A Root-Cause Approach to Constipation

If you struggle with constipation, you know how yucky it feels when you don’t have satisfying bowel movements on a daily basis! Healthy stools are a big deal and something we don’t tend to talk about. When I work with people one-on-one we get into the nitty-gritty of talking about stool frequency, quantity, shape, color, and consistency. Let’s face it, we are all aware of the quality of our poop. We notice if it doesn’t feel or look right.

We use the Bristol stool chart (a real clinical tool) to label your stool as one of seven types. Types 1 and 2 are considered constipated, types 3, 4, and 5 are healthy (4 is optimal), and types 6 and 7 are considered diarrhea. Here we talk about the constipated types and how to troubleshoot the root causes.

What does constipation actually mean?

The old-school medical definition of constipation is:

“Constipation is generally described as having fewer than three bowel movements a week.”

I don’t know anyone who feels comfortable with only three bowel movements a week! A functional definition of constipation is the lack of a complete bowel movement on a daily basis. Functionally, you’re constipated if you:

• Don’t poop every singe day on a regular basis.
• Struggle, strain, or take a lot of time to eliminate.
• Have stool that is hard, painful, or incomplete.
• Need to use your hands or fingers to get your poop out!

Ideally, we should poop like any healthy animal: squat or sit, relax our anal sphincter, gently push, and done. In under 5 minutes. No need for long potty sits with a magazine or cell phone. If this doesn’t describe you, you may be functionally constipated.

Nobody feels good if they are constipated. After all, your stool carries out waste products. and when it sits for too long in your colon, you can reabsorb and re-circulate undesirable and even toxic debris that is meant to be eliminated. Constipation can lead to an unhealthy balance of gut bacteria called dysbiosis, an undesirable change in colonic pH, and even colon cancer.

First steps to troubleshoot constipation

With chronic constipation, first, visit your doctor to find out if there is a physical problem with your colon or rectum. Next, get your hormones checked because hormone imbalance can contribute to constipation, the most common is low thyroid hormones. Certain medications, and pregnancy, can also cause constipation.

You can also test your transit time so you know exactly how long it takes for food to move through your system. The ideal transit time is between 12 to 24 hours. Above 24 hours means transit time is slow, and above 48 hours means waste is sitting dangerously too long in your colon. You can do this by eating a half a cup to 1 cup of red beets or taking four charcoal tablets. Beets will turn your stool red and the charcoal tablets will turn your stool black. Voilà! You can see your transit time when you check out the color of your stool.

Check for SIBO or dysbiosis

If your transit time is slow, and you have significant abdominal bloating throughout the day, you may have an overgrowth of bacteria in your small intestine. This is called SIBO (small intestine bacterial overgrowth). It doesn’t mean that the bacteria in your small intestine is bad bacteria, but it does mean that it’s growing in the wrong place. Constipation can be the root cause of SIBO, and SIBO can make constipation worse.

Bacteria in the small intestine ferment the fiber from foods you eat, and the gas they produce causes bloating and discomfort. The hallmark symptom of SIBO is bloating that continues throughout the day. If you suspect you have SIBO, you can follow a low-fiber diet, called a low FODMAP diet, as a diagnostic test. If your bloating and constipation improve, that’s a sign that you may have SIBO. The next step is to see a gastroenterologist or a functional medicine provider who can test for SIBO with a breath test.

Dysbiosis is an imbalance of gut microbes in general, and it usually refers to bacteria. However, we also have other microbes in our GI tract such as yeast. It’s useful to do a functional stool test such as the G.I. Map that uses PCR (polymerase chain reaction) technology to map out your gut microbes, including yeast, viruses, parasites, and bacteria. Then instead of guessing what type of dysbiosis you have, you get an accurate picture and can treat it accordingly.

Check for deficiencies

Often constipation is a sign of deficiency. This could be a deficiency of movement, fluids, fiber, stomach acid, digestive enzymes, beneficial colonic bacteria, or magnesium. These are all things you need enough of to eliminate efficiently and get a stool score of type #4. But how do you know if you’re deficient in any of these things? This can all be determined by trial and error, and most can be tested on the G.I. Map.

Here are suggestions for ways to test at home:

1. Movement: Try a 15-30 minute brisk walk on a daily basis.
2. Fluids: Calculate half your body weight, multiply that by 1 oz, and drink this amount of non-caffeinated fluids per day. So if you weigh 150 pounds, that is 75 ounces.
3. Fiber: Keep track your fiber intake using an app like My Fitness Pal, and aim for a minimum of 30 g per day. If that’s difficult, add a fiber supplement. The benefit of a fiber supplement is that soluble fiber also feeds beneficial gut bacteria so it’s a win-win.
4. Stomach acid (HcL): Do a home test of drinking 4 ounces of water with 1/4 teaspoon baking soda first thing in the morning. You should belch within 5 minutes. If you don’t, it’s likely your stomach acid is low. Take a betaine HcL supplement with meals (1-3 tablets) as a trial to see if that helps.
5. Digestive enzymes: Take an enzyme formula with a high dose of pancreatic digestive enzymes (1-4 with meals) and observe the difference.
6. Probiotics: Take a high dose of bifidobacteria (this won’t provoke SIBO whereas lactobacillus strains have the potential to exacerbate SIBO) and observe the difference.
7. Magnesium: Citrate and oxide are the best forms for constipation.

With all these trial and error tests, it’s useful to do one thing at a time for at least several days so you can really observe the difference with one change. Let me know if you’d like any help troubleshooting constipation. You can first order a G.I. Map test on your own, and then book a new patient appointment with me.