• Infrequent bowel movements (typically three times or fewer per week)
• Difficulty during defecation (straining during more than 25% of bowel movements or a subjective sensation of hard stools)
• The sensation of incomplete bowel evacuation
• Two or fewer bowel movements in a week.
Constipation is the most common digestive complaint in the United States, as more than 4 million Americans have frequent constipation, accounting for 2.5 million physician visits a year. In addition, over $725 million is spent on laxative products each year in America.
How often a person should have a bowel movement is debatable. It is highly individualized, but in general a daily bowel movement should be considered normal (though some people eating a particularly high-fiber diet may have bowel movements three times a day). Going longer than three days without a bowel movement is of definite concern, as after three days the stool or feces become harder and more difficult to pass.
Causes
There are a number of possible causes of constipation, as noted below, but by far the most common cause of constipation is a low-fiber diet.
Causes of Constipation
• Not enough fiber in the diet
• Inadequate fluid intake
• Lack of physical activity (especially in the elderly)
• Medications:
Pain medications (especially narcotics)
Antacids that contain aluminum and calcium
Blood pressure medications (calcium-channel blockers)
Anti–Parkinson’s disease drugs
Antispasmodics
Antidepressants
Iron supplements
Diuretics
Anticonvulsants
• Milk
• Irritable bowel syndrome
• Pregnancy
• Abuse of laxatives
• Ignoring the urge to have a bowel movement
• Specific diseases or conditions:
Stroke
Multiple sclerosis
Low potassium stores
Diabetes
Kidney disease
Pituitary disorders
• Problems with the colon and rectum:
Diverticulosis
Irritable bowel syndrome (alternating diarrhea and constipation)
Colon cancer
Therapeutic Considerations
Constipation will often respond to a high-fiber diet, plentiful fluid consumption, and exercise. There is absolutely no argument from anyone in the medical community that these recommendations should constitute the first step in the treatment of chronic constipation.
Especially important is the recommendation to increase dietary fiber. High levels of dietary fiber increase both the frequency and the quantity of bowel movements, decrease the transit time of stools, decrease the absorption of toxins from the stool, and appear to be a preventive factor in several diseases. The recommended daily intake is 25–35 g fiber from dietary sources. However, higher amounts may be optimal for health, as the diet humans evolved with contained approximately 100 g fiber per day. Most Western diets provide only 10 to 15 g.
Foods particularly effective in relieving constipation are bran and prunes. The typical daily recommendation for bran is 1/2 cup of bran cereal, increasing over several weeks to 11/2 cups. When using bran, make sure to consume enough liquids. Drink at least six to eight glasses of water per day. Whole prunes as well as prune juice also exert good laxative effects. Four to 8 fl oz prune juice or 5 to 10 prunes will usually be an effective dose.
If you need additional support, consider using fiber formulas. These formulas act as bulking agents. They can be composed of natural soluble fiber derived from psyllium seed, kelp, agar, pectin, and plant gums such as karaya and guar, or they can be purified semisynthetic polysaccharides such as methylcellulose and carboxymethyl cellulose sodium. Psyllium-containing laxatives are the most popular and usually the most effective. Psyllium is derived from the seed of the plant Plantago ovago, native to Iran and India. The laxative properties of psyllium are due to the swelling of the husk when it comes in contact with water. This forms a gelatinous mass and keeps the feces hydrated and soft. The resulting bulk stimulates a reflex contraction of the walls of the bowel, followed by emptying. Bulk-forming fiber supplements such as psyllium are the laxatives that approximate most closely the natural mechanism that promotes a bowel movement. They are both safe and effective in the treatment of chronic constipation.1 That said, prunes may be more effective, based upon the results of one study.2 Subjects suffering from chronic constipation received either prunes (50 g per day, providing 6 g fiber; about 10 prunes) or psyllium (11 g per day, providing 6 g fiber) for three weeks each, in a crossover trial with a one-week washout period. Subjects maintained a daily symptom and stool diary. The number of complete spontaneous bowel movements per week and stool consistency scores improved significantly with prunes when compared with psyllium. However, straining and global constipation symptoms did not differ significantly between treatments.
Constipation in children usually occurs at three distinct points in time: in infancy, after starting formula or processed foods; during toilet training in toddlerhood; and soon after starting school (e.g., kindergarten). There are many factors to consider, but just as with adults, increasing fiber content usually produces the desired result. In addition, for children with a history of constipation, the first thing we recommend is eliminating milk and other dairy products from the diet. It is well accepted that cow’s milk intolerance (either allergy or lactose intolerance) can produce diarrhea. What is not as well known is that cow’s milk intolerance can also lead to constipation and is a major cause of childhood constipation.3 About 70% of cases of childhood constipation are cured by eliminating cow’s milk from the diet and substituting soy, nut (e.g., almond), or rice milk. Children with constipation who respond to milk elimination also experience a decreased frequency of allergy symptoms, including runny nose, eczema, and asthma. Our recommendation is that if a child is constipated, start by eliminating cow’s milk and other dairy products while increasing the intake of high-fiber foods, especially pears, apples, and other whole fruit. If this approach is not successful, try barley malt syrup or powder. Definitely avoid mineral oil as well as stimulant laxatives unless absolutely necessary.
Types of Laxatives |
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TYPE OF LAXATIVE |
HOW IT WORKS |
SIDE EFFECTS |
Bulk-forming fibers (psyllium, guar, methylcellulose) |
Absorb water to form soft, bulky stool, prompting normal contraction of intestinal muscles |
Bloating, gas, cramping, choking, or increased constipation if not taken with enough water |
Oral osmotics (magnesium hydroxide) |
Draw water into colon from surrounding body tissues to allow easier passage of stool |
Bloating, cramping, diarrhea, nausea, gas, increased thirst |
Oral stool softeners (docusate) |
Add moisture to stool to allow strain-free bowel movements |
Throat irritation, cramping |
Oral stimulants (senna and cascara) |
Trigger rhythmic contractions of intestinal muscles to eliminate stool |
Belching, cramping, diarrhea, nausea, urine discoloration |
Rectal stimulants (glycerin suppositories) |
Trigger rhythmic contractions of intestinal muscles to eliminate stool |
Rectal irritation, stomach discomfort, cramping |
Bulk-forming fiber supplements are preferred to other forms of laxatives. However, occasional use of other types of laxatives definitely has its place. In general, stimulant laxatives, even natural ones such as cascara sagrada (Rhamnus purshiana) or senna (Cassia senna) should not be used long-term. If they are, the bowels will need to be “retrained.” The list below offers a plan for reestablishing bowel regularity; the recommended procedure will take four to six weeks.
Rules for Bowel Retraining
• Find and eliminate known causes of constipation.
• Never repress an urge to defecate.
• Eat a high-fiber diet, particularly fruits and vegetables.
• Drink six to eight glasses of fluid per day.
• Sit on the toilet at the same time every day (even when the urge to defecate is not present), preferably immediately after breakfast or exercise.
• Exercise at least 20 minutes three times per week.
• Stop using laxatives (except as discussed below to reestablish bowel activity) and enemas.
Week one: Every night before bed take a stimulant laxative containing either cascara or senna. Take the lowest amount necessary to reliably ensure a bowel movement every morning.
Weekly: Each week decrease dosage of the laxative by half. If constipation recurs, go back to the previous week’s dosage. Decrease dosage if diarrhea occurs.
PRUNES: NOT JUST A LAXATIVE
A prune is a dried plum, just as a raisin is a dried grape. Prunes are well known for their ability to prevent and relieve constipation. In addition to providing bulk and decreasing the transit time of fecal matter, prunes’ insoluble fiber also provides food for the “friendly” bacteria in the large intestine. When these helpful bacteria ferment prunes’ insoluble fiber, they produce a short-chain fatty acid called butyric acid, which serves as the primary fuel for the cells of the large intestine and helps maintain a healthy colon. These helpful bacteria also create two other short-chain fatty acids, proprionic acid and acetic acid, which are used as fuel by the cells of the liver and muscles.
Prunes contain large amounts of phenolic compounds (184 mg/100 g), mainly as neochlorogenic and chlorogenic acids. As well as aiding in the laxative action, these compounds inhibit free radical damage to LDL cholesterol and might serve to protect against heart disease and osteoporosis. Eating five prunes or drinking 4 fl oz prune juice is all that is required to help relieve constipation in many sufferers.
When a stimulant laxative is required, we prefer senna. The laxative components are compounds known as sennosides. Senna relieves constipation by increasing the strength of contraction of the intestinal muscles. Like other stimulant laxatives, it should be limited to occasional use, as long-term use of senna can lead to dependence.
Stimulant laxatives, such as senna, are likely to cause abdominal cramping, nausea, and increased mucus secretion. Less common side effects are associated with chronic use and are usually related to loss of potassium and other electrolytes (e.g., muscle spasms, weakness, and fatigue). Call your doctor right away if you have any of these side effects: a sudden change in bowel habits that persists over a period of two weeks, rectal bleeding, or failure to have a bowel movement after use.
CAUTIONS AND WARNINGS
• Do not use senna for more than seven days unless directed by your doctor.
• Stimulant laxatives should not be used by patients with abdominal pain, nausea or vomiting, intestinal obstruction, inflammatory bowel disease, or appendicitis, or by women who are pregnant or lactating.
• Do not take more than the recommended amount. Excessive laxative use or inadequate fluid intake may lead to significant fluid and electrolyte imbalance.
A benign blackish-brown pigmentation of the lining of the colon (pseudomelanosis coli) may occur with prolonged use (at least four months) of senna, owing to the anthraquinones it contains. This condition generally disappears within 4 to 15 months after discontinuation.
Senna and other stimulant laxatives may decrease the absorption of drugs that pass through the gastrointestinal tract. If you are currently taking an oral medication, talk to your pharmacist or doctor before self-medicating with senna.
Senna may potentiate the action of digoxin and other heart medications, owing to potassium depletion. The use of senna with thiazide diuretics and corticosteroids may further decrease potassium levels.
Generally, take senna on an empty stomach. Drink six to eight glasses of liquid per day while taking senna or any other laxative.
QUICK REVIEW
• Constipation is a common problem in Western societies.
• The most common causes are inadequate consumption of dietary fiber and fluids and/or a sedentary lifestyle.
• Treatment involves addressing the cause and helping with supplemental fiber and herbal laxatives as needed.
TREATMENT SUMMARY
Keep in mind that constipation is a symptom, not a disease. Determining the cause is the first step in treatment. In most cases constipation is not serious and responds quickly to dietary and supplement strategies.
Follow the guidelines in the chapter “A Health-Promoting Diet.” In particular, try to consume 25 to 35 g fiber from dietary sources each day and drink at least six to eight glasses of water per day. Bran cereal can be helpful; start with 1/2 cup daily, increasing over several weeks to 11/2 cups. Whole prunes and prune juice also possess good laxative effects. Four to 8 fl oz prune juice or 5 to 10 prunes will usually be an effective dose.
• Soluble fiber supplement (e.g., psyllium): 5 g in at least 8 fl oz water, followed by another 8 fl oz of water, one to two times per day
• Probiotic (active lactobacillus and bifidobacteria cultures): a minimum of 5 billion to 10 billion colony-forming units per day
• Senna: Follow label instructions (usual dosage recommendation is based upon sennoside content: 15–30 mg sennosides at bedtime); use only on an occasional basis.