Most of us wouldn’t have a problem asking a doctor about allergy symptoms or the flu, but how can you get help for a serious problem when that problem is so embarrassing you don’t even want to talk about it? Constipation is one of those issues – just look at ads for yogurt and fiber supplements. Most of the ad is dedicated to telling you what the product does, without actually coming out and saying it. It “helps keep you regular” or treat “digestive irregularity:” the ad has to talk around the issue because making people feel uncomfortable or embarrassed doesn’t sell products.
This refusal to call a spade a spade might be fine for advertising purposes, but it won’t do much for people who want to understand their problems and actually get at the root causes, instead of just buying a pill or a box of yogurt and hoping it will work. It might be embarrassing or awkward at first, but the best way to get at the root of this issue is to talk about it frankly and understand the causes.
So what are the causes of constipation, and how can you treat it? As with so many other health problems, the answer is fairly complicated. Possible culprits range from thyroid problems to pregnancy to gut flora dysbiosis, and almost everything in between. By fully understanding these potential causes, you’ll be much better equipped to identify which one (or more) is relevant to you, and then take action accordingly to handle it.
For some people, constipation can be just a temporary side-effect of the transition from a modern to a Paleo diet. In the first few weeks of any new diet, especially if that diet is a radical change from how you were eating before, it’s normal for your body to need some time to adjust. Additionally, many people find that their bowel movements on Paleo are just smaller in general. This makes sense Paleo replaces grains with fat, which is much more calorie-dense, so the volume of food consumed on Paleo is often much smaller. This obviously makes for smaller bowel movements, especially if you’re also going from eating a calorie surplus to eating a calorie deficit (less food overall).
During the first week or so, give your body a chance to adapt before you assume that Paleo is obviously unhealthy. If you’re very uncomfortable during this period, using a bulking laxative (not a stimulant laxative; more on this below) or some of the other temporary fixes listed later in the article can help get you through the initial adaptation more smoothly.
But what if you’ve been on the Paleo train for months, or even years: obviously you aren’t still adapting, so what else might be wrong? One place to look might be your macronutrient intake. People who adopt a very low carb diet often report serious constipation problems. If you’re doing fine without any starches in your routine, this is no reason to switch, but if you’re having bowel troubles, upping your carb intake is definitely worth a shot. Make sure to get those additional carbs from glucose, not fructose, though – as discussed below, fructose intolerance is itself a fairly common cause of bloating and constipation, and you definitely don’t want to cause another problem while fixing the one you have.
One of the easiest causes of constipation to address is dehydration. Your body has a very sophisticated system for regulating how much water it absorbs and how much it excretes; if you aren’t drinking enough water, your body clings on to every last drop because it needs all that fluid to maintain blood volume and perform other important functions. Since you don’t have any fluid left over for less essential needs like pooping, the poop in your colon becomes very dehydrated and hard, which makes it difficult to pass and often painful on the way out. If you increase your water intake, your body will have more to excrete, so your feces will become softer and easier to pass.
There is no magic amount of water necessary for proper bowel function (it varies from person to person depending on age, activity level, and other factors), but since drinking more is such an easy and non-invasive remedy, it’s worth a try if you think it might be even a remotely plausible explanation.
In conventional diet wisdom, fiber is the king of healthy bowel movements. As well as eating plenty of fruits and vegetables, many people are routinely advised to take fiber supplements, and a whole industry of Fiber One products has sprung up around this supposedly miraculous additive.
So what exactly is fiber? Biologically, it’s a type of carbohydrate that isn’t broken down in your small intestine. This is why so many weight-loss diets advise eating foods high in fiber: it has a lot of bulk, but since it isn’t digested, you don’t get any calories from it (although your gut bacteria thrive on it). There are two types of fiber: soluble and insoluble. Both types of fiber are commonly regarded as being useful for constipation, but they work very differently. Soluble fiber is beneficial because it gives your gut flora something to feed on, helping you maintain a flourishing gut microbiome. Insoluble fiber, on the other hand, makes your stool more bulky, which stimulates the intestines to expel it more quickly.
Clinical studies have shown a correlation between fiber intake and regular bowel movements, but a closer examination of these studies shows that they might not be only about fiber. One study, for example, compared rural Africans eating a traditional diet to city dwellers in England eating a modern diet – the Africans got more fiber and had more regular bowel movements, but they also probably got fewer industrial foods and processed food products, fewer toxins, more exercise, and more sleep. Thus, these studies don’t necessary prove that fiber itself is the missing factor.
In fact, despite the advice we all get to increase our fiber intake, too much of the wrong kind of fiber can actually be damaging. While both types are commonly recommended as digestive supplements, too much insoluble fiber isn't healthy since it can be irritating to the intestinal wall in the long term. Occasional doses of insoluble fiber as a bulking agent aren’t necessarily harmful, but relying on a daily dose of it is just a way to mask a bigger problem. Most people get plenty of fiber from fruits and vegetables; if you’re constipated despite eating several servings of vegetables a day, the problem is probably not that you aren’t getting enough fiber. Barring occasional exceptions, you shouldn’t need Metamucil or other supplements just to have normal bowel movements. Instead of treating the symptoms, it’s more effective in the long run to address the real cause of your constipation.
Your gut flora – the friendly bacteria that inhabit your digestive tract – seem to be involved in almost every health-related issue, and constipation is no exception. Healthy gut flora help increase "intestinal motility," which is the scientific term for regular bowel movements. If you don’t have enough friendly gut flora (due to antibiotic use or a lifetime of poor dietary habits), one possible consequence is constipation. On the other hand, bacterial overgrowth (especially small intestinal bacterial overgrowth, or SIBO) is also dangerous: the ideal situation is to have a balanced population of gut flora, without either too many or too few.
Thus, disruption of the gut environment in either direction (too many or too few bacteria) can lead to constipation. In turn, constipation produces noticeable changes in gut flora, and also in immune response (since the gut flora are such an important part of the immune system, this shouldn’t be surprising). If these immune changes cause you to get sick, and take more antibiotics to treat the disease, the original problems can kick off a cycle of increasingly serious gut dysbiosis.
The solution to this problem is, of course, to treat the underlying gut flora dysfunction rather than constantly living with the symptoms. Prebiotics (supplements that help nourish friendly gut bacteria) and probiotics (supplemental bacteria either in pill form or in fermented foods) can both help. And while going low carb in the long term can contribute to constipation, a therapeutic very low carb diet for bacterial overgrowth can be helpful.
If you have the resources to go see a gastroenterologist about your constipation, you can get more specific about your efforts to restore your gut flora by finding out exactly what’s wrong. A hydrogen/methane breath test can discover any evidence of bacteria in your small intestine (where they shouldn’t be). In this test, a doctor gives you a dose of sugar (glucose or lactose), and then measures your breath afterwards – if you have bacterial overgrowth in the small intestine, the bacteria will ferment this sugar into hydrogen and/or methane, which will then be noticeable in your breath. Methane in particular is strongly associated with constipation-predominant Irritable Bowel Syndrome. This kind of test doesn’t give you a solution, but it can at least help you narrow down the problem (or alternatively, let you cross SIBO off your list of possible causes).
Eating certain foods that you’re sensitive to can also cause constipation. Dairy, for example, often causes chronic constipation in people sensitive to lactose or casein. If you’re eating lots of yogurt every day in an effort to get more probiotic bacteria, you might try switching to another source of probiotics (dairy-free fermented foods like sauerkraut and kimchi, or a probiotic supplement).
Intolerance to FODMAPs (a family of carbohydrates found in legumes and grains, as well as some fruits and vegetables) can also cause constipation in some people (in others, it causes diarrhea). Fructose is one type of FODMAP that some people are particularly sensitive to; fructose malabsorption can cause constipation even in people who aren’t sensitive to other FODMAPs. The good news is that restricting or eliminating these foods often frees you from the digestive symptoms associated with them. This isn’t always easy to do on a Paleo diet (especially if you’re also balancing other food sensitivities like eggs or nightshades), but a 30-day elimination diet for FODMAPs or just for fructose might be able to give you some useful information.
Low Stomach Acid
The pharmaceutical industry spends so much time and money getting us to buy Tums and other antacid drugs that it seems ridiculous to cite “low stomach acid” as a problem. But in fact, most people actually have it backwards: having too little stomach acid is a more common problem than having too much.
As well as being the real root cause of acid reflux (if you don’t have enough stomach acid, your food is never digested, so it stays in your stomach and the pressure forces acid up into your esophagus), low stomach acid can also lead to serious constipation issues. For the digested food in your stomach to empty into the small intestine, it first has to reach a certain level of acidity, so low stomach acid can gum up the works and cause serious bloating and discomfort. Especially if you feel like your food just sits in your stomach like a brick, you may be suffering from this problem.
Fortunately, the solution is widely available and fairly cheap: Betaine HCL supplements are available online or over the counter at most health food stores. To find the correct dose for you, start with one tablet taken just before you eat, and add another tablet with each successive meal, until you feel a slight warm sensation in your stomach and throat. Go back to one tablet less than the dose that caused the warm sensation.
If you’re skeptical of taking acid as a supplement, you could also try increasing your intake of acidic foods. Vinegar is the most common example of this – a tablespoon full of apple cider vinegar in a glass of warm water or some balsamic sprinkled over a salad is often plenty for people with less serious stomach acid deficiencies.
Although scientists don’t completely understand the gut-brain axis, researchers are increasingly discovering that mental health plays a significant role in the development of all kinds of functional digestive symptoms, including constipation. For example, one study found that children enduring stressful life events (from divorce to warfare in their home country) had significantly higher rates of constipation than non-stressed children. Anxiety and depression are strongly linked to irritable bowel syndrome (IBS).
This makes intuitive sense to many people – when stress and tension often causes a stomachache or “ties your stomach in knots,” so it’s not such a stretch to understand how it might affect other parts of the digestive system as well. A more frustrating question is what to do about it: stress seems to be a chronic feature of modern life and in many ways chronic stress is even harder to tackle than dietary changes.
For some ideas on tackling a chronic stress load, see this article on stress and the modern lifestyle – it isn’t easy, but it’s possible to at least reduce the burden of stress in your life, if not eliminate it entirely.
As many trans-Pacific travelers have learned from uncomfortable experience, physical inactivity can bring on occasional constipation even in people who don’t usually have any problems. Maintaining a base level of daily activity is the best way to prevent this from becoming a problem, but travelling or special events can sometimes disrupt your plans. As soon as you get back to your regular physical activity, the problem will go away by itself; in the meantime, some of the short-term solutions below can help move things along.
Pregnancy can also cause constipation, not only from the hormonal changes, but also because of the amount of space the fetus takes up and the angle of the uterus relative to the colon. While it doesn’t happen to all women, it’s fairly common, and it’s certainly uncomfortable. More serious medical conditions can also have digestive symptoms: thyroid problems and Celiac Disease, for example, often cause constipation among other symptoms. If you’re only suffering from constipation without any other problems, this type of disease is unlikely to be the cause, but if you also have other symptoms typical of thyroid problems or Celiac, it might be a fruitful avenue to explore.
Most people’s first instinct when they’re constipated is to drive 20 miles across town to a pharmacy where nobody knows them and shamefacedly stock up on laxatives. This is exactly what advertisers want you to think of; this is why they spend so much time talking about “digestive irregularity” and showing pictures of little yellow balls floating around your stomach as though actually discussing normal body functions were somehow shameful. If they keep you too embarrassed to seek out a long-term solution and constantly needing quick relief, they can keep selling that quick relief to you in the form of Ex-lax.
This should already make you suspicious of these products – they’re designed to make money for pharmaceutical companies, not do anything for you. In fact, many of them are actually downright harmful, but to understand this, it’s important to distinguish between the two types of laxatives: bulking or osmotic laxatives, and stimulant laxatives.
Bulking agents do exactly what they sound like: they add more volume to the stool in the intestines, which prompts your body to expel it more quickly. This is why fiber supplements are commonly recommended as gentle laxatives. Many of this type work through osmosis – they draw more water into the stool, which makes it softer and easier to pass, as well as larger. This isn’t harmful if you only use these products occasionally, so for a one-time problem (like constipation brought on by the Paleo transition period or a day of travelling), bulking laxatives aren’t a bad way to get things moving. With continuous use, though, these can become irritating to the gut, so they aren’t a long-term solution.
The other type of laxatives, stimulant laxatives (such as Ex-lax), are severe gut irritants: that’s actually how they work (by irritating the wall of the intestinal tract, they stimulate it to contract, pushing its contents out of your body). If you’re already struggling with gut flora imbalances and an intestinal environment damaged from years of unhealthy food, this is the last thing you want to do to yourself. As well as damaging the gut lining, these laxatives are also dehydrating, and can bring on more severe problems like an electrolyte imbalance because they force your body to expel too much at once. If you have to take a laxative, stimulants should be your absolute last choice.
As you can see, laxatives aren’t an ideal way to approach constipation, especially for a recurring problem. The long-term solution is to treat the underlying cause – whether that means restoring your gut flora, adding more carbohydrates to your diet, or identifying what foods you’re sensitive to. But in the short term (or as an additional aid), several home remedies are useful as band-aids.
Caffeine is one of these: caffeine is a stimulant and a diuretic, which means that not only does it excite your muscles, but it also helps draw water out of your body. Since feces are pushed out of your body by internal muscle contractions, caffeine can help stimulate the urge to poop (this is why so many people head to the bathroom after their coffee in the morning). The diuretic effect draws water into the stool, which makes it softer and easier to pass. Essentially caffeine is a very gentle version and more natural version of a stimulant laxative like Ex-Lax.
Magnesium supplements are another common solution. If you choose this route, it’s better to get Magnesium Citrate than Magnesium Oxide – the Oxide looks cheaper on the bottle, but it isn’t as well absorbed by the body, so you’ll need more of it to get the same effect and the price difference disappears. Take the magnesium before bed, since most people find that it makes them sleepy.
Physical activity of various kinds can also help – many people find that just getting regular exercise of any kind helps keep their bowels regular. Some specific yoga poses are commonly helpful: for example, try lying flat on your back, and pulling one knee up to your stomach. Hold it there for a few minutes, then switch knees. Sit-ups and other abdominal exercises also help some people. Abdominal massage is a more involved form of physical therapy that was once much more commonly prescribed as a treatment for constipation than it is now. The obvious advantage of these physical treatments is that they have no chemical side effects, so they’re completely safe to continue indefinitely (unlike laxatives). Like drinking more water, they’re so easy and cheap to try that there’s no real reason not to – at worst, the only benefit will be nicer abs!
As a symptom, constipation can point to a variety of different root causes – the real culprit behind it might be local to the gut (an imbalance in gut flora or a reaction to a food intolerance) or something apparently unrelated, like stress. Like a fever, constipation is more a symptom than a problem in itself, and the best way to treat it is to find out what’s causing it. Relying on fiber supplements or short-term laxatives is like taking fever reducers for tonsillitis: it might bring relief in the moment, but the best way to get long-term help is to treat the underlying problem so you don’t have to rely on pharmaceuticals. If you have no clue what might be causing your constipation, start with the easy fixes (drinking more water or adding a probiotic supplement) and use process of elimination to figure out what’s ailing you; it might take a few experiments to figure it out, but the result is definitely worth it.
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