Constipation Protocol


Chronic constipation is the number one gastrointestinal complaint in the United States, particularly among the elderly. Constipation accounts for more than 2.5 million physician visits a year and is among the most frequent reasons for patient self-medication (Sweeney 1997).

The American Family Physician reported in 1998 that constipation affects as many as 26% of elderly men and 34% of elderly women (Schaefer et al. 1998). Constipation is a health problem that has been related to diminished perception of quality of life. The good news is that there are conventional and alternative treatments that can provide immediate relief.

Common Symptoms

Normal evacuation should occur 1-2 times daily. The movement should be formed, but not hard, with a slightly sweet odor. Movements that are hard or small and occur only every other day signify constipation. Any sudden change in a person's ability to move their bowels should be treated with suspicion, particularly in the elderly (constipation can be a first sign of colon cancer due to obstruction). Constipation associated with fatigue can also be an indication of hypothyroidism. More often than not, however, constipation is purely a functional problem unrelated to an underlying disease. Most individuals with uncontrolled constipation develop a variety of symptoms, ranging from large bowel pain, rectal discomfort, abdominal fullness and bloating, nausea, and anorexia to a general feeling of malaise. These individuals feel as if they never completely evacuate their bowels. Severe chronic constipation may be accompanied by fecal impaction.

Fiber Is Not the Solution for Some People

Studies show that some chronically constipated people do not find relief from fiber supplements.

An example of fiber not working was the report of a trial showing that 80% of patients with slow transit and 63% of patients with a disorder of defecation did not respond to dietary fiber treatment. In 85% of patients without these disorders, fiber was effective. This study showed that slow gastrointestinal transit and/or a disorder of defecation might explain a poor outcome of dietary fiber therapy in some patients with chronic constipation and why nutritional laxative therapy may be important (Vonderholzer et al. 1997).

Another study evaluated whether laxatives and fiber therapies improve symptoms and bowel movement frequency in adults with chronic constipation. Fiber and laxatives decreased abdominal pain and improved stool consistency compared with a placebo. The conclusions were that both fiber and laxatives modestly improved bowel movement frequency in adults with chronic constipation. The results of this study showed that there was inadequate evidence to establish whether fiber was superior to laxatives or whether one laxative class was superior to another (Tramonte et al. 1997). Clearly, fiber is not the solution to chronic constipation for many people, despite the endless television commercials and physician recommendations that tout the benefits of fiber.

Aggressive Alternative Therapies

Dietary modifications can help most people, but some cases of constipation are caused by insufficient peristalsis, which means there is not enough colon contractile activity to completely evacuate the bowel. However, there are specific nutrients that, if taken at the right time, can induce healthy colon peristaltic action without producing side effects. Although pharmaceutical laxatives have been linked to the development of cancer, nutritional laxatives have many health benefits.

On an empty stomach, certain nutrients have been shown to induce healthy colon peristalsis. One combination is 4-8 grams of vitamin C powder and 1500 mg of magnesium oxide powder taken with the juice of a freshly squeezed grapefruit. A convenient product sold by several vitamin companies is a buffered vitamin C powder product that contains magnesium and potassium salts mixed with ascorbic acid. Depending on the individual, a few teaspoons or, in some cases, 1-2 tbsp of this buffered vitamin C powder produce a powerful but safe laxative effect within 45 minutes. This therapy has to be individually adjusted so it will not cause day-long diarrhea.

Vitamin B5 (pantothenic acid) in a dose of 2000-3000 mg, on an empty stomach, will produce a rapid evacuation of bowel contents. Vitamin B5 powder is unpalatable, but there are many health benefits attributed to it--in addition to its ability to stimulate peristalsis (Mancinella et al. 1982). One way of taking vitamin B5 and other peristalsis-inducing nutrients is to use a multinutrient formula, such as Powermaker II. This better-tasting powder contains vitamin B5, vitamin C, choline, and L-arginine, all of which induce significant peristaltic action when 1-2 tbsp are taken on an empty stomach.

Nutritional laxatives such as magnesium, ascorbic acid, and pantothenic acid are becoming more popular in persons with constipation that is resistant to fiber therapies.

Fiber and Constipation
Dr. Dennis Burkitt (a well-known British surgeon practicing in Africa after World War II) noticed that very few people in Africa suffered from constipation. His epidemiological surveys and studies led to the now well-known fact that dietary fiber in North America is sadly lacking. Burkitt connected low dietary fiber to many illnesses, such as hemorrhoids, diabetes, varicose veins, heart disease, and appendicitis (Jones et al. 1985; Trowell et al. 1986).

Constipation also means that the stool is in contact with the surface of the large bowel wall for a longer time than in the person whose bowels move regularly. Some have suggested that this increased contact between the stool and the bowel wall may increase our exposure to toxins and carcinogens.

Fiber
There are two kinds of fiber: soluble and insoluble (each indigestible by humans). Soluble fiber attracts water and turns to gel during digestion. This slows digestion and the rate of nutrient absorption from the stomach and intestine. Soluble fiber is found in oat bran, barley, nuts, seeds, beans, lentils, peas, and some fruits and vegetables. Insoluble fiber is found in foods such as wheat bran, vegetables, fruits, and whole grains. Insoluble fiber appears to speed the passage of foods through the stomach and intestines and to add bulk to the stool. The average American now eats 10-15 grams of fiber daily. The recommendation for older children, adolescents, and adults is 20-35 grams daily. Fiber is excellent for overall intestinal health as well as for its benefits in alleviating chronic constipation in some people. Although human beings cannot digest fiber, the 5 lbs or so of intestinal bacteria known as "friendly bacteria" will use fiber for fermentation purposes and for the production of useful short-chain fatty acids that the cells of the intestinal tract can use for their energy source. The following table lists food sources of fiber. Most foods contain a mixture of soluble and insoluble fiber

Food Sources of Fiber
Food ..............Serving size ..........Total fiber............. Insoluble ........Soluble
......................................................(grams).................(grams)..........(grams)
English muffin............1 .......................2.0 ......................0.5 ...............1.5
Spaghetti, cooked.....1 cup .................2.0 ......................0.5 ...............1.5
Whole-wheat bread..1 slice ................2.5 .......................0.5 ...............2.0
White rice, cooked.1/2 cup ................0.5 .......................0 ..................0.5
Bran flake cereal.....3/4 cup ...............5.5 ........................0.5 ..............5.0
Corn flake cereal.......1 cup ...............1.0 .........................0 .................1.0
Oatmeal, cooked.......3/4 cup ............3.0 .........................1.0 ..............2.0
Banana.......................1 medium ........2.0 ........................0.5 ..............1.5
Apple, with skin.........1 medium ........3.0 .........................0.5 ..............2.5
Orange......................1 medium ........2.0 .........................0.5 ..............1.5
Pear, with skin...........1 medium ........4.5 .........................0.5 ..............4.0
Strawberry.................1/2 cup ...........1.0......................... 0 ................1.0
Broccoli.....................1/2 cup ...........2.0 .........................0 ................2.0
Corn..........................1/2 cup ...........1.5......................... 0.................1.5
Potato, baked with
skin............................1 medium ........4.0 ........................1.0 ..............3.0
Spinach......................1/2 cup ...........2.0 ........................0.5 ..............1.5
Kidney bean...............1/2 cup ...........4.5 ........................1.0 ..............3.5
Popcorn.......................1 cup ............1.0 .........................0 ................1.0
Peanut butter,
chunky.........................2 tbsp ............1.5 .........................0 ................1.5

Ispaghula Husk (Psyllium)
In a multicenter trial, psyllium fiber was compared with lactulose and other laxatives in 381 patients who were constipated. After 4 weeks, Ispaghula (psyllium) husk was rated as superior compared to lactulose and other laxatives because bowel movements were more frequent and of greater bulk. There was a lower incidence of side effects as well (Dettmar et al. 1998). However, an article in The Lancet suggested that Ispaghula husk could increase the probability of developing benign tumors on the colon in persons who had a previous history of these tumors (known as adenomas) (Bonithon-Kopp et al. 2000).

Lifestyle Changes
There are a number of factors that contribute to constipation: poor dietary practices, including lack of dietary fiber; not drinking enough water; lack of exercise; improper laxative use; hypercalcemia; inflammatory bowel disorders; and some neurological disorders. Additionally, taking antacids containing aluminum or calcium, as well as reactions to taking medications (e.g., painkillers containing codeine, antidepressants, antiparkinsonism drugs, and diuretics) may cause constipation. In many people, anxiety, depression, and grief (even a routine pregnancy) may also precipitate constipation.

In addition, aging itself can increase the incidence of constipation. As a person ages, the colon wall thickens. When this thickening is combined with a lifetime diet that is low in fiber, constipation can result.

As noted earlier, dietary content can have a significant effect on constipation. People may become constipated if they begin to eat fewer vegetables, fruits, and whole grains. In addition, eating high-fat meats, dairy products, eggs, and sweets high in refined sugars can also lead to constipation.

Unfortunately, many elderly people who live alone lose interest in cooking and eating. As a result, they often turn to eating convenience foods. These foods tend to be low in fiber and high in fat and may contribute to the problem. Furthermore, bad teeth often cause older people to choose soft, processed foods that contain little, if any, fiber.

Constipation can contribute to a loss of bladder control by weakening the pelvic floor muscles as a result of straining. A full bowel pressing on the bladder, causing it to empty prematurely or block the outflow of urine, is a common effect of constipation. People with bladder control problems often do not drink enough fluids for fear of incontinence, which can result in constipation or worsen it, causing more discomfort and anxiety.

Many other people also do not drink enough fluids, especially if they do not eat regular meals. As already noted, water and other liquids add bulk to stools, making bowel movements easier (Krugan 1996).

What the Europeans Are Doing

The most popular digestive aid sold in Europe is called Digest RC. This product was introduced in Europe over 45 years ago, and today more than 100 million doses of the product are sold annually, primarily in Eastern Europe.

The mechanism of action of the formula is to stimulate peristalsis of the intestines, speed digestion of fats, and prevent stagnation of food in the digestive tract. Benefits for the user are a reduction in esophageal acid reflux; alleviation of the feeling of fullness and bloating after eating; decreased digestive tract tension; alkalinization of gastric contents; constipation relief; and normalized elimination.

Black radish juice extract is the primary active ingredient in Digest RC. Virtually unknown in the United States, radishes contain a variety of chemicals that increase the flow of digestive juices. The most important function of black radish extract is that it encourages the liver to produce fat- and protein-digesting bile and lowers the tension of the bile ducts. It also improves peristaltic movement. Constipation is one problem benefiting from radish consumption. Rich in fiber and digestive stimulants, regular consumption of radishes helps regulate the bowels. Because dehydration is a major cause of constipation, radishes help hydrate and lubricate the intestines and encourage relaxed bowel movements. The root juice extract of the black radish used in Digest RC is the most potent part of the plant.

A bonus is the ability of the radish to assist the immune system because it contains a variety of chemicals that possess natural antimicrobial actions (Terras et al. 1992). Regular consumption of radishes may lead to a significant improvement in resistance against common microbial infections such as colds, sore throats, ear infections, and the flu. A French study in which liquid radish extract was administered to mice before they were inoculated with influenza virus demonstrated protection against the influenza infection. There was a significant decrease in the mortality rate and a significant increase in the rate of survival as compared to the untreated controls (Esanu et al. 1985).

A second constituent of Digest RC is artichoke, which acts directly on the liver, further increasing production of bile and causing it to flow through bile ducts. It is used in cases of low food tolerance, troubled digestion, and assimilation.

Peppermint, another ingredient of Digest RC, helps relax gastrointestinal smooth muscle (Hills et al. 1991).

The charcoal in Digest RC is particularly useful in absorbing toxins. Charcoal is commonly used for gastrointestinal decontamination by a majority of North American poison control centers (Juurlink et al. 2000). It also calms a stressed digestive system, allowing digestive enzymes to be produced and released. Indigestion and nervous vomiting are also treated with this ingredient. The charcoal in Digest RC is actually a special herbal preparation of linden tree bark, traditionally used in Europe as a digestive aid. This special preparation has antibacterial properties, which when used as directed helps balance the digestive tract and support the creation of the proper intestinal flora. At the same time, it creates an inhospitable environment for parasitic infestation.

Another key ingredient in Digest RC is cholic acid (or pure processed ox bile), a liver enzyme used for digestion. Cholic acid is particularly helpful in digesting fats and meat protein.

Independent clinical research was conducted on Digest RC to analyze the therapeutic effectiveness of the product among patients with chronic digestive problems. Results showed statistically significant improvement in patients' symptoms during treatment. Digest RC was most successful in eliminating the most frequently occurring symptoms such as gas in over 95% of the cases. Symptoms such as constipation, intestinal pains and cramps, heartburn (reflux), and stomach pains and cramps were helped or completely eliminated in over 90% of the cases. Bloating ceased in over 80%, diarrhea in about 75%, and nausea and vomiting in approximately 65% of the cases.

Digest RC was found to minimize the assimilation of undigested toxic products which often stay in the gut for a prolonged period of time. Due to its bile-stimulating abilities, Digest RC was particularly effective in preventing stasis of food and bloating in those patients whose diet was rich in animal protein and fat. Because there are no specific contraindications, Digest RC can be taken together with any medication and can be taken by patients who have various respiratory, cardiovascular, and musculoskeletal disorders. The only people who should avoid Digest RC are those with biliary tract obstruction or gall bladder disease because of the bile-stimulating effects of the black radish and artichoke extracts. It is not known how this product would affect persons who have had their gall bladder removed.

Suggested dosage: Take 2-3 tablets of Digest RC with every heavy meal for the first 2-3 weeks. The dose may then be reduced as symptoms of digestion discomfort are alleviated (Anon. 1999).

Additional Suggestions

As previously discussed, fiber supplements frequently fail to correct chronic constipation. However, one fiber that may work when all others fail is chitosan. Chitosan is a fiber composed of chitin, which is a component of the shell of shellfish that is used for weight and cholesterol reduction. Chitosan has unique properties in its ability to bind fat from food in the stomach and the intestines. When fat content in the bowel increases, it makes the feces soft and smooth (Rossner et al. 1995). If you do not obtain results from other commonly used fiber sources, six 500-mg capsules of chitosan along with 1000 mg of vitamin C before each meal may help alleviate constipation. Ascorbic acid (vitamin C) helps activate chitosan in the stomach and intestine into a fat-absorbing gel. When ascorbic acid was given with chitosan to rats, far more fat was trapped and excreted in the feces than when chitosan was given without ascorbic acid (Kanauchi et al. 1995).

Constipation is a common childhood condition, estimated to occur in 5-10% of children. In most cases, the cause is functional. However, constipation may occasionally indicate a significant organic disorder which can usually be determined by a thorough history and physical examination. Constipation that is present from birth or that begins in the neonatal period is most likely to be congenital in origin. Acute constipation usually has an organic cause, although chronic constipation usually has a functional cause.

A trial on functional constipation in children showed that most children with fecal incontinence benefit from a strict treatment plan that includes defecation trials, a fiber-rich diet, and laxative medications. Surgery followed by medical treatment was required in patients with Hirschsprung's disease (congenital colon defect) and in some patients with anal stenosis (Loening-Baucke 1997).

Chronic constipation at any age can be a disabling condition that may require removal of part of the colon (colostomy). However, one study showed fiber, cathartic laxatives, or biofeedback therapy to be successful in 65% of patients. Among the remaining patients, two-thirds underwent surgery, of which 83% was successful (Rantis et al. 1997).

Laxative use was significantly reduced in a long-term care facility when an interdisciplinary program was implemented based on a philosophy of prevention and health promotion. Specifically, increased fluid and fiber intake, timely toileting habits, and regular activity or exercise led to a 50% reduction in the number of patients receiving laxatives that were required relative to pre-program levels and in a control unit not receiving the program (Benton et al. 1997).

Constipation is a problem frequently encountered during pregnancy, as is excessive weight gain. Treatment commonly used to control constipation has some drawbacks and often does not help control weight. However, a preparation of lactulose and glucomannan was shown to be effective and well tolerated in pregnant women with constipation and was also shown to be effective in controlling excessive food intake. Fifty pregnant females with constipation were treated with a preparation of glucomannan (3-6 grams) and lactulose (8-16 grams) twice a day for 1-3 months. This preparation resulted in a return to normal frequency of weekly number of evacuations and a parallel control of weight gain (Signorelli et al. 1996).

Drug Therapies

For many persons with chronic constipation that does not improve with fiber or laxatives, a new drug called prucalopride has been shown to help relieve chronic constipation. Prucalopride is a novel, selective, and specific serotonin receptor agonist (5-HT4) that belongs to a new class of medications known as the benzofurancarboxamides. The latest studies report that prucalopride may increase the frequency of bowel movements and improve colonic transit (the time it takes for food to move through the colon), both of which are key factors in the effective treatment of chronic constipation (Slootes et al. 2002). One study involving 10 healthy subjects found when taking prucalopride, stool frequency increased, consistency decreased, and subjects strained less (De Schryver et al. 2002). In all studies, prucalopride was safe and well tolerated.

Some Conventional Therapies

Physicians often recommend fiber supplements (bulk producers) to prevent constipation. They also recommend eating more fresh fruits and vegetables, either cooked or raw, and more whole grain cereals and breads. Dried fruit such as apricots, prunes, and figs are especially high in fiber. Some physicians suggest adding small amounts of unprocessed bran ("miller's bran") to baked goods, cereals, and fruit. However, some persons experience bloating and gas for several weeks after adding bran to their diets. Gradually adding bran to the diet is advised to allow the digestive system to adapt. Remember, if your diet is well balanced and contains a variety of foods high in natural fiber, it may not be necessary to add bran to other foods.

Therapies may include:

Bulk producers, such as psyllium, are natural or semisynthetic polysaccharides and cellulose, which hold water, soften the stool, and increase the occurrence of the passage of a stool. They are the most physiologic of the laxatives. Bulk producers are generally recommended for managing irritable bowel syndrome. Results occur within 12-24 hours (may be delayed up to 72 hours).
Saline laxatives are in the hyperosmotic family, meaning their mode of action is to attract water into the lumen of the intestines. The fluid buildup alters the stool consistency, expands the bowel, and encourages peristaltic movement. They are used mostly as a bowel preparation to clear the bowels for rectal or bowel examinations and are not recommended for long-term use. Results occur rapidly (within 0.5-3 hours). Examples include magnesium citrate and magnesium oxide.
Stimulant laxatives, such as sennacides, increase motor activity of the bowels by direct action on the intestines. They are used to evacuate the bowel for rectal or bowel examinations. Most of these laxatives act on the colon; castor oil acts on the small intestine. Results occur in 6-10 hours.
Lubricant laxatives, such as mineral oil, lubricate intestinal mucosa and soften stools. They are used prophylactically to prevent straining in patients for whom it would be dangerous to strain. Generally, mineral oil is recommended at 5-30 mL at bedtime. Results vary. Chronic mineral oil ingestion can result in malabsorption of fat-soluble vitamins and minerals and is not recommended for continuous treatment.
Fecal softeners or emollients (Docusate) promote water retention in the fecal mass, thus softening the stool. They are generally used to prevent straining and are most beneficial when the stool is hard. However, it may require 3 days before results are experienced. Stool softeners and emollient laxatives have limited use because of their resorption of water from the forming stool. Fecal softeners should not be used exclusively but may be useful when given in combination with stimulant laxatives.
Lactulose is an undigestible sugar that is broken down into acids in the colon. Lactulose is used to clear the bowel with minimal water and sodium loss or gain. When it is broken down in the colon, lactulose produces lactic acid, formic acid, acetic acid, and carbon dioxide. These products increase the amount of water in the stool which softens the stool and increases the frequency. Results generally occur in 24-48 hours. The metabolism of lactulose requires the presence of "friendly bacteria" known as Lactobacillus acidophilus. The consumption of Lactobacillus acidophilus together with lactulose will help to normalize intestinal friendly bacteria content and will eliminate pathogenic bacteria such as Clostridium, which are frequently present in the normal bowel. Lactulose is available only by prescription.
Golytely (Colyte) is an electrolyte solution available by prescription and used to clear the bowel with minimal water and sodium loss or gain. It is typically prescribed before a colonoscopy.

Summary

Constipation is a universal affliction of Western civilization. In the United States, Americans spend more than $725 million annually on over-the-counter laxatives in an attempt to self-treat constipation, which is the most common gastrointestinal complaint. There are alternative therapies that are safer and more effective than conventional laxatives and they work better for more people than fiber supplements.

For the most part, chronic constipation is amenable to changes in lifestyle. Begin by increasing exercise or general activity during the day. This can be as little as 20 minutes of walking briskly on a regular basis. Remove as many processed foods as possible from your diet and replace them with fiber-rich foods such as fruits, vegetables, and whole-grain cereals. The addition of 1 tbsp of wheat bran, ground flaxseed, or oat bran to your diet will speed up the process. In most cases, over days or perhaps weeks, your bowels will begin to move more frequently and more easily as a result of these changes. If these changes do not produce the desired effect, and you have ruled out the possibility of underlying disease with your health-care provider, then the suggestions below may be helpful.

For relieving acute constipation, one of the following techniques may be tried to induce peristaltic action within 45-60 minutes:

Mix 4000-8000 mg of ascorbic acid powder with 1500 mg of magnesium oxide powder and take with the juice of a freshly squeezed grapefruit or orange (best taken on an empty stomach).
Mix 1-6 tsp of a "buffered vitamin C powder" that contains magnesium and potassium salts along with ascorbic acid (vitamin C) and take on an empty stomach using room-temperature water.
Mix 1-2 tbsp of Power Maker II Sugar-Free Powder in water or juice and take on an empty stomach.
Take 2000-3000 mg of pantothenic acid (vitamin B5) powder on an empty stomach. Pantothenic acid powder is unpalatable.
Note: Drinking several cups of green tea will enhance the bowel-evacuating effects of the above four suggestions. Decaffeinated green tea may be taken late in the day to prevent insomnia. Persons with gastritis or stomach ulcers may not be able to tolerate these aggressive peristalsis-inducing approaches.
For relieving chronic constipation, one or all of the following may be used:

Chitosan: Take six 1000-mg capsules of chitosan before each meal with one 1000-mg capsule of vitamin C.
Digest RC: For 3 weeks, take 2-3 tablets with every meal that contains fat or protein. Dosage may be reduced after symptomatic relief occurs.
Fiber Food is a bulk-producing soluble fiber that provides a blend of guar gum, apple and/ or citrus pectin, and psyllium seed husk. Six capsules or 1 tsp should be taken with each meal; 1-2 tbsp of flaxseed may also be helpful. Flaxseed can be sprinkled on cereal at breakfast time. The flaxseed should be purchased fresh and should be ground in a coffee grinder daily. The omega-3 oils present in flaxseed offer an additional benefit.
Castor oil: 3 tbsp mixed with a liquid.
Follow the dietary and lifestyle changes discussed in this protocol.
Refer to the Digestive Disorders protocol for additional information.

For more information

Contact the Consumer Nutrition Hotline of the National Center for Nutrition and Dietetics, (800) 366-1655.

These statements have not been evaluated by the FDA. These products are not intended to diagnose, treat, cure, or prevent any disease