No one likes to talk about constipation, formally defined as having three or fewer bowel movements per week. (Though I would argue that this is an excessively conservative definition. My personal working definition is failure to have a minimum of one bowel movement per day. Most of us know when we are constipated, even if it does not fit the standard definition.) Constipation is, contrary to earlier expectations, proving to be more complex than originally thought, likely due to a combination of factors involving disrupted colonic (and perhaps small bowel) microbiome composition, overgrowth of methanogens such as Methanobrevibacter smithii, lack of prebiotic fibers, and possibly disruptions of serotonin and bile acid metabolism.

Constipation is also common, afflicting as many as 10-20% of people at any one time, children and adults alike. Gastroenterologists and other scientists working in this area break constipation down into several types:

  • Irritable bowel syndrome-C—I.e., irritable bowel syndrome, IBS, with constipation
  • Functional constipation—the most common variety, labeled “functional” because no physiological cause has yet been identified.

Functional constipation can be subdivided into normal transit constipation (in which transit time, the time required from ingestion to defecation, is normal but the sufferer perceives hard stools and incomplete evacuation); slow transit constipation (slowed passage through the length of GI tract); defecatory disorders (e.g., weakening of the pelvic floor, as occurs with aging, especially in females); and mixed types. Different forms may therefore have different causes.

Efforts to characterize the gastrointestinal (GI) microbiome have yielded mixed, sometimes conflicting, results. However, it appears that people dealing with constipation have a microbiome depleted of Lactobacillus and Bifidobacteria species, as well as a reduction in overall species diversity. Beyond that, no specific microbial “signature” has yet emerged. More detailed DNA methods, rather than culture methods that miss >90% of species, may yield some new lessons in coming months and years. Likewise, efforts to improve the situation with probiotics have yielded generally disappointing results. Multi-species probiotics yield modest improvement, but no specific microbial species nor mix of species has yet emerged as a consistently successful remedy.

I hope that by now you recognize that I see my role as pointing out the devastating flaws that afflict conventional “solutions.” Let’s take each solution dispensed by doctors as remedies for constipation and highlight their problematic aspects:

  • Irritative agents—These are what most recognize as laxatives. This includes phenolphthalein (the old Ex-Lax) and senna (Sennokot). These were removed from the market a number of years ago by the FDA when evidence emerged that such irritative agents increased risk for colon cancer. (This is, admittedly and, by necessity, low-quality observational evidence, as other factors could be at work, such as alterations in the colonic microbiome in people who are constipated and thereby resort to such agents. But we shall never have a prospective, double-blind, placebo-controlled study for this question due to ethical limitations.)
  • Osmotic agents—The most widely used is polyethylene glycol (PEG), the same agent used in antifreeze for your car’s radiator. While declared safe by the FDA and widely prescribed for both acute and chronic use by doctors, emerging evidence suggests that alterations in the GI microbiome can develop, some irreversible. There are also changes provoked in the intestinal mucus barrier and immune response. The mucus barrier, in particular, can be obliterated for a few days after PEG consumption, a major potential disruption that increases endotoxemia, body-wide inflammation, and insulin resistance. Loss of mucus can result in reduced populations of the important species, Akkermansia, while also stimulating proliferation of the dangerous pathogen, Clostridium difficile. The likelihood of such changes is less with acute administration, such as that used as prep for a colonoscopy, more likely with chronic repetitive use (>14 consecutive days), as in medical management of constipation. PEG is also abused by people with bulimia, anorexia, and binge eating disorder to control weight, but likely generates a downward spiral of GI microbiome deterioration, as well as overall health and chronic diarrhea even after the PEG is stopped. In other words, contrary to popular opinion, PEG is not a benign agent and is likely quite toxic if taken chronically, if we believe the emerging evidence.
  • New prescription agents—There is a class of drugs such as linaclotide (Linzess), widely advertised on TV, that increase intestinal water and electrolytes, thereby loosening stool and encouraging bowel movements. These agents are plagued with side-effects including explosive diarrhea, as well as monthly cost of $500. Conventional “treatments” have therefore graduated from irritative agents for a few dollars to agents that cost thousands of dollars per year. (Read the reviews from people who have taken Linzess: it is both sad and funny to read the incredible experiences of explosive diarrhea, as well as other side-effects.)

Recall that indigenous human populations unexposed to such things as antibiotics, food additives (preservatives, emulsifying agents), chlorinated drinking water, stomach acid-blocking drugs, and other microbiota-disruptive factors almost never experience constipation. Even the experience of Irish surgeon Dr. Dennis Burkitt, witnessing the  differences between South Africans of European descent vs. indigenous South Africans in the first half of the twentieth century—the former having small, hard rabbit-like fecal material, while the latter had large steaming mounds of fiber-rich fecal material—highlights how constipation should not be viewed as a lack of pharmaceutical agents.

We do not yet have all the answers, but consider the following if you are struggling with constipation:

  • Ensuring magnesium intake—Magnesium is a natural osmotic agent and virtually all modern people are deficient due to reliance on filtered water. (Restoration of an agent generating a normal osmotic gradient, such as magnesium, should be viewed as distinct from the much greater artificially increased osmotic gradient of an agent like PEG.) Whether your drinking water is filtered in a municipal facility or a home filtration unit, all water filtration efficiently removes magnesium. Unlike water from a river or stream flowing over rocks and minerals, filtered water is not a source of magnesium. Magnesium supplementation is therefore a natural way to increase intestinal water content and accelerate transit. Magnesium malate, chelate, glycinate, and citrate are among the better absorbed forms, though the citrate is the superior choice for greatest osmotic effect. We gauge intake by the amount of “elemental” magnesium provided, i.e., the quantity of magnesium alone without the weight of the malate, chelate, etc. and obtain at least 450-500 mg per day. For periods of resistant constipation, doses can safely be increased for several days (provided kidney function is normal). 
  • Wheat and grain elimination—While we are often advised to increase grain intake for bran or cellulose fiber, the fact is that the gliadin protein and related (prolamin) proteins in other grains yield opioid peptides upon digestion that slow intestinal peristalsis, just as opiate drugs such as morphine and oxycodone cause troublesome constipation. This can be a dramatic effect in some people, even occasionally responsible for obstipation, the most severe form of constipation with bowel movements occurring no more than once per week.
  • Including a variety of prebiotic fibers in the diet—While it may not serve as a single solution to constipation, the other benefits, such as metabolic benefits that derive from increased butyrate production, healing of the intestinal lining, and improved sleep and mental health, all make this an essential part of a bowel flora health program. 
  • Test for methane on the breath—Methane, CH4, produced by Archaea methanogens, such as Methanobrevibacter smithii, slows intestinal peristalsis. The ancient creatures that pre-date bacteria evolutionarily, also called “extremophiles” because they have adapted to extreme environments such as boiling water of Yellowspring geysers, the extreme pressure at the bottom of the ocean, or the high salinity of the Dead Sea—and the human GI tract. The AIRE device*, the TrioSmart test, and some labs and clinics can perform this test. In my view, the AIRE device is superior to other methods because 1) CH4 is measured directly, as you blow into the sensor, and there is no need for the cumbersome step of trying to capture breath in a vial. 2) It is a real-time method that yields results within seconds, rather than the weeks typically required for testing in a lab or clinic. 3) You only buy the device once for around $200 and can use it over and over again, unlike having the test in a lab or clinic where each round of tests costs $300 or more (depending on markup). 4) Having the AIRE device means you can test every day during efforts to eradicate CH4-producing microbiome species to know whether your regimen is working or not—imagine spending 4 hours and $300 every day for conventional testing. If you test positive, I invite you to join my conversations in because the efforts can be a bit complicated and it’s nice to talk it through, as we do in our weekly two-way Zoom live video meetings.

In short, efforts to restore the gastrointestinal microbiome, address a common deficiency, return to a diet that was followed by humans for the first 99.6% of our time on this planet nearly always restores normal bowel habits and does not cost you hundreds of dollars per month.

*I have no financial relationship with the AIRE device nor its manufacturer, FoodMarble.