Constipation And The NHS: What Are Your Options?

It costs the NHS around £189 million every year to deal with unplanned hospital admissions due to severe constipation. Prescriptions for constipation cost another £101 million, and one in seven UK adults are affected by constipation at any one time. It’s a similar picture across most of the developed world.

Why is this happening? If you’re one of the many bunged up Brits, life can be miserable. If you want to know more about what causes constipation, and how the NHS—and Healthpath—can help you can tackle it, read on.
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Contents

What is Constipation? The NHS Definition
Constipation: The Healthpath Definition
What Causes Constipation? The NHS Answer
What Causes Constipation? Healthpath Looks for the Root Cause
How the NHS Treats Long-Term Constipation?
How Healthpath Approaches Long-Term Constipation?
How the NHS Relieves Short-Term Constipation?
How Healthpath Approaches Short-Term Constipation?
What To Eat For Constipation: The NHS Guidelines
What To Eat For Constipation: The Healthpath Approach
CONSTIPATION FAQs
What Is Constipation A Sign Of?
How Long Is Too Long To Be Constipated?
How Can I Relieve Constipation Quickly?
Can You Can Still Be Constipated If You Poop?
Conclusion

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What is constipation? the NHS definition

The NHS defines constipation as:

• not having a poo at least three times in a week
• the poo is often difficult to push out and larger than usual
• the poo is often dry, hard or lumpy

Because the NHS is split into separate regional trusts, each one may have a slightly different definition of constipation and how to treat it. For instance, Guy’s and St. Thomas Hospital Trust says: “People often think that they should pass stool every day to have a normal bowel habit.

“However, how often people pass stool differs from one individual to another. Most people will have a bowel movement between three times a day and three times a week. It is when your bowel movements become less frequent than is usual for you that you may need to consider whether you are constipated.

“A normal bowel motion should be well formed, soft and easy to pass. If you notice any persistent change in your bowel habit, such as needing to go to the toilet more often, having looser stool, bleeding from your bottom or stomach pain please visit your GP, as these symptoms could indicate other problems.”
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Constipation: the Healthpath definition

Our definition of constipation is a bit different to the NHS’s. For instance we would say that you’re constipated if you’re finding it difficult to go to the loo: even if you ‘go’ every day, you might have to strain to do it, or feel like you haven’t finished.

Or, you may go days without passing anything at all. For some people, this can cause discomfort and pain, but others may feel fine having a bowel movement perhaps as little as once a week. Some of our Registered Nutritional Therapists have seen clients who often wait up to a month between bowel movements.

We think that having a bowel movement should be an everyday activity. That’s in both senses of the term: you should have at least one a day, and it should be an uneventful, ‘everyday’ thing, with no pain or straining.

People in traditional societies who live on natural, whole foods from the beginning of their lives don’t, as a rule, have issues with bowel movements (Source: ONLINE LIBRARY). The researchers who lived with the community in this study —the Hadza in Tanzania—observed that they generally have a comfortable bowel movement after each meal (Source: NCBI).

Many Functional Medicine Practitioners and gut health experts think that three bowel movements a week is far too low. “Optimal bowel transit time is 12 to 24 hours,” says Liz Lipski, PhD, author of Digestive Wellness: How to Strengthen the Immune System and Prevent Disease Through Healthy Digestion. “Three bowel movements a week amounts to a transit time of 56 hours, which is way too long.”

While we can’t state an optimal number of bowel movements to be having per day or per week, we can look at what happens in the few communities that still live in the way humans have done for the last 200,000 years or so. Although it would be difficult for most of us to live this way today, our bodies and brains have evolved over all this time to function optimally on a whole foods, fibre-rich diet (Source: NCBI) from the start of our lives, which, from observing traditional societies, we can see usually results in a bowel movement after each meal.

At Healthpath, we know that this isn’t achievable for everyone. Our Functional Medicine Practitioners and Registered Nutritional Therapists usually recommend that everyone aims for at least one bowel movement a day.
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What causes constipation? the NHS answer

• not eating enough fibre, such as fruit, vegetables and cereals
• not drinking enough fluids
• not moving enough and spending long periods sitting or lying in bed
• being less active and not exercising
• often ignoring the urge to go to the toilet
• changing your diet or daily routine
• a side effect of medicine
• stress, anxiety or depression

The NHS says: “Constipation is more common as we get older because as we age we tend to eat and drink less, become less active or less able to exercise, and have greater difficulty reaching a toilet. We are also more likely to be taking medicines that cause constipation, and have medical conditions that affect the bowel. People in hospital are especially prone to constipation.”
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What causes constipation? Healthpath looks for the root cause

While we agree with all the causes of constipation that the NHS puts forward, we have a few others too. Let’s take a closer look at them all:

SIBO

SIBO—which stands for ‘small intestine bacterial overgrowth’—can produce gases that lead to constipation (Source: NCBI).

SIBO is what happens when too many bacteria start living in your small intestine. Under normal conditions, the number of bacteria in your small intestine would be very low (Source: NCBI). For a variety of reasons—which researchers are still investigating—too many set up shop there and cause symptoms like diarrhoea, bloating and constipation.

Research has found that up to 78% of people with IBS have SIBO (Source: NCBI). While diarrhoea and bloating are more common symptoms of SIBO, people with an overgrowth of the types of bacteria that produce a gas called methane more commonly have constipation. If you think you might have SIBO, you can take a breath test at home to find out for sure.

Researchers, holistic medicine practitioners and conventional doctors have been using the test routinely for many years in the U.S, and it has a good weight of evidence behind it (Source: NCBI). Many NHS trusts in the UK now offer it too.

Dysbiosis

Bacterial imbalance in the large intestine can influence constipation too. Many recent studies have found that people with constipation are more likely to have an imbalanced microbiome (Source: NCBI) than people with no gut symptoms. These particular researchers state that constipation is actually ‘caused by dysbiosis of the microbiota’.

A 2017 review of research on the connection between dysbiosis and chronic constipation found that a type of bacteria called Bacteroides was more common in the walls of the intestines of patients with chronic constipation, along with higher levels of Clostridium difficile and Bifidobacterium in their stools. In contrast, numbers of Lactobacillus and Faecalibacterium prausnitzii tended to be low in constipated patients. Interestingly, researchers found that it was possible to predict how often a patient had a bowel movement by looking at levels of Firmicutes —a family of bacteria—in their stools (Source: NCBI).

Chronic stress

High levels of stress hormones can disturb the digestive system and contribute to constipation. Women with constipation have been found to have increased levels of the hormones norepinephrine, epinephrine, and cortisol at night (when these hormones should be low), while women with diarrhoea measured significantly lower on norepinephrine and cortisol (Source: NCBI).

We know from several studies that people with constipation are more likely to have a psychological disorder like anxiety or depression, or to have suffered physical or sexual abuse, as well as anorexia nervosa or other eating disorders (Source: PUBMED NCBI), (Source: PUBMED NCBI), (Source: PUBMED NCBI).

Despite all the evidence on the link between stress, trauma and constipation, one study reported that there is no relationship between psychological distress and stool frequency in patients with slow transit constipation (Source: PUBMED NCBI), which goes to show how important it is to remember that the conclusions experts draw from research constantly change and evolve.

Low water intake

If your body is dehydrated, it will take water from your large intestine. This can make your stools dry and difficult to pass.

If you suffer from constipation, you’ve probably been told to increase your fluid intake, often to six to eight glasses per day. However, there’s not much scientific evidence to suggest that the strategy is effective unless you’re dehydrated, or you’ve been told to eat more fibre (when you should always up your liquid intake).

Constipated people don’t appear to drink any less than non-constipated people (Source: PUBMED NCBI). If you don’t drink much at all: less than around 500ml per day, upping your fluid intake to normal levels will help, but drinking over two litres a day is unlikely to ease constipation (Source: PUBMED NCBI).

One study did show that people who increased their fibre intake and drank two litres of water a day were able to reduce the amount of laxatives they took and have more bowel movements, while the group drinking only one litre a day were not (Source: PUBMED NCBI).

Not enough fibre (but it’s not that simple)

Fibre bulks up the stool. Too little fibre can mean your stools are insufficiently formed, resulting in a slow transit time. However, it’s not always that simple: upping your fibre intake won’t necessarily cure your constipation. In some cases, it can even make it worse.

If you have mild or temporary constipation, increasing fibre usually does a good job, especially if your normal diet is low in fibre. If you’ve had constipation for a long time, or if it’s severe, you might need to dig a bit deeper.

When a group of scientists conducted a meta-analysis (research that looks at the results of multiple studies to form a conclusion) they found that dietary fibre did increase stool frequency in patients with constipation. However, the result also showed that dietary fibre did not improve stool consistency, the success of treatments, the need to use laxatives or painful defecation (Source: NCBI).

Confusingly, multiple studies have found that stopping fibre improves constipation. In one, patients who stopped fibre completely went from having one bowel movement every seven days to one every day. Others who reduced their fibre intake went from going every seven days to every two days. Out of all these patients, the ones who went back on to a high fibre diet after the trial returned to their usual pattern of one bowel movement every seven days (Source: NCBI).

Sometimes constipation is caused by impaired intestinal motility (your intestines don’t move properly, for a number of reasons). If you’re one of these people, fibre can make your constipation worse. If stools are passing through your colon too slowly, then fibre will just bulk up stools without speeding up their passage (Source: NCBI), potentially creating more gas, discomfort and pain.

Of course, there are many different sources of fibre. Some processed breakfast cereals are high in fibre yet they have very little in common with high-fibre whole plant foods, like avocados or raspberries. If you want to increase your fibre intake, like many people, you might reach for the whole grain bread or wheat bran.

If your constipation gets worse, you might blame the fibre. But the culprit could be some other part of that food: for instance the gluten, or the starch. Ideally, dietary fibre should be coming from whole food plant sources.

There’s two different types of fibre: insoluble and soluble, each with different jobs to do in your gut.

Soluble fibre

As the name suggests, soluble fibre easily dissolves in water.

It’s found in foods like:

• barley
• rice
• oats
• legumes
• chia seeds
• sunflower seeds
• flaxseeds
• guavas
• apples
• pears
• apricots
• figs
• broccoli
• cabbage
• asparagus
• turnip
• sweet potatoes

When we eat these foods, the soluble fibre swells up with water in our stomach to form a thick gel-like substance. It also feeds the bacteria in our large intestine.

Insoluble fibre

Insoluble fibre does not dissolve in water: it actually passes right through our digestive system, adding bulk to our stool.

Some foods high in insoluble fibre are:

• whole wheat
• popcorn
• kidney beans
• chickpeas
• lima beans
• black-eyed peas
• cauliflower
• potatoes
• green beans

While you need both types of fibre, you don’t need to keep a record of how much you eat of them: most sources of fibre contain a bit of both. The NHS recommends 30 grams per day for adults. Most people are eating well under that amount.

The good news is that if you stick to whole foods and get plenty of fruit and vegetables, your fibre intake will look after itself.

FODMAPs and food intolerances

Even a seemingly healthy, whole foods diet could be causing your constipation and other digestive woes. Lots of fruits and vegetables are high in natural sugars known as FODMAPs, which have been found to cause IBS—including constipation—symptoms in many people (Source: PUBMED NCBI).

FODMAP is an acronym that stands for Fermentable Oligosaccharides Disaccharides, Monosaccharides And Polyols. High FODMAP foods include garlic, onion, legumes, pulses, and some fruits, vegetables and forms of dairy. Wheat is high in FODMAPs too.

Working out what foods help or hinder your constipation can be confusing and frustrating. Everyone is different, but as you can see, there are certain types and groups of foods that you can experiment with to make the process less painful. That’s why we recommend working with a Functional Medicine Practitioner or Registered Nutritional Therapist: they’re trained to find the root cause of uncomfortable or painful symptoms, not to just make them go away.

Being intolerant to FODMAPs or any food is a symptom in itself, not the root cause of your constipation. A healthy gut can tolerate a wide range of foods (Source: NCBI). So, while eliminating foods from your diet could be necessary for a short time to get your constipation under control, an experienced practitioner will work to heal your gut so you can eventually tolerate the foods you’ve cut out.

Hypothyroidism

This is a condition where—for a variety of reasons—you don’t have enough thyroid hormone available for your body to use. This slows everything down, contributing to constipation.

Muscles line the digestive tract, including the small and large intestines. The muscles contract to move the stool through the intestine to the rectum. Hypothyroidism can weaken the contraction of these muscles causing the stool to move too slowly.

Neuromuscular issues

Your intestines move stool through and out of your body via a series of signals that involve your nerves and hormones. If your nerves aren’t working properly, constipation can result.

Constipation is more common in people with multiple sclerosis, Parkinson’s disease, spinal injuries, and the neuromuscular disease muscular dystrophy. People with these conditions can have problems relaxing muscles in the pelvic floor which makes it hard to push stool out. Their colons may also work more slowly, leading to fewer bowel movements.
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How the NHS treats long-term constipation

If you’ve had constipation that hasn’t gone away for over three months, an NHS doctor may diagnose you with IBS. A lot of people think that only people with diarrhoea can have IBS, but the NHS say “IBS is a long-term condition where pain in your abdomen is accompanied by a change in bowel movements: diarrhoea, constipation or both.”

Is it constipation, or IBS?

GPs usually use the ‘Rome IV criteria’ when diagnosing IBS:

Recurrent abdominal pain, on average, at least one day a week in the last three months, associated with two or more of the following criteria:

• related to defecation
• associated with a change in frequency of stool
• associated with a change in form (appearance) of stool.

The criteria must be fulfilled for the last three months, with symptom onset at least six months before diagnosis.

If a doctor diagnoses you with IBS, initially they are likely to offer lifestyle advice like cutting down on fast food, keeping a food diary, finding ways to relax, and exercising. Recently the NHS started recommending that IBS patients try probiotics for a month.

If you don’t fit the criteria for a diagnosis of IBS, you might be told you have chronic constipation or long-term constipation. Whatever your diagnosis, the treatment you get will depend on your individual symptoms, the professional opinion of your doctor and the treatment options available in your area.

For instance, your GP might suggest an over-the-counter medicine like Fybogel, or Movicol, a gentle laxative. Every doctor will have a slightly different approach. If you still have trouble after trying lifestyle changes and different types of laxatives, a GP might refer you to a gastroenterologist (a doctor that specialises in diseases of the digestive tract). Gastroenterologists are able to prescribe specialist medication for IBS symptoms.

The NHS gives the following lifestyle advice to reduce constipation:

• drink plenty of water to help make your stools softer
• increase how much soluble fibre you eat—good foods include oats, pulses, carrots, peeled potatoes and linseeds

The NHS uses a range of medications for people with IBS. Every region, and every doctor, has their own preferred protocols.

Some of the prescription medicines—usually only prescribed by a gastroenterologist—used for constipation include:

• Prucalopride (Resolor) acts on serotonin receptors in your gut to stimulate peristalsis (the muscular movements that push stools through your bowel). It is licensed to treat severe laxative-resistant constipation in women.
• Lubiprostone (Amitiza) works through chloride channel receptors in your bowel, stimulating them to release liquid.
• Linaclotide (Constella) treats constipation associated with bloating and abdominal pain and reduces intestinal sensitivity.

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How Healthpath approaches long-term constipation

The average fibre intake in the developed world is 18 grams a day (SOURCE:NCBI). Compared with the 30 grams of fibre the NHS says we need to keep our bowels healthy, that’s far from good enough. Even the NHS recommended fibre intake is a fraction of the 100 grams or more people in traditional societies eat.

As you found out earlier, not everybody with constipation gets better by eating more fibre. However there’s a lot of evidence to show that a high-fibre diet works for many. At Healthpath we know that every person’s response to foods and supplements is as individual as they are, so there’s no standard protocol that we follow if someone has constipation.

We often recommend two tests to our customers with constipation:

1. A SIBO test, to find out if you’ve got too many bacteria growing in the wrong place
2. A stool test, to explore the health of your microbiome, which looks at:

• stool consistency, pH levels, microbe diversity, enterotype, and levels of dysbiosis
• bacteria, yeasts (including candida), moulds, parasites and H. Pylori
• advanced gut health biomarkers that read digestive function, immunity and inflammation

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How the NHS relieves short-term constipation

The NHS usually recommends some form of laxative for short-term constipation. However, as we’ve said, every doctor treats patients with constipation in their own way, usually based on the recommendations of their regional trust.

There are three main types of laxative:

Stimulant laxatives

Stimulant laxatives include:

• Bisacodyl
• sodium picosulfate
• senna

They make your gut move faster and often cause cramps in your abdomen.

Faecal softeners

Faecal softeners like Docusate sodium or glycerol suppositories relax your gut walls and increase intestinal fluid.

Osmotic laxatives

Osmotic laxatives increase the amount of water in the large bowel. Some examples are:

• macrogol 3350 with potassium chloride
• sodium bicarbonate
• sodium chloride

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How Healthpath approaches short-term constipation

At Healthpath, we look for the reasons why your symptoms are happening so we can find a long term solution.

We’re not doctors, so we can’t prescribe any drugs, and we recommend talking to your doctor before drastically changing your diet or taking new supplements, as they can interact with prescribed medication.

You can find out more about our approach to constipation in our blog.
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What to eat for constipation: the NHS guidelines

The NHS say that if you’re constipated, you should make these changes to your diet:

• drink plenty of fluids and avoid alcohol
• increase the fibre in your diet
• add some wheat bran, oats or linseed to your diet

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What to eat for constipation: the Healthpath approach

Because every person is different and has constipation for different reasons, we don’t have a list of foods that everyone with constipation should or shouldn’t eat.

However, as a very general rule, we recommend that you eat a minimum of 30 grams of fibre a day. This won’t work for everybody, but it’s a useful ‘first line’ suggestion. That means you should try it first, before trying anything more complicated. If it doesn’t work, you need to dig deeper.

High fibre foods include:

• apples, bananas, oranges, strawberries all have around three to four grams of fibre per serving
• raspberries have a whopping eight grams per serving
• exotic fruits are also good sources of fibre: A mango has five grams and a serving of guava has about nine
• carrots
• beets
• broccoli
• collard greens
• swiss chard
• artichokes are among the highest-fibre veggies, at ten grams for a medium-sized one
• potatoes: white and sweet potatoes all have at least three grams of fibre in a medium-sized one, with skin on

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CONSTIPATION FAQs

What is constipation a sign of?

Constipation can be a sign of so many things: it’s impossible to say what could be causing your constipation without digging into your health history and lifestyle. We went through some of the most common causes earlier: see ‘What causes constipation’.
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How long is too long to be constipated?

Ideally, you should be having at least one bowel movement a day, but again, this depends on what your ‘normal’ is. If you’re used to going twice a day, and you go down to once, it might mean you’re constipated, especially if you’re uncomfortable and feel like you haven’t finished.

On the other hand, you might usually only have one bowel movement every two days, but feel fine. In our eyes, once a day is a better pattern but if you have no symptoms and are otherwise healthy, it’s probably nothing to worry about. You should always let your doctor know if your bowel habits suddenly change.
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How can I relieve constipation quickly?

If you’re uncomfortable and need to have a bowel movement but you’re having trouble, speak to your doctor or pharmacist, who can give you a laxative.

At Healthpath, we focus on finding the root causes of ill-health, which usually takes a bit of time and perseverance. Having said that, one thing we often recommend is magnesium citrate: it’s gentle, is unlikely to give you cramps and gives you some added health benefits too.
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Can you can still be constipated if you poop?

Yes, you can still be constipated if you poop. In fact, it’s quite common for constipated people to have a bowel movement and feel like they’re not ‘finished.’

This is usually because they’re not: for some reason, some stool remains in the rectum, causing discomfort and even pain. But it’s also a common symptom of IBS to feel like you need a bowel movement when you don’t, so you may not necessarily need a bowel movement even if you feel like you do. However, this is usually a hallmark of diarrhoea rather than constipation (Source: PUBMED NCBI).
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Key takeaways

Constipation is now so common that in the UK, one person in seven is now bunged-up at any one time.

At Healthpath, we want to know why you’re constipated.

Your doctor should always be your first stop if your bowel habits change, or if you haven’t had a bowel movement for over five days.

If you’re chronically constipated, the NHS will probably offer you (in this order):

1. lifestyle advice
2. over-the-counter-laxatives
3. stronger laxatives
4. a referral to a gastroenterologist, who can prescribe specialist drugs

Because we at Healthpath look for the root causes of ill-health, and we’re not doctors, our approach is a bit different. If you have constipation, we recommend:

• carrying out a SIBO or gut health test to explore why you could be constipated
• experimenting with short term exclusion diets to identify the foods causing your symptoms
• devising a long term plan to heal your gut for good by changing your diet and lifestyle

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Author

Alexandra Falconer MA (Dist) DipCNM mBANT is a Registered Nutritional Therapist specialising in IBS and related conditions. A graduate of Brighton’s College of Naturopathic Medicine, she is committed to fighting the root causes of chronic illness and bringing functional medicine to everyone who needs it.

Before her natural health career, Alex was a journalist and copywriter. She continues to write for magazines and media agencies, and now combines her two great passions—writing and health—by creating content that empowers people to claim their right to a healthy body and mind.