Constipation. What a glorious topic. Especially if you are immature and mostly unprofessional, like myself.
I know what you’re thinking. “Oh no.” But also, “What is there to rant about with constipation?”
Great question. Don’t poo poo this idea, it’s solid. 🙂
Today, I want to discuss the natural management of constipation in rant format, because I believe many natural practitioners and propaganda sites known as “blogs” mislead consumers around the topic.
I believe the wrong products and strategies are implemented at the wrong times. I believe too many people who have constipation go untreated because of the effort it takes (ha!) to help get to normal.
Many are too quick to dismiss some of our most effective options to deal with constipation because they are “chemicals” and not “natural.”
This was a bit challenging to write, but I’m glad I was able to push out today’s article with normal frequency and consistency.
There’s a Venn diagram somewhere for this article. This is the intersection of people who want to learn about constipation, are OK with 3rd grade potty humor, and like their healthcare professionals to be a bit sarcastic.
I hope you’re inside the middle of that. If not, buckle up as there are more poop jokes than other words.
A note: We’re not here to give advice to those with severe constipation. This is best discussed with a doctor. For those of us who suffer from occasional or chronic, non-severe constipation, we can help you set up a sound strategy.
The, uh, Hard Truths About Constipation
I’ll leave the boring definitions of acute and chronic constipation and discussions to other sites on the web and instead focus on what matters.
First, the basics. Constipation is when we go to the bathroom less often than normal, or stools are harder, smaller, and more difficult to produce. Chronic constipation, where it happens often, is pretty prevalent (20% of people) but often over-reported (30+% of people with constipation believe they have chronic constipation).
My words of wisdom, in the spirit of brevity: constipation is based on what’s normal for you. We have these weird perceptions around what a regular bowel movement should be and how often. For some of us, that’s one daily and others, it’s maybe a bit more or less frequently.
Here’s ranty point number one: what’s normal for you isn’t necessarily normal and should be improved.
I’ve worked with so many people on a holistic plan who are resigned to the fact their bowels are normal, even if they are infrequent and difficult. Natural and traditional practitioners alike will say in a very formal manner, “Hey, if they ain’t complainin’…”
You should not accept what most would consider constipation as normal, even if that has been “you” forever. This year alone, I’ve worked with dozens of people to get to more regularity and they feel better than they ever have.
I challenge people who are looking to live healthier lives who have “good diets” or who are “fine with their low-quality stools” to push harder (without straining), to reset their broken expectations of what healthy should be.
So, what should a healthy, non-constipated bowel movement look like? Well, a picture IS worth at least 980 words…
There’s a visual representation of the different stages of constipation or quality of bowel movements called a Bristol Stool Chart. I am fond of the one that use different candy bars to represent each stage.
I’m definitely not putting that here for all to see. Talking about poop is one thing. Visualizing it is another. But, it’s here if you want to check it out. Stage 1-2 is indicative of constipation, 3-4 is the target area, and 5-7 might be diarrhea.
The Three Bins Of Constipation
Another misconception around constipation is that it’s one problem and if everyone does squats or eats a wicker laundry basket daily for fiber it will go away.
In reality, nutritional or lifestyle-caused constipation is just one of three types of constipation.
Another is slow transit constipation. This can be genetic. Your pipes just move slower than most. It can also be drug induced from medicines like opioids.
The final bin is a big one – IBS. Irritable Bowel Syndrome can manifest in a number of ways, but one is constipation-predominant. You will get rid of your constipation if you manage your IBS.
It’s easy to see my big point, I think. All treatment isn’t going to be the same for all constipation types, so we should stop thinking generally about it.
A stool softener and some normal first choices won’t really work for slow transit patients, as this is less about the stool and more about the tube.
The thing is, it’s tough to know which bin you are in most of the time, especially at counter-side and if the constipation is moving into the chronic stage. The steps we’d take to manage constipation are generally similar across all three groups, at least at the start.
If those steps fail, all is not lost, in fact it may just be impacted. Digging deeper (sorry, bad visual) may be necessary to find targeted therapy strategic for your type of constipation.
Now, let’s get some real movement on this rant! 😉
Problem 1 – Natural practitioners rely on magnesium because “it’s natural.”
I was motivated to rant about constipation based almost solely on the idea that many people are advised to only use “natural” options for their constipation, one of them being magnesium.
We touched on this briefly in our article Making Magnesium Supplements Easy, but basically most magnesium supplements people use are very poorly absorbed (6% or less) and most of that magnesium stays in your gut.
If you’re looking to supplement magnesium for your whole body, look to true chelates of magnesium like Easy Magnesium. Magnesium oxide and magnesium citrate are best ONLY if you need a bowel movement.
Magnesium DOES work for GI issues. If you deliver magnesium to the large intestine, as does when you use poorly absorbable forms, you’ll cause a shift in your body’s fluids.
Water moves from the body to the GI tract, softening the stools and helping you along. You normally can get results within 6 hours. All of that is great!
My problem with this is three-fold, as three points are the most efficient at getting a point across.
Magnesium Should Be Cheap
If you remember my discussion around the 3 Types of Dietary Supplements, some supplements are just McDonald’s cheeseburgers, not steaks. We shouldn’t overpay for fast food.
Magnesium oxide and citrate for constipation are McDonald’s cheeseburgers. The natural products industry has come up with creative ways to overcharge you for the McDiarrhea, normally by hiding the magnesium.
Many natural products that look like these healthy herbal blends for natural constipation relief are just dressed-up magnesium oxide pills.
They sprinkle in small amounts of herbs or supplements and then charge $20+ for something that costs less than $5 at every drug store in the country.
To protect yourself from this deceit, stop looking at just the front of a bottle. The front panel of a supplement bottle should be considered 100% marketing, and not much good info can be gleaned from it.
The REAL product information is found on and around the Supplement Facts Panel (SFP).
Because you know I keep it real, let me throw one of our products under the bus:
GI Regularity is a product we carry. The front looks pretty appealing. Looking at the SFP, the primary ingredient is magnesium citrate.
It also has Triphala and aloe, both botanical agents that help support regularity and GI issues. Unlike other brands, our product actually has good forms of those herbs and enough to actually impact (nyuk) the bowels, with a reasonable price tag for the combo.
It’s not as dramatic as the “other guys”, but transparency is my jam. BUT – it’s truly just magnesium citrate, which you can get for cheaper by itself from us and everywhere.
Magnesium Is A Bad Choice
The second problem is that magnesium is a bad choice, especially as the first pick. We actually have what are called “bowel protocols,” which are treatment algorithms used to guide healthcare professionals on the management of constipation.
We’ll go over that before we finish up the rant today. The important point here is that osmotic laxatives are normally not the first choice on any treatment algorithm.
Magnesium’s a horrible choice for regular use. Advising someone to take a magnesium pill daily for constipation is bad medicine, especially because of problem 3 with magnesium.
Magnesium Isn’t Innocent
The third problem with magnesium is that it’s got lots of liabilities. It has way more GI side effects like cramping and pain than other laxative agents.
It can cause electrolytes like potassium or calcium or sodium to be absorbed poorly. Magnesium toxicity is a real thing, and it can happen easily in older patients or people with kidney disease.
If you have heart problems, magnesium can affect your heart rhythm when used excessively.
Magnesium as a laxative is a great choice if you’ve tried other things first and you need some quick relief in the right patients.
Problem 2 – Miralax is bad because it’s chemicals.
When you hear something like “polyethylene glycol” you probably think of something yucky and harsh. When I hear it, I think “sugar.”
Polyethylene glycol (PEG) is a bit like fatty acids, chemically. If you remember from our Guide to Fats, fatty acid chains have varying lengths, and the effects will vary based on the size of the chain.
PEG is like that too. PEG that’s used in humans is a specific length and different from other PEGs used in industry.
To simplify its mechanism, PEG laxatives work because they are a sugar chain not absorbed at all by the body nor metabolized in any way, they then bind to water and keep some of it in the GI tract just like other “osmotic” laxatives do.
Drink a whole bottle if you have a colonoscopy, drink a capful if you have constipation.
Despite all of this information being readily available, the “experts” warn that it’s a scary-sounding chemical and shouldn’t be used. It’s not an industrial chemical that’s used in humans, it’s an indigestible sugar that has application in industry settings. That’s a big difference.
On top of this semantic misinformation, the idea that it’s not safe is insane. It actually is a much better option than most osmotic laxatives, like magnesium.
GI side effects are minimal, it doesn’t cause electrolyte disturbances, and it doesn’t have to be limited in specific patient populations (elder, heart disease, kidney disease).
In most bowel protocols, PEG is recommended over old-school osmotic laxatives like magnesium.
Problem 3 – Senna is great because it’s an herb!
In secret, I’ve been walking you through the different types of compounds used to manage constipation. Slick, aren’t I?
Senna is an herb used for centuries to stimulate the bowel movements of Pharaohs and now that power is in your reach.
Senna is in a group called stimulant laxatives, and these compounds basically improve movement in the GI tract and increase water secretion into the gut.
Senna is fine! It’s helpful! There is a place for it. Just because it is natural, though, doesn’t mean it can or should be used indiscriminately.
There are risks of serious side effects if used at improper doses. Stimulant laxatives have a risk of abuse. Almost no healthcare professional would recommend them continuously unless we’ve exhausted other options. See a theme here?
Many people are told that a daily senna tea or supplementing with senna is a good strategy for managing their irregular bowels. That doesn’t fit in with best practices based on our best evidence.
Problem 4 – I can manage chronic or regular constipation on my own/without my doctor.
I know that most doctors aren’t really the savviest when it comes to natural products. Some don’t respect supplements at all, and that can be justified by all of the quality issues.
Many of them don’t have the time to spend with you to go over lifestyle modifications. I can empathize with the patient perspective: “Doctors bark at me, don’t give me answers, and want to give me drugs.”
That interaction sequence can be real, or quite frankly, imagined and reinforced by our cultural bias against traditional medicine. If your doc is really like that, get a new doc. The best docs have a great bedside manner and can be there for you despite the constraints of modern medicine.
Our instinct is to spend money on a “natural” practitioner who does have time to spend with you. As I’ve argued before, if you paid your regular doctor the amount some of these “experts” get, your doctor would move in with you, slap food out of your hand, or practice breathing with you through the bathroom door as you go number 2.
If said natural “practitioner” is not a licensed physician you need to have a conversation with your doctor about your chronic constipation. There could be something going on there, and they can do the proper assessments to ensure there are no hidden causes or serious complications coming at you like a freight train.
You can certainly continue to use the natural practitioner, but just make sure your doctor is looped in.
The Constipation Flow Chart
All this talk about treatment algorithm and batting order for managing constipation, I might as well share with you a simplified version of one.
This is a very general guideline for initial options. Specific cases will have specific steps. In general, here’s the batting order:
- Fiber – we will talk more extensively about fibers on their own, but for now, shoot for 30g of dietary, non-fermentable soluble fiber like oat bran, barley, nuts, seeds, beans, peas, or psyllium.
- Osmotic Laxatives
- PEG first
- Magnesium if PEG doesn’t work, and don’t spend a lot on it!
- Stimulant Laxatives with help from a doc or pharmacist
Stool softeners are not typically recommended due to their limited evidence to support regular use. People have used them forever, but they’re not right for different types of constipation and will give mixed (if any) results for chronic constipation.
Good Gut Tips and Natural Relief of Constipation
Preventing constipation should be our ultimate goal. We can have the best gut health quite simply. I’ve outlined 4 Pillars of Gut Health and even did a little video about it if you’re sick of reading all my words.
The 4 Pillars of Good Gut Health are fluids, fiber, probiotics, and prebiotics. The fifth point is the foundation that the pillars sit on. We have to avoid foods that cause constipation or irritation in us in particular, or in people in general. Unhealthy stuff like packaged and hyper-processed foods or common offenders like cheese and dairy.
Sometimes, healthy things like fruits and veggies can be a problem. As we discussed in our podcast The Mind-Gut Connection, a low FODMAP diet may help people with IBS, so this is something worth exploring with a trained, licensed expert.
The big gut health secret? All of the “gut gurus” and the advice around gut health is just derivative of those 5 points. Get rid of the problems, eat healthy stuff, stay hydrated, meet or exceed your dietary fiber requirements, and use great probiotics and prebiotics.
Supplements may be needed, and some even can give you an edge. Probiotic Complete is our standby and Fiber Plus is a really cool product that’s inexpensive and dense in fiber.
Sometimes there are supplement options to support GI health that are pretty advanced. We had written about hyperimmune egg and GI Immune Plus, which is hyperimmune egg and our favorite prebiotic. Those suffering from IBS can benefit from additional strains of probiotics studied for IBS. This is best covered in a wellness consult.
Wipe Away Constipation
When it comes to constipation, you should be pushing, but not while going to the bathroom. You should be pushing for normal, healthy stools WITHOUT the need for any laxatives – natural or synthetic.
What I mean is that you should be climbing the Wellness Pyramid. Pull all the levers we have the most control over first. Dietary fibers, hydration, and eliminating foods that can induce constipation in us.
Use properly made probiotics and prebiotics. Loop your doctor in. Make sure none of your meds are contributing to it. Manage untreated IBS.
If we’ve checked the boxes and hit all the switches and still are not at a 3-4 on the Bristol Chart (Payday or Twix for those brave enough to click the link before), then regular laxative therapy is justified. We then should only choose laxatives based on established evidence.
What’s the most effective? What has the least chance for side effects? Get the right dose, give it the right amount of time, and then move down the treatment algorithm in best order.
What we’re looking for is for you to have the ideal poop. Quick question: if we have the ideal poop, could we say it belongs on a pedaSTOOL?
Just trying to keep it real…
Neal Smoller, PharmD
Owner, Pharmacist, Big Mouth