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This week's topic: Constipation (overview and causes)
So many people are unaware of what constipation is, and especially how it impacts health beyond the gut! Let's review this topic a bit more....
Overview of today's email:
- Brief review of constipation
- Potential causes of constipation
- Practical clinical tips
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1. Brief review of constipation
Mainstream medicine goes by the Rome IV Criteria (see below), but in functional medicine, we often educate on what a "normal" bowel movement should be (1-3x/day depending on the number of good sized meals, a length that is equivalent of our forearm from wrist to elbow crease, a good consistency)...and a bowel movement 3-4x/week would not be normal!
Rome IV Criteria (2 or more of the following symptoms for at least 3 months) for functional constipation:
- Fewer than 3 bowel movements a week
- Straining for more than a quarter of bowel movements (BMs)
- Hard, lumpy stool (Bristol Stool Form 1-2) in more than a quarter of BMs
- Sensation of incomplete evacuation in more than a quarter of BMs
- Sensation of blockage in more than a quarter of BMs
- Requiring manual maneuvers to assist in completing a bowel movement in more than a quarter of BMs
- Do not meet the criteria for IBS
Note, it is ok to skip a day periodically (e.g. with travel, if a "clean out" occurred due to frequent loose stools), and still have "normal" BMs. I mention this because of an experience I had with a patient (she had frequent diarrhea due to a very limited diet that involved no starch or complex carbs, and if she ate things that bulked up her stool, she would periodically miss a BM and call this constipation).
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2. Potential causes of constipation
I find that many patients and practitioners skip over the foundations of gut motility (especially a deep dive into lifestyle habits) and gut physiology, and may jump to expensive testing and lots of supplements before thoroughly addressing the foundations. Here's a brief overview of the causes of chronic constipation:
Lifestyle
- Low fiber diet (or too much fiber without adequate hydration)
- Dehydration
- Stress (impacts the vagus nerve, which supports gut motility)
- Inadequate physical activity (especially exercises that involve gentle twisting, bouncing, to support lymphatics)
- Inadequate food intake
- Low carb diet (carbs are one of the primary food sources for the microbiome, and some studies on keto diets suggest various microbiome species decrease)
- "Holding it in" (e.g. due to fear of defecating in public restroom, travel, being rushed, childhood events including micro- and macro-traumas, etc)
- Excessive intake of foods that have been shown to trigger constipation (e.g. dairy, gluten, sugar, processed foods, bananas, high-fat foods, alcohol, sugary foods)
Medications and Nutraceuticals
- Pain medications (Opioids, NSAIDs)
- Antihistamines
- Antihypertensives (CCB, BB)
- Chronic laxative use
- Psychiatric and anticonvulsants (gabapentin, clozapine)
- Antidepressants
- Iron
- Excessive calcium
- Too many supplements
Conditions
- Weakened pelvic floor muscles or uncoordinated pelvic muscles
- Ehlers Danlos Syndrome (EDS) or hyper-mobility syndromes
- Systemic sclerosis/scleroderma or other connective tissue diseases
- Hypothyroidism or hyperthyroidism (I've seen chronic constipation improve after addressing elevated free T3 levels that were medication-induced)
- Diabetes
- Parkinson's
- Multiple sclerosis
- Pregnancy
- Lupus
- Mast cell hyperactivity
- Significant mental or physical trauma
- Blockages or structural defects
- Spinal cord compression - subtle or more serious (e.g. I've seen chronic constipation resolve after removal of fibroids that were compressing nerve innervating the gut, and constipation improve after patient visited chiropractors)
GI-Based Conditions
- Celiac
- SIBO (especially methane dominant)
- Low levels of beneficial molecules/bacteria, including SCFA (especially butyrate), Bifidobacterium, Lactobacillus, Roseburia, and serotonin
- Poor digestion (e.g. bile acids support peristalsis)
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3. Practical Clinical Tips
Always start with food and lifestyle! Here are a few tips to share with patients:
- "Chug" 16-20oz of lukewarm or warm water first thing in the morning after waking (option to add 1/8 to 1/4 tsp salt, which draws more fluid into the gut lumen; so slowly with adding the salt, though!)
- Consume at least one serving daily of the "4 P's" (Pears, Plums, Prunes, Peas)
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Prioritize the "3 F's" = Fluids, fiber, and fitness
- Ideally water as the primary fluid (add minerals if reverse osmosis filtration is used), aiming for around half of one's body weight in ounces
- 25-40 grams of fiber daily
- Aim for at least 20 minutes of gentle walking and cardiovascular exercise daily, and consider moves that gently twist the abdomen (e.g. Yoga moves for digestive support)
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I hope this was clinically useful!
Remember my recent emails on cholesterol, and how I mentioned I'd cover ApoB in a webinar? It's done (and available to purchase for $37 if you are not a member of the Collective)! Click here if you're interested in purchasing and supporting my "practical" approaches... and in 30 minutes know more about ApoB than most of your colleagues!
Meg
Additional resources that may be helpful
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