Constipation & Plant-Based Diets

Studies suggest 1 2 that around 20% of people in Westernised countries suffer from constipation. That’s a lot of unpleasant and largely unnecessary toilet trouble by any standards. But is there a simple, drug-free remedy? You can bet your beans and greens there is!

Fibre, fibre, fibre

The most common lifestyle choice associated with the development of constipation is eating a low-fibre diet.

It still comes as something as a surprise just how many people are completely unaware that fibre can only be found in foods derived from plants – fruit and veg, beans, whole grains, etc – and that there is ZERO fibre in meat, dairy products, and eggs.

The average daily fibre intake in the UK is 17.2 grams/day for women and 20.1 grams/day for men, with a government recommendation of a minimum of 30 grams/day 3 . In the US, the recommendations vary from 19-38 grams/day, whilst US fibre intake is even less than the UK, at around 16 grams/day 4 5 . And, because these are averages, it means there are plenty of people eating considerably less than this.

A previous blog 6 discussed fibre in more detail, and pointed out that eating as much as 100 grams of fibre daily was quite normal in earlier human evolution.

In those countries where traditional diets contain much more fibre, it’s no surprise to find that constipation is much less common. But how can we know that it’s the fibre that’s making so much difference? Well, studies have looked at the changes that occur when such countries adopt the modern Western diet, which is much lower in fibre content. And what they’ve found is that constipation prevalence increases. 7 8

Constipation by country

There’s a very detailed list of reported constipation cases available at 9 , but the following selective chart from a 2008 study 10  shows a common finding: namely, that women tend to suffer more than men.

Key: United States (US), United Kingdom (UK), France (FR), Germany (GE), Italy (IT), Brazil (BR) and South Korea (SK).

Problems arising from constipation

There are a number of complications which may arise from constipation 11 12 , including:

  • haemorrhoids (from “straining at the stool”)
  • anal fissures
  • rectal prolapse
  • faecal impaction (also called malignant constipation), which may lead to:
    • bowel obstruction
    • nausea
    • vomiting
    • tender abdomen
  • encopresis (where soft stool from the small intestine bypasses the impacted faecal mass in the colon)

How to prevent and alleviate constipation

It’s pretty obvious that the most sensible and natural method will involve increasing fibre content in the diet.

In children, studies show 13 14 that a lower intake of dietary fibre differentiates children with chronic constipation from those who have regular bowel movements. It’s so sad that children have to undergo such suffering simply because their parents and carers fail (whether through ignorance or conscious choice) to feed them a diet that maintains their gut health. Of course, it’s not just the problem of constipation that’s at issue here; maintaining a healthy gut microbiome from early life is vital for overall health through childhood and into old age 15 16 17 18 . And it’s such an obvious yet largely unappreciated fact 19 that our GI tract (along with all the trillions of essential bacteria, fungi and other microbes therein) is best maintained by a whole food plant-based diet rather than a diet of processed and/or animal foods.

As would be expected, therefore, additional studies show that increasing dietary fibre improves constipation and significantly reduces the need for laxatives in all societal groups:

  • children 20
  • young adults 21
  • elderly people 22 , and
  • post-surgery patients 23

When fibre supplementation may be necessary

Naturally, the first and best option is to increase the consumption of high-fibre foods. This is because, by eating whole plant foods, we don’t just facilitate easier gut transit, but the fibre itself and the natural healthy bacteria included with plants act as probiotics and prebiotics for our gut bacteria, and a variety of plants provides a vast array of minerals, vitamins, and an almost inestimable number of beneficial phytochemicals.

However, there are situations where chewing away on fibrous plant food is not an option, and so, in the following cases, fibre supplements may be the best option:

  • individuals lacking teeth (edentulism)
  • patients who can’t swallow easily or at all (dysphagia)

Prescribing laxatives is a very general knee-jerk reaction of medical professionals. They seem to choose this because they don’t appear to believe their patients have the wherewithal to significantly alter their diets. However, suggesting fibre supplements, in the case of the above two conditions, or changing to a high-fibre diet, in the case of most patients, is far more successful than merely pouring laxatives down your throat while still eating the same constipating diet. When the second best alternative (fibre supplements) are offered, evidence suggests 24  that around 60% of constipated patients can dispense with the laxatives they had been previously taking.

Different types of fibre supplements

The following have been shown to be effective for constipation relief:

  • psyllium (Metamucil) 25 (although prunes have been shown 26  to be more effective than psyllium)
  • methylcellulose (Citrucel) 27
  • Japanese konjac root (glucomannan) 28

But, I repeat, the first and best option is to transition to a plant-based diet (ideally non-SOS WFPB) unless, of course, you have no teeth or cannot swallow easily. And, even the latter two cases, I would suspect that there may be some way found to ensure whole plant foods are eaten, even if they have to be pulped or liquidised to some extent. I have some personal experience of this situation, since my father developed COPD 29 and dysphagia. Being crippled and having to be cared for my my mother, she was told that he would only ever be able to eat pureed food. However, she found that with some careful selection of foods, he was able to eat “solid” food almost until the time of his eventual death.

Dehydration & constipation

Even mild dehydration is a very common factor in cases of constipation 30 31 . This has also been found 20  to be the case in young constipated children. And it’s easy to understand why this is the case, and how it links inextricably with diet, when you realise that whole plant foods contain loads of water, while processed and animal foods can contain considerably less – and also usually contain loads of dehydrating salt.

Becoming dehydrated, without being aware of it, is much easier and more widespread than most of us realise. This can be seen from a US study 32 which found a shocking 75% of US citizens were chronically dehydrated.

In patients with functional chronic constipation, it’s been shown 33  that combining fibre and fluid (25 grams and 1.5-2.0 litres, respectively) on a daily basis was more effective for constipation relief than simply taking fibre alone.

It’s no surprise, then, that Dr Greger includes water consumption as one of the essential items in his Daily Dozen list 34 , stating that “…authorities from Europe, the U.S. Institute of Medicine, and the World Health Organization recommend between 2 to 2.7 liters of water a day for women. That’s 8 to 11 cups a day for women, and 10 to 15 cups a day for men. Now but that’s water from all sources–not just beverages–and we get about a liter from food and the water our body actually makes. So these translate into a recommendation for women to drink 4 to 7 cups of water a day, and men 6 to 11 cups, assuming only moderate physical activity at moderate ambient temperatures.” 35 .

Constipation & cow’s milk

Many children with chronic constipation are found 36 to be allergic to cow’s milk, manifesting IgE antibodies 37 to cow’s milk antigens38 . It’s always worthwhile for parents to ensure that any difficulties occurring during potty training are not associated with constipation resulting from the child drinking cow’s milk.

This is no insignificant matter, since consumption of cow’s milk has been found 39 to be significantly higher in infants and children with constipation and anal fissure than in those without these disorders.

And it gets even worse. Colonoscopies revealed 40  that around 50% of constipated, cow’s milk-allergic children and adolescents had lymphoid nodular hyperplasia 41 , compared with 20% of controls. The same study also found that around 33% of all cow’s milk-allergic individuals had a significantly higher number of intraepithelial T cells 42 , indicating an enhancement of local immune responses against food antigens. Another study of children with lymphoid modular hyperplasia found 43  that in 43 of the 52 individuals a diagnosis of cow’s milk or multiple food hypersensitivity was made.

Such activation of the immune system is known 44 to affect gastric motility 45 , thus indicating a likely role for an immune response to food antigens in cases of constipation.

Cow’s milk or soy milk?

Cutting out cow’s milk totally, in the diets of those children with cow’s milk sensitivity and constipation, has been shown 46  to result in significant improvement in up to 66% of cases.

In a small-scale study 47 of children with constipation, 100% of the participants had full resolution of chronic functional constipation when soy milk was used as a replacement for cow’s milk.

A further study found 48 that when cow’s milk was reintroduced, constipation returned within 5-10 days.

Previous blogs 49 50 have discussed in much more detail the range of health issues associated with cow’s milk. In basic terms, for all humans, irrespective of age, there’s absolutely no nutritional need for “baby calf growth fluid” 51 to be included in the diet. And, for a significant number of both children and adults who experience constipation, it would seem a sensible plan to try cutting out cow’s milk completely to see whether relief of symptoms follows.

Final thoughts

So, getting lots of fibre, drinking plenty of fluids and avoiding cow’s milk seem to be the major routes towards non-drug prevention and treatment of constipation in all age groups. One area we haven’t covered is regular physical exercise, which, counter to popular belief, does not have any overwhelming study evidence to support its value for constipation treatment or avoidance. Some studies consider that it can be an important adjunct for males 52 and females 53  of all age groups in the prevention and treatment of constipation. However, other studies, including the following 2017 French study, question whether increasing exercise per se has any positive effect:

The benefi[t] of increasing water intake or daily physical exercise in the treatment of chronic constipation have a lack of evidence, except specific situations such as elderly, hospitalized, institutionalized, dehydrated people or people consuming fluids less than 500mL/day. Change in environmental defecation conditions or bowel habits are probably anecdotal recommendations.” 54

Yet other authorities consider 55 that, in some cases of particularly intense exercise, constipation can be worsened. More research is needed on which level of activity (stationary yoga movements, gentle walking or marathon running, for instance) has what effect on constipation.

Whilst lack of exercise is particularly important as we age and run the risk of becoming too sedentary 56 , the increasing rates of childhood obesity – and the associated reduction in physical exercise – are reported by some studies as revealing a worrying increase in cases of constipation and other GI health concerns 57 58 .

My personal experience is that the effects of exercise appear to be determined, at least to some extent, on the quality of diet you are consuming. If you’re already eating a low-fibre diet and then exercise, I have no doubt that it might lead to increased constipation; however, when a high-fibre diet is your norm, exercise may not have the same effect. A comparison study would be of interest in this respect.

What all studies agree on, however, is that the main and overreaching factor of importance in avoiding and treating constipation is fibre, fibre and more fibre.

So, in conclusion, whilst it’s easy to say that best means of achieving healthy GI tract activity is to follow a varied WFPB diet, keep hydrated and ensure that you get plenty of daily exercise, when we have had a lifetime of practising ingrained and unquestioned habits, it can be really difficult to make such lifestyle and dietary changes.  However, ensuring that our children do not fall into bad habits will both protect them and encourage us to embrace healthier practices ourselves.

References & Notes

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