Chronic constipation is no laughing matter. It can be physically uncomfortable, emotionally upsetting, and may even lead to toxins and waste products being reabsorbed into the body when stool remains in the colon for an extended period of time. Fortunately, chronic constipation is relatively simple to resolve with dietary and lifestyle changes. The tricky part is identifying which particular ones might best benefit an individual.

The first step is in defining constipation. Many people become alarmed if they change their diet and go from having a daily bowel movement (BM) to skipping a day or even two. But constipation is not defined by the frequency of BMs; it’s defined by the consistency of the stool and the level of pain or difficulty in passing it.

According to the American Society of Colon & Rectal Surgeons:

“The belief that one must have a bowel movement every day simply is not accurate and can lead to unnecessary concern and even abuse of laxatives.  In fact, if one’s daily bowel movement is hard, requires great effort to expel, or does not satisfactorily empty, the individual would still be considered to have constipation in spite of having a ‘normal frequency.’  On the other hand, if one has a movement every third day but it is not hard, does not require straining and completely evacuates, then one may very well consider this normal bowel movement, in spite of the fact it is not a daily event.”

Information from the University of Michigan Health System concurs, explaining that “normal bowel habits range from 3 times a day to 3 times a week.”

So if a patient is concerned because they’re not having daily bowel movements, it’s best to ask about stool consistency and level of pain or straining during a BM, because they might be concerned about “constipation” when they’re not actually constipated at all. If someone does experience discomfort during a BM or has difficulty completely emptying their bowels, then an assessment of potential causes and solutions is in order. 

Hydration

An obvious place to start is hydration. If someone is inadequately hydrated, the body may look to hold on to precious water from wherever it can, including by reabsorbing some from the stool, leading to stools that are hard, dry, and difficult to pass. (Feces are typically 75% water.) Proper hydration can prevent this, and many people across the age spectrum do not consume adequate water. If someone already does have sufficient water intake, though, increasing it further may be unlikely to help. According to researchers, “There is no evidence that constipation can successfully be treated by increasing fluid intake unless there is evidence of dehydration.” Nevertheless, fluid intake should be inquired about to rule out dehydration as a possibility, or to recommend increased water consumption if warranted.

Fiber

If feces are about 75% water, that leaves 25% for solid material. Of this 25%, about one-third consists of indigestible matter such as cellulose and other fibers. With this in mind, it’s easy to see how inadequate fiber intake could contribute to constipation and why low fiber diets are a risk factor for constipation. An “n=1” experiment of increasing dietary fiber should tell someone within just a few days whether that simple intervention is enough to get things moving smoothly.

It should be noted, though, that while increased stool bulk may help stimulate colonic motility and improve transit time for some patients, in others, increasing dietary fiber can actually make things worse. If constipation is not caused by a lack of fiber, then adding more fiber would be unlikely to help. If dietary fiber is already adequate and colonic motility is compromised for some other reason, increased dietary fiber would result in larger, bulkier stools that are still not being eliminated in a timely manner, ultimately leading to more constipation. Increased bloating and abdominal distension resulting from increased fiber intake is often cited as a reason for not complying with advice to increase fiber consumption.

Some people who adopt a low-carb or ketogenic diet find that they have less frequent BMs. This is often attributed to the lack of fiber in ketogenic diets, but the truth is, between vegetables, nuts, seeds and low-sugar fruits, there’s plenty of room for fiber on keto. It’s possible the decreased frequency—which, again, does not necessarily indicate constipation—is due to the elimination of high-carb foods like grains and beans, which are gut irritants for many people, and which may have been causing artificially increased BM frequency. 

Exercise

No surprise here: getting moving can…get things moving, at least for some people. Increasing physical activity is a frontline recommendation for those with idiopathic constipation—as little as 30 minutes a day may alleviate symptoms in some people. To be fair, though, findings are mixed, and there’s a lack of overwhelming evidence that daily exercise is effective for relieving constipation. (Exercise is wonderful for physical and mental health; it just might not be a silver bullet for constipation.)

Medications & Supplements

Last but not least, when a patient presents with constipation, healthcare practitioners should be on the lookout for supplements and pharmaceutical drugs that may cause constipation, such as iron supplements, pain relievers (including opioids), aluminum-containing antacids, blood pressure medications, antidepressants, and drugs for Parkinson’s disease.

Thyroid Function

When hydration, fiber intake, exercise and medications have all been addressed and someone still experiences chronic constipation, hypothyroidism is another avenue to investigate, particularly if the patient exhibits other signs and symptoms of the condition, such as weight gain (or difficulty losing weight), hair loss, depression, fatigue, slowed heart rate, low blood pressure and low body temperature.

When all else fails, consider a low fiber diet for those with unexplained and difficult-to-treat constipation. A study in the World Journal of Gastroenterology found that reducing or even altogether stopping dietary fiber intake could effectively reduce idiopathic constipation and its symptoms.