Constipation is no fun.
I have a memory from a time when I was visiting my great uncle and aunt in sunny West Palm Beach Florida for winter break. I was 12 or 13 at the time. My uncle would start every day with a bowl of stewed prunes and bran cereal at breakfast. I also remember overhearing my aunt say to my grandmother how my uncle Don would obsess if he didn’t have his daily poop. OK, she said bowel movement but let’s face it, it’s all about having a good poop.
According to the Canadian Digestive Health Foundation, constipation is very common. Between 25 to 30% of Canadians are affected by chronic constipation. A lot of us are poor poopers! And, a lot of us are a little desperate for an effective and reliable constipation remedy.
Constipation. It’s real and it’s no bueno
Like the common cold and flu, or bad headaches and migraines, constipation confusion is everywhere.
Come fall, all we hear about is the flu, flu, flu and why we need the flu shot. Ever notice how no one has a cold anymore? Everyone who’s sick in the winter, has the “flu”. Same thing with headaches, anyone with a bad headache has a “migraine”.
It’s kinda the same thing with constipation. I hear it all the time. Someone hasn’t had regular bowel movements and suddenly they’re constipated or worse; ‘impacted’. Often, the go-to solution in the ‘natural’ health world is a colonic (enema), a.k.a. colonic “irrigation”, to rid them of years’ worth of backed up stool.
Luckily, assessing whether or not someone is constipated isn’t subjective. Specialists in this field have a very specific definition for constipation like they do with other digestive disorders.
The Rome Foundation, which creates the diagnostic guidelines for functional gut issues, has defined functional constipation as 2 or more of the following symptoms occurring over the last six months:
- Straining to evacuate: >25% of time
- Hard, lumpy stools: >25% of time
- Feeling of incomplete evacuation: >25% of time
- Feeling of blockage: >25% of time
- Less than 3 stools per week
No need for guess work. More importantly, thinking constipation is simply a lack of regularity is too simplistic. It’s NOT just a matter of how often you go, but rather, when you go, is it something you can be proud of? 🙂 It’s a question of quality, quantity, effort and frequency.
A client’s journey to better clearance
I had a client, we’ll called him ‘Adam’. Adam contacted me complaining of cramping, ‘constipation’ and a feeling of incomplete evacuation. In his own words, his main reason for contacting me was to “feel better” and to “get relief from my symptoms”.
He’s had a long history of digestive woes. He told me his gut issues had been going on for over 8 years; he’s 24 so we’re talking about problems going back to when he was 16 yeas old. That’s a long time to feel ‘off’ when it comes to digestive health.
In 2012 IBD (Crohn’s and Ulcerative Colitis) had been ruled out and he was given a catch-all diagnosis of “IBS”. His symptoms weren’t consistent with IBS but it tends to be what doctors tell patients when the big ones like IBD and Celiac have been ruled out.
It’s worth noting, he was diagnosed with OCD and was also on a max dose of SSRI (anti-anxiety/depressant medication). He also had 5 courses of antibiotics for ear infections over the previous 7 years too. There’s a time and place for antibiotics to zap bacterial infections but they don’t ‘play nice’ with our gut bacteria; they get zapped as well. Studies have shown that it can take months, or even up to years for our gut to recover. He reported significant stress in 3 areas of his life: school, his gut issues and his personal relationship with his girlfriend.
The influence of the gut-brain connection is a big part of this puzzle.
He came to me in a bit of a panic. He wondered if he should start the low FODMAP diet to address his issues. He had heard that it could help with bloating, gas, and cramping. Two weeks prior to meeting with me, he had been to the hospital ED twice with severe gut pain. A CT scan revealed nothing “remarkable”; there was an appreciable amount of stool in his colon but he wasn’t impacted (a dry mass of stool that is immobile which blocks passage allowing a build up of waste). He was discharged with a recommendation for Restoralax (a non stimulant laxative).
He told me that since being discharged, he had bought gluten free bread and was debating taking a probiotic. He was also thinking about IgG food sensitivity testing which a friend of his had mentioned.
He needed a lot of support and more importantly some clarity!!
Adam and I worked together to address his overall functional picture. The digestive tract is not simply an organ of elimination. It’s made up of muscles, has 1000s of neurons (nerve tissue), includes 70% of the immune system, is home to trillions of bacteria, produces hormones and neurotransmitters and in a perfect world, has a nice thick layer of protective mucous that is produced optimally under ideal conditions.
All organic disease had been ruled out (no Celiac disease, no IBD, no polyps, no cancer, etc). His stool was free of mucous and blood, and didn’t have signs of fat maldigestion nor malabsorption. Check! I provided education about the ins and outs of IgG testing, the possibility of SIBO and whether or not he had a constipation-promoting infection and when and why a gluten free diet would be needed. I answered lots of questions about probiotics, gut bacteria and the impact of antibiotics on his gut ‘ecology’.
A closer review of his symptoms indicated that he did in fact have functional constipation.
He reported lactose intolerance with respect to milk but could tolerate some cheese and yogurt (typical presentation). As a 24 year old, university student living sway from home, his schedule and eating habits and food choices were characteristic of a lot of students. His overall diet was low in total fiber and prebitoic fiber. He was eating a lot of refined foods and foods with plenty of added/refined sugar. His intake of fluids was adequate, he was getting a decent amount of sleep – 7 hrs per night – but his activity level wasn’t the best; a lot of sitting.
SIDE NOTE: Adam’s diet didn’t provide some of the more important nutrients when it comes to supporting mental health, including anxiety. He wasn’t getting enough omega-3 fats, vitamin D, magnesium, zinc and folate.
I supported Adam by having him fill out a detailed food, symptom and bowel habit/activity journal which also tracked stress and situational triggers (gut-brain remember?!). Helping him to set realistic goals, we came up with a specific amount of fiber to get at each meal (using a list of foods and their fiber content). He and I strategized to overcome any barriers he had to healthy eating as it related to his constipation and personal goals taking into consideration his schedule, how often he ate on the go versus preparing meals at home. We also had to tailor my recommendations based on how much he wanted to spend time cooking AND based on his cooking skills.
As an initial step, I also recommended supplements for a specific amount of omega-3 and vitamin D unique for Adam’s situation. He needed to start re-nourishing his brain with crucial nutrients research has shown to benefit anxiety.
Adam’s situation slowly improved. Making changes doesn’t happen overnight. Over a 2 month period, he slowly increased his fiber intake, improved his overall eating habits and saw his cramping and bloating resolve significantly. During that time, he broke up with his girlfriend, while not for me to decide if that was good or bad, he did report sleeping better and feeling less stress in his life overall.
His bowel habits started to normalize; he was pooping like a champ. He was pleased that this stools where formed, softer and easier to pass – no more straining but he still didn’t quite feel ‘normal’. The next step included targeted sources of prebiotics; unique fibers that help to support the growth of healthy gut bacteria. We needed to rebalance them so that they could do their job of improving bowel motility (movement), reduce gut inflammation AND support the gut’s job in producing neurotransmitters.
Because his schedule was erratic enough to cause some inconsistency with his food choices, we talked about different fiber supplements as a way to help him reach his fiber goal. Now, not all fiber supplements are created equal. Some are gritty like Metamucil, others can produce too much gas and some lend themselves better as an ingredient to food such as oatmeal or smoothies while others can be taken with water. We figured out which one worked best for Adam’s life and went from there. Many may see this as ‘failure’ but it’s not; these products are safe, effective and are designed to improve our lives.
Don’t be a hero, leverage the tools that work best for you and your goals.
In the end (pardon the pun?), we reached a point where Adam felt his goals, for now, were met. With help from me, he was able to get relief from the digestive issues that were interfering with his quality of life and his symptoms improved. Because we started with the basics of gut motility and gut health, we could rule out the need for a low FODMAP diet (when needed, it is effective but it’s not an easy thing to do follow without support). We could also rule out the needed for functional testing for other explanations like SIBO. Adam was able to get his tract back on track and for the first time in a long time, felt what he assumed to be was the ‘normal-ness’ that everyone else felt when it came to number 2.
SIDE NOTE: Before sending him on this way, I also recommended two additional mood-supporting supplements: a B Complex vitamin with the preferred forms of the vitamins and magnesium.
Doug Cook RDN is a Toronto based integrative and functional nutritionist and dietitian with a focus on digestive, gut, and mental health. Follow me on Facebook, Instagram and Twitter.