Chronic constipation is a prevalent condition marked by the infrequency of passing stool, difficulty passing stool, or both. Estimates indicate that 10% to 15% of the population suffer from this painful condition (1). However, the definition of constipation varies, so the estimates of sufferers differ as well, with one estimate being as high as 80% of the population (2)! The actual number of sufferers is likely around 1 out of every 5 or 6 people. Symptoms can vary, but one thing can be agreed upon; chronic constipation can be highly uncomfortable and potentially dangerous if left untreated.
Temecula Center for Integrative Medicine believes in functional medicine approaches to addressing chronic constipation, including functional nutrition and the “5R” framework. The 5R framework is a methodology for repairing the digestive system that practitioners can customize to fit the patient’s needs. Functional nutrition is not a methodology. Instead, it’s a general term encompassing the holistic and customized nature of the nutrition recommendations and a nod to how food “functions” in the body. The 5R framework and functional nutrition can be applied to many health issues, not just chronic constipation. Still, both excel at addressing the underlying root cause for many destructive digestive disorders. Details about these approaches are in the second half of the article. First, chronic constipation is a complicated issue, so a review of the condition is in order.
Chronic Constipation: A Blockade of the Bowels
The definition of chronic constipation (CC) is often derived from the “Rome” criteria, which is an attempt at standardization. The Rome Foundation takes evidence-based information, deriving diagnostic criteria used by health care practitioners and researchers performing health studies. Rome identifies four subtypes of CC, which are identified through a series of examinations (1):
Constipation concurrent with Irritable Bowel Syndrome (IBS)
Constipation as a result of opioid medications
Functional defecation disorders
Functional constipation is the category that may be most familiar, but the identification of four subcategories is an indication of how complex CC can be.
Rome’s definition of “functional constipation,” which is problems in the lower intestinal tract indicating a chronic condition, says that two or more of the following criteria must be met for three months (3).
For 25% or more of all bowel movement attempts:
2) Hard or lumpy stools
3) Feeling as if the bowel isn’t empty
4) Feeling as if there is something blocking waste from coming out
5) Using hands to push the lower abdomen or using a finger to clear stool from the rectum
Other possible criteria (that does not occur 25% or more of the time):
6) Three or fewer spontaneous bowel movements (SBMs) per 7 days
7) Rare presence of loose stools (without purposefully causing them through the use of laxatives)
8) Irritable bowel syndrome (IBS) has been excluded as a potential cause
Symptoms of CC
The inability to have regular, easy bowel movements can result in many unpleasant symptoms. The following is by no means an exhaustive list:
Items 1-7 listed above (straining, lumpy stools, etc.)
Abdominal pain, cramping, bloating
Needing a long time on the toilet to achieve a bowel movement
Damaged tissues around the anus and in the rectum from straining or hard stools
Traces of blood on hard stools after straining
Difficulty bending over or moving the body into specific postures
Decreased appetite or nausea
Potential Causes of CC
A variety of factors can contribute to chronic constipation. Some of the most common causes are diet and exercise-related:
Lack of fiber in the diet
Food sensitivities (low-level immune reactions to foods)
Imbalanced flora (bacteria/yeast/parasites) in the intestines
Hormone imbalances affecting digestion
Lack of exercise
Inadequate digestive enzymes (stomach acid, pancreatic enzymes, bile)
Chronic constipation may be secondary to some other event or disease. Secondary CC may be a result of (4):
Side effects or direct actions from medications
Re-arrangement of anatomy due to injury or surgery
Organic diseases (tumors or polyps) or systemic diseases (affecting the whole body, such as Celiac Disease or Irritable Bowel Syndrome)
The Extreme End: When CC Becomes Dangerous
Serious health consequences can occur as a result of long-term CC. It is crucial to address this health condition before it causes (5):
Impacted fecal matter (feces “stuck” to the intestine walls)
Anal fissures (damaged tissues of the anus)
Prolapse of the rectum (inner parts of the rectum protrude from the anus)
Perforation of the bowel (from straining / hard stools)
The Functional Medicine Approach to CC
The goal of the functional medicine doctor is to figure out the root cause (or causes) of health issues and treat the whole person rather than just their symptoms. Interestingly, there is no single all-encompassing test that can assist with diagnosing chronic constipation. The doctor will lean heavily on their expertise, the patient’s history, and the reported symptoms to select the test or tests that will help identify the root cause of CC. The doctor may order blood tests, stool tests, or even imaging. Test results help narrow the focus of attention for the patient and the doctor. Functional medicine doctors often suggest natural remedies first to gently nudge the body into a healthy state. What follows are a few examples of natural approaches that a functional medicine doctor might suggest for CC.
Just as functional medicine considers the whole person when diagnosing and treating health problems, functional nutrition makes dietary recommendations based on the person as a whole. Functional nutrition (FN) recommendations consider a person’s medical history, stress level, religious dietary restrictions, food choices, exercise frequency, and results from various tests. Food choices that cause constipation in one person may not cause it in another, so the FN dietary suggestions are customized to fit the reported personal experiences.
One example of a Functional Nutrition approach is in the diagnosis and treatment of Celiac Disease and recommendations regarding wheat gluten, which does not affect everyone alike. Celiac Disease (CD) is the genetic predisposition that allows wheat gluten to damage the small intestine lining, resulting in potentially extreme symptoms such as uncontrollable diarrhea. It was once thought that CD sufferers would only have diarrhea, not constipation associated with it. However, in the late 1980s, constipation began being a symptom associated with CD. The delay in identifying constipation as a valid symptom caused many cases to be overlooked in the young, when CD is typically diagnosed. Back then, doctors didn’t know to look for CD if constipation was involved. These undiagnosed people grew to adulthood, constantly battling constipation without understanding that it was connected to a case of CD. Functional nutrition approaches would suggest removing gluten-containing foods and repairing the small intestine lining, incorporating the CD-specific nutritional suggestions into the 5R method outlined below. Note, functional medicine practitioners can test for Celiac Disease and “gluten sensitivity” with a simple blood test.
Another example is stress, which can also be either harmful or helpful, depending on the person. Stress can contribute to CC because the “fight or flight” response occurs, shunting circulation away from digestive organs to the arms and legs. Under high stress, digestion, including the absorption of nutrients and the movement of waste through the intestines, can suffer tremendously. Exercise can help dispel stress, as well as nutritional supplements such as adaptogens which help reduce cortisol, the “stress hormone.” FN suggestions might include these dietary strategies and recommend a variety of stress reduction strategies.
The 5R Framework
The 5R framework is a customizable set of steps used frequently in functional medicine that can restore health to the digestive tract. It was initially proposed by the Institute of Functional Medicine, which provides resources and education to functional medicine practitioners and their patients. The 5R framework has since taken on a life of its own, so several variations exist online.
The 5R framework focuses on healing and repairing the digestive system, addressing numerous (potential) root causes simultaneously. 5R can be conveniently merged with functional nutrition recommendations to customize and, more precisely, address the unique set of symptoms the patient is experiencing. Below is a summary of the steps in the 5R framework (6).
1) Remove – The first step is to remove food that causes negative symptoms due to an intolerance or a sensitivity to it. There are various strategies to aid the identification of triggering foods, such as systematic elimination diets and advanced food sensitivity testing. The most commonly identified triggers include:
High sugar foods
Non-gluten grains like corn and oats
Your healthcare practitioner can review your medications and help spot side effects such as chronic constipation. (Note, never quit medicines without speaking with your doctor, as some medications require careful withdrawal.)
Remove can also represent the need to remove pathogenic microbes such as certain bacteria, yeast, and parasites that, when overgrown in the intestinal tract, can contribute heavily to constipation and many other frustrating chronic bowel symptoms.
2) Replace – This step addresses what is missing from the diet (including what was removed in the previous step). For example, if you are suffering from dehydration, water intake should be increased.
One crucial part of this step is helping the various enzymes and substances that help break down foods into their smallest, most absorbable pieces. It might be necessary to replace (or increase) the following:
Digestive enzymes (break down fats, proteins, and carbohydrates)
Hydrochloric acid (in stomach acid - it breaks down fats, proteins, and carbohydrates)
Bile acids (break down fats)
Luckily, there are over-the-counter and professional-grade supplements that provide the equivalent of stomach and bile acids and digestive enzymes. These supplements can be taken with meals to help break down foods into the smallest possible pieces for maximum absorption.
3) Reinoculate – The lower intestine is full of bacteria and microorganisms that can benefit from a re-introduction of beneficial bacteria. Sometimes these microorganisms (gut flora) get out of balance, a situation called “dysbiosis.” An insult to the gut, such as food poisoning or heavy alcohol intake, can allow certain strains of bacteria to grow to unhealthy levels or kill off whole families of bacteria, causing constipation, increased yeast in the bowel, intestinal permeability, and other disorders.
Introducing beneficial bacteria, “probiotics,” can change the power structure, allowing more beneficial bacteria to gain the upper hand in the intestines. Taking probiotics will often reverse the disruptive symptoms. Beneficial bacteria can be re-introduced using capsules, liquids, or even chewable supplements. Foods high in probiotics include yogurt, kefir, and fermented vegetables.
Another way to reinoculate is through dietary fiber, which acts as a “prebiotic.” Prebiotics feed beneficial bacteria and provide substances that do not break down easily to act as a kind of broom on the inside of the intestines. Diets low in fiber can contribute to stubborn constipation that can become a chronic case. Increasing fiber can increase the need for water intake. The fiber swells with the water, providing bulk that the muscles of the intestines find easier to push along the tract.
4) Repair – This step focuses on providing nutrients and applying lifestyle advice to repair the intestine lining. The small intestine absorbs nutrients into the system. If this lining is impaired, nutrients are not adequately absorbed. Additionally, the small intestine lining can form tiny cracks, allowing large food particles and inflammatory compounds to enter the bloodstream. This condition is called “leaky gut” or “intestinal permeability.”
When large particles of food and inflammatory compounds get into the bloodstream through a leaky gut, it provokes an immune response, leading to increased food sensitivities and global inflammation in the body. This results in various symptoms such as skin eruptions and rashes, fatigue, brain fog, joint and muscle pain, insomnia, headaches, and mood changes, among others. If left unchecked, leaky gut may ultimately lead to various autoimmune conditions.
Healthcare practitioners might recommend lifestyle changes such as reducing or managing stress or eliminating alcohol. Stress is powerful enough to wreak havoc on intestinal linings all by itself (7), but made much worse in combination with alcohol. Alcohol speeds up the erosion of a healthy gut lining, causing it to be leaky, and disrupts the bacteria balance in the intestines (8).
5) Rebalance – The step of rebalancing takes into consideration the environment and lifestyle. An effort is made to address stressors and maintain a good work-life balance. Functional medicine practitioners are very good at spotting destructive habits, lack of sleep, and overwork. Sometimes it just takes a professional saying, “Slow down, your health is suffering!” to motivate a fresh look on balance. It also provides a convenient and meaningful reason to say things such as “I need to reduce my work schedule.”
Functional medicine practitioners have many tools to discover the root causes of chronic constipation and often completely resolve it with customized therapy. The experienced practitioners at Temecula Center for Integrative Medicine can help evaluate stubborn cases of constipation and formulate easy, concrete steps to address the underlying causes for a long-lasting correction. Take a step to relieve your burden today by scheduling an appointment.
Jonathan Vellinga, MD is an Internal Medicine practitioner with a broad interest in medicine. He graduated Summa cum laude from Weber State University in Clinical Laboratory Sciences and completed his medical degree from the Medical College of Wisconsin.
Upon graduation from medical school, he completed his Internal Medicine residency at the University of Michigan. Dr. Vellinga is board-certified with the American Board of Internal Medicine and a member of the Institute for Functional Medicine.
Aziz I, Whitehead WE, Palsson OS, Törnblom H, Simrén M. An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation. Expert Rev Gastroenterol Hepatol. 2020 Jan;14(1):39-46. doi: 10.1080/17474124.2020.1708718. Epub 2020 Jan 2. PMID: 31893959.
Forootan M, Bagheri N, Darvishi M. Chronic constipation: A review of literature. Medicine (Baltimore). 2018 May;97(20):e10631. doi: 10.1097/MD.0000000000010631. PMID: 29768326; PMCID: PMC5976340.
Rome IV criteria [Internet]. Rome Foundation. 2020 [cited 2022Dec16]. Available from: https://theromefoundation.org/rome-iv/rome-iv-criteria/
Andrews CN, Storr M. The pathophysiology of chronic constipation. Can J Gastroenterol. 2011 Oct;25 Suppl B(Suppl B):16B-21B. PMID: 22114753; PMCID: PMC3206564.
Constipation Complications [Internet]. Stanford Health Care (SHC) - Stanford Medical Center. 2017 [cited 2022Dec16]. Available from: https://stanfordhealthcare.org/medical-conditions/primary-care/constipation/complications.html
This video introduction to the 5R framework for treating digestive disorders is presented by Vincent Pedre, Md.. [Internet]. The Institute for Functional Medicine. 2019 [cited 2022Dec16]. Available from: https://www.ifm.org/news-insights/5r-framework-gut-health/
Dodiya HB, Forsyth CB, Voigt RM, Engen PA, Patel J, Shaikh M, Green SJ, Naqib A, Roy A, Kordower JH, Pahan K, Shannon KM, Keshavarzian A. Chronic stress-induced gut dysfunction exacerbates Parkinson's disease phenotype and pathology in a rotenone-induced mouse model of Parkinson's disease. Neurobiol Dis. 2020 Feb;135:104352. doi: 10.1016/j.nbd.2018.12.012. Epub 2018 Dec 21. PMID: 30579705.
Engen PA, Green SJ, Voigt RM, Forsyth CB, Keshavarzian A. The Gastrointestinal Microbiome: Alcohol Effects on the Composition of Intestinal Microbiota. Alcohol Res. 2015;37(2):223-36. PMID: 26695747; PMCID: PMC4590619.
Zhang T, Chon TY, Liu B, Do A, Li G, Bauer B, Wang L, Liu Z. Efficacy of acupuncture for chronic constipation: a systematic review. Am J Chin Med. 2013;41(4):717-42. doi: 10.1142/S0192415X13500493. PMID: 23895148.