How to fix constipation

Constipation is a gastrointestinal disorder affecting a considerable percentage of the population. Based on severity, it can have a significant negative impact in health and quality of life. In this article we explore how to fix constipation.

What is constipation?

Constipation is a gastrointestinal condition characterised by infrequent bowel movements (1, 2), hard or lumpy stools (1), difficulty passing stools (1, 2) and the sensation of incomplete evacuation (1).

The prevalence of constipation has been reported to be 12-17% of the global population (1). The prevalence is higher in elderly people (1, 2), women (1, 2), particularly when pregnant (2).

Factors associated with constipation

• Intrinsic factors, including age, gender, genetic predisposition, irritable bowel syndrome (IBS), slow colonic transit, depression, hormonal imbalance (2)
• Extrinsic/lifestyle factors, including type of diet (e.g. low fibre/vegetable intake, inadequate water intake), sedentary lifestyle/lack of mobility, certain medications*, neurological disorders (e.g. Parkinson disease, spinal cord injury), psychological conditions (e.g. depression, history of abuse) (2, 3, 4), endocrine conditions (e.g. diabetes, hypothyroidism) (3, 4), and low socioeconomic status (1, 2)

* Medications that can cause constipation include opiates, anticholinergics, antidepressants, antipyretic drugs (e.g., morphine and codeine), antiepileptics, anticonvulsants, antipsychotics, antispasmodics, calcium channel blockers, iron and calcium supplements, lipid lowering drugs, anti-ulcers, antihistamines, antioxidants (2, 3, 4).

Types of constipation

Constipation can be acute if symptoms last less than a week or chronic, if symptoms last for 3 or more months (1).

Furthermore, constipation can be classified based on aetiology as below:

• Irritable bowel syndrome with constipation (IBS-C), characterised by bloating/distension and abdominal pain more than once a week (1, 5)
•  Functional constipation (FC), similar to IBS-C but with no or less frequent pain (less than one day a week) (1, 5)
• Opioid-induced constipation, as it name implies, a side effect to opioid therapy (1)
• Functional defecation disorders, which mean that there is an anatomical issue preventing the person from eliminating properly (1)

How to fix constipation

Due to the differences between the types of constipation and individual variability in symptoms, there is no single solution that works for every case. However, there are evidence-based algorithms that clinicians can use to guide interventions. They logically move from the least invasive strategies (i.e. lifestyle modifications) and finish with the most invasive (i.e. surgery), with pharmaceutical interventions in the middle.

As a dietitian, I will discuss in more detail those strategies that fall within my professional scope.

Fluid intake

One of the first strategies to address constipation is ensuring adequate fluid intake (1). Recommendations in Australia are 2.1 and 2.6 litres per day for adult women and men, respectively. It is important to adjust this rough guideline to body size, physical activity level, sweat rates, climate, etc.

It is important to note that increasing fluid intake will not automatically fix constipation, especially in individuals who are meeting their requirements.

Exercise

Exercise is another first-line strategy to combat constipation. Some researchers have speculated that exercise works because it combats inflammation and oxidative processes in the body (1). However my personal view is that the prescription should be to increase movement or physical activity rather than exercise, as an increase in physical activity is likely to increase gut motility.

Fibre

Dietary fibre is the third component of the anti-constipation holy trinity. As discussed previously, fibre is important for several aspects of health but the types and quantity of fibre in food vary.

Eating fibre from plant foods is super important but when it comes to constipation, the evidence points to gel-forming soluble fibre (e.g. psyllium, ispaghula) as the most effective treatment for chronic constipation (1, 2, 3) and IBS-C, but not slow colonic transit (2). Insoluble fibre (e.g. wheat bran) is not effective (1, 2).

The recommended dose of psyllium is 3-4 grams per day taken with plenty of water as a starting point, building up to 20-30 grams per day as tolerated. Psyllium supplementation can cause pain and bloating due to fermentation (1). Symptoms should resolve with time but supplementation should be discontinued if they don’t.

Kiwifruit

A few studies have investigated the effect of kiwifruit on constipation in elderly patients (6), constipated adults (7) and IBS-C patients (8). Although the studies were small and relatively short in duration, they suggest that 2 kiwifruit per day can modestly yet significantly improve consistency and volume of stools (6), decrease colonic transit time (7), increase frequency of defecation (7, 8), decrease need for laxatives and improve satisfaction with bowel habits (8).

The nutrients in kiwifruit thought to be responsible for its laxative effects are:

• Dietary fibre which is not particularly high but, when the kiwifruit is ripe, can hold a lot of water, which would increase the bulk of stool (6, 7).
• Oligosaccharides present in ripe kiwifruit that may have laxative properties (6)
• Actinidin, a proteolytic enzyme (i.e. it breaks down proteins) which may stimulate receptors in the colon and increase motility (6, 8)

Probiotics

Both Lactobacillus and Bifidobacterium have been shown to be low in patients with chronic constipation, leading to believe that probiotic supplements could be used as a potential therapy. However, there is very little evidence that probiotics can help.

A small double-blind placebo-controlled randomised trial found that supplementing with L. reuteri can improve the amount of bowel movements in chronically constipated individuals. The probiotic supplement used in this study contained 10⁸ colony-forming units and was taken twice a day for 4 weeks (9).

Other non-invasive strategies

Other strategies that can be useful include:

• Leaning forward and place feet on a stool when sitting on the toilet (4)
• Practising relaxation techniques when defecating (4)
• Drinking coffee upon waking up (4)
• Drinking warm water upon waking up
• Following a regular meal pattern (5)
• In patients with IBS-C and FC, avoiding heavy/fatty meals, and foods that cause flatulence (5)

Other therapies

If the initial strategies outlined above do not work, doctors may recommend other therapies, which have different levels of evidence and include:

• Laxatives, including osmotic (e.g. lactulose and polyethylene glycol) and stimulant (e.g. senna) (1, 2)
• Other pharmaceuticals, including pro-secretory agents (1)
• Biofeedback (1, 2)
• Trans-anal irrigation (a.k.a. colonics) (1)
• Surgery (1, 2)

Summary and recommendations

If you suffer from chronic constipation, make sure your water and fibre intake are adequate and you are physically active. If you have ticked those boxes, you can trial psyllium husk taken as described in the article. If this doesn’t work, you can try eating 2 ripe kiwifruit per day, or the other non-invasive strategies described above. If your symptoms have not improved, please visit your doctor for a pharmaceutical option (e.g. laxatives).

References

1. Aziz I, Whitehead WE, Palsson OS, Törnblom H, Simrén M. An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation. Expert Rev Gastroenterol Hepatol. 2020 Jan;14(1):39–46.
2. Forootan M, Bagheri N, Darvishi M. Chronic constipation: A review of literature. Medicine (Baltimore) [Internet]. 2018 May;97(20):e10631–e10631. Available from: https://pubmed.ncbi.nlm.nih.gov/29768326
3. Leung L, Riutta T, Kotecha J, Rosser W. Chronic Constipation: An Evidence-Based Review. J Am Board Fam Med [Internet]. 2011 Jul 1;24(4):436 LP – 451. Available from: http://www.jabfm.org/content/24/4/436.abstract
4. Hayat U, Dugum M, Garg S. Chronic constipation: Update on management. Cleve Clin J Med [Internet]. 2017 May 1;84(5):397 LP – 408. Available from: http://www.ccjm.org/content/84/5/397.abstract
5. Mearin F, Ciriza C, Mínguez M, Rey E, Mascort JJ, Peña E, et al. Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult. Rev Esp enfermedades Dig organo Of la Soc Esp Patol Dig. 2016 Jun;108(6):332–63.
6. Rush EC, Patel M, Plank LD, Ferguson LR. Kiwifruit promotes laxation in the elderly. Asia Pac J Clin Nutr. 2002;11(2):164–8.
7. Chan A-O-O, Leung G, Tong T, Wong N-Y. Increasing dietary fiber intake in terms of kiwifruit improves constipation in Chinese patients. World J Gastroenterol [Internet]. 2007 Sep 21;13(35):4771–5. Available from: https://pubmed.ncbi.nlm.nih.gov/17729399
8. Chang C-C, Lin Y-T, Lu Y-T, Liu Y-S, Liu J-F. Kiwifruit improves bowel function in patients with irritable bowel syndrome with constipation. Asia Pac J Clin Nutr. 2010;19(4):451–7.
9. Ojetti V, Ianiro G, Tortora A, D’Angelo G, Di Rienzo TA, Bibbò S, et al. The effect of Lactobacillus reuteri supplementation in adults with chronic functional constipation: a randomized, double-blind, placebo-controlled trial. J Gastrointestin Liver Dis. 2014 Dec;23(4):387–91.

[Photo by Claire Mueller on Unsplash]

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