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CONSTIPATION

Updated 7/24/2013   


         Dr. Bernard Presser D.C.

5696 Magnolia Woods Drive

Memphis, TN 38134



 

If you have any questions, please contact us at 901-417-7905

 More articles coming soon.

 


Like happiness, constipation "is different things to different people".  But that's where the similarity ends.  Constipation is a common complaint with one out of eight people reporting difficulty with bowel function.  Women are twice as likely to complain as men.  One third of people over age 60 have trouble.  Afro-Americans say they are constipated more often than caucasians.  Sedentary individuals, people with low incomes, and those with fewer years of formal education are more likely to report constipation.  In one survey, 71% said they used laxatives at least occasionally.

"Because of the wide range of normal bowel habits, constipation is difficult to define precisely."  Seven out of 10 people have a good bowel movement once a day.  Some people have two or more in a day while others have a movement every two or three days.  There is "no such thing as a ‘normal bowel pattern' that everyone should aspire to."  It is uniquely individual.  Anywhere from three to 20 bowel movements a week may be normal, depending on many factors.

Some people define constipation as straining to have a bowel movement.  Others define it in relation to frequency of movements.  Stool frequency alone "is not a sufficient criterion to use," because many constipated persons have regular or "normal" frequency, yet describe excessive straining, hard dry stools, lower abdominal fullness (bloating, discomfort), and a sense of incomplete evacuation.

Both the color and consistency of stool can vary within wide limits and still be considered normal.  A moderately firm consistency - a "formed" stool - and colors from light to dark brown fall within the norm.  Food can modify color since the pigments that color some vegetables may not be changed by the digestive process and will tint the fecal material.

Elderly people are more prone to constipation, though it is not a normal consequence of aging.  Rather, they are more likely to suffer from chronic illnesses, have impaired mobility, take more medications, and often have poor diets with fewer whole and fresh foods.

Constipation can be associated with a wide range of illnesses - obstructing lesion of the colon, multiple sclerosis, appendicitis, Crohn's disease, ulcerative colitis, irritable bowel syndrome, Hirschsprung's disease, diabetes mellitus, scleroderma, lesions of the central nervous system, hypothyroidism, diverticulitis, chronic inflammatory bowel disease, multiple chemical sensitivities and/or food sensitivities, etc.  Some medications can lead to constipation including antipsychotics, antidepressants (e.g. Elavil, Prozac), codeine and other narcotic analgesics, aluminum- or calcium-containing antacids, sucralfate antacid (Carafate), some bile acid supplements used to treat high cholesterol, oral contraceptives, non-steroidal anti-inflammatory drugs (e.g., ibuprofen, naproxen), calcium antagonists (e.g. Cardizem) inorganic high-potency iron supplements.

For the majority of people, though, "no obvious [clinical disease] cause can be identified."

CAUSES

When no disease is present, constipation is most likely "functional," -- resulting from an interaction of factors that may encompass physical, dietary, and/or emotional issues.

Disturbed or altered colonic motility (the power of the colon to move spontaneously) is frequently a cause.  Peristalsis, the progressive wavelike movement from circular contractions of smooth muscles, normally and involuntarily propels the contents of the colon toward the rectum.  Motor activity of the gastrointestinal tract is controlled and coordinated by intestinal nerves that receive input from the autonomic (sympathetic and parasympathetic) and central (brain and spinal cord) nervous systems.

Disruption of parasympathetic stimulation to the colon may produce constipation with lowered motility, colonic dilatation, decreased rectal tone, and impaired defecation.  This may be due to injury, misalignment, or lesions of the lumbosacral spine or encroachment or damage to sacral nerves.  Nutritional deficiencies which affect the nervous system can be significant contributors.  Metabolic changes or disturbances may influence bowel function, including pregnancy (possibly due to altered estrogen and progesterone levels), hypothyroidism, diabetes, hypercalcemia (elevated calcium including hyperparathyroidism), etc.  Anxiety, depression, or other psychological matters may be involved.

Altered rectal sensation or motor function can cause constipation.  Entry of feces into the rectum arouses the desire or urge to defecate by stretching the nerve receptors in the rectal mucosa.  If this sensation is reduced or ignored, stool remains in the rectum rather than being evacuated.  Inappropriate contraction or failed relaxation of rectal muscles may be involved, a condition in which the rectum and external anal sphincter (circle of muscle) cannot properly contract or relax.  This can be a learned - rather than an organic or neurogenic -- problem.

Pelvic floor resistance is a primary expulsion mechanism during defecation.  It is important that the pelvic floor muscles are trained.  Since the learned habit may have begun in childhood, an adult may have to reprogram those muscles.  Sometimes biofeedback can help teach how to voluntarily relax the appropriate muscles.  Chronic straining at defecation may lead to descent of the perineal floor and stretching of the pudendal nerve, causing an incompetent anal sphincter and fecal incontinence.  Similarly, rectal prolapse or rectal herniation may interfere with defecation.  Encroachment on sacral nerves can reduce rectal sensations.

Disregarding the urge to defecate because of inopportune circumstances, inability to spend the time, or development of toilet habits during childhood are frequent sources of bowel difficulties.  Excessive time in the bathroom - a search for emotional and physical privacy - may upset bowel function.  Dietary changes, emotional stress, travel, or shyness (e.g., using communal toilets in military barracks or school dormitories) can cause a sudden change in bowel habits.

The makeup and volume of bowel contents is an essential consideration.  Ingesting sufficient fluid, consuming adequate and varied amounts of dietary fiber, obtaining ample quantities of nutrients for gastrointestinal health and function, and supporting bowel bacterial balance are all necessary to create and maintain a healthy colon and normal bowel function.  Liver and/or gallbladder congestion or dysfunction causes diminished biliary secretion, affecting both digestion and excretion, and contributing to constipation.  Gallstones and constipation have been linked in studies.

Constipation is not a disease, but chronic constipation can lead to health problems including hemorrhoids (cause or irritate), anal fissure, fecal impaction, rectal prolapse, urinary retention, etc.  When constipation exists, waste matter moves too slowly, more fluid is absorbed (resulting in small, hard, dry stools), and feces remain in the bowel longer so it putrefies and becomes toxic.  "If these toxins are not eliminated, they may be absorbed into the system and get stored in the body's fatty tissue," says Linda Berry, D.C.

Reduced fluid intake or excessive fluid loss (vomiting, exertion in hot temperatures or high altitudes, etc.) will deplete the water available to the colon.  A high concentrated-protein diet (meat, seafood, eggs, cheese, etc.) reduces the volume of intestinal waste and is associated with low stool weights (hard, dry stool).  A diet high in whole, natural carbohydrates (whole grains, legumes, fresh vegetables and fruits) increases the volume of intestinal contents as well as fecal output. i

LAXATIVES

"Except for bulk laxatives, routine use of laxatives over long periods of time should be discouraged because of the risk of side effects..." Overuse of pharmacologic (drug) laxatives or extended use of enemas or colonics may actually cause constipation.  They can result in suppression of the defacatory reflex ("lazy bowel"), dilation of the lower bowel, and possibly haustra in which the bowel wall no longer folds normally.

Stimulant laxatives include anthraquinones (aloe, cascara sagrada, senna, rhubarb, etc.), castor oil, and diphenylmethanes (Perdiem, Correctol, Dulcolax, Senokot, etc.).  These laxatives directly increase intestinal motor activity.  Stimulant laxatives and hyperosmolar agents may stimulate the mucosal nerve plexus or they may work by local irritation of the intestinal mucosa (inner lining).  They can produce excessive irritation, cramping, and significant fluid and electrolyte disturbances.  Occasional use is generally safe, particularly with the natural items as aloe, cascara sagrada, rhubarb, and senna.  Long-term use, though, can produce dilation, lazy bowel, smooth muscle atrophy (wasting) or damage intestinal nerves.

Hyperosmolar agents include mixed electrolyte solutions (sodium sulfate, sodium bicarbonate, potassium chloride, sodium chloride) containing polyethylene glycol and nonabsorbable sugars such as lactulose and sorbitol, which act as osmotic agents.  They cleanse the bowel by inducing diarrhea and are used prior to barium enema and colonoscopy examinations.

Saline laxatives contain nonabsorbable cations and anions (atoms with a positive or negative electric charge) that increase fluidity of intestinal contents by retention of water via osmotic forces, indirectly increasing motor activity.

Lubricant or emollient laxatives act by softening the feces and reducing friction between them and the intestinal wall.  These include mineral oil and docusate salts. Lubricant laxatives by themselves may have some role in short-term treatment, but are generally ineffective in the long run.  These agents are most useful when straining with defecation must be avoided.  Mineral oil interferes with the absorption of fat-soluble vitamin complexes (A, D, E and K), depleting the body of these beneficial nutrients.

Bulk forming laxatives stimulate evacuation of the bowel by increasing the bulk of the feces.  These included natural or synthetic polysaccharides (sugars) or cellulose (carbohydrate derivatives that act in a similar manner to fiber).  Plenty of fluid should be taken with these preparations since they are quite absorbent.  Chronic use of pharmacologic laxatives can be "dangerous" and is not a solution to the constipation condition. ii

FIBER

"Initial therapy" for constipation "is usually dietary, with an emphasis on increasing dietary fiber intake."  Many constipated people definitely respond to additional dietary fiber.  Increases in stool weight and frequency of defecation occur along with decreases in gastrointestinal transit time.  The bulking effect of fiber on stool may be due to additional water retention, proliferation of colonic bacteria, and proper production of gases in the stool.

Insufficient fiber in the diet is the most common cause of constipation.  Dietary fiber absorbs water and fats, softening the stools and making them easier to pass.  Current intakes average only about 12 to 17 grams per day but should be 20 to 35 grams daily.  Diverticulosis, a condition in which small pouches form in the colon wall, is almost always a result of a low fiber diet and from pressure of straining during bowel movements.  Sufferers usually find increased fiber consumption alleviates symptoms such as constipation, and/or diarrhea, abdominal pain, flatulence, and mucus or blood in the stool.

Fiber is the part of vegetables, fruits, whole grains, nuts, and legumes - plant foods - that passes undigested through the stomach and small intestine.  Refined and processed foods have little or no fiber remaining.  This includes refined grains (e.g. "white flour," white rice, commercial cereals, most breads), vegetables and fruits that have been peeled or juiced.

Since high fiber foods contain innumerable vitamin complexes, minerals, phytochemicals, and other natural substances, researchers cannot say for certain that fiber alone is responsible for the benefits they observe when such foods are consumed.  Whole natural foods are a package of many healthful, cooperative components.  "Moreover," notes FDA nutritionist Joyce Saltsman, "no one knows whether one specific type of fiber is more beneficial than another since fiber-rich foods tend to contain various types."  It is when humans alter or process foods that difficulties develop, including constipation.  "In populations in which fiber constitutes a major portion of a diet, conditions such as constipation, diarrhea, hemorrhoids, gallstones, hiatus hernia, varicose veins, appendicitis, and heart disease are unknown."

There are two basic types of fiber: soluble and insoluble.  Soluble fibers (mucilages, pectins, gums) form a gel when mixed with liquid.  They lubricate the fecal material and increase bulk, making elimination easier.  This type of fiber is abundant in prunes, flaxseed, oats, beans, barley, carrots, potatoes, apples and psyllium.

Insoluble fiber does not gel and is found in whole wheat, brown rice, other whole unrefined grains, unprocessed vegetables, fruits, edible seeds (sunflower, pumpkin, sesame, etc.).  It unquestionably aids bowel regularity, prevents constipation, hemorrhoids, diverticulosis, etc.

Fiber is nature's "broom," increasing stool weight and the speed stool travels through the intestines.  It decreases abdominal discomfort and stool frequency.  Over-cooked or over-processed foods become only a "mop" rather than a broom.  So vegetables and fruits should be consumed raw or lightly cooked; nuts and seeds should be eaten raw; grains and beans should be properly prepared.

Use whole-grain cereals, those that contain at least 5 grams of fiber per serving.  Top with fresh raw fruit or dried fruit.  Eat unprocessed grains: whole wheat bulgur, kasha, whole-grain breads, stone-ground corn meal, brown rice, millet, quinoa, amaranth, whole rye, steel-cut oats, whole grain flours.  Whole grain berries or groats can be sprouted.  When possible eat vegetables and fruits raw, (shredded, grated, minced if needed).  When vegetables are cooked, steam or bake only until tender but still firm to the bite, a bit crunchy.  Keep fresh and dried fruit on hand for snacks or dessert.  Buy organic foods when possible so peeling fruits and vegetables will be unnecessary.  Make raw vegetable and/or fruit salads a daily part of the diet.  Dip vegetable crudits in yogurt-based or tahini-based or bean-based dips.  Add raw seeds to salads, or mix nuts and seeds with dried fruits for a treat.  Add legumes to soups, stews, salads, grains, vegetables.  Beans should be soaked (depending on type and size, from 2 to 12 hours; discard soaking water) before cooking.  Lentils, mung beans, and others can be sprouted.  Legume-based dishes (lentil soup, bean burritos, rice and beans, etc.) can sometimes substitute for meat.  Top a baked potato with steamed vegetables or cooked beans.

James Duke, Ph.D., is convinced that diet can control constipation.  "Every whole-grain item and every fiber-rich fruit and vegetable helps prevent and relive constipation.  In folk medicine the foods that get special recognition as laxatives include almonds, apples, avocados, chicory, dandelion, dates, endive, figs, flaxseed, grapes, mangos, papayas, parsley, persimmons, pineapple, prunes, rhubarb, rutabagas, soybeans, turnips, walnuts and watercress."  Tea should be avoided; it is rich in tannins that bind stools and hold back bowel movements.

Increase the fiber content of the diet slowly.  Add only a few grams at a time to allow the intestinal tract to adjust.  Otherwise some gas, bloating, cramping, diarrhea, or constipation may temporarily result.

Drink plenty of water when boosting fiber consumption to assist the transition.  Physiologists recommend drinking at least ½ ounce of water for every pound of body weight every day (a person weighing 160 pounds would drink 80 ounces, 10 cups).  However, in reality, how much water is "enough" varies from person to person.  Consumption can be increased to determine how it affects constipation and other factors, then adjusted to meet the individual's needs.  Dehydration results in dry, hard stool, difficult to pass and/or painful evacuation.  This can be caused by inadequate fluid intake, fever, vomiting, excessive physical activity (without sufficient hydration), deviations of electrolyte and water balance, or inadequate fiber intake.

Fiber supplements can alleviate constipation but should be considered for only short-term use if possible.  They are not substitutes for fiber-rich foods.  Eating a variety of whole foods provides several types of fiber - along with associated nutrients and other synergistic compounds - whereas most fiber supplements contain only a single type of fiber.iii

PROBIOTICS

There are about 500 different "species" of bacteria (depending on the substance engulfed) in the intestines with a total bacterial count of nearly 100 billion per gram of fecal matter.  Most are unidentified and unclassified.  Among the many benefits of the so-called "good" or "friendly" bacteria is keeping the internal environment essentially clear of so-called "bad" bacteria (which have ingested toxic substances).

Diminished bowel bacteria can be a factor in constipation.  Poor diet (processed, altered, refined foods), pesticide residues, preservatives and other food additives, alcohol consumption, drugs (particularly antibiotics), emotional upsets and psychological pressures can all contribute to the disruption of normal, healthy bacterial balance.  About half the antibiotics produced in the U.S. are administered to farm animals; residues may be consumed in beef, pork, and poultry.  Eating organically-raised meats eliminates this exposure.  Chlorine in municipal waters destroys gut lactobacteria.  About 50% of the pharmaceutical drugs available can have gastrointestinal side effects including disruption of bowel flora.  "Medical treatments cause serious derangements in the structure and function of probiotic flora..."

The typical American diet "predisposes the human body" to inflammatory, ulcerative, degenerative, and neoplastic (cancer-causing) diseases - on top of constipation.  In part, this is due to consumption of well over 100 pounds of refined sugar per person per year, excessive consumption of altered fats, regular ingestion of artificial sweeteners, refined flours, artificial fats, food additives; decreased consumption of fiber-rich whole foods, minerals and trace minerals, enzymes, and a considerable reduction in consumption of omega-3 fatty acids, other unaltered fats, total proteins, vitamin complexes, phytochemicals, and more.  A diet rich in complex carbohydrates (vegetables, fruits, whole grains, etc.) and total (bioavailable) proteins promotes the growth of beneficial intestinal bacteria and discourages the "bad."

Traditional cuisines contained "several thousand times more bacteria" by use of cultured or fermented foods which also enhanced the enzyme content.  Lacto-fermentation was a common method of food preservation before the advent of freezers or canning machines.  Included were dairy products (such as yogurt, kefir, cheese), fermented ("pre-digested") fish, fermented vegetables or condiments (kimchee, sauerkraut, pickled carrots, cucumbers, beets, etc., miso, soy sauce, tempeh, natto), well-aged or marinated meats, lacto-fermented beverages (from fruits, sap of trees, herbs, grains, wines, beers).  Food was preserved either by drying or storing it in holes in the ground where food became naturally fermented.  The valued health-promoting qualities included relief of intestinal problems and constipation as well as promotion of overall well-being and stamina.

"The modern lifestyle has dramatically reduced the availability of foods produced by natural fermentation and commercial manufacturing has continued this process."  Although yogurt, cheeses, pickles, sauerkraut, wines and beers are widely available in developed countries, they are pasteurized, processed, industry-modified, stored and otherwise treated so they no longer provide the same health benefits.

Lactic acid is a natural preservative that inhibits putrefying (decomposing) bacteria in food.  There are many species of lactic-acid-producing bacteria which convert starches and sugars from vegetables, fruits, unpasteurized milk, grains, and legumes into lactic acid.  The proliferation of lactobacilli in fermented foods enhances their digestibility, increases levels of some nutrients, and produces numerous helpful enzymes.

The capacity of probiotic ("enhancing life") bacteria (Lactobacillus plantarum, Lactobacillus rhamnosus, Lactobacillus reuteri species) to eliminate other (decomposition) bacteria has been used by the food industry and families around the world to preserve food.  According to the Institute of Food Technologists, lactic acid bacteria can even be used to prevent the growth of spoilage organisms and pathogens in fruits and vegetables that have not been fermented. 

Natural lactic acid, the primary by-product of lactobacillus bacteria also promotes production of healthy flora throughout the intestine.  In effect, lactic-acid yeast provides the "soil" in which the beneficial intestinal bacteria can grow.  Friendly bacteria are extremely important for proper digestion and excretion, and are responsible for maintaining proper pH (acid/alkaline) balance in the colon.  Lactobacteria increase the bulk, frequency, and ease of bowel movements, help control flatulence, and reduce the putrefactive odor of feces.  They suppress the growth of unfriendly putrefactive bacteria and keep "environmental balance" of yeasts and fungi such as Candida.  

Lactic acid from fermented foods contributes to both decomposition (breaking down of ingested foods) and reconstruction (building up of nutrients) needed by the body.  It supplies organic acids that help break down foods and activates metabolic processes that transform the foods into new living substances.  Lacto-fermented foods normalize the acidity of the stomach, help break down proteins, aid the absorption of iron by virtue of the balanced stomach acid and vitamin C complex content, activate pancreatic secretions, and more.  Sauerkraut and similar fermented items contain choline and acetylcholine (destroyed by cooking).

Acetylcholine has a powerful effect on the parasympathetic nervous system and a beneficial influence on peristaltic movements of the intestines.  Byproducts of fermented foods that benefit the gastrointestinal tract include short chain fatty acids, other fatty acids, amino acids, vitamins, lectins, phytoestrogens, polyamines, and more.  Also, the immune system is stimulated - "up-regulated."

Since ancient times, lacto-fermented foods and juices were used as remedies to clean the intestine against typhus and other illnesses of this type (associated with unsanitary conditions).  Research "has confirmed this beneficial action of lactic acid producing bacteria," and has shown it can "prevent the growth of coliform bacteria and agents of cholera from establishing themselves in the intestine."  Even certain carcinogenic (cancer-causing) substances "are inhibited and inactivated."

Probiotic supplements usually contain bacteria found in cultured dairy foods - Lactobacillus acidophilus and Bifidobacterium bifidum and/or Lactobacillus bulgaricus. L. acidophilus and L. bulgaricus manufacture lactic acid and lactase, the enzyme that breaks down lactose (milk sugar). L. bifidum additionally produces B vitamins such as niacinamide, biotin, and folic acid.  However, the entire acidophilus group of organisms requires the presence of lactose for their function.  Most acidophilus supplements do not contain milk or milk sugar.  But similar bacteria - from other fermented foods - can be supported on ordinary carbohydrates in the digestive tract.  They will convert starches and sugars from foods into lactic acid, and they contain a higher percentage of B complex nutrients than Brewer's yeast.

Most probiotic bacteria in supplements "do not seem to have the ability to adhere to the human mucosa" lining the intestinal tract.  Yet adhesion properties have been documented for natural food-fermentation bacteria including L. plantarum, L. rhamnosus, and L. reuteri.  Also, most commercial yogurts do not contain enough beneficial bacteria to make a real difference.  Only freshly-made yogurt, consumed within 24 hours, contains an abundance.  After 24 hours, the lactobacteria in yogurt begin to decline rapidly.  Similarly, by the time most freeze-dried acidophilus capsules reach the consumer, much of the active bacteria are dead.

Cabbage, Jerusalem artichokes, and other fiber-rich foods like whole grains, psyllium, carrots, apples, and sprouts help support lactobacteria.  Yogurt, homemade or purchased within a day of production, is at least a viable source of friendly bacteria.  The "catch" in probiotic supplements is there is no certainty of the amount friendly bacteria they contain and whether or not they are even viable.  But a good supplement (fresh, properly processed, bioactive) or unprocessed fermented food can be extremely helpful.  Although some scientists doubt that live strains in yogurt or supplements survive to colonize the digestive tract (believing bacteria are killed by stomach acids), research indicates the friendly bacteria "survive transit through the gastrointestinal tract" when ingested in fermented milk or other naturally-fermented foods.

Prebiotic substances are nondigestible food components which "selectively" stimulate the growth and/or activity of a specific type of bacteria in the colon.  These include non-starch polysaccharides ("resistant starch"), non-digestible oliosaccharides like fructo-oliosaccharides (FOS), galacto-oliogosaccharides, and inulin.  These carbohydrates reach the colon undigested where lactobacilli and bifodobacteria use them to thrive, aiding the health of the colon and decreasing the toxicity of colon contents.  Isolated from foods, these substances provide limited, if any, real benefits.  The synergistic effect from whole foods or real food complex supplements would be far superior.  Vegetables, fruits, whole grains, unaltered milk, and other natural foods are good sources.

Symbiotics are mixtures of pro- and prebiotics that improve the survival and implantation of live microbial dietary supplements in the gastrointestinal tract.  Again, whole fermented foods or food supplements are the best way of obtaining all associated factors in one balanced, cooperative source.

In sum, active, naturally-fermented (not sterilized or pasteurized) food products and whole, unaltered food complexes provide the "soil" and the "seed" for healthy bacterial conditions in the colon.  One of the benefits is regular and comfortable bowel function. iv

NUTRIENTS, HERBS, OTHER REMEDIES

Inadequate intake of B vitamins - particularly B1 (thiamin), B3 (niacinamide), B6 (pyridoxine), folic acid, B12, and B4 plus associated choline, inositol, and pantothenic acid - are associated with constipation, indigestion, insufficient hydrochloric acid secretion, loss of appetite for natural foods (often an increased appetite for devitalized, refined ‘non-foods'), loss of gastrointestinal tract tone, smooth muscle failure of the digestive tract, and inability of gastrointestinal muscles and glands to obtain proper energy from carbohydrate metabolism.  B4 is needed to maintain optimal transmission of nerve impulses.  The whole B complex is imperative to nervous system function, stimulation of gastrointestinal musculature, peristalsis, digestion and elimination.

Minerals and trace minerals are also essential to the health and proper operation of the gastrointestinal tract.  Deficits of calcium, magnesium, potassium, and zinc have been associated with constipation.

Foods containing fats have a lubricating effect on the mucous membrane lining of the colon walls.  Fat-soluble vitamins and unsaturated fatty acids are important to the gastrointestinal tract.  Vitamins A complex, D complex, E complex, and unsaturated fatty acids (including the often deficient omega-3 fatty acids) are all beneficial.  Foods rich in these fat-associated nutrients are often sources of mucilage - Gum-like gels or thick liquids.  For example, the 12% mucilage content in flaxseeds makes them "the best natural laxative available," according to Udo Erasmus.  This soft, water-soluble fiber "soothes and protects" the delicate stomach and intestinal linings, prevents irritation, and keeps the contents moving along smoothly.  It absorbs water - up to 20 times its dry volume - so stools do not become hard and dry.  Unrefined, unaltered natural oils containing essential fatty acids have stool-softening effects.  By adjusting the type and amount of oil in the diet, the desired stool consistency can often be obtained.

Insufficient vitamin C complex can adversely affect digestion as well as the musculature, lining, and function of the stomach and intestines.  But, ingesting large amounts of ascorbic acid (so-called "vitamin C") for relief of constipation is counterproductive.  Ascorbic acid is a synthetic or manufactured interpretation of the tiny portion of the vitamin C complex which protects the functional components.  Taking this chemical in high doses - 5,000 milligrams may be recommended ­ to "bowel tolerance" will certainly have a laxative impact.  But it is due to irritation of the mucous membrane lining of the gastrointestinal tract.  The offense to delicate tissues prompts evacuation of bowel contents.

The same pharmacologic approach is used with large doses (400 to 1,000 milligrams a day) of isolated, inorganic magnesium.  Magnesium, sodium, potassium, and other minerals in forms used as osmotic laxatives can be effective on a short-term basis.  But they do not solve the underlying problem and can cause difficulties.  Magnesium preparations, for instance, "may evacuate the bowel rapidly when taken in high doses, but they result in a watery stool, considerable urgency in defecation, and occasionally incontinence," as well as the possibility of hypermagnesemia (excessive magnesium imbalance).

Diminished secretion of digestive juices, including digestive enzymes, results in partially digested food reaching the colon.  Complaints may include flatulence, sour stomach, belching or burping, heartburn, bad breath, intestinal gas, a full feeling hours after eating, bloating, light-colored stools, diarrhea or constipation.  Inadequate nutrient intake or consumption of refined, processed, denatured, or overcooked foods can lead to digestive woes.  In some instances, digestive assistance in supplement form may be needed until nutritional status and dietary habits have improved sufficiently.

Prunes and prune juice have long been viewed as "a safe, effective, gentle laxative."  Prunes are thought to contain some "mystery" ingredient due to the fact that prune juice - containing very little fiber compared to the fruit - also has a laxative effect.  "The" chemical responsible for the intestinal benefit has not been identified.  It was thought that isatin, a stimulant used in some commercial laxatives, was the key, but isatin has never been isolated in prunes or prune juice.  Phenophthalein was another contender, but there is almost no evidence to support this either.  The synergistic effect of many components in the fruit, including some "special quality in prune sugars" may be the answer.  Such is the way with Nature.

Garlic stimulates the walls of the intestines and has been used for constipation; a few minced cloves put into a clear soup can be taken before the evening meal.  Barley water is another age-old remedy.  Drinking a glass of room temperature or warm water mixed with the juice of half a lemon first thing in the morning is enough to stimulate peristalsis in some people.  Adding a tablespoon of bentonite clay and/or a teaspoon of psyllium husk powder to the lemon water often aids more stubborn cases.  A few individuals may initially feel bloated when they take intestinal bulking substances.

Consumption of one to two tablespoons of honey - preferably raw - in a glass of water is a mild treatment for constipation, often bringing relief within 10 hours.  Apples contain sorbitol and pectin as natural carbohydrates with laxative properties.  Starting the day with an apple or freshly made juice containing apple, beet, carrot, and a little fresh ginger may be helpful.  Or fresh juice with apple and green leafy vegetables (such as spinach, romaine, red cabbage, parsley, etc.) benefits many.

Many herbs can be used for bowel relief.  Aloe, buckthorn, cascara sagrada, frangula, and senna all contain anthraquinones, chemical compounds with powerful laxative effects.  For example, in one study an oral preparation of senna at bedtime proved to be the most effective - compared with other remedies and placebos - in eliminating constipation within 24 hours.  Senna can be quite powerful by itself, sometimes causing minor diarrhea, discomfort, heartburn or nausea.  Combining it with other herbs like peppermint, fennel seed, and caraway seeds usually counteracts such effects.  Senna and other sources of anthraquinones are better tolerated (less gripping) and more physiologic compared to pharmacologic laxatives.

Commission E, a body of scientists that provides information and advice to Germany's equivalent to the FDA, endorses the use of all these herbs for constipation with certain reservations.  These particular herbs may be best utilized as last resorts after increasing fiber, trying other gentler herbs, and improving nutritional status.  Anthraquinone-containing laxatives should not be taken for extended periods of time or during pregnancy or nursing.

Fenugreek seeds are a source of fluid-absorbing mucilage.  They usually produce a soft to semi-fluid stool within 6 to 12 hours after ingestion.  No more than two teaspoons should be used at a time to avoid any possible abdominal distress.  Flaxseed is also endorsed by Commission E, suggesting one to three tablespoons of whole or crushed flaxseed two or three times a day.  Drinking plenty of water - at least eight glasses a day - with either seed is recommended to keep all the bulk moving through the digestive tract.

The mucilage in psyllium seeds absorbs a great deal of fluid in the intestines, making the seeds swell.  This provides bulk which presses on the bowel walls, triggering the muscle contractions known as "the urge."  Commission E approves 3 to 10 tablespoons a day for chronic constipation.

Again, drinking adequate water is a must.  Psyllium increases butyrate production in the colon.  Butyrate is the "most important" of the short-chain fatty acids produced by bacterial fermentation of fiber in the bowel.  Sufficient amounts are needed for "healthy metabolism and welfare of the colonic mucosa."

Rhubarb contains a natural laxative chemical similar to that in senna and cascara sagrada, so is fairly powerful.  It is also high in fiber.  Ronald Hoffman, M.D., recommends this recipe:  Puree three stalks of rhubarb (without the leaves).  Add one cup of apple juice, a quarter of a peeled lemon and one tablespoon of raw honey.  This makes a thick, tart drink.

The following herbs may gently assist: alfalfa, blessed thistle, chicory, dandelion, dong quai, fo-ti, kelp, nettle, rosehips, sarsaparilla and yellow dock.  Wheat grass and barley grass are frequently suggested for their "positive effects on intestinal regularity."  Other natural therapies reported to prevent or relieve constipation include acupressure, aromatherapy, Ayurveda, homeopathy, massage, reflexology, relaxation techniques, meditation, and yoga.  A study on color therapy found that "sun colors" - yellow, orange, and red - may help ease constipation.

To promote the normal flow of energy and move bowel contents along, exercise is essential.  Aerobic activities such as brisk walking, swimming, and bicycling are excellent.  Actually, any type of daily physical activity for at least 30 minutes will assist.  This can be anything from gardening to household chores.  The point is to get moving!  With exercise, the abdomen is massaged and circulation in the gastrointestinal area is increased.  Constipation can result from a lack of tone in abdominal muscles; activity strengthens this musculature. v

CONCLUSION

Generally, chronic constipation is associated with nerve, muscle, digestive, and/or mucous membrane well-being and performance.  Without pathology, remedies for difficult bowel function can include:

1. Developing good bowel (bathroom) habits.

2. Phasing out denatured, devitalized, refined ‘non-foods' from the diet.

3. Gradually expanding the amount of whole, natural, unaltered foods with emphasis on plant foods for fiber and lubricant qualities.  Enzyme-rich raw foods should be stressed.

4. Approaching any deficiency situation with real food complex supplements.

5. Supporting healthy bacterial balance with naturally fermented foods or active probiotic supplements.

6. Temporarily using bulk and/or lubricant supplements or gentle natural laxatives.

7. Exploring activities and therapies which aid relaxation and assist emotional health.

8. Engaging in physical activity daily.

9. Obtaining, if indicated, neuromuscular or musculoskeletal therapies.

i Harrison's Principles of Internal Medicine, 13th Ed., eds. Isselbacher, Braunwald, Wilson, Martin, Fauce, Kasper, NY: McGraw-Hill, 1994, pp.219-20; C. Northrup, Health Wisdom for Women, Vol.4, No.5, May 1997, pp.6-7; K. Whatley, Nat Health, Vol.29, No.4, May 1999, p.70; A. Bruckheim, News- Journal, 18 Mar 1995, p.18B; C. Poulos, Healthkeeper's J, Vol.16, No.10, Oct/Nov 1995, pp.20-22; UC Berkeley Wellness Lttr. Vol.14, Is.5, Feb 1998, pp.6-7; W. Douglass, Second Opinion, Vol.II, No.4, Mar 1992, pp.4-5; L. Lesaffer, Lancet, 25 Mar 1989, p.674; D. Williams, Alternatives, Vol.4, No.21, Mar 1993, p.167; Complem Med for Phys, Vol.2, Is.10, Dec 1997, pp.73-80; A. Coca, Pulse Test, NY: Arco, 1972, p.17; S. Astor, Hidden Food Allergies, Garden City: Avery Pub, 1988, p.8.

ii Harrison's Principles of Internal Medicine, p.221; C. Poulos, Healthkeepe's J, Oct/Nov 1995, p.22; C. Northrup, Health Wisdom for Women, May 1997, p.7.

iii Harrison's Principles of Internal Medicine, p.221; K. Whatley, Nat Health, May 1999, pp.70-3; C. Northrup, Hlth Wisd Women, May 1997, pp.6-7; V. Haack, et al, J of Clin Nutr, Vol.68, Sept 1998, pp.615-22; J. Duke, Green Pharmacy, Emmaus: Rodale, 1997, p.141; Nutr in Clin Care, Vol.2, No.3, May/June 1999, pp.187-8; Healthline, Vol.17, No.2, Feb 1998, pp.3-11; W. Rea, Chemical Sensitivity, Vol.4, Boca Raton: CRC, 1997, p.2412; UC Berkeley Wellness Lttr, Vol.II, Is.2, Nov 1994, p.8; J. Groppel, L. Knight, Winning Edge of Sports Nutrition, Orlando: FL Hospital Nutr Serv, 1998, p.9.

iv Natural Health, May/June 1993, pp.74-76 & Jul/Aug 1998, p.157; Energy Times, Vol.8, No.6, June 1998, p.20; S. Bengmark, Gut, Vol.42, 1998, pp.2-7; S. Fallon, Nourishing Traditions, San Diego: ProMotion Pub, 1995, pp.44, 51, 81, 92-94; Amer Coll Nutr Newsletter, Fall 1997, p.5; S. Bengmark, Clinical Pearls News, Vol.8, No.10, Oct 1998, pp.160-162; D. Reid, Chinese Health & Healing, NY: Barnes & Noble, 1994, pp.123, 141-142; C. Northrup, Health Wisdom for Women, May 1997, p.6; UC Berkeley Wellness Letter, Vol.13, Is.1, Oct 1996, pp.6-7; P. Pochart, et al, Am j Clin Nutr,Vol.55, No.1, Jan 1992, pp.78-80; G. Gibson, A McCartney, Biochem Soc Transactions, Vol.26, No.2, May 1998, pp.222-228.

v M. Werbach, Nutritional Influences on Illness, 2nd Ed., Tarzana: Third Line, 1993, pp.220-1; W. Rea, Chemical Sensitivity, Vol.IV, Boca Raton: CRC, 1997, pp.2588-98; U. Erasmus, Fats that Heal, Fats That Kill, Burnaby: Alive Bks, 1993, pp.283-84, 345; W. Douglass, Second Opinion, Vol.IV, No.11, Nov 1994, p.4; UC Berkely Wellness Lttr, Vol.11, Is.2, Nov 1994, p.8; Nat Health, Vol.25, No.1, Jan/Feb 1995, pp.70-71 & Vol.27, No.2, Mar/Apr 1997, p.21; Compl Med for Phys, Vol.1, No.5, Sept 1996, pp.34-5; D. Williams, Alternatives, Vol.4, No.4, Oct 1991, p.31; J. Duke, Green Pharmacy, pp.140-143; I. Nordgaard, et al, Scand J Gastroenterol, Vol.31, 1996, pp.1011-20; M. Werbach, M. Murray, Botanical Influences on Illness, Tarzana: Third Line, 1994, pp.128-30; J. DeCava, Real Truth About Vitamins & Antioxidants; Yarmouth: A Printery, 1995, p.199; New Choices in Natural Healing, Emmaus: Rodale, 1995, pp.251- 256; S. Foster, V. Tyler, Tyler's Honest Herbal, 4th Ed., NY: Haworth, 1999, pp.12, 27, 115, 138, 141, 164, 233, 320, 335; R. Seibold, Cereal Grass, New Canaan: Keats, 1991, p.80; G. Kirshmann, Nutrition Almanac, 4th Ed., NY: McGraw9 Hill, 1996, pp.196-7; K. Whatley, NatHealth, Vol.29, No.4, May 1999, pp.72-3; C. Northrup, Health Wis Women, Vol.4, No.5, May 1997, pp.6-7.

Originally published as an issue of Nutrition News and Views, reproduced with permission by the author, Judith A. DeCava, CNC, LNC.