Introduction: Constipation and Natural Remedies for Constipation
Constipation commonly refers to infrequent bowel movements, but it may also refer to a decrease in the volume or weight of stool, the need to strain to have a movement, a sense of incomplete evacuation, or the need for enemas, suppositories or laxatives in order to maintain regularity. There may be several, possibly simultaneous causes for constipation, including inadequate fiber and fluid intake, a sedentary lifestyle, and environmental changes. There are many natural remedies for constipation described here. Constipation may be aggravated by travel, pregnancy or change in diet. It can be successfully treated by a number of options as described below.
Constipation and Exercise:
Encourage exercise daily and utilize physical therapy services if deconditioning is a factor for inadequate activity levels. See aerobic exercise and resistance training sections in Preventive Health Advisor for further information.
Constipation and Fluid Intake:
Unless fluid restriction is necessary, increase water intake throughout the day to change urine color from yellow to slight hint of yellow shade with urination. Water intake should be at minimum of 1-2 liters daily.
Constipation and Daily Regularity:
Bowel movement regularity is generally established naturally by the body at the same time daily or sometimes every other day. Patients should be encouraged to attempt bowel movements at approximately the same time every day and establish timed toilet training. Patients should be educated to attempt a bowel movement at least twice a day, 30 minutes after meals, and should not strain more than five minutes.
Laxative Choices in Constipation:
Initial laxative choice should include the bulk forming fiber supplements psyllium ( Metamucil®), glucomannan, calcium polycarbophil (FiberCon®), methylcellulose (Citrucel®), wheat dextran (Benefiber®), or bran. If response to these fiber laxatives fail, the next choice is
an osmotic laxative, polyethylene glycol (Miralax) preferred at a dose of 17-34 grams in liquid of choice daily. Other osmotic laxatives include sorbitol and lactulose. Sorbitol is better tolerated than lactulose, is less expensive and is similarly efficacious. Magnesium citrate is also a reasonable second choice. The next choice would be a stimulant laxative such as senna or bisacodyl. A stool softener may benefit patients which typically experience hard impacted stool or hard pellet-type stool. Suppositories with glycerin or enemas with tap water or sodium phosphate would be the next choice.
Fiber Treatment of Constipation:
To help treat and prevent constipation, patients should be advised to start a high-fiber diet which should include 20 to 25 grams of fiber per day. Increase fiber in the form of fruits and vegetables throughout the day.
A Superior Fiber, Laxative and Stool Softener for Constipation:
Psyllium husk is a naturally derived fiber which may be used to reliably and routinely add enough fiber to the diet over simply increasing high fiber foods to produce constipation relief. Psyllium may also be used to produce more immediate results until dietary habits with higher fiber intake are established.
According to a study involving 170 participants, psyllium, a dietary fiber treatment is a superior laxative when compared to docusate sodium. Participants received either psyllium (5.1 g twice daily) or docusate sodium (100 mg twice daily). At the end of a 2-week treatment period, pysllium showed a superior efficacy over docusate sodium (a common laxative) for softening stools (water content increased 2.33% for psyllium vs. 0.01% for docusate), and has a greater overall laxative effect. Total stool output for psyllium was 359.9 g/week vs. docusate which was 271.9 g/week. (1)
When compared with lactulose and other laxatives, ispaghula husk (also known as psyllium or Metamucil brand name) is a more effective treatment for simple constipation (more normal, well-formed stools and fewer hard stools) with less reported side-effects. In this open, multi-center study 394 participants were randomly assigned to receive either ispaghula (n=224) or other laxatives (n=170) for 4 weeks of treatment. (2)
Constipation is believed to worsen hemorrhoid symptoms, and thus, bulk-forming fibers are often recommended for those with hemorrhoids. A double-blind trial (n=52) reported that 7 grams of psyllium (Vi-Siblin), an herb high in fiber, mixed with water three times daily before meals reduced the pain and bleeding associated with hemorrhoids in outpatients with symptomatic first and second degree hemorrhoids. Compared to the placebo group, at the end of six-weeks of treatment, the psyllium group had a significantly lower recurrence of hemorrhoid bleeding (8% vs 44%) and pain when going to the bathroom (4% vs 32%). These beneficial effects continued at follow-up after 3 months (bleeding: 26% vs 60% and pain with bowel movements: 31% vs 56%). Additionally, though no statistically significant, an unpleasant sensation causing a reflex to scratch (pruritis) and/or anal secretion, and prolapse (the falling down or slipping of a body part such as the rectum from its usual position) were also reduced by psyllium compared to placebo (4% vs 16% and 4% vs 24%, respectively). However, these benefits disappeared at follow-up after 3 months (pruritis/anal secretion: 23% vs 20% and prolapse: 8% vs 12%). (3)
Constipation relief, measure by stool frequency and weight, was reported in 63% of participants taking psyllium plus senna compared to 48% taking only psyllium. This study included 42 participants with constipation (less than 4 bowel movements per week) randomly assigned to 7.2g/day of psyllium alone or 6.5 g/day of psyllium plus 1.5 g/day of senna. (4)
Another Effective Fiber for Treatment of Constipation:
Glucomannan, a water-soluble dietary fiber that is derived from the konjac root, increased daily and weekly bowel movements in individuals. Participants (n=60) received 2 doses of glucomannan (3 gr/day and 4 gr/day) or placebo for 5 weeks. Treatment with glucomannan increased daily and weekly bowel movements from start of study by 0.5 times per day and 3 more times per week for 3 gr/day, by 0.9 times per day and 6 more times per week for 4 gr/day. No significant difference was reported for the placebo treatment. (7)
Glucomannan may help treat childhood constipation. A study involved 46 chronically constipated children, each of whom was treated with either glucomannan taken as 100 mg/kg body weight daily (maximal 5 g/day) with 50 mL fluid/500 mg or matching placebo for 4 weeks. Among the 31 children who completed the study (average age was 7 years old), researchers found that glucomannan was more effective in alleviating constipation with 45% of children successfully treated (vs 13% for placebo). Glucomannan also appeared to reduce abdominal pain. (8)
Prunes and Constipation
Constipation and natural remedies for constipation includes prunes. Prunes were found to be safe, effective, and palatable for constipation. Attaluri A, et al found that prunes are more effective for constipation than psyllium (brand name Metamucil) in single-blind, randomized cross-over study. The authors compared 50 grams of prunes with 11 grams of psyllium and found that symptoms and straining were not different between the 2 groups over 8 weeks, but the number of bowel movements and the softness of the stool was better in the prune group than the psyllium group. (15)
A systematic review by Lever E, et al determined that after reviewing a number of trials, the number of stools per week and consistency of the stool were increased by prunes more than psyllium fiber. (14)
Senna and Constipation:
Senna (Cassia senna) is an herb that contains compounds that act as an effective laxative. Senn is a common choice as one of the natural remedies for constipation. This herbal agent is approved for laxative use in adults to treat constipation. This herb has a powerful effect on the digestive system and patients should not drink senna tea or take supplements containing senna long-term because this agent may result in dependence. Senna may also reduce the absorption of drugs (Fugh).
A Safe Laxative in Post-partum Women:
The use of senna tablets immediately after giving birth resulted in treatment of constipation in over 90% of women of different races. Corresponding results for women on placebo were 51% and 59%. Side effects included minor stomach cramps in 13% of women taking senna and 4% in placebo. Senna was not reported to affect breast-feeding. (5)
A Comparison of Senna to Miralax:
Prior to a colonoscopy, thirty study subjects aged 6-21 years old were randomized in two groups: Group 1 received 1.5 g/kg of Miralax orally the day before procedure and one day of clear liquid diet, while subjects in Group 2 received two doses of senna (15 mL daily [ages 6-12] or 30 mL daily [ages 12-21]) the day before procedure with two days of liquid diet (one day full liquid and one day clear liquid diet). Of the patients taking Miralax, 88% received an excellent/good score on the Aronchick scale which measures the quality of bowel preparations with a standardized cleanliness measure. Only 29% taking the senna preparation scored as well. Therefore, the authors concluded Miralax is an effective colonoscopy preparation while senna is not. Laboratory tests did not different between groups. (6)
Caution on Chronic Use of Senna:
According to van Gorkom BA et al, chronic use of sennoside laxatives has been known to cause increased pigmentation termed pseudomelanosis coli. This author stated that this condition may increase the risk of colorectal cancer by causing an initial large amount cell death within the colon and decrease the length of colon crypts after a large dose of senna. This resulted in increased cell growth and reduction of apoptosis to restore the cells of the colon. This finding was noted by the author to explain possible mechanisms for risk of colon cancer with long term use of senna. (4) The same author also revealed research linking a possible relationship of senna to inducing colorectal cancer in lab and animal studies. (van Gorkom).
Most Commonly Recommended Treatment for Constipation:
Miralax for constipation: The most commonly recommended treatment for constipation is Polyethylene Glycol 3350, (Miralax brand) available over the counter which is an effective treatment for constipation without urgency, cramping, bloating and gas. It does not work by stimulation of bowel movements, but instead draws water into the colon to soften stool and produce evacuation in a comfortable manner. For further information, see: http://www.miralax.com/miralax/why-miralax/how-miralax-works.jspa .(10)
Polyethylene Glycol (Miralax and Go-Lytely) vs Senna:
Polyethylene Glycol (Miralax and GoLytely brands) have also been used routinely for many years to prepare patients for colonoscopy and has not been noted to result in severe adverse effects. Also, senna may not be as effective as Miralax but this may be dose dependent (6).
Fruit Used for Constipation in Irritable Bowel Syndrome (IBS):
IBS is a disorder in bowel movement that causes pain, cramping, gassiness, sudden bouts of diarrhea, and constipation. A study of 54 patients with IBS and 16 healthy volunteers found that IBS suffers who ate 2 kiwi fruit a day for 4weeks had less constipation and a general lessening of symptoms than those who didn’t. All participants were on treatment except 13 patients with IBS who were given dummy capsules for comparison. Results showed that IBS patients with constipation had better and more frequent bowel movement after consuming kiwifruits for four weeks. Results from colon transit time also revealed that patients who consumed kiwifruit had shorter colon transit time meaning lesser stagnation and better bowel movements. (9)
Laxatives and Weight Loss
The rate of obesity in the United States is at an all time high. People are searching for a magic pill to make the process of weight loss simple, easy and painless. Unfortunately there is no magic pill. Weight goes ‘on’ the same way it comes off. If more calories are consumed than are expended, weight will occur. If less is eaten than is burned, weight is lost.
But while the concept is simple, the practice is not. In this high stress, fast-paced world many forgo exercise in order to spend time at the movies with their children or sitting on the sidelines watching their children play sports. Grabbing a hamburger at the local fast food restaurant has taken the place of sit down dinners, complete with vegetables and salad. It’s no wonder that obesity is at an all time high!
Some, in desperation, have turned to laxatives. Laxatives and weight loss are not synonymous. Laxatives and weight loss are not healthy or safe. The majority of weight that is lost when using laxatives is from fluid and the health dangers are significant. The use of laxatives in an attempt to lose weight is often abused. It seems to be common with people who have an eating disorder. After a laxative is ingested, the active ingredients target the cells of the large intestines. They irritate the cells and encourage the large intestines to empty, many times earlier than the body is ready.
While the food is in the large intestines the body is reabsorbing some of the fluid before it passes as waste. If you evacuate your bowels too soon you run the risk of dehydration. The calories from the food you eat are actually absorbed in the small intestines and laxatives don’t affect the small intestines. This means that while the intent behind taking laxatives is to decrease the amount of calories absorbed by the food, the only thing these medications do is cause the large intestines to evacuate AFTER the small intestines has extracted all of the necessary calories.
After losing fluid from an early bowel movement the body compensates by retaining fluid. So laxatives cause an initial dehydration which makes the person ‘feel’ thin, but within hours the body compensates by retaining the remaining fluid and making the person ‘feel’ bigger.
The body needs fluid to remove wastes and toxins, so retaining fluids will make you feel bad because you can’t get rid of all of the waste products normally evacuated. At this point patients might be tempted to take more laxatives to get rid of the full feeling again. It’s a vicious cycle that sets patients up to be at risk for irritable bowel syndrome and colon tumors. Prolonged use of laxatives can also lead to cramping, bloating, water retention and the added problem of withdrawal.
The use of laxatives to promote weight loss is not recommended. Those that do are endangering their health and won’t be moving toward achieving this goal. The abuse of laxatives should be discontinued using several steps. Unless they are prescribed by a doctor you should stop using laxatives immediately. This may be easier said than done and may require the help of a mental health professional.
Drink at least 6-10 eight oz glasses of water each day. Not caffeine drinks or alcohol or juices, just water. Include some physical activity each day to encourage regular bowel function.
Eat regularly and spread it out over at least 3 meals. Include lots of fruits and vegetables, which will improve your success rate for weight loss and improve normal bowel function. Keep a record of your bowel movements so they can be monitored. If you find you are constipated for more than 3 days call your doctor – do not treat yourself! Your colon will react differently than a normal colon after it has been abused by a laxative regimen.
Laxatives and weight loss don’t mix. They don’t work. But you can stop the vicious cycle and move on to a more healthy and fit way of losing weight for life!
Summary: Constipation and Natural Remedies for Constipation
- To help treat and prevent constipation, patients should be advised to start a high-fiber diet which should include 20 to 25 grams of fiber per day. Increase fiber in the form of fruits and vegetables throughout the day.
- Encourage exercise daily and use physical therapy if necessary. See aerobic exercise and resistance training sections in Preventive Health Advisor for further information.
- Unless fluid restriction is necessary, increase water intake throughout the day to change urine color from yellow to slight hint of yellow shade with each urination. Water intake should be at least 1-2 liters daily.
- Bowel movement regularity is generally established naturally by the body at the same time daily. Patients should be encouraged to attempt bowel movements at approximately the same time every day and establish timed toilet training. Patients should be educated to attempt a bowel movement at least twice a day, 30 minutes after meals, and should not strain more than five minutes.
Initial laxative choice:
- Initial laxative choice should include the bulk forming fiber supplements psyllium ( Metamucil®), glucomannan, calcium polycarbophil (FiberCon®), methylcellulose (Citrucel®), wheat dextran (Benefiber®), or bran. 50-100 grams of prunes have been shown to be more effective than psyllium for stool frequency and consistency (14,15), but psyllium has excellent evidence for reduction of bleeding from hemorrhoids(3), as well has been established as more effective for hypertension, diabetes, and weight loss.
- If response to these fiber laxatives fail, the next choice is an osmotic laxative, polyethylene glycol (Miralax) preferred at a dose of 17-34 grams in liquid of choice daily. Other osmotic laxatives include sorbitol and lactulose. Sorbitol is better tolerated than lactulose, is less expensive and is similarly efficacious. Magnesium citrate is also a reasonable second choice.
- The next choice would be a stimulant laxative such as senna or bisacodyl.
- A stool softener may benefit patients which typically experience hard impacted stool or hard pellet-type stool.
- Suppositories with glycerin or enemas with tap water or sodium phosphate would be the next choice.
Psyllium husk fiber:
- Psyllium husk is a naturally derived fiber which may be used to reliably and routinely add enough fiber to the diet over simply increasing high fiber foods to produce constipation relief. Psyllium may also be used to produce more immediate results until dietary habits with higher fiber intake are established.
- Psyllium husk added more water to stools, was a more effective stool softener, and was a better laxative at a dose of 5.1 g twice daily than docusate sodium (Colace brand) at a dose 100 mg twice daily (1).
- Psyllium husk may also be as effective as other stimulant laxatives but the use of this fiber results in less adverse effects (2).
- Compared to placebo, 7 grams of psyllium fiber mixed with water three times daily before meals reduced the pain and bleeding associated with hemorrhoids in outpatients with symptomatic first and second degree hemorrhoids after 6 weeks and with less hemorrhoid bleeding (8% vs 44%) and also had less pain when going to the bathroom (4% vs 32%) (3).
- Constipation relief, measure by stool frequency and weight, was reported in 63% of participants taking 6.5 g/day of psyllium plus 1.5 g/day of senna compared to 48% taking 7.2g/day of psyllium alone (4). Therefore, psyllium and senna taken together is likely more effective than either agent taken alone when a stronger laxative effect is needed.
Glucomannan, a water-soluble dietary fiber:
- Glucomannan increased daily and weekly bowel movements by 0.5 times per day and 3 more times per week for 3 gr/day, by 0.9 times per day and 6 more times per week for 4 gr/day with no change for the placebo group (7).
- Glucomannan treated 45% of chronically constipated children successfully and reduced abdominal pain at a dose of 100 mg/kg body weight daily (maximal 5 g/day) with 50 mL fluid/500 mg vs. 13% for matching placebo after 4 weeks (8).
Senna
- Senna is an effective natural plant based laxative which is effective for constipation (5).
- Senna is often considered a safe and mild benign laxative because it is derived from a plant source, but it can have many of the same harmful effects of prescription cathartic laxatives if taken long term.
- Patients should be aware that senna may reduce the absorption of drugs(11).
- According to van Gorkom BA et al, senna may not only result in dependence, but also may increase the risk of colon cancer by shortening crypts, increasing cell growth, and by reducing apoptosis (12,13).
- Laxative use following childbirth: Use of senna tablets immediately after giving birth resulted in treatment of constipation in 93%-96% of women.
Miralax for constipation:
- The most commonly recommended treatment for constipation is Polyethylene Glycol 3350, (Miralax brand) available over the counter which is an effective treatment for constipation without urgency, cramping, bloating and gas. It does not work by stimulation of bowel movements, but instead draws water into the colon to soften stool and produce evacuation in a comfortable manner. For further information, see: http://www.miralax.com/miralax/why-miralax/how-miralax-works.jspa .(10)
- Miralax is more effective than senna (6), and works by drawing water into the gastrointestinal tract, softens the stool, and promotes a natural bowel movement resulting in elimination rather than functioning as a stimulant.
- Irritable bowel syndrome (IBS) with constipation: IBS suffers who ate 2 kiwi fruit a day for 4weeks had less constipation with more frequent bowel movements and shorter colon transit time than a placebo group (9).