Sluggish gut? Let’s talk about constipation.

Today’s topic is all about constipation. We don’t typically like to talk about GI issues in the US, (I do hope this will change) but constipation is a big problem in America. Constipation accounts for at least 8 million annual visits to health care providers in the US and occurs in about 1 in 5 people globally. 

Today’s post is a primer on constipation including: some tips to help manage a sluggish gut, underlying causes, and a Q & A, with gastroenterologist and constipation expert, Richard J. Saad, MD, MS, FACG, Associate Professor of Medicine at University of Michigan. Dr. Saad specializes in functional  bowel  disorders, pelvic floor disorders and geriatric gastroenterology.

On a side note, I had the pleasure of getting to know Dr. Saad when we worked together lobbying Congress in 2014 with the International Foundation for Functional Gut Disorders ((IFFGD) regarding, the Functional Gastrointestinal and Motility Disorders Research Enhancement Act  (HR 1187). Learn more here.

Let’s start with some basics, shall we?

What is constipation? Infrequent passing of stool (typically fewer than three bowel movements per week). The stool is often dry, hard and may be accompanied by a sense of incomplete emptying.

In the GI world, we often refer to two primary forms of constipation: chronic idiopathic constipation (constipation of unknown cause) and irritable bowel syndrome with constipation predominance (IBS-C). Although constipation may be referred to as slow transit constipation (due to a slow moving intestine), dyssynergic defecation, or pelvic floor disordered constipation with hyposensitivity or hypersensitivity of the rectum. Of course, constipation can occur due to opioid medications too.

What is the difference between chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C)?

IBS is a debilitating, painful GI disorder prevalent in 10 to 15 percent of North Americans,
and IBS-C accounts for about 5% of those who suffer with this condition. Although constipation is part of the diagnostic criteria for IBS-C and CIC (obviously), the major differentiator between the two is that IBS-C presents with pain as well. 

Symptoms of BOTH IBS-C and CIC symptoms include: gas, bloating, straining with elimination and hard stools. Both IBS-C and CIC can disrupt the quality of life.

Here are some tips for managing constipation:

• TRY DIFFERENT FIBER SOURCES> Increasing intake of a variety of different fibers offers health benefits such as bulking stool, hastening transit time, and feeding healthful probiotic gut bacteria. Psyllium husk as a fiber supplement has the best evidence to support its use in IBS-C at this time. In my clinical practice and in research, only a small subset of patients benefit from psyllium– the majority do not. It’s worth discussing with your GI doctor, however, if the use of psyllium may be appropriate for you to try. It is a simple and low cost remedy that seems to work miracles in some people.
• HYDRATE> Consuming adequate fluid is a modifiable lifestyle factor that may improve constipation.
• EAT REGULARLY> Eating induces the gastro-colic reflux, stimulating intestinal movements that may relieve constipation. I am not encouraging grazing here…but eating 3 discrete meals might be helpful vs. skipping meals.
• ADD EXERCISE> Walking and other types of exercise that add weight-bearing, jarring movements to the body can stimulate GI motility.
• LISTEN TO THE BODY> Listen to your body when the urge to move the bowels occurs rather than waiting until later. Water is reabsorbed in the colon, and the longer the stool remains, the drier or more difficult it will be to pass. Did you know there is something called shy bowel syndrome?  This brochure called Toilet Phobia (ha!) reviews how shy bowel syndrome can impact constipation. Perhaps, TMI but I definitely have a shy bowel! Ha! How about you? 🙂
• GET CULTURED> Probiotics may minimize constipation in some, though the exact mechanism is unknown. L. reuteri DSM 17938 marketed in the product by BioGaia ProTectis has been shown in one study to reduce methane gas (methane is associated decreasing motility and constipation) and increase the number of bowel movements. Study can be found here. 
• EAT 2 KIWIFRUIT PER DAY> Emerging studies show 2 green kiwi per day help with elimination patterns. For more info on kiwifruit and constipation, check out my previous post, here. 
• MAKE TIME FOR A BM IN THE MORNING> Allowing time in the morning to wake up, sip on some hot coffee or tea (caffeine and warm beverages can stimulate motility) and digest your first meal can aid in producing a more complete bowel movement! (In our busy culture, 15 extra minutes or so in the morning can be therapeutic, too!). Try setting your alarm just 15 minutes earlier so you and your colon can ease into the morning.
• CONSIDER A SQUATTY POTTY– this Shark Tank show winner is a stool designed to provide the proper posture to help your body poop. There is science to support its use too. Read about it here.  Modern toilets encourage a position that only allows partial opening of the rectum and anal canal, making you work harder to have complete bowel movement. Raising your knees above your hips helps open the canal for easier elimination!  Check out the squatty potty here. 

Let’s talk a bit about fiber:

Are you eating enough fiber? Fiber comes in many shapes and forms–and various degrees of fermentability (i.e. ability to increase gas).  Some fiber is rapidly fermented by our gut microbes, such as FODMAP carbohydrates while other fibers are slowly fermented or not at all, such as most insoluble fibers found in fruit and veggie skins. Some fibers are viscous (form a thick gel) and can benefit those with constipation (softening stools) or help act like a sponge and soak up extra fluid in the gut and aid diarrheal symptoms.

I often say, adding fiber to the colon–can be like adding cars to a traffic jam. Sometimes, it is best to move out the stool with aid of a laxative–and then slowly add in a variety of different fibers. In some cases, when my patients present with constipation, the GI doc will check an x-ray to assess for fecal loading. Fecal loading means that there is a high burden of stool in the colon. If the colon is full of stool, the small bowel motility can be impacted. I personally think this is risk factor for patients prone to small intestinal bacterial overgrowth. So, moving out the stool is important. Should everyone get an x-ray of their belly? No. But, imaging can help assess whether or not you are emptying your bowels properly.

Intake of a variety of different fibers can provide a more diverse gut microbiome.  Tolerance to fiber varies person to person. In clinical practice, I find patients tolerate fiber best when it is slowly increased over time (with adequate fluid).

What does a fiber rich low FODMAP diet look like?

Breakfast: ½ cup uncooked oats (4 grams fiber), 1 tablespoon chia seeds (5 grams fiber), 10 medium-size strawberries (2 grams fiber). Total breakfast fiber: 11 grams fiber.

Lunch: 1 cup raw baby spinach (1 gram fiber), 1 cup cooked quinoa (5 grams fiber), 3 ounces grilled chicken (0 grams fiber), 2 kiwi (4 grams fiber). Total lunch fiber: 10 grams fiber.

Dinner: Salmon steak (0 grams fiber), 1 medium-size white potato, baked + skin (3 grams fiber), 1 cup cooked zucchini (2 grams fiber), 10 raspberries (1 gram fiber). Total dinner fiber: 6 grams fiber.

Now let’s get to my Q & A, with constipation expert, Richard Saad, MD. Dr. Saad and I recently spoke at the U. Michigan on my favorite topic, you got it…constipation.

Kate: Some medications, pelvic floor dyssynergia, even methane gas in the bowel may play a role in constipation. Can you briefly go into some details on how these factors may lead to constipation?

 Dr. Saad: Constipation is often times the result of more than one cause.  Many medications can slow the colon prompting constipation.  The biggest offenders by far are narcotic based pain medications.  Anyone taking these should also be on laxative therapy to prevent this constipation.  Other common medications that can contribute to constipation include certain blood pressure medications such as calcium channel blockers.  If constipation symptoms have developed following the initiation of a particular medication, one should discuss this with his/her physician prescribing the medication(s).   

Another cause of long standing constipation can be problems with the muscles of one’s pelvic floor.  This is felt to represent a learned behavioral problem often times stemming from a traumatic experience such as abuse, injury, surgery or even child birth.  This results in uncoordinated or abnormal relaxation/contraction of the muscles during defecation (called dyssynergic defecation) resulting in straining and incomplete emptying. This problem can be identified by examination or specialized testing of the pelvic floor and typically requires retraining of the muscles to correct the problem sometimes referred to as biofeedback. 

Methane gas is byproduct of fermentation of bacteria in the intestines.  Methane has been shown in studies to reduce the motility of the colon, slowing movement of stool through the colon.  This in turn can lead to constipation.  Reducing or eliminating the methane gas in the intestines may allow the colon to speed back up.  This is done by either changing the type of bacteria in the intestines to microbes that do not making methane or by reducing the methane producing bacteria.  This can done by interventions such as diet, probiotics and/or antibiotics.  These treatments can be discussed with your physician and/or dietitian.

Kate:   In your clinical practice and experience, do you find your patients with constipation benefit from the low FODMAP diet? 

Dr. Saad: I have found the FODMAP diet helpful in constipated patients with associated gas and bloating problems.  Most of my patients still require daily laxative therapy as well for management of their constipation symptoms.

Kate:  I have read about the role of serotonin in the gut and constipation.  What is the role of serotonin in constipation? Are there serotonin or serotonin precursors in medication or supplement form that patients might benefit from?

Dr. Saad: Serotonin is a chemical used by the GI tract (much like in the brain), that allows nerves to communicate with one another.  Most serotonin in the body is actually found in the GI tract.  Serotonin has been shown to affect may functions of the intestines including absorption, secretion and contraction.  Changes in these specific functions of the bowels can result in either diarrhea or constipation, depending on which receptor the serotonin is acting upon.  There are actually several different serotonin receptors in the GI tract, all with different effects on the intestines.  We presently have a medication that acts on a specific class of serotonin receptors, to address diarrhea.  We do not presently have any medications to address constipation in the US, but they are available in Asia, Europe and Canada.  I am not aware of any serotonin supplements known to affect the bowels or the GI tract.

Kate:  There is much information online that stimulant laxatives can be habit forming. Patients often are concerned that using senna, for instance, will lead to dependence on stimulants for life. Is this what we see in the literature? 

Dr. Saad: There is no evidence that stimulant laxatives are either habit forming or damage the functioning of the GI tract.  There have been several recent long-term studies demonstrating safety and efficacy of stimulant laxatives.  Furthermore, in someone who is constipated due to a slow colon stimulant laxatives such as senna or bisacodyl are the most effective laxatives for the constipation symptoms.

Kate: Most patients with IBS-C at one time or another are prescribed fiber supplements. Is there good evidence adding fiber helps most or just a sub-set of patients with IBS-C?

Dr. Saad: Fiber supplement use in IBS-C has been extensively reviewed in the literature.  Overall, there a few studies in IBS-C, as most studies were only done in chronic constipation.  Due to the pain component associated with IBS and the common side effect of bloating with fiber supplements, fiber supplements have limited use in IBS.  With that said, fiber supplement are very safe and may provide relief in those with mild forms IBS-C.  Therefore, a trial with a fiber supplement is a reasonable first step.  If a 2-4 week trial is ineffective, often times due to worsening of bloating or lack of effect on the abdominal pain component of IBS, I would suggest moving on to another therapy. 

So there you have it! Constipation is a very common problem–but there are remedies to get your gut moving.  Do you have any favorite and effective constipation remedies? Please share!