The first-line treatment for chronic constipation is to eat lots of foods that are full of fiber such as fruits and vegetables, to severely restrict processed foods, particularly those made from refined carbohydrates (bakery products, pastas and many dry breakfast cereals), and to exercise. If these lifestyle changes do not solve your problem, you may benefit temporarily by taking over-the-counter laxatives (J Clin Med, Apr 2021;10(8):1738), or by adding prunes, kiwi fruit or foods with psyllium (The Am J of Gastroenterology, October, 2020;115:S229).
Chronic constipation means:
• straining and difficulty expelling stool,
• a sense of incomplete evacuation,
• hard or lumpy stools,
• prolonged time for bowel movements, and/or
• a need for manual maneuvers to pass stool.
When to Check With Your Doctor
Debilitating constipation affects about 20 percent of North Americans and 33 percent of those older than 60 (Gastroenterology, Jan 2013;144(1):218-238). If you have tried the recommended lifestyle changes and are still constipated, check with your doctor who will look for more serious causes, such as:
• intestinal blockage
• cancers or other intestinal diseases
• kidney failure
• high blood calcium
• Endocrine problems such as low thyroid function or an overactive parathyroid gland
• strictures (narrowing of colon) or rectocoele (protrusion of the rectum)
• rectal cracks or infections
• weak muscles in the pelvis
• causes of nerve damage such as multiple sclerosis, Parkinson’s disease, spinal cord injury or stroke
Viral infections, such as herpes, Epstein-Barr, chicken pox or cytomegalovirus, can damage nerves to decrease peristalsis, the natural action of intestinal muscles that pushes food along the intestines (Cell Host & Microbe, June 8, 2016).
Lifestyle Changes to Treat Constipation
Our epidemic of constipation is due largely to our food industry that produces mostly ultra-processed foods that contain little or no fiber. People keep looking for constipation cures in a pill, but it is usually curable just with lifestyle changes:
• Diet: increase your intake of fiber, found in whole fruits, vegetables, whole grains, beans, nuts and other seeds. Try to avoid or limit refined carbohydrates (foods made from flour and added sugars) and other ultra-processed foods that contain little or no fiber.
• Exercise: Try to exercise every day. When you exercise while you have stool in your colon, you usually develop giant contractions that push stool along your colon. The longer and harder you exercise, the greater the movement of food toward the outside.
• Hydration: Drink plenty of fluid because dehydration increases the rate that fluid is absorbed from your colon to make your stool even harder.
• Staying Regular: Get in the habit of trying to empty your colon at the same time of day every day, and try not to let stool remain in your colon. When you eat, food is not allowed to pass into your small intestine until it is converted to a liquid soup in your stomach. This soup remains as a liquid until it reaches your colon, where the fluid is rapidly absorbed. The longer stool remains in your colon, the more water is absorbed, the harder stool becomes and the more difficult it is to pass. Try to empty your colon about half an hour after eating to take advantage of the gastro-colic reflex: When food reaches your stomach, the stomach is stretched, sending a message along nerves from the stomach to cause the colon to contract and push stool forward.
The Magic of Prunes
All dried fruits contain significant amounts of soluble fiber and sorbitol, which produce gas that helps to push stool along (Pediatr Gastroenterol Hepatol Nutr, Dec 2014;17(4):203-208). Prunes (dried plums) have a particularly strong laxative effect because they contain a compound called chlorogenic acid that stimulates the muscles that line your intestines and colon.
Soluble fiber helps to relieve constipation because your intestines lack the enzymes to break it down, so it is not absorbed until it reaches your colon. There bacteria ferment the soluble fiber into small particles called Short Chain Fatty Acids (SCFAs) that draw large amounts of fluids into the colon and produce gas that dilates the colon and pushes stool toward the opening. Prunes and other dried fruits also stimulate growth of healthful colon bacteria called Bifidobacteria that reduce inflammation (Avicenna J Phytomed, Sept, 2014;4(5):343-353) by causing increased production of a mucous layer that covers and protects colon cells from other harmful bacteria that try to invade the cells lining the colon (Clinical Nutrition, January 12, 2018). In one study, prunes were more effective than pills containing psyllium to treat constipation (Aliment Pharmacol Ther, 2011; 33: 822B828). To avoid excessive amounts of gas, take only a couple prunes at a time, and work up to five or more times a day or as many as you need. Soluble fiber has many other benefits; see How Soluble Fiber Promotes Good Gut Bacteria
You Need Both Soluble and Insoluble Fiber
Don’t worry about whether you are getting soluble or insoluble fiber; you need to eat both kinds, and you will get plenty if you eat a wide variety of fruits, vegetables, whole grains, beans, nuts and other seeds. If you are not eating enough fiber to prevent constipation, don’t try to correct the situation by adding fiber supplements, lots of bran cereal or foods made with added ground-up fiber. When you eat whole fruits, vegetables, seeds and other plant parts, you get all of the vitamins, minerals and phytochemicals that nature packages with the fiber. Introduce more high-fiber whole foods into your diet gradually to avoid temporary discomfort.
Drugs That Can Cause Constipation
Many common prescription drugs and over-the-counter medications can cause constipation. If you need to take any of these drugs and experience constipation, try the lifestyle changes listed above. If that does not solve the problem, talk with your doctor about altering your dosage or trying another medication. Drugs that can cause constipation include:
• blood pressure medications (calcium channel blockers, beta blockers)
• NSAIDS such as ibuprofen, Motrin, Aleve, naproxen
• drugs to treat urinary incontinence
• iron pills including multivitamins with iron
• antacids containing calcium or aluminum
and many more. Check with your doctor or pharmacist.