Constipation refers to bowel movements that either occur less often than expected or with a stool that is hard, dry and difficult to pass.  (Types 1-3 on the Bristol Stool Chart, below.)  A healthy adult should pass one to two stools a day, although some otherwise healthy adults pass a stool every other day.  There are a number of reasons one might not pass feces, including diet, fluid intake, medications, stress, anal pain from hemorrhoids  or fissures, lack of probiotic gut bacteria, laxative abuse, specific diseases, such as stroke, diabetes, thyroid disease and Parkinson’s, change in circardian rhythm (due to irregular sleeping while traveling) and a poor posture while eliminating

In Chinese medicine proper digestion has been seen as a paramount hallmark of health and one school of medicine considered poor digestion to be the root of almost all diseases. Chinese medicine looks at whether the constipation is because of a dry hard stool (dryness, usually due to heat) or a normal stool without peristalsis (qi stagnation).  Heat can be of  external or internal origin and is the major cause of constipation, especially if stools are hard or dry. Qi stagnation involves anything that blocks peristalsis, from emotions (Liver qi stagnation) to physical blockages  or lack of exercise.

Laxatives and Laxative Abuse

Western medicine  recognizes two types of laxatives:  hyperosmolar and stimulant.  The hyperosmolar laxatives (MiraLax, GoLytely, and Philips Milk of Magnesium) are agents that draw water into the bowel, making the stool softer and promoting movement of the stool.  Hyperosmolar laxatives are over the counter medications, often used in healthcare as they have few risks and tend not to cause abdominal cramping.  Stimulant laxatives, on the other hand, stimulate the propelling action of the bowel..  These include the anthraquinone laxatives  These medications are associated with cramping and potentially harmful side effects.

In Chinese medicine we use three classes of laxatives.  Emergency cathartics  are given only in serious circumstances such as constipation accompanied by ascites.  Only experienced practitioners should use this category which causes serious cramping and diarrhea. Strong laxatives like Da Chen Qi Tang are often based on stimulants like rhubarb root and hyperosmolar magnesium, which are only taken until the first bowel movement. The second category is comparable to the anthraquinone laxatives (like senna, cascara sagrada, buckthorn, or aloe), Mirelax, phenolphthalein and bisacodyl.  Gentle bulk laxatives make up most treatments for constipation. The gentle bulk laxatives include flax and psyllium seed (Metamucil), methylcellulose (Citrucel) and prunes.  Stool softeners (emollient laxatives like docusate) are more benign western laxatives which are similarly gentle and allow fluids to penetrate the hard stool. Stool softeners are commonly used when there is a need to soften the stool temporarily and make defecation easier (for example, after surgery, childbirth, or heart attacks). They are also used for individuals with hemorrhoids or anal fissures.They have temporary uses,  but over the long run water in the diet should do the trick for most people.

A unique forth class of nourishing laxatives comes from Ayurvedic medicine and is based on the rasayana (longevity tonic) Triphala which consists of three fruits: : Amala  (Emblica officinalis) one of the highest natural sources of Vitamin C, Bibhitaki (Terminalia bellirica), and Haritaki (Terminalia chebula).  This is the only nourishing laxative I know of and can be used to recover peristalsis after damage from overuse of anthraquinone laxatives.  It may be combined with other herbs like guggulu,

Laxative abuse can be a major cause of constipation since people with constipation will often inappropriately choose stimulant laxatives, use them too frequently or use them for purging in a misguided attempt to control weight.  This can take over the body’s natural peristalsis and  the person will no longer be able to have a normal bowel movement. The anthraquinonne laxatives will cause laxative dependence within two weeks of constant use. Herbalist David Hoffman tells how the British Navy in its wisdom wanted its sailors to be regular, so issued a daily dose of senna, dooming the sailors to lifetime laxative dependence.  (Perhaps if they had listened to the Indians they were colonizing, they might have learned to overcome the dependence with triphala!)

Medications and Constipation

There are a number of medications that can cause constipation, notably pain killers and other medicines based on opiods.  I once treated a woman on methadone maintenance who had retained so much stool that she appeared 9 months pregnant.  She spent a large part of each day trying enemas and other actions to move a little stool.  The opiate killed her peristalsis.  Codeine based pain killers are known for causing constipation that can be worse than the pain being treated.  Examples include Tylenol #3, oxycodone (Percocet), and hydromorphone (Dilaudid.)  Ibuprofen (Motrin) often works as well after the first few doses of codeine.

Diuretics like Lasix and calcium channel blocking drugs such as diltiazem (Cardizem) and nifedipine (Procardia) can dry the stool out. Antidepressants such as amitriptyline (Elavil, Endep) and imipramine (Tofranil and anticonvulsants such as phenytoin (Dilantin) and carbamazepine (Tegretol)  are constipating although Prozac is not. Parkinson’s disease medications including anticholinergic medications, Artane and Cogentin can constipate, but then so can the disease.  Even iron supplements and aluminum-containing antacids such as Amphojel, Maalox, Mylanta, Gelusil and Rollaids can cause constipation.  Speak to your doctor about non-constipating alternatives and consider natural alternatives to iron and antacid supplements.  For instance dock (Rumex crispus) tincture helps iron assimilation in drop doses. And bitters before meals can reduce the need for antacids (which are usually the wrong remedy for people over 30.)

Diet and Constipation

Diet is perhaps the main cause of constipation and can be the easiest to remedy once laxative dependence is addressed.  Dietary influences come from a variety of sources. For example magnesium  has decreased by over a third in most foods tested by the USDA since the mid 1970s and magnesium helps attract fluid into the stool.  But we also have less fiber and fewer bitter vegetables, both of which would help reduce constipation..

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  Fluids:  If you don’t get enough fluids from food or drink, your constipation won’t go away. You need 6-8 servings of fluid a day, approximately 2 liters.  It does not have to be from pure water although water is good.  Fluid can come from drinks, fruit like watermelon, vegetables like cucumber, coffee and tea (although a small amount of caffeinated beverages will pass through without hydrating you.) If you sip- half a cup or less at a time- you will hydrate better.  If you gulp, you will trigger your urinary reflex.   That is a good thing because it flushes out the tissues but you need hydration to stop constipation.

• Lots of fluid-rich fruits and vegetables like watermelon, honeydew melon, cucumber and celery.
• Allergens or food sensitivities, especially milk can cause chronic constipation by creating inflammation that causes changes in the lining of the gut, specifically the  eosinophilia of the rectal mucosa. (see references below.) Sometimes this causes diarrhea or mixed constipation and diarrhiea, but constipation alone can be triggered.
• Insufficient fats.  Fats lubricate the intestines and allow for smooth passage of the feces.  In Chinese medicine we use oily seeds like apricot pits, flaxseed, cannabis seed and olive seed.  Coconut or olive oil also work.
• Fiber: You need about 25  to 30 grams of fiber every day to soften the stool and encourage proper bowel function. Most American diets contain less than half that amount. Fiber from powdered supplements can impact if you don’t take them with enough fluid. Fruits and vegetables provide fiber in a hydrating package.  Bananas, apples, celery, fennel root and cucumber all help.

• Mucilage is a specific kind of water-soluble fiber that provides lubrication.  Sea vegetables, mucilage from slippery elm bark, hibiscus flowers, marshmallow root, okra, chia seeds or flax seeds will also lubricate the intestines.

• Lack of bitters. The bitter taste stimulates the liver to make bile and to stimulate both digestive juices in the stomach and peristalsis.  We have significantly reduced this important digestive signal by hybridizing bitter fruits and greens to have a sweeter taste.  Bite into a lime peel, then squeeze the sour juice into water and drink it before your meal.  Or eat grapefruit, radicchio salad, Karela (bitter melon), drink black coffee or have a little Angostura bitters in water before your main course.  Urban Moonshine makes purse-sized bitter sprays that make it easy to get the bitter trigger in the go (tiny amounts work.)

• Coffee.  This is one of the most common agents to stimulate the bowel and a cup in the morning is often followed by a bowel movement.  Coffee is a bitter, is rich in magnesium,  chlorogenic acids, cafestol, kahweol, caffeine, theophylline and theobromine.

• Fermented foods: are a source of probiotics wrapped up in fluid, frequently fat and often fiber.  Aside from buttermilk, yogurt, kefir, sour cream, fermented butter, live blue cheese, gorgonzola, kombucha and live vinegar, which don’t appreciably contain fiber with their organisms,  pickles, kim chee, sauerkraut, fermented veggies, olives, miso and fermented fish all help repopulate the gut and move things along.  The fermented vegetables are easy to make if not found nearby, and they contain prebiotic foods for the probiotic organisms.  Te good bacteria form a living wallpaper in your gut and help the health of the intestinal villi.

• Probiotic supplements can be useful to repopulate the gut after antibiotics but very few probiotics have much more than 4-5 Lactobacillus or Bifidobacteria species and we have hundreds to thousands of naturally-occurring gut species.  So while there is value in populating the most common probiotic species there is a need to take in probiotic foods.   The two probiotics I recommend are Pharmax Sinbiotics Human Lactobacillus Complex  which come with very potent sachets and Florastor which uses the less common probiotic yeast Saccharomyces boulardii.  In Europe one can find probiotic strains of benign e-coli (the kind thin people have naturally) like Escherichia coli Nissle, but the FDA does not permit their sale in the USA.

• Vitamin C is also laxative in large doses.  1000 mg of the vitamin in the morning can help stimulate a bowel movement.

Physical Aspects of Constipation

First, movement is necessary to provide qi to the bowels so peristalsis can occur.  A person who never moves is likely to have trouble moving their bowels.  Engaging in walking after meals is good for someone who is beginning to move.

Acupuncture can also help move the bowels.  Your acupuncturist might us points near your belly button, with additional points on your lower leg to moisten the stool and points below your knee for peristalsis.  The acupuncture acts as a reset button for your body to take over normal elimination.

But another, less-appreciated issue in western society is that we eliminate in the wrong position. For most of human history and in most places people have defecated in a squatting position. With the knees above the hips and the pelvic floor engaged, elimination is easier and more complete.  I did not appreciate this until going to Beijing and getting intestinal problems.  We stayed in a fine hotel that provided both western thrones and eastern squat toilets and surprisingly it was easier to manage with the eastern toilets because you could clear out more easily.

More significant to constipation is the understanding of the role of the puborectalis muscle. The large intestine unloads at the rectum.  However the rectum is supported by a loop of muscle, the puborectalis muscle which in a sitting or standing position chokes off the rectum to maintain continence. When one squats, the anorectal angle is increased, the rectum straightens and the stool can be easily evacuated.  We pay a high price for retaining the Victorian “throne”. Because the anorectal angle is in a kinked position while sitting one is forced to strain in order to move the bowels, which is the main cause of hemorrhoids. While squatting the angle straightens out allowing the fecal matter to eliminate quickly and easily without straining.

Since most of us will be unable to install a squat toilet in a western home or business, the Squatty Potty was designed as a corrective to the toilet. It consists of an elevated step stool that has a cutout to hug the toilet and allows elimination with a 35 degree anorectal angle.  It is better  than using a narrow foot stool and certainly better than standing on an unstable toilet seat.

Sitting with elevated feet is not quite as efficient as eliminating in a true squatting position. Weight rests on the buttocks instead of the feet, although one probably could work up to a true squat on the wood  versions, as seen in the second video below.  Nonetheless it is better than sitting at either a 90 degree angle or balancing on an unstable toilet seat.

Chronic Constipation and Food Hypersensitivity – An Intriguing Relationship. A. Carroccio, G. Iacono. Aliment Pharmacol Ther. 2006;24(9):1295-1304

Multiple food hypersensitivity as a cause of refractory chronic constipation in adults. ANTONIO CARROCCIO, LIDIA DI PRIMA, GIUSEPPE IACONO, ADA M. FLORENA, FRANCESCO D’ARPA, CARMELO SCIUME` , ANGELO B. CEFALU`, DAVIDE NOTO & MAURIZIO R. AVERNA. Scandinavian Journal of Gastroenterology, 2006; 41: 498
/504.

Health Benefits of the Natural Squatting Position by JONATHAN ISBIT

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