One of the most common concerns that comes up in my practice is constipation, often a topic one only wants to discuss with their doctor, if even that. Although survey data varies, it is estimated that 42 million American adults struggle with this at one time or another. Constipation is characterized by infrequent bowel movements (less than 3 times per week), hard, dry stools, and/or difficulty with passing stool.
The new criteria for functional constipation, Rome IV, are at least 3 months of the following symptoms:
1. Two or more of the following:
-Straining during more than 25% bowel movements.
-Hard stools in > 25% of bowel movements (use Bristol Stool Scale to determine if your stools are in this category).
-Sensation of incomplete defecation >25% of the time.
-Sensation of blockage in the anal and rectal region >25% of the time when trying to have a bowel movement.
-Needing to manually evacuate the stool >25% of defecations.
-Less than 3 spontaneous bowel movements per week.
2. No or rare loose stools, unless laxatives are used.
3.There are not enough criteria to satisfy the Irritable Bowel Syndrome diagnosis.
Constipation can be caused or exacerbated by lack of movement, insufficient hydration, caffeine, stress and diet (not enough fiber, too many refined grains (think white bread or white rice), processed food, dairy and meat. It can be a side effect of medications (e.g., narcotics or antihypertensive medications), or it can be part of irritable bowel syndrome and small intestinal bacterial overgrowth. There is also the possibility of secondary causes, ranging from hypothyroidism, diabetes, Parkinson’s disease, or even colon cancer, so please don’t shy away from discussing constipation with your physician.
My Top 3 Tips For Constipation
- Evaluate and, if needed, improve your FIBER intake (think of all the vegetables, fruit (except bananas, which can worsen constipation), legumes and whole grains, and find a way to insert them in your diet, while eliminating or significantly reducing processed food and refined carbs). According to Institute of Medicine, adult men (up to 50 years of age) should have 38g of fiber per day and adult women (up to 50 years of age) should have 25g of fiber per day. Talk to your licensed healthcare practitioner to find out if fiber intake is something you need to change. Ensure that you are well hydrated, that you move every day, and don’t delay going to the bathroom!
- Talk to your doctor about whether any of your medications could be causing constipation, and whether, in addition to lifestyle and diet improvements, over the counter medications may help you. Psyllium (Metamucil; fiber), docusate (Colace; stool softener) and Polyethylene Glycol 3350 (Miralax; osmotic laxative), are typically tried first. Senna, a stimulant laxative, is more potent and can have significant concerns for dependence. This is often reserved for opioid-induced constipation. There are other agents used to manage constipation that can be quite effective, if the above choices fail or are contraindicated. Speak to your doctor about other options that may be helpful to you.
- If you are anemic, have low energy, blood in stool, change in caliber of stool (especially thin stools), unintended weight loss, stomach pain, nausea and/or vomiting, or any other concerning symptoms, see your doctor ASAP for further evaluation.
When I see a new patient, I take the time to get to know my patient’s story. This story goes far beyond her or his medical conditions, but encompasses lifestyle, sources of support, family and relationships, sense of purpose and sources of joy and stress. So, when it comes to constipation, it’s important to know if there are other associated symptoms, such as bloating and gas, that may suggest small intestinal bacterial overgrowth. Is there also weight gain and fatigue, which may suggest an underactive thyroid. I review their diet, hydration, activities, stress levels, and other relevant factors, to come up with a customized, comprehensive, evidence-based plan that will not only alleviate their symptoms, but get to the root of the problem and help prevent future disease.
Remember, healthy gut is essential for a healthy metabolism, and has implications in both physical and mental health. Gut microbiome and integrity of our gut wall play important roles in our regulation of weight gain or loss, inflammation and mental health, so pay attention to what your gut is telling you!