This newsletter was created out of a desire to help others, and each day I hear from dozens of readers with thoughtful and pressing questions. For a while I tried my best to answer them, but given the volume and how long writing in-depth articles takes—it’s no longer possible (e.g., I’ve spent the last week learning the nuances of organ donation regulations for an article reviewing the tangible spiritual consequences from non-consensually harvested organs—a surprisingly common issue).

To strike a balance, I’ve started hosting monthly open threads. These serve as a space where readers can share questions—especially follow-ups from still unaddressed topics—and I make a point of answering them. Keeping everything in one thread also makes it easier for others to learn from the discussion.

Each open thread also features a theme; usually a topic I’ve been reflecting on but haven’t yet written about in full. For this month, I want to focus on a frustrating but common issue—constipation.

Note: since there are also many questions about this publication and how its contents can help each reader, I recently revised a page covering all of that here.

Missing Bowel Movements

Over the last year, I’ve received quite a few correspondences from readers asking me to write about constipation. This I believe is reflective of how widespread but rarely discussed constipation is, especially as one becomes older (where it often becomes a primary concern of everyday life). Likewise, the primary diagnosis for constipation is “chronic idiopathic constipation” (CIC). Idiopathic, for reference, means “no one knows why” which is remarkable given that existing studies find between 9-20% of adults (averaging at 14%) have CIC. This figure in turn varies greatly by country:

In tandem, there is no clear consensus on how to treat CIC (e.g., if you review the treatment guidelines, you will see they vary greatly depending on which country they were made in).

Likewise, the majority of patients do not even discuss their condition with their doctors:

Overall, 4,702 participants had experienced constipation (24.0% met the Rome IV CIC criteria). Among all respondents with previous constipation, 37.6% discussed their symptoms with a clinician (primary care provider 87.6%, gastroenterologist 26.0%, and urgent care/emergency room physician 7.7%).

We found that the locus of control—the extent to which individuals believe they can control events that affect them—is associated with constipation healthcare seeking. Namely, those with lower locus of control (i.e., believe symptoms are driven by others, chance, or fate) are more likely to consult with providers regarding their symptoms. However, individuals experiencing this maladaptive cognition may be resistant to both undergoing indicated diagnostic testing and accepting and adhering to treatments, thereby undercutting treatment success and reducing patient satisfaction.

Additionally, many who seek out medical help end up getting colonoscopy, a procedure which carries real risks and has no benefit here:

Among those who sought care, 54% reported previous diagnostic testing. Colonoscopy was the most commonly performed test; 46% of health seekers specifically underwent the procedure to evaluate their constipation. Although we did not ask the respondents about alarm features or have access to their medical records to confirm the “true” indication for the procedure, this suggests potential overuse of endoscopy in the evaluation of constipation. This is an issue because the diagnostic yield of colonoscopy for constipation is limited.

Pepin and Ladabaum noted that in 234 individuals undergoing lower endoscopy solely for constipation, no cancers were found and only 3% had advanced lesions. The American Society for Gastrointestinal Endoscopy states that colonoscopy should not be performed in the initial evaluation of constipated patients without alarm features or suspicion of organic disease. The high usage of endoscopy and other tests seen in our study, in combination with the high prevalence of constipation, further reinforces the significant impact of constipation on population health and healthcare costs and emphasizes that efforts to reduce unnecessary testing are needed.

In short, there is a surprising gap of knowledge in this area, which I believe is best demonstrated by how many times I’ve been asked to admit a patient to a hospital who was essentially just severely constipated.

Note: the current research shows constipation hospitalizes 92,000 Americans each year and results in 1.3 million visits to American emergency rooms, which again illustrates our society’s lack of knowledge in this area, especially as the rate of this is increasing (e.g., from 2006 to 2011, there was a 42 percent rise in ER visits for constipation).

The Effects of Constipation

While it is relatively unlikely one will be hospitalized for constipation, the condition nonetheless has a significant effect on their quality of life as it is stressful to be unable to defecate when you attempt to and often quite uncomfortable once too much has built up inside you. Conversely, after a large bowel movement (especially if they’ve been constipated), individuals often feel much better and clear headed.

Note: I always wondered why the sense of well-being followed passing a large stool (especially a “toxic” one). Presently, I suspect Gerald Pollack’s model provides the answer. In it, he argues that the body is constantly forming a fourth phase of water (H₃O₂) that behaves like a liquid crystal and is formed by eliminating protons from H₂O, and that this fourth phase of water makes much of life possible (e.g., it’s responsible for the structural integrity of the body and generating the flow of fluids through the body). This process however creates a large number of protons the body must excrete to maintain its negative charge, which Pollack argues occurs through the breath, sweat, feces and urine. I, in turn, suspect that the rapid sense of well being individuals feel after certain bowel movements is a result of the electrical charge gradient of the body normalizing, as many of the descriptions I’ve heard match what happens when there is an improvement of the physiologic zeta potential (which likewise comes from increasing the net negative charge of the body).

Furthermore, constipation frequently results in a variety of significant issues. Most commonly, we recognize its connection to the fact the pressure created by strained bowel movements can lead to hemorrhoids, rectal prolapse, and anal fissures (all of which make bowel movements much more challenging).

However, it also can lead to a variety of less appreciated issues. These include:

•Dysbiosis within the gut microbiome (and the variety of complex issues which can accompany it). In many cases, the gut dysbiosis which leads to constipation results from the foods you digest not being fully digested.
Note: one of the most interesting things I learned relating to this is that SIBO (one of the more challenging gut dysbioses) often results from slowed bowel transit time, and in turn, the practitioners who I find are the most successful with treating SIBO focus on increasing peristalsis.

•Fatigue (e.g., consider this study in the elderly), headaches, abdominal pain, nausea, and vomiting.

•Chronic constipation being linked to a variety of progressively more severe illnesses including diverticulitis, kidney disease, gastric and colorectal cancer, ischemic colitis, and Parkinson’s disease.

Note: certain chronic illnesses (e.g., multiple sclerosis) can cause constipation (e.g., MS does it by interfering with the normal function of nerves within the body) which is unfortunate as constipation and a dysfunctional microbiome increases one’s risk for these degenerative conditions.

The Dangers of Laxatives

Since most constipation is labeled as “idiopathic” treatments to constipation are typically symptom based (which many are happy to do for the rest of their lives given how challenging constipation is to deal with). Unfortunately, while laxatives are relatively benign if used occasionally, over time, they can impair the normal function of the GI tract (e.g., they can alter the gut microbiome) and hence create a situation where one requires chronic laxative use.
Note: clinicians have also reported instances where laxatives destroyed the normal functioning of the colon which then required part of the colon to be surgically removed.

Additionally, we find one of the most commonly used laxatives (MiraLAX) can create issues because a surprising number of people have sensitivities or allergies to polyethylene glycol (e.g., I know people who were unaware they had the allergy and then had anaphylaxis after they took it as preparation for a colonoscopy along with patients who developed neurological complication from it). Furthermore, when individuals have a delayed bowel transit time (e.g., anyone who is constipated), individuals are more likely to systemically absorb MiraLAX and experience toxicity from it.

Note: one of the major concerns with the COVID vaccines was that fact the lipid nanoparticles contained within it had polyethylene glycol (PEG) and hence would affect those within the population who had an undiagnosed allergy to it. Sadly, because the medical field believes “vaccines are 100% safe and effective,” even people I know who had documented anaphylactic PEG allergies predating COVID-19 were not given exemptions from COVID vaccination (and neither were those who had documented anaphylactic reactions to the first shot).

As such, it is critical to identify the actual cause of constipation rather than just trying to perpetually treat the symptoms (especially since the condition will frequently worsen over time and one of the most challenging issues older adults frequently face is significant chronic constipation).

Conventional Causes of Constipation

When evaluating the root cause of someone’s constipation, it is critical to never forget constipation can also be a symptom of a more serious illness.

For example, when a tumor grows in the colon, it progressively blocks transit through the colon, which in turn leads to the feces which get through becoming narrower and narrower (along with abnormal weight loss, anemia and rectal bleeding). Because of this, if you notice that gradually happening to you, it is worth getting a preliminary test to see if you made have a cancer (there are simple and complex ways to test the stools for colon cancer).
Note: red meat (especially for those who do not eat it frequently) and beet juice (which also reddens the urine) can also make the stools turn red. Because of this, I’ve had numerous panicked people contact me over the years about rectal “bleeding” they thought was a cancer which in reality was due to drinking beet juice.

Other diseases which can frequently cause constipation include:

•Hypothyroidism—One of the common symptoms of hypothyroidism (beyond hair loss, coldness, fatigue, and weight gain) is delayed bowel transit time. As such, if you are constipated, you need to consider if you are hypothyroid.

•Hyperparathyroidism—This is a surprisingly common but unrecognized condition which can make individuals feel quite ill (e.g., it can cause pain throughout the body, cognitive issues, arrhythmias, kidney stones, unexpected fractures and a variety of gastro intestinal issues).

Note: endometriosis can also sometimes cause constipation. Likewise, a variety of neurological disorders can affect the normal motility of the gastrointestinal tract .

•Anxiety or Depression—Many report stress and anxiety causes constipation, and extensive data supports this. For example, a large study found anxiety was significantly more common in constipated patients, another found 65% of constipated patients had psychiatric conditions—most frequently anxiety or depression (with a third more detailed study yielding similar results).

Proposed mechanisms include brain-gut axis dysfunction, increased pelvic floor muscle tension due to anxiety, altered gut microbiota in anxiety, and hormonal pathways affected by stress—and my leading hypothesis—sympathetic activation directly reducing bowel transit. Because of this, mind-body practices which relax the body can sometimes be quite helpful, as is psychological support which can allow the constipated individual to relieve or resolve the underlying emotional distress causing the constipation. Likewise, addressing sources of depression can be extremely helpful when depression exists alongside constipation.

Note: the natural treatments for anxiety (and the dangers of benzodiazepines, which are routinely misprescribed for anxiety) are discussed further here. The natural treatments for depression (and the dangers of antidepressants) are discussed here.

Additionally, many medications, particularly opioids, can cause constipation, with potential offenders also including antacids, anticholinergics (such as those taken for incontinence) antidepressants, antihistamines, antipsychotics, calcium channel blockers, certain blood pressure medications, and NSAIDs. Because of this, if you develop constipation after starting a new prescription, it is always important to see if that drug is linked to impaired bowel movements.

Note: iron and calcium supplements can sometimes cause constipation (e.g., iron supplements cause constipation for approximately 10% of users).

Other Causes of Constipation

Unfortunately, in most cases , the cause of constipation remains unknown (e.g., outside of opioid induced constipation, providers rarely evaluate if a pharmaceutical drug is contributing to it) and typically the advice given is to “eat more fiber,” which while sometimes helpful often is not. Additionally, in some cases, the benefits of fiber are not due to their stool bulking activity but rather than they directly stimulate peristalsis.
Note: conditions like slow intestinal transit or defecation disorders (such as rectocele, internal prolapse, or rectal hyposensitivity) often show limited improvement with fiber alone. Additionally, chronic fiber consumption can bind essential minerals, so it is sometimes necessary to also take an appropriate multivitamin.

Presently, I believe there are a few major contributors to the epidemic of constipation we face that are largely overlooked.

Dietary Causes

•Dairy consumption (particularly in children)—which has been shown in many studies (e.g., this randomized trial found that 71.4% of children with chronic constipation not responding to laxatives significantly improved within 4 weeks of stopping dairy whereas only 11.4% of the control group, with similar results seen in this blinded crossover trial).

Note: while this is often attributed to food allergies, it may also due to the opioid-like substances in dairy (e.g., beta-casomorphin) as individuals often improve on milk lacking these substances and severe constipation (without opioid use) has been found to be reversed by naloxone (an opioid blocker). Likewise, gluten (another common cause of constipation) contains opioid like peptides (gluten exorphins) which have been shown to slow bowel transit time and cause constipation. Lastly, the variable sensitivity to these compounds (and being predisposed to constipation) may be a result of genetic susceptibility (e.g., OPRM1 A118G polymorphisms have been repeatedly shown to influence sensitivity to opioids).

•Poor diet and food triggers of constipation. Beyond dairy, we find the constipation causing agents often vary person to person (making it necessary to evaluate how each alters your bowel transit time), with the most commonly reported (ordered by the most frequent first) being cow dairy, gluten, goat's milk, beef (red meat), legumes, eggs, fried foods, rice (white), bananas (unripe), chocolate, caffeine (excess), alcohol (excess), tea (excess). Additionally, refined grains frequently lack the fiber needed to facilitate healthy bowel movements and many readers have found using freshly milled whole grain flour (e.g., wheat, within 24 hours of milling) cured their constipation.

Note: within Chinese medicine, they have an entire diagnostic model based on looking at the characteristics of one’s stools. While this is largely avoided in our society (due to the disgust it will often illicit), I have often found it to be extremely useful, and I often monitor my own stools to assess how my body is handling my current diet (or how long it takes food to transit my GI tract). Likewise, I have had many patients who found the Chinese medicine approach to treating constipation quite helpful for them.

Nutrition and Hydration

In addition to certain foods causing constipation, a lack of critical substances can as well.

For example, chronic dehydration is widely recognized to be a cause of constipation (due to it drying out the stools and making them harder to push through. Additionally, I strongly suspect dehydration causes peristalsis (bowel motion) to shut down, as I’ve seen numerous cases where “frozen bowels” rapidly softened and resumed their normal function once the individuals received either a saline infusion or a zeta potential restoring treatment (which to some extent occurs from saline infusions)—all of which I attribute to the bowels not properly functioning with insufficient blood flow (something zeta potential treatments and saline infusions restore by eliminating microclots). Likewise, ultraviolet blood irradiation (a highly effective suppressed natural therapy that shares many of these mechanisms) has been repeatedly observed to rapidly restore bowel function.
Note: older adults often have much worse constipation and while many likely mechanisms have been identified, I suspect it is also tied to gradual loss of zeta potential with age (which also predisposes them to cognitive impairment or dementia and serious injury from trauma).

Likewise, mineral deficiencies (primarily magnesium and in some cases potassium can sometimes cause constipation.

Gastrointestinal Dysfunction

As we rely on the gastrointestinal tract to push food along (through a process known as peristalsis), constipation can also signal gastrointestinal dysfunction is occurring. Some of the most common causes of this include:

•Low stomach acid creates a variety of other digestive issues such as pathogenic bowel colonization, acid reflux, food allergies, and severe nutritional deficiencies). Stomach acid restoration protocols, in addition to treating acid reflux can also be extremely helpful for constipation.
Note: symptomatic low stomach acid is extremely common (e.g., Senator Ron Johnson recently shared that learning about this allowed how to treat his chronic acid reflux).

•A disrupted gut microbiome (which conversely often becomes disrupted by bowel stasis).

•Hormonal shifts (e.g., some women develop constipation during pregnancy, menopause, or with hormone replacement therapy). Because of this it is vital to be aware of this issue, and if applicable, work with a hormone specialist who can address it.

•Dysfunction within the autonomic nervous system (which amongst other things is a common consequence of many of the constipation triggering drugs and psychiatric states I discussed above.

Habit and Exercise

Our modern lifestyle (e.g., with its constant stress) sets many of us to be constipated. Fortunately, once we recognize what’s happening, one can easily address much of it. In turn, wwe find the following are the most problematic:

•Individuals not allowing themselves the time to go to the bathroom when they need to defecate as once they miss this window, they often subsequently cannot.
Note: within Chinese medicine, it is believed that different organs activate at certain times in the day. In that system, the colon activates between 5-7 AM, and I’ve had numerous patients who have found if they do not use that time to have a bowel movement at that time, it’s often quite difficult to for the rest of the day. While the time varies from person to person, I believe it is important to prioritize listening to the defecation signals your body gives you and not putting off going to the toilet.

•Peristalsis depends upon movement within the rest of the body. For this reason, sedentary lifestyles greatly reduce the inherent motion within the gastrointestinal tract and treating constipation often requires addressing a lack of physical activity.

•The position we go to the toilet on.