Causes and Cures for Constipation

Constipation seems to be very common; we’re frequently asked about it. Constipation can afflict low-carb dieters: It was widely reported among Atkins dieters, and is the most common side effect reported on clinical ketogenic diets for epilepsy. [1]

Fortunately constipation is usually easily cured. There are a few common causes, and most of them have simple fixes.

Antioxidant Deficiency

Among the most common causes of constipation among low-carbers is deficient antioxidant capacity.

The gut is a challenging environment, full of oxidizing compounds. If glutathione and other antioxidants become deficient in intestinal cells, then the gut becomes leaky [2], leading to inflammation and the potential for constipation. Oxidative stress can also lead to loss of neurons or neuronal axons from the colon and consequently a loss of motility. Constipation is a common symptom of irritable bowel syndrome.

The cure is simple: supplement. Specifically:

  • Selenium, 200 mcg/day (perhaps 400 mcg during a starting period). Selenium is needed for glutathione peroxidase, a glutathione recycling enzyme.
  • Vitamin C, 1 g/day (perhaps 4 g/day during a starting period). Vitamin C and glutathione recycle one another.
  • Zinc and copper. Total zinc intake should be 30-50 mg/day including food and multivitamin; copper intake should be 2-5 mg/day. Food typically provides 15 mg zinc and 1 mg copper.
  • Cysteine and glycine. These are the component amino acids for glutathione. For constipation I would suggest eating some beef gelatin for glycine, and taking one 500 mg capsule of N-acetylcysteine per day.

Egg yolks also increase glutathione production [3], and eating a dozen per week is highly recommended. Lipoic acid may also help. [4]

Glutamine, a supplement frequently recommended for gut ailments, can also enhance glutathione production [5]. However, I would generally avoid this, because it can promote proliferation of pathogenic bacteria.

Hypothyroidism

Hypothyroidism may be the most common cause of constipation.

A vicious circle often develops: Gut problems lead to autoimmune hypothyroidism, and constipation is only one symptom of the damage hypothyroidism does to the gut. The vicious circle can be broken by treating the hypothyroidism.

The cure:

  1. Eliminate wheat, soy, and other autoimmune-promoting or goitrogenic toxins from the diet.
  2. Supplement with thyroid supporting nutrients like:
    • Selenium (as above).
    • Magnesium (citrate or chelate) 200 mg/day.
    • Zinc and copper (as above).
    • Iodine.
  3. Improve circadian rhythm. Circadian rhythm therapies for hypothyroidism were discussed in two posts, Intermittent Fasting as a Therapy for Hypothyroidism (Dec 1, 2010) and Seth Roberts and Circadian Therapy (Mar 22, 2011).
  4. See your doctor to consider replacing thyroid hormone and investigating related problems. Your doctor can prescribe thyroid hormone and can explore related problems that may contribute to hypothyroidism, such as adrenal fatigue or iron deficiency.

As always, a few cautions about iodine supplementation. Before starting iodine, eliminate wheat from the diet and supplement with selenium, copper, and magnesium. If you have thyroid-related effects from copper supplementation, before proceeding further supplement copper until your thyroid no longer reacts. Start iodine at a low dose, say 500 mcg (0.5 mg) per day. Increase the iodine dose no faster than one doubling per month. When you increase the dose, if you have a reaction to the higher dose, phase it in: say, alternate between 0.5 mg and 1 mg for a week before trying 1 mg/day every day. Go slowly, plan on spending 4 months to reach 3 mg/day, which is a quarter Iodoral tablet. Tablets can be cut into pieces with razor blades and liquid solutions can be diluted; don’t hesitate to reduce doses.

Insufficient Dietary Fat and/or Bile

Not long ago Jamie Scott (That Paleo Guy), a very smart nutritional advisor, discussed his solution for constipation. There were several gems in there, for instance, that foods that stimulate opioid receptors can cause constipation [5b]:

For example, both gluten grains (and I suspect grains in general) plus dairy contain opiate-like compounds that serve to reduce the motility (movement) of your gut.  This effect is commonly seen in those who have to take the likes of codeine (also an opiate) for any length of time.

Chocolate also has opioid peptides. But don’t worry, chocolate isn’t usually the cause of constipation!

But Jamie’s main advice was:

[M]any of the people I work with just are not eating enough fat….

People are a bit skeptical when I suggest increasing fat intake to overcome constipation.  Thankfully I can now point to a clinical study in which a high fat diet, in very short time, increased gastrointestinal transit time, reducing the likelihood of constipation occurring;

Gastrointestinal transit, post-prandial lipaemia and satiety following 3 days high-fat diet in men

High-fat diets promote stool passage for several reasons.

  1. Just a tiny bit of undigested fat can help grease the passage of stool through the colon. Even modest amounts of fat in the stool make it difficult to retain feces and cause fecal incontinence. This is why indigestible oils, like jojoba oil or Olestra, cause diarrhea.
  2. A second factor is that bile is released into the intestine when fats are eaten, and bile acids have a laxative effect. Both the primary bile acid chenodeoxycholic acid (CDCA) and the secondary bile acid deoxycholic acid (DCA) act as laxatives by inducing water secretion in the colon. An excess of bile therefore causes diarrhea and an insufficiency can cause constipation. [6] This is why people who have had their gallbladders removed typically develop diarrhea: bile is constantly leaking into the digestive tract.

Just be sure that the high fat you eat comes from healthy natural sources, not high-omega-6 industrially processed seed oils.

Also, bile acid metabolism has a diurnal rhythm. [7] Improved bile acid metabolism may be another pathway by which circadian rhythm therapies could help constipation.

Insufficient Gut Flora

Fiber is often recommended for constipation, and though I believe insufficient fiber is rarely the primary factor in constipation, it can help by several mechanisms.

First, bacteria, dead and alive, form a large fraction of the stool, and the more fiber you eat, the more bacteria you will have. Bacteria are surrounded by fatty cell membranes which are a little bit slippery.

Second, and probably more important, gut bacteria tend to increase the laxative effect of bile.

This is because the body controls water secretion in the colon in part by sulfation of bile acids; sulfation eliminates the induction of water secretion.

Gut bacteria usually want more water in the colon than the body does, so they’ve evolved sulfatase enzymes that desulfate human bile acids. [8, 9] The desulfated bile causes water release and the stool becomes soft and loose.

Some bacterial species do this more than others – especially virulent strains that spread by inducing diarrhea – and I’m sure everyone’s experienced at some time in their lives what happens when one of these species overpopulates the gut. We often call this “food poisoning” and it can be treated by large doses of probiotics, to displace the bad species with bacteria that release fewer sulfatase enzymes.

At the opposite extreme, if gut bacteria are lacking then bile acids will be excessively sulfated and won’t induce water secretion. Constipation may develop.

Thus, antibiotics can induce constipation. Presumably a zero-carb, zero-fiber diet would also make constipation more likely.

Adding some fiber to your high-fat diet, therefore, can relieve constipation.

Choline

Even though choline deficiency is not a proven cause of constipation, I’ll put this in because choline is so important for health. Choline is needed to produce the neurotransmitter acetylcholine. A deficiency of acetylcholine is associated with loss of colonic motility and constipation. [10]

Egg yolks and liver are good sources of choline. There’s nothing wrong with choline supplementation either.

Hypercalcemia

Some people over-do vitamin D supplementation and/or calcium supplementation. Elevated blood calcium levels, which can be brought about by too much vitamin D, will cause constipation. If you supplement either vitamin D or calcium and have constipation, ask your doctor to check serum 25OHD, 1,25D, and calcium levels.

Gut Infections

Some pathogenic bacteria are able to paralyze the gut and induce constipation. Some bacterial species that induce diarrhea can also induce constipation when they choose – for instance, C. difficile. This is one reason why patients with bowel disorders such as Irritable Bowel Syndrome or ulcerative colitis often experience both constipation and diarrhea.

Antibiotics like vancomycin that work well against Clostridium have successfully reversed cases of constipation. [11]

Infection-induced constipation may also cause bloating, gas, acid reflux, and gastroparesis, so if your constipation is accompanied by these symptoms you should see a doctor.

Don’t over-use laxatives

It can be risky to over-use laxatives. The riskiest is probably senna, which promotes bowel movements by (a) inhibiting water absorption by the colon and (b) promoting muscle spasms in the colon wall. Unfortunately, senna is a toxin that can cause lasting damage, notably to nerves.

If you must use laxatives, magnesium citrate liquids are the best. This will restore your body’s magnesium status as well as promote clearing of the bowels.

Conclusion

With good diet and nutrition, and normalization of thyroid function, constipation is usually easily cured. The exceptional cases are those of chronic gut infections; these may require some detective work on the part of a doctor.

I’m sure this reads like a laundry list, but it should give those with constipation some ideas!

References

[1] Neal EG et al. The ketogenic diet for the treatment of childhood epilepsy: a randomised controlled trial. Lancet Neurol. 2008 Jun;7(6):500-6. http://pmid.us/18456557.

[2] Rao R. Oxidative stress-induced disruption of epithelial and endothelial tight junctions. Front Biosci. 2008 May 1;13:7210-26. http://pmid.us/18508729.

[3] Young D et al. Egg yolk peptides up-regulate glutathione synthesis and antioxidant enzyme activities in a porcine model of intestinal oxidative stress. J Agric Food Chem. 2010 Jul 14;58(13):7624-33. http://pmid.us/20540508.

[4] Chandrasekharan B et al. Colonic motor dysfunction in human diabetes is associated with enteric neuronal loss and increased oxidative stress. Neurogastroenterol Motil. 2011 Feb;23(2):131-8, e26. http://pmid.us/20939847.

[5] Cao Y et al. Glutamine enhances gut glutathione production. JPEN J Parenter Enteral Nutr. 1998 Jul-Aug;22(4):224-7. http://pmid.us/9661123.

[5b] Tuteja AK et al. Opioid-induced bowel disorders and narcotic bowel syndrome in patients with chronic non-cancer pain. Neurogastroenterol Motil. 2010 Apr;22(4):424-30, e96. http://pmid.us/20100280.

[6] Hofmann AF et al. Altered bile acid metabolism in childhood functional constipation: inactivation of secretory bile acids by sulfation in a subset of patients. J Pediatr Gastroenterol Nutr. 2008 Nov;47(5):598-606. http://pmid.us/18955863.

[7] Abrahamsson H et al. Altered bile acid metabolism in patients with constipation-predominant irritable bowel syndrome and functional constipation. Scand J Gastroenterol. 2008;43(12):1483-8. http://pmid.us/18788050.

[8] Huijghebaert SM, Eyssen HJ. Specificity of bile salt sulfatase activity from Clostridium sp. strains S1. Appl Environ Microbiol. 1982 Nov;44(5):1030-4. http://pmid.us/7181500.

[9] Ridlon JM et al. Bile salt biotransformations by human intestinal bacteria. J Lipid Res. 2006 Feb;47(2):241-59. http://pmid.us/16299351.

[10] Burleigh DE. Evidence for a functional cholinergic deficit in human colonic tissue resected for constipation. J Pharm Pharmacol. 1988 Jan;40(1):55-7. http://pmid.us/2896776.

[11] Celik AF et al. The effect of oral vancomycin on chronic idiopathic constipation. Aliment Pharmacol Ther. 1995 Feb;9(1):63-8. http://pmid.us/7766746.

Leave a comment ?

253 Comments.

  1. Jan, L-Glutamine could actually cause rather than ameliorate constipation. At higher doses (10g), L-Glutamine can take water out of the colon and make your colon bone dry. The effect is more pronounced if your L-Glutamine quality isn’t pharmaceutical grade. Supposedly, “free form” types of L-Glutamine aren’t as susceptible to this as “budget” brands that tend to be cheaper. If it doesn’t say “free form”, then it’s probably the budget brand more easily implicated with constipation.

    Also, L-Glutamine can cause neurological symptoms — I’ve heard of instances where someone megadosing ended up with neuropathy and permanently numb limbs. It’s an excitotoxin, so mania could also happen. And those taking very high doses (like 40g) could also fuel cancer cells. After experimenting with L-Glutamine, I became disturbed by some of its side-effects and have since discontinued. I have 3 huge jars of L-glutamine sitting in my kitchen pantry, undisturbed. I think Paul is right about its potentially pathogenic nature. I’m worried about those taking doses as high as 40 grams upon recommendation to rebuild the gut lining for autoimmune conditions. My neurologist is also deadset against it and warned me never to take it again.

  2. Hi,
    What about a child with constipation? Been on GAPS for a year but not resolved the problem. I find adding more fruit and nuts to diet seems to help. Do you think adding rice would help? I seem to feel white potatoes make the constipation worse.
    Other than that this 5 year old eats healthy: broth/stock twice daily, fermented foods with every meal, yolks daily, liver meal weekly. Plenty of natural fats etc… Not sure what else to do and not that keen on supplements for a child this age.
    I’m now wondering if it’s a gut infection.

  3. Hi,

    is it okay to use organic pork gelatine from the supermarket (usually used for baking) instead of cooking a gelatine rich beef bone broth?

    Thanks!

    • Hi Chris,

      While not an expert by any stretch, I have heard that the answer is No. Can’t remember if it just lacks the good stuff or contains some harmful stuff, either way, no.

      The good news, Now Foods sells powdered beef gelatin in bulk and you can find that in several online health food stores. It smells kind of strange, but adds an excellent rich thickness to otherwise boring home-made soups. But beef jello square snacks, not so good, you just can’t get the savory out of it.

  4. Hi Paul,

    I am one of those whose constipation gets worse with probiotics (I think it’s the lactobacillies). Do you think this indicates a gut dysbiosis and a FMT might helpful?

    • Which ones have you tried? Chris Kresser recommends Prescript-Assist for cases with constipation, and I had success with it myself. FMT would likely help, but of course it’s a much more involved procedure than taking a probiotic, and should be done under the guidance of a trained professional.

      • You wouldn’t know the brand since I am located in Germany. But it were regular ones with 9-13 different kinds of bacteria (like lacto, bifido, etc).
        I read about Prescript-Asisst recently too and ordered it. Good to know that you had success with it. Does the success last when you stop taking Prescript-Asisst?

        Regarding FMT. I am looking forward that I may participate in a study and so the FMT will be done by a clinic. But what speaks against a DIY FMT?

        • I have taken many steps to improve my health and gut flora alongside and since my first course of Prescript-Assist, so I have not needed it on an ongoing basis, but I am trying it again now to see if it will give me further improvement. As for DIY FMT, I think it has been discussed elsewhere on this site.

  5. I do get constipation occasionally. I just can’t figure out what’s causing it. Just recently I’ve started to suspect coconut oil. Could that cause constipation in any way? Thanks

  6. i really like you so much, but i’m so angered by anyone’s glib statement about how easy constipation is to cure.

    NO. IT. IS. NOT. EITHER.

    I am fifty-two years old. I have suffered with this since my twenties. I have tried every thing and i do mean every thing. I am so exhausted with thinking about what i eat, what i supplement, and all the many interacting factors.

    please take back that hopeless word, “easily.”

    • Hi st,

      OK. It’s easy unless it’s not. You should try a fecal transplant. If thyroid and antioxidant treatment and circadian rhythm entrainment isn’t enough, then it’s a gut flora issue.

      Best, Paul

      • Hi Paul,

        I wonder – if it were a gut flora issue, and the prospect of trying to figure out how and where to get a fecal transplant were an bit too daunting…what is your opinion of resistant starch. Kresser and Sisson seem to like it, but further reading of Eades and Robillard seems to just be confusing to the layman. At issue is the fact that the initial information I gleaned (and the prevalent theme) is that it preferentially feeds “good” bacteria and creates butyrate, yadda, yadda, miracle. But the nay-sayers and saying, nay, it feeds bad bacteria and can exacerbate SIBO which is talked about as a cause of IBS and related constipation.

        Where are we to turn when such contradictory opinions exist amongst respected authorities – to our friendly neighborhood PHD? Can you shed some light? Or if you have previously opined on such, please point the way. Thanks Paul.

      • Back to this gut flora thing.

        I went to my MD. I said, what about gut flora? Could that be why constipation continues to come back even after I’ve done everything in the world—including treating my hypothyroid?

        He said, Nope can’t be gut flora. It would have shown up in the CDSA (stool test).

        He had also told me, “Nobody’s going to give you a fecal transplant. It’s very experimental. It’s only being used to treat C. difficile.”

        • So does that mean my MD just doesn’t know a lot about gut flora? He made a face when I used the word “dysbiosis.”

          Or does it mean he’d rather see it as a simple effect of my hypothyroid?

          Is it true that a stool test would demonstrate if there were a dysbiosis?

          • PS.
            My circadian rhythms are good. i always go outside. I even go outside barefoot. I watch no tv, and I avoid computer—-typically turn it off for good every afternoon.

            Hypothyroid, yes, but I was on Armour for years and it never mattered in the bathroom. None.

            SCD in 2012 cured me for 3 months. Then it was back again.

            I started following PHD after that.

            Last year I tested positive for parasites, got treatment, and then had bathroom happiness & rainbows for months.

            Constipation is just much more complicated for some of us. I hate its guts. If I could forget about it…. I’d take a break from thinking about health for at least a year.

      • Hi st, I totally agree. After years of trying everything; being told by gastroenterologists that I would have to take laxatives and suppositories for the rest of my life and not even colonoscopy strength laxatives would make things move I was close to giving up on life. Then I discovered the FODMAPS diet. It took 6 weeks before things started to turn around, they’re not perfect but I can now go most days. It may be worth trying?

        • Hi Karen,

          out of curiosity, have you already tried the Fast Track Diet from Dr. Robillard? Here he is writing a piece why he thinks that FTD might be better than FODMAPS. http://digestivehealthinstitute.org/2012/08/sibo-diet-and-digestive-health/

          I have severe constipation by myself and laxatives only help for a couple of days until they stop working so I have to switch to from drug to drug to have some bowel movement.

          I tried FTD, but because of various reasons less than 4 weeks with not much result other than my eczema went away (must be triggered by hard to digest carbohydrates) which proves that the diet is working in some way but didn’t relief constipation. But maybe I should have sticked with it longer.

        • Thank you Karen. I should probably give FODMAPS some thought.

          I did the SCD in 2012, and I gave it one full year to see if it would cure me. Afterwards, I had to work for another year to overcome the food phobias it inflicted.

          I made a vow: never again follow a list and be severe about food. Never create enemies of any foods. Receive food with thanksgiving, be flexible about it, pray for healing. I am a poor PHDer, as I don’t eat as much fish as I should and cannot manage to eat liver. But I hope and pray to just be well ENOUGH!

          Currently hoping that changing my thyroid treatment is going to improve bathroom habits. If not, maybe I should be tough and try FODMAPS, maybe for at least a month?

          • Sadly, I see now that my switch from Armour to Levothyroxine, though it is helping some of my hypo symptoms, is not making a difference to constipation. I have become desperate enough, I’m taking Colon Cleanse (from Trader Joe’s) which contains senna and buckthorn.

            Just the diet does not help me. I’ve got selenium, copper, and zinc in various supplements as well as diet. There’s plenty of fat in my diet; doesn’t matter. Fiber doesn’t help. Hydration no help. Circadian rhythms, no help. I could try the daily beef gelatin, haven’t tried that nor the really expensive probiotics nor the N-acetylcysteine. Neither cascara sagrada, nor magnesium citrate help me. Nor an oxy-something magnesium product a previous doc had me try.

            (BTW: Is health a pursuit of the somewhat affluent?)

            Increased amounts of aloe and of ginger have marginally helped. Topical magnesium chloride, maybe a fraction helpful.

            Weary of counting doses and making sure I took this & that. Want to think about other things in the world.

            But as soon as I woke up today, WITHOUT the brain fog I’ve awakened to these past several months, I saw that it has been a result of the persistent constipation. And since I know I can’t keep taking the senna, I just want to cry.

          • I have been there, and there is hope! No one thing is going to solve the problem—you have to put all the pieces together. Keep your circadian rhythms, magnesium and everything else going, and try the FTD or at least low-FODMAPs+low-fiber, then gradually introduce starches (rice, potato starch), then soluble fibers (raw plantain chips, low-FODMAP fruits and veggies cooked soft), then insoluble, and then finally each category of FODMAPs to see what helps/hurts, all while taking probiotics—a good probiotic is vital! (Prescript-Assist was the first one that worked for me, and Primal Defense ULTRA seemed to help later on—YMMV. I know they are expensive, but so worth it! Making your own fermented veggies is cheaper and *might* also work—I did both.) In the meantime, check out Gut Sense, and you might try Life Extension Buffered C Powder (similar to Monastyrsky’s Hydro-C but cheaper) for a “vitamin C flush” (google it) and maybe Bulletproof Coffee with plenty of MCT oil (known to have a laxative effect). Good luck!

            Disclaimer: I am not a doctor. The above is what worked and makes the most sense for me—Your dietary/healthcare decisions are your own responsibility.

          • Hi st,

            Also try supplementing vitamin C, taurine, and glycine. This will create more conjugated bile which should help. Be sure to eat your egg yolks for choline and gut motility (to help move things along).

          • Success update.

            For me, Paul’s advice about addressing underlying symptoms AS WELL as optimizing diet has been the biggest help. After 2 years following PHD, and many years trying to solve the digestive problem, I’m amazingly improving. I finally found an alt practitioner who has helped me steadily discover and treat a series of pathogenic things.

            Things are finally FINALLY changing.

  7. Any recommendations on when one should discontinue supplementing zinc and copper at the above levels? In order to maintain a proper ratio with the above zinc recs one would need to supplement up to 4 mg copper a day if not obtaining some of it from foods, or more likely 2 mg a day.
    Should supplementation be changed to regular PHD recs after awhile of normal bowel movements?
    Thank you Paul!

  8. Paul, can you clarify the appropriate amount of zinc and copper to supplement? I’ve been taking 30 mg. zinc daily, and 3 squares of 98 % cacao dark chocolate daily for copper. Now I noticed on your supplement suggestions you’re recommending 50 mg. zinc per week.

    Can you clarify? I thought I remembered reading here that dark chocolate daily provided enough copper. Thanks very much.

    • Hi Debbie,

      How much zinc you need depends on how much copper you get. Are you eating liver? If you eat your 3 squares of chocolate and duck or goose or chicken liver, which are low in copper, then about 50 mg zinc weekly is probably about right. If you eat beef or lamb liver weekly, giving you more copper, then 100 mg/week zinc is what we recommend, but 200 mg/week which is what you are getting would probably be fine. On the other hand, if you don’t eat beef or lamb liver, I think you should cut down on the zinc a bit.

  9. I usually eat about 1/2 lb. of chopped liver (chicken) a week – but not every week. And it’s not organic. I eat the 3 squares of dark chocolate every day – don’t want to miss that!

    I think I should cut down on zinc, then. I decided to take zinc feeling it might help with my thyroid issues (low T-3). But, my constipation is much improved after adding SBO probiotics and potato starch. It is a process!

    Thank you for responding so fast. I will cut down on the zinc.

  10. I should add that my constipation improved also because of this diet – I am eating a lot of sweet potato and orange squashes such as kombucha and butternut.

  11. HI,
    I plan on purchasing your book when i can afford it. Could you please help me to see if the book is going to be applicable to me first ( sorry i really have very little money and dont want to purchase a book i cant use ).

    firstly i have coeliac disease and want to know if the dietary advice in your book will be for the majority suitable for me?

    secondly i enjoy resistance training and am aiming to reduce bodyfat to possibly 10% or lower for a short period of time, would your book help me shed these lbs and retain or allow muscular hypertrophy?.

    As a final question, if i can indeed afford the book my daughter may use it and is lactose intolerant would it be helpful to her also.

    Many thanks for you reply.

    best regards

    • Hi Adrian,
      Pauls books is definately worth it. Paul mentions in his book that gut diseases can be tricky to treat and need to be individualized. I’ve suffered with IBS for years, but have seen success with following a low FODMAPS version of PHD. My mother has ulcerative colitis and follows the same protocol. Paul also mentions that a low fiber, ketogenic version of his diet is often successful with bowel disorders. He believes that most gut problems are caused my chronic infection, so you’d also want to optimize immunity by following his intermittent fasting guidelines, get enough vitamin A from vegetables and liver, plenty of sunshine and bright lights during the day, and adequate vitamin d. Initially you may do well by getting most of your carbs from dextrose powder, and other simple sugars, because they will be absorbed in your small intestine and will not feed pathogenic bacteria in your large intestine. As you recover, you can add more fibrous foods and see how you do.

      • Aaron,
        How long have you followed a low FODMAPs version of PHD? And can you describe a typical day’s meals?
        thanks

        • ST,
          Breakfast: coffee with 1-2 tbs coconut milk. Maybe banana if really hungry

          Lunch: Fried rice with scrambled egg yolks, meat or seafood, spinach, tomatoes, and carrots cooked in ghee. Banana, yogurt, blueberries

          Snack: Rice crackers with liverworst

          Dinner: Baked Potato with butter, sour cream and vinegar; Salmon filet, with small salad or kimchi (fermented vegetables easier to digest)

          Desert: 1 Cider beer or ice cream (can buy lactose free if you don’t tolerate lactose)

        • ST,
          Breakfast: coffee with 1-2 tbs coconut milk. Maybe banana if really hungry

          Lunch: Fried rice with scrambled egg yolks, meat or seafood, spinach, tomatoes, and carrots cooked in ghee. Banana, yogurt, blueberries

          Snack: Rice crackers with liverworst

          Dinner: Baked Potato with butter, sour cream and vinegar; Salmon filet, with small salad or kimchi (fermented vegetables easier to digest)

          Desert: 1 Cider beer or ice cream (can buy lactose free if you don’t tolerate lactose)

        • Followed it for around 1 year now

  12. Hi Paul, I have never struggled with constipation before in my life up until the past month. I was very nauseated for a week (not sure why), and then the constipation started. I have been going once a day, which is a reduction in movements for me, as I generally go 2-3 times per day with no problems. For the last week, I’ve been having a terribly difficult time passing stools and I seem to have a weakened urge. I’ve also been feeling full faster when I eat. Not sure if it’s from being constipated or if I now have gastroparesis too. From researching online, it would seem that my digestive tract is paralyzed or something. The only cure I read about is drugs or having the colon removed. What could cause a healthy and functional digestive tract to go from fully functioning to this in less than a month’s time? Could stress play a role? I have definitely been very stressed about all of this. Lastly, I have been diagnosed with chronic lyme. My symptoms have mainly been achiness and fatigue. Could lyme cause GI problems? I’ve been on antibiotics for a week now. My GI symptoms started about a month ago, but the constipation has definitely gotten worse within the past week…

    • Jennifer – have you tried magnesium (Mg) supplementation to relieve the constipation? Make sure the primary source of the Mg is NOT oxide but another Mg salt such as Mg citrate. Magnesium is an efficient muscle relaxant and is very effective for constipation, muscle spasms in the legs, low back pain, etc…. Magnesium will work well for at least short term relief.

      You probably will have to experiment a bit to find the right level for you. If you are not getting any Mg at all right now (in other supplements) I would start with 200 mg of Mg citrate at bedtime. Slowly increase until you get results (usually the following morning).

      Paul also discusses this topic at . As with many things in PHD World, nutrient balance is of primary importance (both from food and supplemnents) so it’s worth checking up on what nutrients you’re actually getting.

    • Maybe you’re not getting enough safe starches? Resistant starch can also help (leftover, reheated potatoes). I was very low carb for several years before starting this diet, and mis-read the recommended one pound. I mixed it up with the protein recommendation, which is 1/2 to 1 pound. Once I fixed that, many of my problems began to fade.

      My wife still has trouble eating the full pound/day because of GERD issues, but we’ve been bumping her up gradually, and each time she’s able to increase a bit, her arthritis symptoms diminish and constipation problems improve. Despite fearing weight gain, that hasn’t been an issue. According to our scale, her muscle percentage is increasing, body fat decreasing, and weight is the same.

      In addition, you need the full pound of fruit or sugary veggies. I don’t feel right if I don’t eat at least 12 oz. of fruit/day. I usually get the other four ounces from carrots, onions, or tomatoes. Altogether, that can add up to a lot of carbs for someone who’s been eating very low carb. But it didn’t make me gain weight.

      Maybe you’re already doing all that—just thought I’d mention it.

  13. Thank you, Hillary. Yes, I have tried magnesium (citrate and glycinate).

    • Same here. Mag citrate was part of my doctor’s standard protocol. I wish I had realized years ago it wasn’t helping me. Recently started using topical magnesium oil. It is more helpful, at least I can see it reduces foot cramps. I suppose if taking magnesium doesn’t relax the muscles, then an absorption problem is part of the problem.

  14. Hi Paul,
    I’m still concerned about my 5 year old. She regularly gets constipated. This last week the stool was so wide that it was very difficult to pass. I don’t know why it is getting so wide. She has always eaten very healthy. SHe has been eating PHD for many months now which resolded her burping after we did a short time of GAPS. Nothing is fully resolving her constipation issues.
    Typically she eats an egg or 2 and fruit for breakfast. Lunch and dinner she has safe starches, veg, meat/fish. Stock soup daily. Acid with main meals. Fermented foods daily eg, homemade sour cream/yogurt/kefir/sauerkraut.
    She usually does get 2 yolks a day. She usually gets some leafy greens each day. SHe eats plently of healthy fats.
    As for supplements I give her Vitamin C- 200 to 500mg daily. Every other day I give her a seagreens seaweed capsule.
    I don’t know what else to do. Her last eppisode of constipation was scary so I am now giving her magnesium oxide (as that’s what I have in the cupboard but I’ll try find magnesium citrate as you advise.

    Any ideas what else I should try? I’ve been trying to resolve her constipation issues since she was 2. I wonder if I should reduce her safe starch as I think she ate more of it the week she got constipated. she also had a lot of stuff made with coconut milk and coconut cream. I wonder if that exacerbated the problem too.

  15. Paul, Do you think beef gelatin is a safe supplement? http://www.ncbi.nlm.nih.gov/pubmed/22628656 Thx, Randy

  16. Paul, my coworker’s year-old has been miserable since birth. (He was born using another woman’s egg and her husband’s sperm.) He is very constipated and agitated. I’ve been searching your site for specific suggestions for babies, but can’t seem to locate anything. Where should she start? Do babies need milk, for instance? He’s now on lactose-free milk and barley water – she seems to feel the barley water helps his stomach – but who knows what is helping or hurting at this point. I’d appreciate any help here for her. She is in her forties and wanted this baby desperately, went through so much to have him, and has been deep unhappy and frightened because of all his problems. Thanks so much.

    • Hi Debbie,

      It should be possible to fully wean him at one year old, but possibly if human breast milk is available it might help fix the baby’s gut. Maybe 20% of calories as milk would be great.

      I wouldn’t recommend lactose-free cow’s milk. Rather, I would try to put the baby on PHD with extra carbs. Try the self-selection of food trick where you lay out a buffet of small amounts of a diversity of food before the baby and let him choose what he wants to eat. Babies tend to correctly choose the foods they need. Include all the PHD supplemental foods such as cooked egg yolks, liver, seafood, fruit, rice and white potatoes, and bone/joint/tendon based stocks/broth/soups. Rice congee is a traditional baby food. Cooking food can be helpful – cook spinach instead of feeding it raw; try overcooking rice, or pureeing meat to make it more digestible.

      The baby is old enough that he can start eating fermented foods. Fermented vegetables are a good start.

      Also, be sure to read our post on constipation and see that he gets the necessary nutrition. You can sneak magnesium, vitamin C, and other supplements into his food in liquid or powder form. Vitamin A and vitamin D are very important.

      Finally, circadian rhythm entrainment is very important for gut healing. He should plenty of daytime sunshine, activity, and social interactions. I know it is hard for parents to provide this, but it will help.

      Best, Paul

    • Hi Debbie,

      I am new to this site, but have had years of bowel issues… I am celiac. What leapt out to me in your post was the barley water. The infant could have gluten issues, and barley contains gluten. It will REALLY mess me up! I would advise anything else. Maybe rice water, or better yet? quinoa water?

      I used to be okay with gluten-free grains (such as rice), but in the last few years have discovered that I am better off without ANY grains. They ALL seem to mess me up now! I also discovered that I react badly to potatoes (through a year long food challenge where I challenged myself with potatoes 3x).

      The things that have made the most difference so far (for me) are magnesium citrate powders added to water (even better with vitamin C – Life Extension has a version of that).

      When I am really constipated, good quality beef seems to work overnight. I usually eat fish. I actually came to this site out of curiosity as to why beef works so well on me. I have only discovered one other person with the same result (but, I don’t usually talk about constipation with people! and a lot of people are just clueless). Most of the time, “they” say that beef will CAUSE constipation. Not in my case!

      Lastly, I was given a supplement by a venerable old chinese acupuncturist. I was in a CRISIS and could not find a doctor to treat me soon enough. This guy had helped me in the past when I had a bowel blockage. I accidentally ate cookies when in a hurry that were labeled “wheat free” but NOT “gluten free”. BIG difference!!! The main ingredient was BARLEY. I was unable to have a bowel movement for over two weeks. I was getting very toxic. I went to this acupuncturist and he fixed me! I went that night, and everything was perfectly normal the next day. Wow! So that worked… but he also gave me a supplement that had Rhubarb and Mirabilitum Salt (which I later discovered was Magnesium Salt – go figure!). He said to use it the next time I needed help, before it got bad. I did, and it worked really good too.

      I tend not to do anything until I get pretty bad. Usually, a good steak will set me right. But it’s really hard (and expensive) to get a GOOD quality steak! (I can’t cook a lot right now). I mix it up between the magnesium citrate (in drinkable form) and steaks. And NO grains! Every time I do, I get worse…

      I got a little verbose – I mainly wanted to point out that the barley could be bad for the infant. It could even be damaging his intestinal villi if he is at risk for being celiac. Hope this helps!

      • I forgot to mention that quinoa is actually a seed, and not a grain!

        I am so grateful that it is popular now, since I apparently can not eat rice anymore… : (

  17. When I tried the Zone Diet (by Barry Sears), maybe over 15 years ago, I experienced a very painful, scary constipation episode away from home. I was desperate not to suffer a repeat occurrence and remembered that Sears listed one of the Type 1 eicosanoids as encouraging water flow into the intestines for softer stools. So I immediately added fish oil and thereafter had no problems.

    Now I’ve been having very laborious constipation on PHD, so I began taking a teaspoon of Carlson’s Fish Oil (1.3 g EPA/DHA) every day and the problem quickly resolved. I had been eating weekly only 3 oz. of sardines and 4 oz. of salmon instead of the one pound of oily fish recommended by PHD. After I get my nerve back I will cut back on the fish oil and see what happens on one pound of salmon.

    (When I was eating whole wheat products, I had the opposite problem with overlarge, soft stools. Typically, I had only a few minutes warning before involuntary elimination, ready or not!)

  18. Good article.
    I highly suggest the books gutsense and fiber menace by konstantin monastrovsky. It will tell you every thing you need to know about this subject. It’s a bible when it comes to the subject. After I read I have never had digestive problems ever again.

  19. Hi Paul & Shou-Ching, just wanted to thank you for all your work on this information & in your book. I have been following it for a couple months now so I feel like I can comment on it here. I’m leaving comment on the constipation page 😯 because I have battled it all my life. I’ve tried everything including regular hycolonics. Finally with PHD supplements & diet I am regular. I’m also losing inches without trying or even the desire. So, that is a cool side effect. I wanted to let everyone know that I seem to be even more regular during the weeks when I eat liver as opposed to when I don’t & just use supplements. Also, the chocolate definitely helps.

    I’ve also battled candida (yeast infections) since starting a VLC diet about 4 years ago. It just got worse & worse & worse no matter what I did. It’s only been a couple months on PHD but no symptoms yet. 😀

  20. Hi, Paul

    You advise:
    “Glutamine, a supplement frequently recommended for gut ailments, can also enhance glutathione production [5]. However, I would generally avoid this, because it can promote proliferation of pathogenic bacteria.”

    In this study the participants were given a relatively high dose of glutamine, what’s your take on the authors’ conclusion?:
    http://www.ncbi.nlm.nih.gov/pubmed/25933498

  21. My wife’s bowel movements – which used to be irregular and very infrequent – have become regular and sufficiently frequent (once a day) after she slightly upped her fat intake, and started supp’ing with myo-inositol and vitamin C (she also takes a selenium supplement but onnly 50mcg per day).

  22. I quit PHD twice because of intolerable constipation and went back to eating whole grains; but now I’m back on PHD with no constipation whatsoever. This time I increased my magnesium taurate and vitamin C, but also started taking one rounded tablespoon of Great Lakes collagen and one teaspoon of cod liver oil. The results are soft stools and effortless elimination.

  23. My daughter now 6 still gets constipated and it’s been worse recently. We are doing PHD. Hardly any dairy. Broths and yolks daily. Chicken/duck liver weekly and beef/lamb liver mixed in with mince/sausages. For supplements only Vit C regularly. Are the others safe for a young child? I gave her magnesium oxide but doesn’t seem to help! Unles I up the does to adult dose perhaps?
    Her stool is wide a bit on the pale side sometimes.
    Not sure what to do. It’s getting me very worried that things are not improving with a year on PHD.
    Also I’ve noticed my younger children that never used to have problems seem to be getting less frequent and harder stools recently.

    I did start giving her half capsule a day of selenium for the last few days but no difference.
    Paul if you cold help let me know what supplement I should start increasing. Or anything else. I’m now considering doing a stool or SIBO test for her. She’s never had any tests done.

    • I should add that we all eat the same in the family. But this daughter is the only one who gets badly constipated.

    • Hi Claire,

      Is she supplementing magnesium, vitamin C, and taurine? I would start with those. Also, if you don’t cook with stock from chicken feet, ox hooves, bones, joints, or tendons, you could supplement glycine.

      • Thanks Paul.

        For magnesium, I have only given her magnesium oxide as I thought that was the best for loosening stool. Sometimes she gets a magnesium spray on her body or an epsom salt bath too.

        She has Vit C upto 1 gram per day. She was getting a lot more during a recent cold.

        I haven’t given taurine, so I’ll get some. What dose is suitable?

        The stock I make is either from chicken carcasses (sometimes some leg bones and ‘socks’, not the feet,). That’s what I can get hold of from the butcher.
        Or I use beef marrow bone with the joints. I can’t get hold of the feet. I’ll ask for ox hooves next time though.

        So perhaps I’ll try some glycine.
        Or would great lakes gelatine help? I do sometimes add that to soup if I felt the broth was not gelatinous enough. But usually my broths set well in the fridge, especially the beef version.

        • None of these supplements or foods cured me of constipation, and even though my conventional test results did not show parasites, I’ve improved very much since I have been working with an excellent alternative practitioner who did identify parasites (testing via energy). I hope you can find a good recommended alt practitioner, or MD with holistic practices. Only after identifying my pathogens, fighting them for a year or so, and meanwhile continuing the good things people normally suggest did the “good things” begin to do the job. In other words: exercise, hydration, PHD, figuring out that my body really needs lots of greens and colorful vegetables daily, fermented foods, probiotic supplements.
          Best wishes!!

      • Hi Paul, I’ve bought some taurine but not sure how much to give. What do you think?
        I also managed to get some calves hooves and will try making savoury jelly like my grandma used to!

        I’ve started giving her chlorela as well as the magnesium oxide this week and it has helped to keep things moving, but I don’t want her to have to rely on these.

        • 500 mg taurine might be good for a 6 year old.

          • Thank you. Do you mean daily?

          • I also realised I didn’t mention tht I have never given her NAC. Perhaps that would help, is that safe for children. I was worried as when I took it in the past I experienced tight chest sensations.

          • Yes, daily. NAC should be safe but I would favor taurine.

          • Hi Paul,
            We tried adding taurine. I didn’t see a noticable difference but I did stop the magnesium oxide that she took occasionally. I have also been giving her pureed prunes or prune juice. Seems to make her stool softer but she still only has a bowel movement about every 3 days.
            So I decided to do a stool test for her and just got the results from Doctor’s Data. No obvious infection found but evidence of dysbiosis. She has no growth of lactobacillus. I have the same issue so I am assuming she inherited my poor gut flora since birth. I know you don’t recommend probiotics but i wonder if in her case I should supplement. For years she already has daily food sources of probiotics (raw kefir/yogurt/sour cream/sauerkraut) but still no growth of lactobacillus.

            Under imbalanced flora she has alpha hemolytic strep, bacillus spp, gamma hemolytic strep but apparently not in huge amounts.
            No yeast or parasites found. Digestion is all within range. Her lysozyme is withini range but seems on the high side at 450 ng/mL (mine was much lower). sIgA is 88 mg/dL so within range. SCFA’s within range at 10 mg/mL.

            I wonder if her slow transit could be to do with no lactobacillus? I was hoping the results would show something that we could work on but not so sure what to do now. We all eat the same food in the family and she is the only one that doesn’t have daily bowel movements.

          • Hi Claire,

            For motility, you might try 3 egg yolks per day and a few tablespoons of vinegar (rice vinegar is good). Mix both with food and cook lightly.

            You might try an experiment with antibiotics – see if they help.

          • Claire, I may differ from Paul here, but I think probiotics are worth trying—specifically Prescript-Assist. It’s one of the things that really seemed to help in overcoming my own chronic constipation. I also find that eating plenty of bananas (in addition to a variety of other plant foods) helps keep me regular.

          • Thanks Paul. Will try the 3 yolks and vinegar. Would apple cider vinegar be OK. That’s what we have at the moment.

            What type of antibiotic would you suggest? Perhaps I could try garlic or olive leaf extract? I would be worried that antibiotics could potentially do more damage.

            Thanks for your suggestion Fraiser. I could try prescript assist. I did try it on myself for a few months to help resolve a gut infection as that was part of my practitioner’s protocol. I did not really notice any difference while on it but I didn’t have constipation then though. My gut flora has improved slightly though.

          • Hi Claire,

            Apple cider vinegar is fine. For antibiotics doxycycline is probably the mildest and safest. You don’t need to stick with antibiotics for long, but you can use them briefly just to see if her symptoms abate. Then you would know for sure that it was the gut bacteria causing the motility issues. Diagnosis is useful, and a few days of antibiotics would tell without doing any real harm.

          • Thanks Paul. I see what you are saying about the antibiotics. The problem now though is that I don’t have a doctor that would prescribe it. If I went to the GP I think they would think I was mad. Mild constipation in an otherwise healthy person is not seen as an issue here. They would probably just prescribe laxatives.
            Perhaps there is a natural version of antibiotic that would work in a similar way, that I can get hold of myself to try out??

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