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 ?

277 Comments.

  1. I don’t have constipation, but I’ve seen beef gelatin come up a couple of times on Paleo blogs. I haven’t seen this in the supermarket (except for Jelly) so I’m wondering where you get this and what sort of meals you include it in?

  2. Thank you for the link Paul and the very kind comments. Great additional advice and one that will be bookmarked and sent to people in the future who present with constipation.

    Just an observation I have seen a few times with people who trial not consuming grains or dairy, they often lurch the other way into a state of diarrhoea. My understanding is that this is common with opiate withdrawal (I always think of the classic toilet scene from the movie Trainspotting in this regard), but people may interpret this as them not consuming enough fibre (or are less comfortable with diarrhoea than they are constipation), and begin to consume the grains and dairy again, creating a bit of a vicious cycle with it all.

    Thanks again for the great work you do.

    Jamie

  3. Hi Jon,

    I’ve added a beef gelatin row to the Recommended Supplements page. Amazon sells it.

    The alternative is to buy bones with collagen attached and make soups. We do that weekly.

    Hi Jamie,

    It’s a pleasure to link, you always have great stuff!

    Best, Paul

  4. This is great. I’m having no trouble in this department but I love to know the mechanisms. I will simply link to this article from now on when the issue comes up. This counts as my definitive go-to about poo resource.

    Cheers!

  5. Paul,
    Thanks. This is helpful. The bigger problem I face is stomach acid which causes excess salivation. It is sometimes accompanied by constipation. I do not think you deal with this exclusively (here or in the book), but do you have any insights? (I tried vinegar, and supplementing with enzymes with hcl… felt the burning getting worse…).
    Elie

  6. Hi Stabby,

    I’ll put that on my business cards — “your go-to resource for poo”!

    Hi Elie,

    I’m going to do a post or two about acid reflux. I’m not sure what the connection is with excess salivation.

    Here’s a prior comment I wrote about acid reflux:

    http://perfecthealthdiet.com/?page_id=781#comment-16159

    Best, Paul

  7. Paul, thanks so much for this post. I will go down your list to deal with my continuing constipation, which started when I started low-carbing 2 years ago. There are 2 aspects to my constipation: (1) pellet-like, Bristol chart 1 type of stool; and (2) lack of moisture in the colon.

    I have found that adding some “safe starch” will make the stool soft and bulky, and easier to pass. As I suffer from T2 diabetes (and Sjogren’s, an autoimmune disease), however, I do this at the cost of BG control.

    I have not been able to solve the moisture problem: the stool may not be particularly dense or sharp, but it’s painful to expel when there is no moisture. This leads to frequent straining and hemorrhoids.

    After reading your prior posts regarding dangers of a VLC diet, I concluded that this may be due to the gut flora (or lack thereof). So I’ve experimented with various probiotics (Philips; Garden of Life Primal Defense Ultra; Swanson Signature; Culturelle; Flora Smart) and even digestive enzymes (Interfase Plus). No result. Any idea? Any particular bacterial strain that may help restore moisture to the colon?

    I’m on a gluten-free diet and avoid dairy (except for heavy and sour cream), and still low-carb. This seems to have put my Sjogren’s in remission but the constipation persists. My rheumy doesn’t think it is related to Sjogren’s (I don’t think either). I would really be interested in solving the Big C; in the past year, I came close to calling 911 a few times and it’s not fun! Perhaps the only solution might be a fecal transplant?

  8. Hi Paul
    Interesting about the glutamine. If it’s supposed to be good for the gut- how would it promote the proliferation of pathogenic bacteria?

  9. I had been adding one teaspoon of fresh ground flax seed to my son’s yogurt smoothies to help him along…is this acceptable, PHD-wise? (I am not comfortable right now putting him on supplements outside of a kids’ D drop and a kids’ B complex lozenge.)

    Thank you for this good information!

  10. Hi natty,

    I almost included a mention that diabetics are especially prone to constipation. The reason appears to be additional oxidative stress, http://www.ncbi.nlm.nih.gov/pubmed/21226884, so the antioxidants are likely to be the cure here.

    Probiotics do not have a very wide range of bacterial species, so eating fermented foods (or, as Art Ayers recommends, unwashed locally grown organic vegetables) is more likely to give you the species you need.

    I suspect the antioxidants and fermented foods will do the trick for you … antibiotics and a fecal transplant are last resorts!

    Hi Ellen,

    Glutamine can be metabolized by gut bacteria for energy, which leads to release of nitrogen/ammonia which is toxic and also potential overgrowth of less desirable species.

    Hi Mary,

    Yes, flax seed is acceptable in moderation. A teaspoon a day is fine. I would still recommend he eat some salmon or sardines however.

    Best, Paul

    • Do you have a reference re: glutamine and bacterial overgrowth? This is the first I’ve heard of that and I’d like to learn more—I have suspected a reaction to higher-dose L-glutamine supplementation in the past, but attributed it to excess glutamate formation or potential contamination in a corn-derived product.

  11. Paul, Is it okay to add beef gelatin to a smoothie? If not, how should it be taken. I am not constipated nor do I have, to my knowledge, acid reflux or other gut related problems other than gas, the former bloating has been greatly mitigated since I started the PHD.

    BTW – GO HUSKIES!

  12. This is a great list, and I’d like to contribute a couple more options to consider:

    When possible, change foods eaten in order to get required nutrients before externally supplementing. The great example here is to make and eat bone broths (full of gelatin) before resorting to purchasing commercial gelatin powders (Knox brand is the usual grocery staple in the US).

    Butyrate! Found in butter and resistant starches/insoluble fibers, this is used as welcome fuel by your friendly commensal bacterial colonies in your large intestine, and it will help to keep gut motility (movement-peristalsis) and moisture within comfort range. Nutrition Data has a great list of butyrate rich foods (look under fats at the 4:00 position).

    There is also a lot your can do to support gut comfort via similar principles a la sleep hygiene/behavior.
    ~Use a regular toileting schedule.
    ~Don’t try to force or hurry bowel movements along. This often produces a paradoxical effect,with your gut acting kind of like toddlers at their terrible-ist two’s saying NO! to everything.
    ~Keep the bathroom warm – the relaxation you get with warmth will help your gut to relax, too.
    ~Try a warm drink prior to evacuation attempts. A cuppa or two often promotes gut relaxation.
    ~Don’t confuse constipation with bowel movement frequency. Constipation means that stools are hard and painful to pass. The gut has a wide ranging ability to allow water to pass into it and moisten stool, and how fast the gut moves it is pretty independent of this. Everyone’s mileage varies, so three times a day versus once every other day doesn’t mean much if the stools are formed and soft enough to pass comfortably.
    ~Practice deep breathing while on (and off) the toilet. This will help with cramping.
    ~Make diet changes gradually so that you don’t shock your large bowel friendlies!
    ~Try to walk around or otherwise be active prior to making attempts. But go easy on crunches and abdominal moves. Mechanically touching the intestines during surgery, for example, causes the entire gut to halt peristalsis.
    ~Stools can be all sorts of colors, but if yours is white, grey, bright red (except after eating beets), green(except after eating licorice) or dark with a coffee grounds consistency, those are all reasons to visit a physician and to stop self treating.

  13. Hi erp,

    Yes, you can add it to anything. I agree with aek that bone broth soups are the best sources of gelatin, but the commercial gelatin products should also be beneficial.

    Congrats to Jim Calhoun, Kemba Walker, and the rest of the Huskies!

    Hi aek,

    Thanks much, those are excellent points. Butyrate is great for the bowel, and the other suggestions are all good.

    Best, Paul

  14. Eating beet soup (borsch) will solve constipation problems. No side effect.

  15. Thanks, Michelle. Borsch is a good idea for a Sunday food.

  16. Thank you so much Paul.
    This is extremely helpful information.

  17. I have been taking cascara segrada and senna daily for several years. Is there any hope of getting off of these supplements? I wonder if the GAPS diet might be beneficial or a ketogenic diet. Thanks!

  18. Hi Sandra,

    I think you want to try to wean yourself off them by slowly lowering the dose, and meanwhile implementing all the healthy constipation cures we suggest beginning with nutritional supplementation and addressing any thyroid issues.

    I know it can be hard to get off laxatives but it’s a good idea to try.

    I don’t think the ketogenic diet is that good for constipation. GAPS diet may be if some kind of food allergy/sensitivity is contributing. I’m not familiar with their experiences with constipation.

    Best, Paul

  19. Here’s something that hasn’t been mentioned yet.

    For women especially, what seems like constipation might also be due (wholly or in part) to posterior pelvic prolapse, otherwise known as rectocele. Rectocele and pelvic organ prolapse has an image of an “old lady’s condition” but can occur at any age, and is rather common to one degree or another after giving birth and during peri-menopause/menopause (most likely due to fluctuating hormone status loosening up the ligaments). Other causes of long-term and permanent prolapse include childbirth injury and trauma (possibly including pitocin use), prior pelvic surgery, chronic coughing, improper posture when sitting and during heavy lifting, straining during bowel movements, etc. When pelvic ligaments no longer support the pelvic organs and bowel well, they allow the lower bowel to sag and move into the wrong areas in the pelvis; over time the lower bowel can sort of balloon out and create a pouch. During a bowel movement, the contraction forces can send the stool into the pouch instead of directly out. One symptom of rectocele is incomplete evacuation or multiple attempts at bowel movements within in a short time, though there are other symptoms. With incomplete evacuation, the remaining stool can eventually become dry and hard and truly constipated, exacerbating the problem with more straining during attempts to move the bowls, which worsens the rectocele condition. Consuming grain fiber can also worsen rectocele as the fiber bulks up the stool so much that the wide bulk combined with constipation can tear painful fissures when it finally does pass. Gynecologic surgeries to repair various prolapse conditions seem to help some women, but surgery never really put things back in place “good as new”, and many women need repeat surgeries some years later, especially if prolapse begins at an earlier age. There is also a great risk of new issues after some repair surgeries (bladder incontinence, for instance), so unfortunately surgery isn’t always the best remedy.

  20. For me, black full-test coffee is a pretty sure-fire laxative, for a bowel movement about 30 minutes after my drink. It’s primarily the caffeine stimulating the bowel, but there may be some additional bowel voiding compounds in coffee itself. Certainly tea doesn’t have the caffeine concentration to do the job.

    I find that capsicum-containing chile seeds are a little problematic, since they tend to irritate the bowel lining for a long time.

    Maybe a stool softener would be a good idea for some people? Sodium bicarbonate is one, but care needs to be taken since it will give you gas and neutralize the pH of your stomach.

  21. So is it a bad idea to supplement with Magnesium Citrate everyday? I normally only have bowel movements about 2 times a week–I’ve always been this way, independent of diet. I can’t say I suffer from constipation, as I don’t have any other symptom associated with it, but I can’t shake off the idea that I should be going more often, and magnesium citrate has helped. I don’t take more than the recommended dose, and I still don’t go everyday–if I take enough to go everyday, the stools are too smelly, soft, and messy. Do I need to bother with the supplement?

  22. Hi ATG,

    Thanks much.

    Actually something similar may have happened to me when I had scurvy – I know from imaging that it weakened the colon wall and gave me diverticulosis, but it also seems to have loosened the fascia and given me a little abdominal pouch. Fortunately just cosmetic in my case.

    Rectocele sounds awful. Perhaps vitamin C would help prevent it, as it would have prevented my pouch.

    Hi Len,

    I’m not sure what the clinical experience is, but I have heard that with too much laxative use the colon muscles weaken and constipation can get worse.

    Possibly nutrition and more fiber may enable you to go more frequently.

    Best, Paul

  23. Hi Paul, Do you have an opinion on liposomal vitamin C? Would it have any advantage or disadvantage compared to ascorbic or ascorbate forms?

  24. Great post..lots to think about incorporating..what about reduced gluthathione supplements instead of NAC? Interesting to hear your thoughts on glutamine, it actually always led to extreme constipation for me and I never use it now. For some reason, the iodine supplements are giving me headaches and general uneasiness (potassium iodide 225mcg), the selenium have no side effects, so maybe worth supplementing copper before re-trying the iodine?

    Also wondering your thoughts on foods which “cause” constipation–bananas, white rice..is there any merit to this? On an unrelated note, do bananas exacerbate yeast overgrowth, I would love small amounts of fruit again. Im constantly feeling brainwashed by the Candida diet stalwarts who are horrified that I eat potatoes with all of my symptoms, and I get confused if I have to avoid sugars/starches to starve yeast?

    Looking forward to posts on acid reflux!!!

    Thanks,
    Devi

  25. Hi Brian,

    I don’t have an opinion, other than that the claims for it seem too good to be true!

    Hi Devi,

    Reduced glutathione is great and I took it myself for a long time … it is a bit more expensive however.

    Yes, I would try copper before iodine.

    I’d be surprised if many people have trouble with bananas and white rice. I can believe tannins in unripe bananas and toxins in brown rice contributing to constipation. I can believe fiber in bananas and rice creating gas or bloating in a constipated person. But in general I don’t see why these foods should be constipation-promoting.

    Just searching Pubmed, the first study I came across found a lower prevalence of constipation in the highest rice eaters, http://www.ncbi.nlm.nih.gov/pubmed/17874828. I believe this. The only paper on bananas and constipation found constipation from eating the seeds of wild bananas, http://www.ncbi.nlm.nih.gov/pubmed/21421885. Of course domesticated bananas have little in the way of seeds.

    Candida – Remember the standard American diet is 1/4 sugar and 1/4 wheat, for 1900 carb calories per day. Cutting sugar and wheat is going to help any of those people fight Candida. Once you go low-carb, going still lower will sabotage the immune response more than it helps the Candida. I know many sites on the Internet suggest that zero-carb is best against Candida. They are wrong.

    Best, Paul

  26. Great list. Also appreciate the comment that infrequency !=constipation. Compared to my prior diet (heavy carb, low fat) I go almost never (2-3x/week), but when I do it’s not a challenge.

    Here’s my tip courtesy of Slate: squat!

    http://www.slate.com/id/2264657/

    (or use a stool to elevate your legs a bit…)

  27. Great article – thank you.

    (Mary) RE constipation in kids – cows milk / dairy is a common cause
    http://www.ncbi.nlm.nih.gov/pubmed/20453672
    http://www.ncbi.nlm.nih.gov/pubmed/11846872

    I had constipation as a kid / adult and it has gone with paleo eating and supplements. Both grains and dairy seem to contribute, a whey protein shake will bung me up for a couple of days.

  28. Hey Paul,

    I recently began Robb Wolf’s autoimmune diet and eliminated eggs, nightshades, nuts and dairy. I feel way better, and constipation is no longer a problem. I am currently eating similar to your diet but with the exclusion of the foods mentioned above. I am consuming close to 2.4 pounds of sweet potato a day to keep up with my active lifestyle, but was wondering if white rice would be OK. Is white rice a no-no for autoimmune conditions? I have asked this question elsewhere but have got mixed answers. I was also wondering whether eggs as a whole are problematic or just the whites.

    Thanks.

  29. Hi Robert,

    Congratulations! Glad to hear the good news.

    White rice is fine. It has no known immunogenicity.

    Egg proteins are the problem, and the protein content of the yolks is very low. So while the risk isn’t zero, it’s much, much smaller once you eliminate the whites. I would try adding yolks back, since they’re so nutritious, but monitor your reaction.

    Best, Paul

  30. Thanks a lot Paul for the quick answer. I’ll experiment with egg yolks and monitor any negative reactions. I love eggs, but if they are a cause for concern I must eliminate them.

  31. Does fat “grease the passage of the stool”, or does undigested fat just get readily excreted?

  32. Hi Greg,

    If it gets readily excreted, it carries other things with it.

  33. Chocolate contains opiate-like peptides?? No wonder that I find it unbelievably addictive (just like dairy).

    And yes, chocolate produces anything but constipatory effects, which is not surprising given the tannins (I find unmilked tea or coffee are the same).

    Incidentally, Paul I’d love it if you were to reveal any health knowledge about tannins, which I’ve found to be related to a wide variety of health problems, in me at least: disordered gut, jitteriness, anxiety, headaches, generally feeling pretty awful. I assumed for years that this was the effect of caffeine, naturally, but some self-experimentation revealed that actually pure caffeine (pro-plus or red bull) had no such effect on me, whereas plain tannins did (probably unsurprising given that I assume they increase gut permeability). This would all be merely good reason to avoid tannins, but for the fact that when lacking sleep, green tea or cocoa wake me up far more than plain caffeine or coffee. Maybe the anti-stressing or vaso-relaxant properties of some of the chemicals in cocoa/tea, but I was also wondering whether there might be a tendency to be drawn to tannic foods in response to infection (gut parasite or otherwise), which would explain their addictive qualities. I defitely read somewhere on pubmed, but can’t find it now, that grazing animals seek out tanniny forage when they have parasitic infections.

  34. Hi David,

    That’s a good idea for a post. Your experiences are interesting, and I’m interested in therapeutic and toxic foods. I’ll keep an eye out for information.

    Best, Paul

  35. Roger Elliott

    Hi Paul

    Interesting info on glutamine. I use it when I get a ‘gut hit’ to aid recovery but perhaps this isn’t such a good idea.

    I have a query on the zinc though. In your book you recommend resisting the urge to supplement zinc, if I remember right. I’ve had to supplement because I keep getting deficient (no idea why), but your warning against it has stuck in my mind.
    Cheers
    Roger

  36. Hi Roger,

    I think we’ll modify that in the next edition. It might be better to take some zinc along with the extra copper. They need to be in balance, and some diets (and water) are low in zinc but high in copper; also some mixes of gut flora may steal zinc.

    Also, with copper supplementation but no zinc supplementation apart from a multi, people will tend to be in the low end of our plateau range for zinc but high end of our plateau range for copper. Might be better to balance that.

    The main problem with excessive zinc is that it can induce a copper deficiency, so with copper supplementation it shouldn’t be that harmful. I might take 1 or 2 50 mg zinc tablets per week, rather than a daily zinc, to minimize competition with copper.

    Best, Paul

  37. Hi Paul, Since I have become grain and gluten free, I have stopped taking psyllium on a daily basis and also found it difficult to be regular. I am drinking 2 tsp. magnesium citrate (Natural Calm) and find now that I go 2-3 times per day. I already supplement as you recommend, we eat lots of raw greens with our meals, and have plenty of safe starches etc. Are you saying I should discontinue drinking magnesium citrate on a regular basis? I think of it as getting my magnesium requirement, as well as keeping me regular…

  38. Hi Susan,

    You’re doing what we recommend … 2 tsp magnesium citrate is I think about 600 mg/day magnesium which is OK (within our “plateau range”).

    So I think that’s fine. Magnesium citrate I think is the laxative least likely to do harm.

    Best, Paul

  39. Three prunes a day seems to work for me. I tried that after 400 mg Magnesium Citrate a day didn’t make any difference.

  40. Hi Paul,

    related to bile, do you know a way to help bile production? Sometimes, when I eat high-fat, I feel queasy and weak after a few hours (once I even vomited at night after dinner at 7 p.m.) and only a Chinese herb medicine helps (very quickly) It’s some kind of stomach upset as if the food is not digested properly. I’m thinking digestive enzymes or bile. (I read that low thyroid hormone might lead to low bile or low stomach acid Dr. Kharrazian)

    I’m taking Mg, lactulose, vit C, Se, Zn, Cu, NAC (with glutamine) Iodine 450 mcg, regularly, but sometimes the stool is still compacted. Dr. Ayers (Cooling Inflammation blog) says it’s very difficult to repopulate your gut with beneficial flora.

    So many different things…

  41. Hi Simona,

    For bile production itself, vitamin C is important (http://www.sciencemag.org/content/179/4074/702.abstract), taurine and glycine which conjugate bile can help.

    As a diagnostic procedure, you might want to narrow down the problem a bit with supplementation of bile salts or digestive enzymes with your food to see what helps.

    Here are examples of bile salt supplement: http://www.allstarhealth.com/f/jarrow-bile_acid_factors_333mg.htm, http://www.swansonvitamins.com/SWU505/ItemDetail?SourceCode=INTL406

    Best, Paul

  42. Hi Paul,

    Do you have any particular recommendation about psyllium husks? I take about 1/2 – 1 teaspoon with water several days per week, and it seems to be pretty helpful.

    If I recall correctly from your book (which I don’t have with me at the moment), you note that small amounts of mucilage may (emphasis on *may*) be beneficial for the gut. As I understand it, psyllium would be one possible source of mucilage.

    Thanks for any thoughts you can offer!

    Best,
    Mark

  43. Hi Mark,

    We have no safety objection to psyllium.

    In general we recommend getting fiber from food rather than supplements.

    However, if you find it helpful, your personal experience trumps our general ideas.

    Best, Paul

  44. Am I missing the point?

    Why nowhere in the above article are the three vital words: EAT MORE VEG ….

    Since following the Paleo Diet and ensuring 50 of intake is fruit and veg, no problems!

    (Unless I succumb to a slice or two of bread …)

    jx

  45. It surprises me that black tea is seldom mentioned as a cause of constipation. The British are famous for being constipated and also for being the biggest tea drinkers in the world, I think.
    There was a study (which I can’t find at the moment) which showed that black tea consumption increased bowel transit time considerably. I think this was said to be because of its astringent effect.
    I find tea has a very noticeable effect on me – I drink it fairly strong, and three mugs or more a day will produce severe constipation.

  46. Thanks, Elima. That’s a great point. I didn’t even get into the ability of food toxins to induce constipation.

  47. Looks like for me it was selenium… eating more carbs and supplementing vit C didn’t really change things. I now eat 3 brazil nuts per day (since I couldn’t easily find a supplement and I read you do that) and have gotten quite regular. It could also be a coincidence of course.

    That said, I found out that the selenium content in brazil nuts can vary quite a bit depending on where it’s grown (found via wikipedia: http://www.ncbi.nlm.nih.gov/pubmed/7889353 ). In the article they found a 10x difference…

    I guess I’m lucky in having a good brazil nut source or very good at autosuggestion 🙂

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