If you're a regular reader, you know I usually provide a short and long answer to nutrition questions, but, unfortunately, there is no short answer for this one because it really does depend (no, not that kind of Depends - that's a completely different problem!).
What is constipation?
Constipation is defined by having difficulty emptying the bowels, which typically presents itself by having less than 3 bowel movements per week (1). Regardless of frequency or difficulty passing stools, however, if you don't feel regular and you feel backed up, it's not fun.
I won't go into much detail, but I spent the years from 2012 (during the end of high school, going into college) to 2017 (going into my dietetic internship) feeling constipated.
There were many times I didn't want to do anything at all because I felt so backed up, heavy, and fatigued. Often times I didn't even want to eat anything even though I knew I was hungry. My doctor said this was likely because my stool was backing up into my small intestine, which was pushing on my stomach, causing it to feel full. I spent many nights crying myself to sleep, hoping I would wake up in the morning and have a bowel movement.
On the other hand, my sister was suffering from the opposite issue: diarrhea. I was jealous. No one should ever wish they had diarrhea, that's not fun either.
I tried everything. First, it was x-rays and sitz markers to make sure my intestines were, indeed, packed with stool (they were). Then it was dietary changes: drink more water, eat prunes, have more vegetables. Then supplements: probiotics, miralax, magnesium citrate, milk of magnesia. Then it was drastic action: ducolax (brand name for bisacodyl, the medication used for colonoscopy preparation - not fun, very painful), enemas (ugh!), Linzess (medication for irritable bowel syndrome)...I just wanted to poop!
The trouble was, all of these treatments only quelled the symptom. I wanted to know why I was constipated in the first place. Throughout those five years I researched and researched, and spent time working with dietitians who specialized in gastrointestinal (GI) issues. I wanted to become an expert, too, so that I could better understand the GI system and help prevent people from going through the same suffering as I did.
At some point I was diagnosed with Irritable Bowel Syndrome (IBS), but, this is only a group of symptoms and can be triggered be a number of issues including stress, small intestinal bacterial overgrowth (SIBO), infection, and food intolerance(s). It still did not solve the underlying issue.
What causes constipation?
Many things! IBS (which has multiple triggers as mentioned above), changes to normal routines and eating habits, like traveling or starting a diet; conditions with hormonal changes like hypothyroidism, which slows down metabolism; physical inactivity, which slows movement of stool through the GI tract; aging, colorectal problems, not drinking enough water, a low-fiber diet, overuse of laxatives, Celiac's Disease, conditions that affect the nervous system, like Multiple Sclerosis and Parkinson's Disease; and pregnancy, which causes hormonal changes, physical changes (uterus pressing on intestines), and potentially changes in diet and physical activity (1).
Eventually my chronic constipation got better over time as I started figuring out what foods my body liked and didn't like, worked on healing my gut, made sure to get enough exercise, and decreased stress as I realized this was a major trigger for me. My constipation was the worst during the most stressful periods of my life: starting college, during my junior year of college (always the hardest), and starting my dietetic internship. It was really only after I became a dietitian that this huge weight of stress was lifted from me. This thing I had been anxious about for the past five years had finally been achieved and I could live my life now without worrying about so many little things.
Yes, non-school life has it's own stressors too, and don't get me wrong, I feel those, but for whatever reason this was very unique for me. I feel like I can take on most things knowing I at least achieved this big, life goal of mine.
How to treat constipation:
These are the steps I would try in order of least invasive to most invasive, but it will really depend on the cause.
For example, eating more fiber is not always the answer. Sometimes, you are eating plenty of fiber, but not drinking enough water, so your stool is bulked up, but hard as rock so it's having a difficult time exiting your colon.
1. Water, water, water!
Water is the most important nutrient. Make sure you are well-hydrated, otherwise your stool will be very dry and hard. Drinking warm water may also be beneficial.
2. Addressing specific foods
Some major contributors to constipation are wheat and/or gluten and dairy (especially cheese). Try eliminating one or both of these foods for 2 weeks to 1 month to see how you feel, then add them back in. It may be these foods themselves that cause issues, or they end up taking up a large part of the diet, so they displace healthier, higher fiber foods. If you eat wheat-containing products, make sure they're whole grain, and use cheese as an accent to higher fiber foods, like sprinkling on roasted broccoli.
If you suffer from IBS, you may be reacting to specific foods high in Fermentable Oligosaccharides, Disacharides, Monosaccharids And Polyols (FODMAPs), which are certain sugars in food that are easily fermentable by bacteria in the small intestine - often a result of Small Intestinal Bacterial Overgrowth (SIBO), a common cause of IBS symtptoms. High-FODMAP foods are those such as garlic, onions, beans, sugar alcohols, and gluten-containing grains (wheat, barely, and rye). Following a low-FODMAP diet may be recommended by your healthcare provider if you have IBS, but it should be followed closely with the guidance of a dietitian.
This is something that I struggled with for a long time before I knew what was going on. During my freshman year of college I went vegan (I'm not anymore) and I was bloated so much all the time, my stomach looked and felt like I had a balloon inside of it! I've now been able to add most foods that were causing me issues back into my diet.
3. Digestion
Digestive Enzymes
Make sure you are digesting your food properly. When and if you do have a bowel movement, check to see if there are any undigested pieces of food in it. If there are, try drinking warm water with 1 tsp to 1 Tbs lemon juice and/or apple cider vinegar, ginger tea, or chew on raw ginger root 10-15 minutes before a meal. This will help produce the digestive enzymes you need to break down your food.
Eat Mindfully
Also check in on how you are eating. If you eat really quickly, slow down. Make sure you are chewing your food well and making your meal last 20-30 minutes. This will ensure everything you eat is digested properly. It was also prevent you from overeating, which can put undo stress on your digestive system.
Try to limit distractions while eating as well and just focus on the meal. Research shows our digestive ability decreases by 30%-40% when we are distracted while eating.
Hum Or Gargle Before a Meal
Something called the vagus nerve runs from the brain and down the spine. It has tons of nerves connected to the intestines. This is why what's happening with our gut impacts our mind and vise versa. Stimulating the vagus nerve through humming or gargling can help stimulate digestion.
4. Fiber
Fiber is essential to a healthy BM because fiber is what makes up a lot of our stool! Fiber is something we do not actually breakdown, but instead it feeds the healthy bacteria in our colon. When bacteria consume fiber, they produce something called short chain fatty acids (SCFAs). These SCFAs feed the cells in our intestinal tract and keep them healthy.
There are two main types of fiber: Insoluble and soluble.
Insoluble fiber is necessary for moving stool through the digestive system, while soluble fiber is great at bulking up the stool as it is water-soluble and absorbs liquid.
I think about it like this: if you were to eat only insoluble fiber, your bowel movements would be more on the liquid side, but if you ate only soluble fiber, you might have a mass of hard stool sitting in your colon, with nothing to help move it along. You need both to have a perfect poop. A number 3 or 4 on the Bristol Stool Chart (Photo source) is what we're after.
Sources of insoluble fiber include:
Non-starchy vegetables
Fruit or vegetable skins (like apple or potato skins)
Nuts & seeds
Whole grains (like wheat bran, if tolerated)
Sources of soluble fiber include:
Fruits, especially berries (raspberries in particular), apples, apricots, kiwifruit, and figs.
Starchy vegetables
Beans & Legumes
Hydrated chia seeds*
Hydrated flax meal*
Avocados
Whole grains, especially oats, buckwheat, and quinoa
Dark chocolate (at least >75% cocoa)
Psyllium husk powder (also a supplement)
*Chia seeds and flax meal are very water-soluble, so if you eat them without hydrating them first, make sure you drink LOTS of water, otherwise, they will steal water from the stores in your body, dehydrating you as they hydrate, or cause a very hard stool. Hydrated seeds, though, are fantastic for good bowel movements.
Chia pudding is usually a perfect, perfect poop recipe. I love making overnight oats with chia seeds and/or flax meal, then adding fruit and nuts for a fantastic fiber-filled portion of breakfast.
How much fiber do I need?
The average adult women needs about 25 grams per day, and men need about 38 grams each day. It is perfectly fine to have more fiber than that, just make sure to drink enough water along with it.
Getting enough fiber is easy when focusing on whole foods and following a balanced plate:
Other foods that feed friendly gut bacteria
Fish & Shellfish
Olives & Olive Oil: The antioxidants feed bacteria, but monounsaturated fats also help lubricate the intestines to help move stool through and pull water into stool to help soften it (2).
Resistant Starch: Overnight oats, cold rice, cold potatoes, cold pasta, green bananas - this type of starch is resistant to digestion, so it helps feed friendly bacteria.
Coffee: Antioxidants in coffee help feed healthy bacteria
Foods that feed unfriendly bacteria or inhibit growth of friendly bacteria
Saturated fats: Coconut oil, palm oil, butter, animal fats
Refined starches: White flour, products made with white flour (bread, crackers, cookies, etc.)
Refined sugar: White, table sugar, corn syrup, high fructose corn syrup, etc.
5. Lifestyle Shifts
Positioning: Use a Squatty Potty® or pull your knees up when going number 2: This helps align your colon, making it easier for stool to exit your body. When we sit at a 90° angle, we create a kink, which makes it harder for stool to move through (Photo source):
Physical activity: Walk or run daily, or as many days as possible - this stimulates the intestinal tract as well as helps promote growth of healthy bacteria.
Abdominal massages: Perform these lying down, especially along the colon: This will help stimulate the intestines to help move stool along. I love to do this prior to going to bed .
Supine Spinal Twist: Lay on your back and pull your right leg across your body, hold for as long as you like. Repeat with the left leg.
Cat Cow: On your hands and knees, inhale as you tuck your stomach in and hunch your back, then exhale as you arch your back.
Manage Stress: Stress causes the body to be in "fight-or-flight" mode, which shuttles blood to vital organs and limbs, preparing the body to either battle, or flee. It shuttles blood away from the intestines because the last thing the body wants to do in that situation is pause to go number 2. We want to be in "rest-and-digest" mode in order for our bodies to have healthy BMs. Stress management looks different for everyone, so do what works for you. For me, there are two things that work really well. One is spending quiet time in the morning in the word of God. I relax knowing I can take comfort in Him, which is not something I realized way back when I was having issues. I had put everything on myself. The other is playing the game 7 Little Words on my phone while drinking coffee in the mornings. This game in particular takes my full attention, so I'm unable to think about any stressors, which helps me relax, and the coffee helps move things along.
Get Enough Sleep: Sleep ultimately affects every system in the body. It's a way for our bodies to recover and is vital to overall health. A good night's sleep get's us in "rest-and-digest" mode. Poor sleep increases the stress hormone, cortisol, sending us back into "fight-or-flight" mode.
6. Supplements & Natural Stimulants
Always talk to your doctor before beginning any supplements
Prunes: Contain a sugar alcohol called sorbitol, which pulls water into the stool, having an oxmotic laxative effect. They also contain fiber.
Coffee: Stimulates the intestinal muscles and helps move stool through the GI tract.
Probiotics: Probiotics are bacteria. If for some reason you don't have enough friendly bacteria in your colon (ex. after taking antibiotics), supplementing may be beneficial. Food sources include fermented foods like yogurt, kefir, kombucha, sauerkraut, and kimchi. For supplement sources, consult your doctor. Commonly recommended supplements include Culturelle and Align.
Psyllium husk powder or Metamucil: A very water-soluble powder that helps bulk up stool.
Natural Calm (magnesium citrate), Milk of Magnesia, or Magnesium Citrate: magnesium helps calm and relax muscles and has an osmotic laxative effect. Be careful though, too much can lead to diarrhea.
Miralax: Has an osmotic laxative effect. Usually works overnight.
Conclusion:
I hope this helps! If you are still having issues with constipation, consult your doctor and/or make an appointment with a dietitian.
Sources
1. Felman, Adam. Constipation: Causes, Symptoms, Treatments, and more. Medical News Today. Nov. 13, 2019. https://www.medicalnewstoday.com/articles/150322#children.
2. Berry, Jennifer. Olive oil and Constipation: Remedies, other treatments, and causes. August 16, 2018. https://www.medicalnewstoday.com/articles/313416#treating_constipation_with_olive_oil.