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clear search termsCuring Constipation
Let’s dive into a topic that almost no one talks about, but everyone thinks about and looks at: our poop. This is a critical topic to 
discuss with every one of your clients. After our fourth birthday, very few of us keep sharing details of our toilet trips with friends and family. But as it turns out, the status of your bowel movements is a powerful reflection of your overall health.
As a practitioner, I ask everyone about their bowel movements. Over the years, this means I have collected a rather amusing bunch of stories. Most typical is the exchange I have with first-time clients about BM frequency…
“So, John, let’s talk about your bowel movements. Are you regular?”
Silence. Throat clearing. Arms cross over his chest.
“Uhhhmmm. Yeah. I’m regular.”
“So what does that mean exactly, John?”
Silence – more fidgety this time.
“Well, you know – I go when I need to.”
“It’s okay, John; I’ve heard it all before. Can we dive into a little detail? To start, how many days a week do you have a regular, formed, complete bowel movement?”
Finally giving up on avoiding this conversation.
“Look, I think my BMs are just fine. I very regularly go at least once a week – and sometimes even twice. As long as I have something to read, I just hang out in the bathroom until things start moving. It doesn’t take long…maybe 10 or 15 minutes at most.”
Because we don’t talk about it, most of your clients don’t understand what makes up “regular” or “healthy” bowel movements. Sure, things like occasional sleep loss or airplane travel will be exceptions. But generally, we should all be having at least one, fully formed, complete bowel movement every day. We may even have 2 or even 3, essentially one for each meal (as is seen in studies of most indigenous cultures). Our stool should be easy to pass (no reading material required). You shouldn’t have to strain to pass a stool; that pressure can build up inside your colon and cause inflammation in the colon (diverticulosis). Healthy BMs should be light brown in color with no discernible food bits, indicating good strong stomach acid and efficient digestion. You want most of your BMs to be long, log-like pieces (or even the fully-formed letter S that Dr. Oz has made famous), not hard little marbles and ping pong balls. If these details don’t describe your client’s typical experience, they are not “regular”. If they have to take some kind of over-the-counter medication or fiber-in-a-canister every day to get these results, they are certainly better off but are still not “regular”. Normal, perhaps. But not regular. And they need your help.
The average American is constipated. Chronically constipated. Early man ate a tremendous amount of fiber each day, drank plenty of water, slept well, exercised all the time, lived in a low-toxin environment, had healthy intestinal flora, and enjoyed a relatively low-stress lifestyle. Compared to the average American today, that sounds a bit like a spa experience. But here’s the truth: if your clients don’t have regular bowel movements, it is only a matter of time until they get sick. Plus, it’s really uncomfortable. Alleviating your client’s constipation will give you immediate credibility and probably earn you some sincere gratitude.
Here’s a great way to explain constipation to your clients: Not having daily BMs is like not taking out the trash 
from your kitchen when the can is full. Things start to spill over and get messy and smelly. Harmful bacteria flourish as your stool continues to ferment. Waste products continue to irritate and perhaps poison your gut lining. Worst of all, your body will eventually begin to reabsorb the trash. Yes, it’s like eating the kitchen trash all over again. This is an image your client will understand! Your stool is the primary exit pathway for waste in your body. I am not just talking about leftover fiber from your salad. A significant part of your body’s waste is toxins, things like pesticides, drugs, chemicals, plastic, heavy metals, damaged cholesterol, and excess estrogen.
Here is a list of key lifestyle changes that can get your clients’ bowels moving:
- Take magnesium. This is really important for your clients! Most Americans are deficient in magnesium. And my experience is that this is actually more important and more powerful than the typical solutions we might recommend for constipation (e.g. water and fiber – which are indeed included below).
Your typical client probably eats few foods high in magnesium (e.g. halibut, almonds, spinach, cashews, seaweed). Even if they do, the magnesium content in many plant foods has plummeted rapidly since the mid-1900s due to over-farming of the same soil. If your clients are constipated and the fiber/water/fat/probiotics combination isn’t working, have them try 400-800 mg magnesium citrate each evening after dinner. Unlike medications which force your body to shove out a stool artificially, magnesium works for bowel movements because it’s what your body naturally uses to move them along in the first place (in a natural wave-like muscle movement all along the GI tract called peristalsis). Many times chronic constipation is just chronic magnesium deficiency. Magnesium is a particularly good idea if your client has other symptoms of being “bound up” or “tight” (e.g. high blood pressure, acid reflux, muscle spasms/soreness, frequent headaches, impatience).
For your clients who are adverse to taking supplement pills, I recommend magnesium powder that fully dissolves in hot water (my favorite brand is called Natural Calm). This allows them to enjoy a relaxing warm drink before bed that will work its peristalsis magic overnight. Note: I have never encountered a case of constipation that I cannot resolve for a client with sufficient magnesium. But warn them ahead of time that taking too much might just give a short-term case of loose stools or diarrhea; you’ll just need to cut back on the dose.
- Take a daily probiotic supplement. Our guts are teaming with microbes – what I call good bugs and bad bugs. Sometimes your client’s gut gets sluggish due to poor digestion (medically called decreased motility) or inflammation in our intestines. Beneficial bacteria help to calm inflammation and move things along. A good multi-strain probiotic is normalizing for the body. However, when your clients are already constipated, make sure the probiotic has a significant percentage (at least 1/3 – ideally ½ or more) of Bifidobacterium units (usually called CFUs on the label). If the variety they choose is mostly Lactobacillus, this will likely make constipation even worse. Lactobacillus is one of the dominant bacterial species in the small intestines (which is helpful for many other concerns), but our large intestines (where stool formation happens) are overwhelmingly colonized by Bifidobacteria.
- Eat plenty of healthy fats. This is an overall concept that many of your clients will need to learn – and be repeatedly
convinced of – due to intense health media emphasis otherwise. Despite common myths otherwise, fat is not bad for you. In fact, a diet relatively high in healthy fat has been shown to be cardio-protective and helpful for body fat loss. Encourage your clients to enjoy foods such as olive oil, coconut oil, avocados, wild salmon, walnuts, almond, pumpkin seeds, and eggs daily. Explain it to your clients this way: the best lubrication for pipes is grease, not water; the same is true for your GI pipes. Fat helps to move your stool along. If your clients have trouble digesting fats (makes them very gassy or stools that float), there are other GI issues at play. Drop me an email, and I’ll give you some more guidance (these issues are extensively addressed in the GI class series).
- Eat plant foods. Here’s one you already probably know! There is no substitute for real, food-based fiber in our diets, especially fruits, vegetables, nuts, and seeds. But realize that this is only one of several potential issues at play. Increase fiber in a constipated client gently, or you will likely make the issue worse. I recommend getting them “moving” with magnesium and healthy fats first. Then, you can work on slowly increasing fiber for better long-term GI flora health and motility. Note there are two kinds of fiber in our food:
a. Soluble fiber helps to form a stool (adds bulking). So it’s key for fully-formed BMs and helpful for intermittent loose stools or diarrhea (think of rice, oatmeal, apples in particular) but not useful for constipation. Psyllium husks are a great natural soluble fiber supplements Mix them up in a smoothie, stir into yogurt, or blend with a protein shake. I also recommend you work with your clients to give up any “PseudoFiber” powders they might use as most of them contain artificial colors, flavors, and sweeteners (e.g. Metamucil). Be sure to read labels carefully.
b. Insoluble fiber helps to move a stool along for easy exit (think of all vegetables, especially leafy greens). This kind of fiber is particularly helpful for constipation. Flaxseed (especially whole) is an excellent insoluble fiber source as well.
- Drink plenty of water. This is one you probably already know but needs repeating as most of your clients are probably a bit dehydrated. Fiber helps form a stool, but water is what allows soluble fiber to work its magic. Think of trying to use a dried out sponge without water: not very effective. Here are some general tips for your clients:
- Ideally, sip water throughout the day. Help them to choose a water bottle with a nipple on it, as they will drink more (vs. using a glass or a water bottle that must be unscrewed or have a wide opening).
- Most important, drink a large glass right after rising in the morning. It’s the time of day when we are most dehydrated and most toxic.
- Hydrate well in between meals – but not during meals. Have a small glass with only a few sips of water as needed to cleanse the palate (or to take supplements). We need strong, undiluted stomach acid in order to have efficient digestion, and a big glass of water will significantly slow upper-GI motility (food leaving the stomach). In addition to poor nutrient absorption, this may also cause belching, bloating, distension, or acid reflux. Small changes like this can bring your clients major relief – and greater trust in you and compliance in your future recommendations!
Register for our free Conquering Constipation Mini Clinical Course here. In this mini course, Tracy reveals 15 possible and powerful causes of constipation and new pearls for you in assessment and remedy, so you can help bring Rapid Relief and Root Cause Resolution to your clients and patients.
P.S. If you are passionate about transforming healthcare through the power of functional medicine, we encourage you to learn more about our training program here.
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Are you able to provide some clarity regarding this statement: “Soluble fiber helps to form a stool (adds bulking). So it’s key for fully-formed BMs and helpful for intermittent loose stools or diarrhea (think of rice, oatmeal, and apples in particular) but not useful for constipation. Psyllium husks are great natural soluble fiber supplements. Mix them up in a smoothie, stir into yogurt, or blend them with a protein shake.”
I believe psyllium with water is one of the most effective chronic constipation treatments, so this statement that soluble fiber is not useful for constipation is confusing. What is a general guideline for helping a client to increase fiber when dealing with constipation, increase soluble or insoluble or both?
In general, soluble fiber is regarded to aid with stool formation, and insoluble fiber stimulates peristalsis, and that’s how both can be helpful for constipation, depending on the root cause in a given client. In the case of psyllium, with plenty of water being effective for chronic constipation, it may have more to d with the psyllium bringing he water well and bringing it to the colon vs acting as a stool formation aid. The exact mechanism of action for this has not been fully elucidated, but there are meta-analyses that speak to the efficacy of both soluble and insoluble fiber:
https://academic.oup.com/ajcn/article/116/4/953/6639855
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544045/
And there are also forms of constipation where stopping all fiber is the only way to bring relief:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435786/
One has always to keep an open mind and think of “who is this person that is presenting this particular problem”.
Can longer-term magnesium supplementation disrupt the microbial balance in the gut?
The research on that is not yet conclusive. There are a couple of studies done in rats where it was shown that magnesium supplementation could have a negative effect. And some studies show quite the opposite, and a couple of studies concluded that magnesium insufficiency is also detrimental to the gut microbiome. Thus, to have a clear view of the effect of the magnesium supplement on the gut microbiome (not to mention which form of magnesium), there is a need for more studies. Let us also remember that any dietary intervention will change the microbial balance. Whether this means ‘disruption’ or a simple shift into another healthy balance would depend on many factors connected to the starting and then the intervention diet, level of stress, and environmental factors.
Is it possible to help someone with fecal impaction or is it too late at that point for a “natural” intervention?
It is possible to support someone with fecal impaction especially if this is detected early. However, if mechanical removal of the impacted stool is needed it is crucial to think of the root causes that created the fecal impaction in the first place to prevent recurrence of the issue. All dynamics outlined in this article and the free course will be helpful. You will likely appreciate the details in these reviews:
https://www.ncbi.nlm.nih.gov/books/NBK448094/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709889/
Do you have any info on paradoxical diarrhea? I have a few clients that have daily bowel movements in which they feel not everything is eliminated.
You may be interested in this publication:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3348734/
For those taking potassium-sparing diuretic hypertension medication, does that mean magnesium citrate would not be effective at all if given or should it not be given at all because of the diuretic use?
Plenty of people talking diuretics have insufficient magnesium levels. But magnesium accomplishes many of its actions by increasing intracellular uptake of potassium. So caution is warranted (and going low and slow) to make sure people don’t get potassium overload.
I have tried many remedies both Rx drugs and magnesium citrate and water and fiber, fiber, fiber. The only results were that my stomach was distended and I was gassy. I was finally diagnosed with colonic inertia. Can your recommendations help me? I have been moving my bowels once a week for several years but ONLY with an enema, never naturally. I have taken manometry tests and pelvic floor therapy. None helped.
I have not though tried a course of probiotics steady or for long periods of time. I also am slightly under weight but not terribly, just 3 pounds below BMI
On the slides of Conquering Constipation says that one of the root causes is Nervous System Imbalance for example, from antihistamine medicine intake…could you explain this interconnectedness?
This is discussed on page 24 of the Conquering Constipation free clinical course linked above. Shortly, histamine plays a critical role in gut health as it is responsible for stomach acid production and gut motility. Thus anti-histamines will affect these functions which can lead to lower gut motility and microbial imbalance which in turn can affect the nervous system balance. This is a good resource for a deeper dive into this topic:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5503283/
I am looking for guidance on how to address constipation on a client I suspect the root cause of her constipation is insufficient serotonin synthesis due to 4 year use of SSRI use. It was not an issue until she quit caffeine (which she discovered helped to evacuate in the morning everyday). At the moment we are focusing on other things and quitting SSRI will be a step she wants to take in the future but not yet. I am planning on recommending Magnesium Citrate (she is using Magnesium Oxide 250mg and not working) to start, along with increasing water consumption and insoluble fiber which she is not consuming as much, but I feel like I am not addressing the root cause since I can’t recommend 5HtP o P5P to support more serotonin production because she is taking an SSRI. Any other suggestion of what could be helpful?
Alas, we cannot offer specific client case support in these Q&A threads as that requires the view of all the salient case puzzle pieces.
If you suspect the root cause to be insufficient serotonin synthesis, the solution to that is not adding 5-HTP, it can be helpful in the interim when appropriate, but that’s not the root cause solution. You need to go deeper and ask WHY is the serotonin synthesis compromised; what’s blocking it? Lack of nutrients? poor digestion and absorption? gut microbial imbalance that affects the gut neurotransmitter production in general? Keep in mind, that functional medicine is not about adding more supplements, but more about truly understanding what is at play and what needs to change in order to help the body in the healing process and restoration of better dynamic.
Why would someone feel exhausted or fatigued after emptying their bowels?
Vagus nerve stimulates bowel movements (BMs) and while doing so we go into a parasympathetic nervous mode that often results in lower blood pressure and slowing down of the heart rate wich can be sensed as ‘fatigue’, and the extent of this phenomenon greatly dependa on someone’s ‘normal’. This is a good little read about this topic:
https://www.health.harvard.edu/diseases-and-conditions/why-do-i-get-weak-after-a-bowel-movement
How long can someone continue to take Magnesium Citrate at 800mg? Can over use cause firm/hard stool?
An overuse of magnesium citrate typically leads to loose stools. And there’s no hard rule around how long one should be taking it, but no supplement should be taken forever. It is absolutely key to work on the root causes and figure out WHY the magnesium may be lacking in the first place and if there are other drivers that are causing constipation. The Conquering Constipation free clinical course goes in-depth into all the possible drivers of this dynamic.
What about chronic constipation in children?
This is na interesting question, Kimberly. While the root causes of constipation are often similar in children as they are in adults, the younger patients/clients may require a bit different focus. First, exploring all the same possible contributing factors discussed in detail in the Curing Constipation course mentioned at the top of the page may be a helpful expansion on the constipation root causes. In the case of chronic constipation in children, there may be a few specific challenges such as: -‘picky eater’ habits that may be preventing them from getting enough healthy fiber to facilitate healthy BMs – too much dairy products in the diet, as those are known to promote constipation – irregular meal times – also sometimes not enough emotional support during transitions, facing new-for-the-child events, aka children’s stress. Another challenge may come from gut microbial imbalance, as the gut microbiome starts being shaped right at birth (possibly even earlier) and continues to develop over the course of the first 4-5 years: https://www.sciencedaily.com/releases/2018/10/181024131304.htm https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306821/ On top of that many children suffer from ear and sinus infections and end up being treated with antibiotics, which can create undesirable gut microbial imbalance and contribute to chronic constipation. As you… Read more »
Can you please review some of the steps in looking for the cause, especially if it has not improved after trying many of the suggests for relief. Thanks.
This is a great question, Gail and we believe that this is where the coaching approach can really shine. Once you review with the client/patient all of the possible root causes of constipation – we highly recommend reviewing the free course mentioned at the top of this page as it expands on the list described in this article and goes deeper into this topic – and have them truly try all that is necessary to resolve it, it usually boils down to regularly practicing what has worked as there is no one time solution. The daily practice is where many fall short as it is so easy to revert back to old habits once the issue seems to be ‘gone’. What helps with this daily practice of what truly helps is education, support & empowerment, and accountability – really good coaching.
What about taking supplemental enzymes? Some research and experience suggests this can help with constipation.
Yes, insufficient digestive enzymes output in the pancreas or the brush border can also contribute to constipation. Keep in mind that the upstream root cause of this insufficiency can be low stomach acid and thus supplemental digestive enzymes could be helpful for a period of time while working on the root causes of the low stomach acid. You may appreciate this post as well:
https://schoolafm.com/ws_clinical_know/acid-reflux-truths-and-myths/
Can you recommend a probiotic which has 1/2 Bifidobacterium as suggested? Thank you!
Yes, there are many great products and blends on the market, often labeled with the word ‘senior’ or ‘colon’ for the fact that they contain proportionally 50:50 or more of Bifidobacterium to Lactobacillus species. Here are a couple of examples:
Colon Care by Renew Life
https://www.renewlife.com/ultimate-flora-colon-care-probiotic-80-billion.html
Therbiotic Senior Formula by Klaire Labs
https://klaire.com/k-tsr-therbiotic-senior-formula
This is a Bifido-only formula by Seeking Health:
https://www.seekinghealth.com/collections/probiotic-supplements/products/probiota-bifido-60-capsules
If a client had trouble digesting fats and gets gassy what are so other options to help with bowel movements. Mine had been chronically constipated her while life and she was just diagnosed with PD.
Typically issues with fat digestion lead to loose stools, so I would question where this assumption comes from and what supports that notion. Constipation can be the cause of gassiness and bloating, of course, and this course addresses many if not all possible solutions to help with that. Interestingly, there is a connection between PD and digestive issues, which was addressed here:
https://schoolafm.com/ws_qa/parkinsons-and-impaired-digestion/
What if the stool is not s shape, long,but it has small pieces of undige
sted food and it passes on as a lump ,
Undigested food is usually an indication of rapid transit time and/or insufficient digestive enzymes (which can be promoted by insufficient stomach acid in some cases too). I would think about ensuring good eating hygiene, using soluble fiber to help bind/form stool, and supporting a trial with digestive enzymes at each meal.
Would Senna be a good option for regular BM?
Senna can be an effective agent (thought it’s very potent), but it’s basically just a stimulant. It is not addressing any root cause. Thus it might be helpful as a short-term triage, but we don’t recommend ongoing use of it.
Pysllium husks not good for constipation correct?
Actually, my experience is that psyllium can indeed be helpful for constipation. It is a mix of soluble (2/3) and insoluble fiber (1/3). For constipation, I would be more likely to choose something like ground flaxseed for it’s overall nutritional (in addition to fiber) value; flax has an inverted ratio of soluble and insoluble fiber. BUT it is super critical that one consume a large glass of water with each dose of psyllium husks. Otherwise, psyllium is likely to be *more binding* by over-absorbing water in the intestines. Soluble fiber is a HUGE water magnet. A good example of the ‘devil in the detail’ of how recommendations are implemented. I have paired psyllium husks along with magnesium with good success when using magnesium alone results in small, “pencil thin” stool.
I think I meant to type diarrhea. Ugh
As Tracy mentions, Pysllium husks when taken with a large glass of warm water, give relief from Constipation. While when taken mixed with very small amount of water, it is more likely to be binding.
Will mag malate help with constipation as well as the mag citrate does?
No, it won’t. In fact, mag malate is usually chosen because it *doesn’t* have a strong effect on the bowels (when systemic magnesium help is needed for someone who already has normal or even loose bowels). Some of my clients needs to use two forms for optimal results: mag citrate for bowels and mag malate or glycinate for systemic needs (esp. cardiovascular or skeletal muscle cramps/tightness).