Written By Krystal Karalli, PNW Intern, Summer 2022

Constipation, though uncomfortable (both literally and figuratively), is a common complaint. If you are suffering from constipation, know that you are not alone as it is a major issue worldwide, affecting a whopping 16 out of 100 adults in the United States. 

Considering that this topic may be something that is difficult to discuss with peers or family, we decided to create a blog post to talk about what exactly constipation is, what may be contributing to its development, and some of our best tips for prevention as well as treatment. 

What is constipation?

Constipation is defined as difficulty with passing a stool characterized by infrequent bowel movements or painful, hard, or incomplete evacuations. Typically, when someone passes a stool fewer than three times a week, there is concern that constipation may be present. However, because everyone has their own individual bowel movement pattern, only you can know what is considered abnormal for you. 

Causes and Common Symptoms of Constipation

The most common kind of constipation (called primary constipation) is usually caused by a lack of dietary fiber. Constipation can also result from a variety of non-diet-related factors (termed secondary constipation), including underlying diseases or conditions (such as irritable bowel disease, irritable bowel syndrome, gastroparesis, or diabetes). Certain medications, such as calcium channel blockers and antidepressants may also be contributing factors. Further, chronic stress, eating disorders, anxiety, and/or depression may be the culprit behind secondary constipation. For some, simply changing their daily routine can cause constipation.

Registered dietitians and doctors often use the Bristol Stool Chart as a reference to help in identifying whether their patient is experiencing constipation. With different stool types ranging from type 1 to type 7, type 1 and 2 are usually indicative of constipation. Symptoms such as straining, hard stools, the sensation of incomplete evacuation, and less than three bowel movements per week are typically associated with constipation.

Treatment, Lifestyle, and Diet Intervention Recommendations

Considering the various causes and types of constipation, it’s important to understand symptom patterns and classification of constipation (which can be determined by your physician) to tailor therapy based on the underlying cause. Treatment of an underlying disease or disorder such as those mentioned above would be the first step in symptom control. In some cases, if medications are the culprit, switching to a new medication can improve symptoms, although consulting your physician is highly recommended. 

Lifestyle recommendations

Fiber, water, and regular exercise

Primary constipation can usually be fixed with a gradual increase in fiber along with higher water intake, and/or an increase in physical activity. Fiber can retain water, which can help with softening BMs. When our gut bacteria ferment fiber, they produce compounds, such as butyrate, that can help in getting things moving. Drinking enough fluid also helps in softening stools, making them easier to pass.

The recommended intake of fiber is between 25-38 grams per day. The right fiber amount can be reached by eating at least four or five portions of fruit and vegetables (including beans, if tolerable) daily. Other foods rich in fiber include whole grains, nuts, and seeds. Note that fiber should be added to the diet slowly as a sudden increase may cause cramps, bloating, and diarrhea. To prevent any further GI distress, make sure to drink plenty of water daily.

Many high-quality studies have shown that engaging in regular exercise, specifically, aerobic exercise (think cardio types of exercise like running, biking, or swimming) can be of help in alleviating symptoms associated with constipation, such as bloating. Aerobic exercise helps in stimulating abdominal muscle contractions and accelerates the movement of poop throughout the GI tract.

Stress management

Research shows that people with chronic constipation often experience more negative emotions such as anxiety, depression, tension, and fatigue. Considering this unfortunate truth, it may be beneficial to incorporate some stress-relief techniques as a way to potentially improve gastrointestinal health. Seeking counseling is one option, although not everyone has access to therapy. Some cost-effective practices that have been shown to be helpful in mitigating chronic stress include:

• Mindfulness and meditation

• Diaphragmatic breathing

• Yoga, tai chi, or qigong

• Engaging in regular exercise

• Journaling

Foods Scientifically Proven to Relieve Constipation

Aside from the general recommendation of increasing fiber with fruits, vegetables and grains, there are certain foods that have decent research behind when it comes to alleviating constipation.

Kiwifruit 

Kiwifruit is well-known for its laxative properties. Research shows that eating two to three kiwis a day did better at improving mild constipation compared to commercially sold Metamucil, a commercially sold product that contains psyllium husk. Researchers aren’t entirely sure why kiwi helps with constipation but they believe it has something to do with a compound it contains called actinidin. They believe that actinidin may play a role in decreasing GI transit time (the time it takes for food to travel through your intestines), although they are not entirely sure of its mechanism. The authors concluded that eating two to three kiwis daily is associated with a significant increase in pooping frequency as well as a reduction in pain and discomfort.

Prunes 

Prunes (AKA dried plums) have been touted as a way to relieve constipation for a long time, but is there any science to back this claim? The answer is, yes. In fact, in 2011, researchers compared the consumption of 11g of psyllium husk (consumed twice daily) with 50g of prunes (eaten twice daily) to observe which would do better in alleviating constipation. Both psyllium and prunes did well, however, prunes did better. Prune juice also has a mild laxative effect, although it may increase the amount of gas produced. 

Fig paste 

Fig paste (which is somewhat like fig jam) is a sweet, thick paste made from softened, mashed figs and sugar. In a 2016 study, researchers tested whether fig paste (300 grams per day) would do better at improving constipation compared to a placebo. The fig paste did better at improving constipation-related symptoms better than the placebo did. The researchers owed the constipation-relieving effects of fig paste to the high amounts of cellulose, phenols, flavonoids, and anthocyanins it contains, all of which have been reported to have laxative effects. Although fig paste can be store-bought, it may contain more added ingredients than we’d like. For those that like homemade remedies, here is an easy fig paste recipe.

Flaxseeds

Flaxseeds are known for providing many health benefits, including their protective effects against heart disease, high blood pressure, and other chronic health conditions, yet they may also potentially be a safe and effective treatment for constipation. In a recent study, comparing lactulose (a commonly used laxative) to flaxseed flour-enriched meals (50 grams per day which is about 8 T), the flaxseed flour-enriched meals did better at improving the number of times the subjects had a BM, decreased the difficulty of pooping, and reduced the stomach pain associated with constipation. If you do try to use flaxseeds as a means to relieve constipation, make sure to grind them first (or buy flaxseed meal), as whole flax seeds often pass through the IG tract undigested, which means you may not get all of its benefits.

Note that there is pretty limited evidence on the role of other fruit being useful in alleviating symptoms associated with constipation. Apricots and apples have been said to be potentially useful, although there is not enough evidence that proves they are of much help. Because there is good quality evidence on the above-mentioned foods, it might be helpful to try these specific foods if you are looking for an alternative approach to over-the-counter laxatives (which we will talk about soon). 

Supplements

There are specific dietary supplements that have been scientifically proven to be beneficial for constipation, including magnesium oxide, partially hydrolyzed guar gum (PHGG), and psyllium husk. Note that you should always consult with a qualified health professional before starting any kind of dietary supplement regimen.

Psyllium/Isphagula Husk

Psyllium husk has been mentioned a few times already, but because it is such a commonly used dietary supplement, we thought it deserved special attention. As stated previously, psyllium husk is a soluble fiber made from the husks of the Plantago ovata plant’s seeds. It is unique in that it can be beneficial for constipation and mild-to-moderate diarrhea. Many well-designed studies have shown that psyllium husk relieves constipation, including the study previously mentioned using 11 grams of psyllium husk per day. One really big 2022 study showed that psyllium husk, taken at doses greater than 10g per day for at least 4 weeks, did significantly better than most fiber supplements that are taken to alleviate chronic constipation in adults. If you can’t get your hands on prunes (or don’t like the taste), psyllium husk supplementation seems to be a great alternative. Psyllium husk is the main ingredient in many over-the-counter laxatives, such as Metamucil, although you can also purchase a dietary supplement that contains psyllium husk without any added ingredients.

Magnesium Supplements 

Magnesium is an essential mineral that is crucial to many bodily functions including playing a vital role in activating vitamin D in the body. Interestingly, in populations whose dietary fiber intake is low, lower intakes of magnesium are associated with constipation. What’s more, magnesium can be used as an osmotic laxative. This means that it can pull water into the intestines, making stools easier to pass through the colon by lubricating the GI tract and softening poop. Interestingly, over-the-counter products such as magnesium citrate and magnesium hydroxide (milk of magnesia) are often used by individuals to self-treat constipation and are also commonly recommended by physicians, however, so far, there are few clinical trials to prove their effectiveness in the treatment of constipation. 

On the other hand, magnesium oxide (MO) has been shown in human clinical trials to improve symptoms of constipation. One study used 0.5 grams of MO, three times a day, while another study used 1.5 grams per day, with both showing improvements in overall symptoms. One of the studies found that MO was just as effective as Senna (a stimulant laxative). Note that magnesium oxide can interact with certain medications. Further, prolonged use of MO may potentially cause hypermagnesemia (abnormally high magnesium levels) in individuals diagnosed with impaired renal function and those taking relatively high doses. There are many different brands that offer magnesium oxide, including NOW foods Magnesium oxide powder (294 mg per 1/4 tsp),   Pharmaceutical grade MAGOX found at CVS (483 mg per 2 capsules), and Swanson Magnesium oxide (400mg per 2 capsules). 

Partially hydrolyzed guar gum (PHGG)

PHGG is a unique kind of soluble fiber derived from guar gum that has been shown to be highly beneficial for both preventing constipation and relieving symptoms related to chronic constipation. A 2014 study using 5 mg of PHGG in patients experiencing chronic constipation showed that PHGG was successful in improving many of their symptoms. Another study demonstrated that using up to 15 grams of PHGG can yield improvements in constipation of a similar magnitude achieved with laxatives. The same study showed that anywhere from 11-36 grams of PHGG per day can be used to prevent constipation. 

According to MONASH University (the creators of the FODMAP diet), PHGG may also be useful in people living with IBS-C (irritable bowel syndrome with constipation), although more studies are needed. PHGG is commercially sold as Sunfiber™ (or Guar fiber). Another good option is Benefiber Advanced Digestive Health. 

What About Laxatives?

Laxatives are a type of medication that is commonly used to treat constipation when lifestyle and diet changes are not effective. Note that laxatives of any kind are typically prescribed for short-term use. There is no science to support the use of laxatives over the long term, at least not for more than 4 weeks. Although laxatives may initially help with constipation, overuse may cause you to become dependent on them for a bowel movement. Long-term use may also lead to electrolyte imbalances which can potentially cause seizures, abnormal heart rhythms, confusion, and weakness. If for whatever reason you are repeatedly using laxatives to normalize your bowel movements, it would be wise to speak with your physician about gradually weaning from them by using milder products and reducing the dose. Below you will find the four most commonly used laxatives along with the pros and cons of taking each:

Bulk-forming laxatives: These laxatives retain fluid in BMs, which can help in increasing its weight and softening its consistency, allowing for easier transit throughout the GI tract. Common examples include ispaghula/psyllium husk (found in Metamucil), and methylcellulose (found in Citrucel).

• Pros: bulk-forming laxatives are useful for people with small, hard stools when they can't increase their fiber intake.

• Cons: They usually take about 2-3 days to work and may cause bloating, gas, and stomach pain. They may also interfere with the absorption of certain medications.

Stimulant laxatives: these kinds of laxatives work by stimulating the muscles that line the gut which helps stool move along with the GI tract, resulting in more frequent bowel movements. Stimulant laxatives are usually recommended when osmotic laxatives dont work. Common examples include Bisacodyl (known as Dulcolax), Senna, Cascara, and Sodium Picosulfate (SPS). Both Senna and Cascara can be found in herbal teas. 

• Pros: stimulant laxatives only take about 6-12 hours to work. Research shows that, in the short term, Senna is more effective in treating constipation than lactulose (an osmotic laxative).

• Cons: common side effects include diarrhea, stomach pain, nausea, vomiting, and headaches. 

Osmotic laxatives: these agents work by drawing water into the intestine to soften the stool, making it easier to pass. They also help in improving peristalsis (i.e. the contraction and relaxation of intestinal muscles that help push poop forward). Lactulose, sorbitol, and polyethylene glycol (PEG) are common examples. 

• Pros: these agents are usually well-tolerated and recommended over other bulk-forming laxatives although drinking enough water throughout the day is required. 

• Cons: The side effects of taking osmotic laxatives include gas, cramping, abdominal discomfort, nausea, vomiting, and diarrhea. They are not very effective for severe constipation, as they may take up to 3 days to work. 

Stool softeners: this type of laxative lubricates and softens the stool by allowing fat and water to build up. Common examples include Docusate Sodium and Arachis oil.

• Pros: stool softeners may help prevent straining with a bowel movement which may be especially helpful in those who have heart conditions or hemorrhoids. 

• Cons: Arachis oil is nut-based, so it should be avoided by people with nut allergies. Some side effects of stool softeners have been reported, including stomach cramping, nausea, bloating, and throat irritation (from ingesting liquid forms). Further, these kinds of laxatives can up to 3 days to work.
  
  

Wrapping up

To summarize all we have covered so far in this blog post:

• Natural, evidence-based remedies for constipation include exercising more, increasing fiber intake, and drinking enough water throughout the day to compensate for the increased fiber intake. 

• Foods that have been proven to relieve constipation-associated symptoms include kiwifruit, prunes, flaxseeds, and fig paste. 

• Certain supplements, including magnesium oxide, partially hydrolyzed guar gum, and psyllium husk are other viable options. 

• Remember that if you have an underlying disease or condition, it is important to seek treatment before trying to treat constipation. 

• Laxatives are over-the-counter medications that may help with alleviating constipation, although there is no evidence that they are safe for use for more than 4 weeks.

We do hope that this post gave some helpful insight into what defines constipation, its causes, and readily available natural remedies that may be of benefit. Remember, it is always important to speak with a physician to get a true understanding of what is going on gastrointestinally before starting any new diet or supplement regimen. If you have any additional questions, please feel free to reach out!