Controlling Constipation

Introduction

People the world over are concerned about regularity. Aloe was used as a laxative by the ancient Egyptians, and Arab healers in the ninth century used senna for the same purpose. The lasting power of laxatives can be seen by the fact that more than a thousand years later the popular laxative Ex-Lax still contains senna-derived compounds.

Different Strokes for Different Folks

When constipation is defined in terms of regularity, no single standard determines what is normal. Some people do well with two bowel movements a week, while others may visit the bathroom three times a day.

Many folks are concerned about how much effort is required or the consistency of stool. Passing “bricks” can be distressing. If bowel movements suddenly become infrequent or difficult, or if increased fluid and fiber don’t help, it is appropriate to see a doctor. Any underlying medical problem, such as Parkinson’s disease or an underactive thyroid gland, requires treatment.

When there is no apparent medical cause, physicians may dismiss constipation as a minor complaint. Patients don’t see it that way. One man suffering from heart disease, failing vision, and prostate enlargement still rated constipation as one of his most troublesome health problems.

Watch Out for Laxative Overuse

Frequent use of stimulant laxatives can sometimes make the bowels “lazy;” constipation becomes a more chronic problem as a result. Some years ago we heard from an elderly gentleman who cursed his parents for turning him into a laxative addict. From an early age he was warned that a daily bowel movement was essential for good health, so he had used laxatives his entire life. His digestive tract, damaged by harsh cathartics, could no longer work on its own.

Physicians may sometimes contribute to constipation unintentionally and without informing their patients. Quite a few medications may cause constipation as a side effect. Narcotic pain medicines and older antidepressants are especially notorious in this regard, and some anti-cancer medicines and AIDS drugs can also be constipating. If this happens to you, don’t stop taking your medicine. It may be a lifesaver. But do discuss the situation with your doctor. In some cases, there may be an alternative that is less likely to produce this complication.

Fiber and Fluid

The first rule in preventing constipation is to get plenty of fiber and fluid. Here’s how: make sure you drink six to eight 8-ounce glasses of water or juice daily. Eat five to ten servings of vegetables and fruits. One reader found that four ounces of prune juice with pulp daily solved her problem.

For extra fiber, whole bran or bran cereal is useful, and so is psyllium (Metamucil, Per Diem Fiber, Reguloid, Serutan and similar products). Fiber can cause bloating or flatulence, though, so it is best to start with a little and increase the dose gradually. Be sure to wash such products down with plenty of water.

Bulk-Producing Laxatives

Bulk-producing laxatives such as polycarbophil or methylcellulose work in a similar fashion to fiber. Brands such as Citrucel, FiberCon, FiberLax, Konsyl Fiber, or Mitrolan should be taken according to instructions. Neither bulkforming laxatives nor others should be used if a person has nausea, vomiting, fever or serious abdominal pain that might indicate appendicitis or intestinal blockage. Such conditions require urgent medical attention.

Stool Softener

If the principal problem is a hard stool, or when recovery from surgery makes it uncomfortable to strain at all, a stool softener such as docusate (Colace, Dialose and others) may be recommended. Mineral oil is sometimes taken to lubricate the stool and make it easier to pass, but this product interferes with absorption of nutrients, especially fat-soluble vitamins, and its regular use is not recommended.

Osmotic Laxatives

When confronted with especially stubborn constipation, gastroenterologists sometimes resort to osmotic laxatives. These substances attract water into the colon, softening stool and triggering movement. Perhaps the best known are Milk of Magnesia (magnesium hydroxide) and Epsom Salt (magnesium sulfate). Such products may upset the balance of fluid and minerals in the body, and should not be given to children or people with chronic disease except under medical supervision. Certain sugars that are not well absorbed, especially sorbitol and lactulose (Chronulac, Duphalac, etc.) also act as osmotic laxatives. (This is why sugar-free gum or candy containing sorbitol or mannitol can cause diarrhea for some people.)

For people who must take strong pain medicines, constipation can be agony:

“I have used over-the counter harsh laxatives from childhood and have tried just about every herbal laxative known to man. I am on numerous prescription painkillers that cause constipation, so I’m in a lose-lose situation. I’ve gone 14 days without relief, and when I do have a movement, it is too painful to describe.”

Polyethylene glycol 3350 (MiraLAX), which also acts as an osmotic laxative, may be helpful in such a difficult situation. Usually used for short-term relief, it may also be used for chronic constipation. Japanese researchers, noting that most European studies of polyethylene glycol 3350 (PEG3350) lasted six months or less, undertook a year-long study of safety and efficacy (Journal of Gastroenterology, Sep. 2019). They found that it improved bowel function over the long term without any alarming side effects. Some people did report stomachache, nausea, diarrhea or bloating, however.

Ten Tips to Combat Constipation

Joe & Terry’s Ten Tips to Combat Constipation

• Lots of fiber & fluid
• Bran-apple-prune mix
• Flax seed
• Sugarless gum
• Psyllium
• MOM (magnesium)
• Unifiber (cellulose)
• Pumpkin bran muffins
• Vitamin C
• Ginger

Inner Cleansing

Many people believe that toxins build up in the digestive tract and cause illness, but there is no research to support this notion. While it is true that constipation is associated with an increased risk of colon cancer, this probably has more to do with a diet high in refined carbohydrates than with mysterious toxic sludge clinging to the wall of the colon. As far as we can tell, the toxic sludge is pure folklore. It was an effective selling point for many patent medicines more than a hundred years ago, and it is still a popular, but erroneous, idea used to sell products to “clean you out.”

Harsh laxatives, including herbs, could cause harm. Heavy use of such products may deplete the body of potassium and other minerals. In some situations, irregular heart rhythms might result. People who take diuretics that deplete potassium, such as hydrochlorothiazide, Bumex or Lasix should avoid over-the-counter laxatives or inner cleansing products that contain aloe, senna or cascara sagrada because of the potential for excess potassium loss. Aloe, senna or castor oil can be irritating to the digestive tract. Some of these compounds can interfere with proper nutrition and may make a person more susceptible to weakened bones. Laxative dependence is also an issue.

As for the idea that regular laxative use will somehow protect a person from cancer, just the opposite might be true. The FDA banned a common laxative ingredient called phenolphthalein (once found in Ex-Lax and Correctol) because of its “carcinogenic activity.” The agency has also raised questions about the safety of herbs such as aloe, cascara sagrada and senna, but it has taken no regulatory action.

Power Pudding Constipation Remedy

Some people refer to this as “nurses’ pudding,” because nurses used to recommend it for people recovering from abdominal surgery, when straining is uncomfortable and undesirable. Here’s the recipe:

Mix: 1 cup coarse unprocessed bran*
1 cup applesauce
3/4 cup prune juice

The mixture will be very thick. Take 1 or 2 tablespoons daily, washed down with plenty of water. Refrigerate unused portion. If there are no results within a week, increase the dose by 1 tablespoon. Do not exceed 6 tablespoons daily. Not drinking lots of water with this remedy could result in an obstruction, so take that part of the instructions very seriously!

*found in the cereal section

Pumpkin-Bran Muffins

One delicious way to pack more fiber into your diet is with these Pumpkin-Bran Muffins. Our friend Kit Gruelle, a fabulous cook, shared this low-fat high-fiber recipe with us.Kit Gruelle offers her recipe for delicious low-fat, high-fiber muffins to banish constipation:

Preheat oven to 400 degrees. Combine in a large mixing bowl and set aside.

• 1 cup whole wheat flour
• 1 1/2 teaspoons baking powder
• 1/2 teaspoon baking soda
• 1 teaspoon cinnamon
• 1/2 teaspoon ground ginger
• 1 teaspoon nutmeg

In another bowl combine and stir well.

• 2 cups bran cereal
• 1 1/4 cups reduced fat milk
• 1/3 cup dark brown sugar
• 1 egg (large)
• 1/2 cup canned pumpkin
• 3/4 cup raisins
• 1/2 cup diced dried apple

Let the bran mixture sit for approximately five minutes to allow bran to soften. Stir it into the dry ingredients (waiting in the large bowl) just enough to blend. (Don’t overmix.)

Drop the batter into muffin pans lightly oiled and lined with cupcake papers. Bake at 400 degrees for about 18 to 20 minutes, until a toothpick inserted in the center of a muffin comes out barely clean.

Fiber-Rich Foods

All-Bran
apples
bananas
barley
beans
blackberries
bran
Bran Buds
Bran Flakes
broccoli
bulgur
wheat
chickpeas
Fiber One
figskiwifruit
lentils
lima
beans
Mother’s Oat Bran
Nabisco 100% Bran
pears
peas
popcorn
prunes
Raisin Bran
raisins
Shredded Wheat’n Bran
split peas
Uncle Sam cereal
winter squash

Warning:

Be aware that using high-fiber foods to fight constipation may cause difficulties. One woman failed to respond to an antidepressant (desipramine) that had worked for her previously. She was extremely depressed by the time her psychiatrist figured out that the bran muffins the woman was eating to counteract constipation she anticipated from the desipramine had blocked the medicine’s absorption. Timing her bran so it no longer interfered with the antidepressant solved the problem.

Digoxin (Lanoxin) is another medicine that is not well absorbed if it is taken at a meal that contains a lot of fiber. One man found that eating a big bowl of oatmeal with Mother’s oat bran interfered with the effectiveness of this heart medicine.

Remedies for Constipation

Many readers have shared their practical wisdom with us. One woman in Seattle, Washington, reminds us that some people experience difficulties with constipation after eating specific foods. Mango has this effect for one person in her family, and many people know that cheese has this reputation. She warns that peanut butter can also slow the system down. Other readers, keeping in mind that coconut macaroons seem to be a helpful antidote for diarrhea, avoid coconut when they are troubled with constipation.

Spinach and Prunes:

People have special favorites when it comes to foods for fighting constipation. One reader proclaims, “The VERY BEST fibers are leafy green vegetables, like SPINACH.” Another swears by prune juice with pulp, a traditional stand-by. Prunes have a well-deserved reputation for combatting constipation. In additional to the natural fiber in this fruit, scientists have found a compound in prunes that is similar to a laxative used in the 1950s. This drug, oxyphenisatin, was taken off the market because it was associated with liver problems. It seems unclear whether prunes really contain this compound, but if they do, it would be smart to follow the advice of the Harvard Health Letter: “It is unlikely that moderate consumption would cause any problems, but prune use, like everything else, should be prudent.”

Dates and apples are popular, too. Another is blackstrap molasses. According to a reader, “I take 3 spoonfuls every other day and I no longer 4 need laxatives. It is not a laxative but it works. When I need extra help, I eat some black licorice.”

A Hot Drink to Banish Constipation:

Another old-fashioned approach to constipation is “hot lemonade”—hot water with a big squeeze of lemon juice first thing in the morning. Coffee is also a classic. Nurses have found it helpful to combat “post-operative ileus.” A study actually found that coffee is more effective than hot tea to get the bowels moving after surgery on the colon (Diseases of the Colon and Rectum, Aug. 2019).

Laura noted that different cultures may embrace this practice more enthusiastically:

“Years ago, I worked for a large Taiwanese-owned steamship Company. I was one if the few Americans and my position fully immersed me in the many unique cultural and food ways including the wonders and importance of a good-working bowel system.

“EVERY morning all of the Taiwanese employees and executives would drink cups of hot (or very warm) water before drinking tea. Why? By doing this guaranteed a healthy bowel and elimination system due Traditional Chinese Medicine. I was advised to never start my day drinking a cold anything. Just a cup of hot water.

“After 45 years and doing this every day I’ve yet to experience anything other than overall good health.”

Sugarless Chewing Gum:

The sweeteners used in sugar-free gum such as maltitol and sorbitol act like laxatives, holding moisture in the colon. Too much may cause diarrhea, so people need to be cautious about using this as a constipation remedy. However, chewing sugarless gum can be very effective.

Flax Seed:

Many people have used flax seed as a way to ward off constipation. Here’s one reader’s method: “Some time ago you had a question from a person who wanted to know how to use flax seed to relieve constipation. I purchase it in bulk at a health food store for about $1.50 per pound. I put three quarts of water on to boil, add two tablespoons of flax seed and simmer for fifteen minutes. Then I cool it and strain it into containers. (It makes just over two quarts.) With two ounces in my orange juice every morning, I am more than satisfied.”

Herbs for Constipation:

Several herbs may be useful, though we don’t recommend regular use of the usual laxative herbs. Ginger can stimulate digestive tract action. It is not habit-forming, and is said to ease flatulence as well. Milk thistle, an herb used to protect the liver, has given one reader relief: “I’m 75 and I’ve had trouble all my life. A few months ago a doctor told me about it. His wife takes it so I tried it. Milk thistle works wonders.” Dong quai also has laxative action.

Bitters:

One traditional way to take herbs is in bitters, frequently used as a tonic to aid digestion. Here’s what one reader says: “I have used Swedish Bitters for several years with good results. When I need it I take a couple of teaspoons in a glass of hot water or herb tea. If I’m traveling I use the capsules instead of the liquid, taking one after each meal if I need it. I have had clerks tell me that they do not carry the capsules because in order for the bitters to work they must be tasted, but my experience belies that claim. The capsules are more expensive or I would use them at home, too.”

Dietary Supplements:

Dietary supplements sometimes cause diarrhea as a side effect. At high doses, vitamin C can cause diarrhea, and some readers have used this to fight constipation. Others utilize the mineral magnesium. After all, milk of magnesia, a magnesium salt, is a time-honored laxative. Taking magnesium with calcium can ease the constipation sometimes associated with calcium supplements. Be aware, however, that people with reduced kidney function should avoid supplemental magnesium, as it may put too much strain on the kidneys.

OTC Treatments:

Psyllium (Metamucil and other brands) can be very effective if used regularly. Unlike stimulant laxatives, it doesn’t lead to tolerance. One reader found a different remedy: “A friend told me about Unifiber—a very fine powder. I combine it with canned peaches and homemade oat bran muffins to really help regulate my system. I didn’t have diarrhea or cramping. Unifiber can be mixed with hot cereal, applesauce, juice or even meatloaf and mashed potatoes! This makes it convenient as well as palatable.” Unifiber contains powdered cellulose and maltodextran.

Polyethylene glycol (MiraLAX) was once available only by prescription, but for years now people have been able to buy it over the counter. It may be the first thing the doctor would recommend, before moving on to prescription-only products. Polyethylene glycol is considered an osmotic laxative that pulls water into the colon to make stool softer and easier to pass. Usually, experts recommend its use for short-term treatment of constipation. Keep in mind that it will take up to three days to get results. People with chronic constipation may need to use this product regularly for a long time.

If these remedies don’t help, and constipation is a persistent problem, please get medical attention. Constipation could be a symptom of something more serious that requires prompt treatment.

Drugs That May Cause Constipation

You might be surprised to learn that something you are taking could be causing your constipation. Even supplements such as calcium carbonate can contribute to bathroom difficulties. Prescription drugs may also cause trouble. Opioid pain relievers are especially notorious for this side effect, but medications for Parkinson’s disease as well as some for depression or schizophrenia can also create constipation for many individuals. The list below is thorough but not exhaustive. Be sure to check the generic names (in parentheses) as well as the brand names; nowadays, more medications are prescribed by their generic name. If you find a medicine you are taking on the list, or if you suspect that something else you take might be causing you uncomfortable constipation, please discuss it with your health care providers. Some of the drugs listed in this table are used to treat cancer or other life-threatening conditions, so you would not want to stop them on your own.

Medications With Constipation as a Side Effect

What the Doctor May Prescribe

If you are having trouble managing your constipation with the remedies suggested, be sure to discuss the problem with your physician. He or she will want to rule out a serious cause, such as a tumor or a motor disease. Obviously, if they found something of that nature, they would need to treat the underlying cause.

If no such underlying reason is found for chronic constipation, doctors have a few medications they could prescribe. Linaclotide (Linzess) and plecanatide (Trulance) are prescribed for stubborn constipation or for irritable bowel syndrome with constipation dominant. Both medications act on the lining of the bowel to encourage cells to increase the concentration of salts (chloride and bicarbonate) inside the colon. This stimulates the movement of material through the digestive tract. Both drugs can be considered roughly comparable to each other in terms of efficacy as well as side effects, primarily diarrhea (JAMA, Nov. 4, 2019).

In addition, a doctor might choose to prescribe prucalopride (Motegrity). This drug, approved late in 2018, works through serotonin to increase gastrointestinal motility. Dr. Arnold Wald, writing in JAMA, suggests that all three of these agents should be reserved for use in cases where standard approaches (psyllium, polyethylene glycol aka MiraLAX or lactulose) have been ineffective. In addition, while Motegrity can be helpful for people with chronic kidney disease and constipation, the doctor should reduce the dose (Journal of Neurogastroenterology and Motility, Oct. 30, 2023).

Combating Opioid-Induced Constipation

Narcotic pain relievers are notorious for causing constipation that can be hard to treat. The first choice for treatment is a standard laxative. However, if laxatives are not helpful, doctors may prescribe medications developed specifically for this problem. Most of these are drugs based on the opioid antagonist naloxone, but they are designed to work exclusively in the digestive tract and not get into the rest of the body. (If they did, they might interfere with the pain relief the narcotic provides.) Naloxegol (Movantik) and naldemedine (Symproic) are less expensive than methylnaltrexone (Relistor). They also appear to have better evidence to support their use.