Jan 28. doi:10.3390/nu13020421
[15] Mori S, Tomita T, Fujimura K, et al. A Randomized Double-blind Placebo-controlled Trial on the Effect of Magnesium Oxide in Patients With Chronic Constipation. J Neurogastroenterol Motil. 2019;25(4):563-575. doi:10.5056/jnm18194
[16] Yamasaki M, Funakoshi S, Matsuda S, et al. Interaction of magnesium oxide with gastric acid secretion inhibitors in clinical pharmacotherapy. Eur J Clin Pharmacol. 2014;70(8):921-924. doi:10.1007/s00228-014-1694-x
[17] Akbar A, Shreenath AP. High Fiber Diet. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559033/
[18] Stephen AM, Champ MM-J, Cloran SJ, et al. Dietary fibre in Europe: current state of knowledge on definitions, sources, recommendations, intakes and relationships to health. Nutrition Research Reviews. 2017;30(2):149-190. doi:10.1017/S095442241700004X
[19] McRorie J, Pepple S, Rudolph C. Effects of fiber laxatives and calcium docusate on regional water content and viscosity of digesta in the large intestine of the pig. Dig Dis Sci. 1998;43(4):738-745. doi:10.1023/a:1018805812321
[20] McRorie JW Jr, McKeown NM. Understanding the Physics of Functional Fibers in the Gastrointestinal Tract: An Evidence-Based Approach to Resolving Enduring Misconceptions about Insoluble and Soluble Fiber. J Acad Nutr Diet. 2017;117(2):251-264. doi:10.1016/j.jand.2016.09.021
[21] Christodoulides S, Dimidi E, Fragkos KC, Farmer AD, Whelan K, Scott SM. Systematic review with meta-analysis: effect of fibre supplementation on chronic idiopathic constipation in adults. Aliment Pharmacol Ther. 2016;44(2):103-116. doi:10.1111/apt.13662
[22] Zhang C, Jiang J, Tian F, et al. Meta-analysis of randomized controlled trials of the effects of probiotics on functional constipation in adults. Clin Nutr. 2020;39(10):2960-2969. doi:10.1016/j.clnu.2020.01.005
[23] Sorathia SJ, Chippa V, Rivas JM. Small Intestinal Bacterial Overgrowth. [Updated 2022 May 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546634/
[24] Rao SSC, Bhagatwala J. Small Intestinal Bacterial Overgrowth: Clinical Features and Therapeutic Management. Clin Transl Gastroenterol. 2019;10(10):e00078. doi:10.14309/ctg.0000000000000078
[25] Shah A, Talley NJ, Jones M, et al. Small Intestinal Bacterial Overgrowth in Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis of Case-Control Studies. Am J Gastroenterol. 2020;115(2):190-201. doi:10.14309/ajg.0000000000000504
[26] Ghoshal UC, Srivastava D, Verma A, Misra A. Slow transit constipation associated with excess methane production and its improvement following rifaximin therapy: a case report. J Neurogastroenterol Motil. 2011;17(2):185-188. doi:10.5056/jnm.2011.17.2.185
