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. Congrats Wout!

    Selenium deficiency is an important one to fix, that causes problems body-wide.

  2. I was wondering if you recommend any certain probiotic supplements? I realize that eating fermented foods is probably the best. Is eating just regular sauerkraut enough (it’s pasteurized)? While I love yogurt, I avoid dairy due to my Hashimoto’s.

    Thank you for this wonderful blog!

  3. Hi CK,

    I don’t really have strong feelings about probiotic supplements. Some readers have recommended Primal Defense which has a relatively large number of species. But fermented foods have even more species. The value:price ratio, not to mention value:taste, is much better for the foods.

    But if for some reason you can’t get foods, then probiotics are good. I would tend to favor ones with more species.

    Best, Paul

  4. Thanks Paul for the reply.

    I will stick with the foods.

    -CK

  5. Paul, at your suggestion, I’ve been taking Primal Defense for a couple/three weeks now and FINALLY am gas and bloat free — no gastric outbursts or constipation either. Again thank you for the best advice on the planet. 🙂

  6. Hi erp,

    Great! Glad the fix was so simple. I guess you weren’t eating your kimchi. 🙂

  7. Paul, I live in a backwater of Florida. Where am I going to get kimchi?

  8. Hi erp,

    I was joking … but it is possible to make your own. Just put cabbage, salt, and anchovies in clay pots buried in the winter snow.

    A little more global warming and you’ll have everything you need!

  9. Paul, I know you were kidding, but I googled up a recipe anyway to see what effort it would entail. What I got was an “Only in America” moment: a recipe for a Korean national dish by David Lebovitz, a bay area chef, now living and writing in Paris.

  10. Hi erp,

    That’s a good recipe. Nice find!

    We’re going to come up with our own kimchi recipe and post it probably in a week.

  11. Although it is usually listed as your primary “safe starch,” and although I find it very delicious to eat, I find white rice to be perhaps the most constipating food (the other would be nuts in excess, though the specifics of the constipation are somewhat unique in that case).

    Without any change in frequency of bowel movements, white rice radically increases the volume (and dryness) of my stools. Unless there is some kind of hydrophobic waste product that is produced in voluminous amounts when I digest white rice, my best explanation is that the rice is not being fully digested, along the lines described by the advocates of the Specific Carbohydrate Diet.

    The effect is not so noticeable with wheat–perhaps because the gut irritants keep things moving–but it happens to some extent with all starches. Unfortunately, this makes it extremely difficult to increase my carbohydrate intake. There’s only so much milk I can drink in one day. The other options come with large doses of fructose…

  12. Hi Max,

    I guess I’d suggest probiotics and fermented vegetables to see if diversifying gut flora aids in rice digestion.

    There are fermented rice foods, those might supply the appropriate microbiota.

    The other choice is to look for other “safe starches” that you like. Taro is a good calorie-rich choice.

  13. Dear Paul and Shou-Ching,

    I have read most of your posts and am looking forward to your book. I am grateful for your insights and your generosity with your time and knowledge. I apologize in advance to you and your readers for a long message.

    I have had mostly good experiences with your diet, but have had bad constipation (extremely hard, dry stools) on and off for years. If you have time, I’d be grateful for any advice you may have for overcoming this problem.

    My background…For years, I destroyed my body with excessive work, insufficient sleep, and a low-fat diet replete with grains and other toxins. I had bad food allergies that caused intense, painful itching, and my toenails developed a fungal infection. I slept poorly, awakening early and feeling unrefreshed. I also had bad nasal and sinus congestion in the evenings. I experienced bad mood swings, low energy, and occasional depression. Switching to a low-carb diet a few years ago, and later to your Perfect Health diet, helped with all of these problems (except the toenail infection and respiratory problems) to varying degrees, and greatly improved my body composition. I have a small amount of fat around my mid-section, but am otherwise lean, athletic, and muscular.

    Even before I changed my diet, I had frequent bouts of constipation and diarrhea, but after the change the constipation worsened, and I eventually developed an anal fissure as a result of straining. I went on stool softeners (miralax) for a while, realized that they were a “band-aid” for serious underlying problems with my gut health, tried to drop the stool softeners, experienced more constipation and another fissure (ouch!), and am now badly in need of advice.

    I have tried eating probiotic foods to improve my gut flora (kefir, yogurt, pickled vegetables, kombucha, etc.), taking probiotics, and following Art Ayers’ advice to eat unwashed organic vegetables. (Because of lingering food allergies, I can’t consume dairy products more than 1-2 times per week.) I am supplementing vitamin C, selenium, iodine, copper, magnesium citrate, and zinc, though I might be a bit low on the selenium. I get good amounts of sunlight and vitamin D. These measures have not helped so far, though I’ve only been using the probiotics and fermented foods for around 3 weeks. Eating extra coconut oil does not help unless I eat enough to give myself diarrhea (which I sometimes develop anyway when not constipated). Tubers and fibrous vegetables just seem to increase the volume of my stools and hence the difficulty of passing them.

    I would welcome any advice you may have for resolving this problem. I would also be curious as to whether you would recommend reducing my consumption of vegetables or tubers (or replacing them with white rice) or continuing to take stool softeners.

    Again, my apologies for a long message. Many thanks to you for your help.

    Sincerely,
    Vincent

  14. Hi Vincent,

    I’m sorry to hear of your troubles.

    You have a gut infection that is causing constipation. You don’t know the pathogen (a Metametrix GI Effects profile would tell), but it’s probably Candida, which would also explain the toenail fungus and the extra fat around the midsection (Candida can do that).

    So I would start an anti-Candida program, by asking my doctor for fluconazole and Nystatin. Cholestyramine is usually a helpful (and necessary) adjunct in order to excrete die-off toxins, although it can exacerbate constipation.

    Eat plenty of turmeric/curcumin, green herbs (esp oregano and thyme). Eat plenty of nitrates from green leafy vegetables and beetroot juice. For oils use olive oil instead of coconut oil. You don’t want ketones, they’ll assist Candida. Eat berries like cranberries. Get around 600 carb calories a day. Gradually build up iodine supplements. Add chromium, NAC, and sufficient selenium to your supplement list.

    I do think you should reduce consumption of indigestible matter, eg replacing tubers with white rice, until the constipation eases and you have a better mix of gut flora.

    Best, Paul

  15. Thanks very much for your advice, Paul. I will report back later and let you know how the treatment turns out.

    All the best,
    Vincent

  16. Hi Paul,

    I’m getting confused by the recommendation to avoid coconut oil to remedy Candida, which seems to conflict with the testimonials and info below. What do you make of it?

    http://www.coconutdiet.com/candida.htm

    Coconut Oil and Candida Yeast Infections

    Research

    There is good research now that shows the medium chain fatty acids in coconut oil kill candida yeast. Caprylic acid is one of the fatty acids found in coconut oil that has been used for quite some time in fighting candida yeast infections. William Crook, M.D., the author of The Yeast Connection and the questionnaire above, reports that many physicians have used caprylic acid successfully for yeast infections and that it works especially well for those patients who have adverse reactions to antifungal drugs.

    Besides caprylic acid, two other medium chain fatty acids found in coconut oil have been found to kill Candida albicans. A study done at the University of Iceland showed “capric acid, a 10-carbon saturated fatty acid, causes the fastest and most effective killing of all three strains of Candida albicans tested, leaving the cytoplasm disorganized and shrunken because of a disrupted or disintegrated plasma membrane. Lauric acid, a 12-carbon saturated fatty acid, was the most active at lower concentrations and after a longer incubation time.”2 This study shows great promise that all the medium chain fatty acids in coconut oil work together to kill Candida albicans.

    So to summarize the Coconut Diet Anti-Yeast program:

    1. Slowly work up to at least 3.5 tablespoons of Virgin Coconut Oil into one’s diet.

    2. Add traditional fermented foods to one’s diet.

    3. Eliminate sugars and simple carbohydrates (white breads, pasta, etc.) as much as possible from your diet.

    Thanks,
    Mark

  17. Hi Mark,

    First, you have to keep in mind that there are two environments we are concerned with: inside the gut with access to food but not blood, and inside the body with access to blood but not food.

    In the first case, they’ll feed on dietary carbs/fiber. In the second case, on ketones.

    So coconut oil which is ketogenic promotes systemic candidiasis.

    Secondly, in the gut you have to consider both the effects on fungi and bacteria. Coconut oil is antifungal and antibacterial. Olive oil is antifungal but not so much antibacterial. Since you’re trying to replace the fungi with bacteria, arguably olive oil is better.

    Likewise the advice to reduce carbs is good for high-carb dieters, but can backfire for low-carb dieters because further reductions in carbs cause ketosis and promote systemic invasion.

    Best, Paul

  18. Paul,

    Looking at this exchange with Mark and the fats involved…and trying to tweak things.

    Too much olive oil looks like it could end up with too much omega-6 right?

    What about other saturated fats? Reduce cream/dairy fats?

    Looking forward to the candida series coming.

  19. Hi Jay,

    I’m not advocating supplementing with olive oil. Just, if you have a salad, a vinaigrette with olive oil might be a good dressing. If you cook, you might consider using the olive oil instead of the coconut oil.

    The advice is not so much to decrease fats as to increase carbs a bit so you have a balance of carbs and fat and aren’t in ketosis.

    Best, Paul

  20. I was imagining people getting 65% calories of olive oil and omega-6 going to high.

    For me on a weight loss diet over the next 3 months, it will work just fine since my lower calories and lower fats shouldn’t be an issue. Up carbs to 600 cals, 375ish protein, 225ish olive oil. The omega-6 should be low enough.

    Rats, and just when I discovered expeller pressed coconut oil!

  21. Hi Jay,

    You are getting some food with that olive oil, aren’t you?

  22. I don’t understand your question??? Your joking right?

    Of course. 1 meal a day: was ~400 cals white rice/potato, 2 cups veggies, 375ish meat, eggs, 450ish was coconut oil. So I’ll up my starches to 600 and change oils. add spices oregano and thyme and I have some activated charcoal already.

  23. Thinking about getting this “Lufenuron.” Looks better than Threelac (sounds shadier).

    Not afraid of diflucan scares hurting the liver?

  24. Hi Jay,

    Yes, I was joking … I know you eat well.

    No, I’m not afraid of Diflucan … Candida die-off toxins raised my liver enzymes more than Diflucan.

    Lufenuron looks interesting, but it’s totally new to me. Thanks for introducing me to it, but I don’t know anything about it yet. If you try it let me know how it goes.

  25. Paul,

    I quoted your explanation to Mark about the two environments for candida to a group I am part of. Of course everyone was shocked to hear that coconut oil could possibly be any thing other than the cure for candida. As was I when you first proposed that it might be causing my GERD through ketosis. I know you must have good research to show that ketosis can feed candida and am hoping you will present it in your upcoming post on fungus. But meantime, do you have any studies, etc. I could refer them to?

  26. Hi Ellen,

    As far as low-carb ketosis goes, this is a woefully under-researched area. It’s more basic biology, if you think about the biology it has to be this way. Also personal experience, nothing flares my fungal infection like ketogenic dieting.

    However, there are papers dealing with diabetics (who experience high levels of ketones, even ketoacidosis) and their vulnerability to fungal infections. “diabetes Candida” brings up 704 papers. Here are some papers:

    http://www.ncbi.nlm.nih.gov/pubmed/3084140. Neutrophils are less able to kill Candida when ketones are present.

    http://www.ncbi.nlm.nih.gov/pubmed/8850487, http://www.ncbi.nlm.nih.gov/pubmed/2495782, http://www.ncbi.nlm.nih.gov/pubmed/3123185 Candidiasis in diabetic patients with ketoacidosis.

    http://www.ncbi.nlm.nih.gov/pubmed/2356851 Obese people develop candida infections when fasting causes ketosis.

    http://www.ncbi.nlm.nih.gov/pubmed/10981686 Virulent strains of Candida may make and release pyruvate causing neighboring human cells to turn the excess pyruvate into ketones which benefit the Candida.

    http://www.ncbi.nlm.nih.gov/pubmed/8067777 Serum drawn from fasting patients is less protective against Candida than serum drawn postprandially, and antifungal drugs work better in the fed state than in a fasted state.

    Hope this helps. Maybe I’ll do a blog post about this next week just to spell it out a bit.

  27. You know this makes me wonder if there is some connection with even slightly elevated blood glucose and the ketone/ fungal issue.

    you said that your A1c was higher than optimal, though technically not in the diabetic range, as is mine.

    Perhaps the fungus is being fed by both the slightly elevated BG and the ketones, somehow making for a kind of super strong strain?

    Clearly some people do successfully deal with their candida on a high coconut oil/ketogenic diet. Maybe they are the ones who are able to keep their BG in the optimal range of low 80’s most of the time.

  28. Hi Paul,

    Can the benefits of autophagy still be realized with protein intermittent fasting while avoiding ketones/ketosis from carb intermittent fasting?

    Something like eating bananas & cream for breakfast (no protein) and restrict protein to the 8-hour eating window.

    Thanks,
    Mark

  29. Hi Mark,

    Yes, some of the benefits of autophagy can be realized by restricting protein intermittently. I do this myself.

    But it’s hard to judge how effective this strategy is without empirical data. Also, a mere 16 hour protein fast may not be enough, if you are replenishing protein daily. Protein isn’t consumed as rapidly as carbs so a “deficiency” sufficient to induce autophagy doesn’t develop as quickly. I would think going low protein for a week or two, followed by higher protein for a week or two, might work better. I often do it months at a time.

  30. I would also suggest higher amounts of Vitamin C to soften the stool. The amount needed to cause laxative effect is usually between 10-20g and effect is called Vitamin C Flush. It works similarly as lactulose but require higher amounts since C is digestible and is far better as C detoxifies gut, prevents stomach cancer, assists fighting H. Pylori infection etc…

    You need to find the amount of C that causes diarrhea and then use 75% of that amount to soften the stool.

    Pure Ascorbic Acid Power no tablets and other mumbo jumbo. No LET technology for this as it is completely absorbed in the small bowel.

  31. Just wanted to add a link to a great resource on constipation and gut health: http://www.gutsense.org/gutsense/constipation.html

    That article and others on that site taught me a lot about guts 🙂

  32. I’m so grateful to you for this information. I’ve been suffering for weeks but I took the recommended supplements and did nothing else — and experienced relief the second day. In a world full of useless and confusing information, having a good source is such a godsend. Thank you for all that you do.

  33. I thought others might be interested in the results of my experiments with preventing constipation over the last few months. (See my previous comments and Paul’s recommendations to me in this thread for background.) My regimen was as follows…

    Diet: Added enough white rice to raise consumption of safe starches above 600 calories daily; ate berries, turmeric, oregano, spinach, and fermented vegetables regularly; initially eliminated tubers (which I had difficulty digesting) and later replaced them with fermented tubers; and replaced coconut oil with olive oil.

    Anti-fungal medicines: I respected Paul’s advice regarding anti-fungal drugs, but decided to postpone using them until after I had tried non-prescription supplements.

    Supplements: Conformed my nutritional supplements to the PHD recommendations and added NAC; added grapefruit seed extract, olive leaf extract, Kolorex advanced candida care (horopito), Now Foods candida clear, and occasional activated charcoal; and tried a few probiotics, including ThreeLac.

    After a few weeks of little improvement, I experienced my first normal bowel movement in a long time (years?). After more changes to my regimen, I now have normal stools on most days. The greatest improvements coincided with the times I added fermented tubers and (later) ThreeLac. I also think that cranberries, turmeric, increased amounts of safe starches, the Now Foods anti-fungal, and removal of my beloved coconut oil were all quite helpful. My victory is not complete — I still get diarrhea fairly easily and the occasional hard stool — but the improvement is incredible.

    Many thanks, Paul, for helping me fix a problem that has plagued me for a long time. I wish you, Shou-Ching, and all your readers the great health and happiness you deserve.

    Sincerely,
    Vincent

  34. Hi Vincent,

    What tubers are you fermenting and how do you ferment them?

    Thanks,
    Peter

  35. Vincent’s experience clearly shows that ditching carbs in order to fight a candida infection is utterly wrong.

    @Vincent

    Which die-off symptoms did you experience before getting better? With all the information available on every candida website, your success with the PHD certainly can be of great benefit for any of us fighting candida. After all, those websites that recommend a low-carb diet cannot possibly have an accurate list of die-off symptoms, and probably, they are listing symptoms of yeast being fed instead of yeast being killed. Congratulations on your success, it’s good to know we are right on track.

    Thanks,

    Juan Camilo

  36. Perhaps this is as good a place on your site as any to share the improvements I experienced after switching from a gut healing diet that generally can be described as VLC Paleo to PHD.

    What’s even more remarkable than the improvements themselves is that they occurred *within 48 hours* of seriously increasing my safe starch consumption. I couldn’t have special ordered it any better.

    1. Constipation is gone.
    2. Fungal (?) rash is gone.
    3. Powdery substance in urine is gone. (After reading here about how VLC diets can cause excess excretion of uric acid, I’m certain this was the problem.)
    4. Energy and mood are way better.
    5. I like what I’m eating now, I am sated, and my instincts are no longer telling me something’s missing. This intangible effect has made perhaps the biggest impact on my day-to-day quality of life.

    Thank you PJ and S-CJ!

    Thanks again for the PHD. Count this one-trial learner as a convert.

  37. I’m sorry for my delay in responding to questions.

    Peter: I primarily ferment yams, potatoes, and sweet potatoes (both the very sweet orange kind and the less sweet yellow kind). To ferment tubers (and other vegetables), I use a simplified version of the instructions on the website wildfermentation.com; see the articles listed in the “Resources” section of that site.

    Juan: To my surprise, the die-off symptoms weren’t too awful — mainly fatigue and poor concentration, sometimes bad enough to interfere with my work a bit, but nothing too debilitating. In addition, I occasionally developed mild headaches (which I otherwise rarely get). These symptoms are now gone.

    Best of luck to both of you.

    Sincerely,
    Vincent

  38. Vincent

    Which article did you get your tuber fermenting process from? I found many articles, none with tuber in the title. Searching tubers on the site, I only found Sandoor’s method of fermenting cooked mashed potatoes (I still don’t understand that one. Wouldn’t they turn to soup?)

    Thanks so much, Terry

  39. Terry: I largely follow the method described in the article “Vegetable Fermentation Further Simplified” on wildfermentation.com; this method works fine for tubers. I do not cook my yams, potatoes, and sweet potatoes before fermenting them.

    Good luck to you, Terry, and thanks again to the Jaminets for providing this forum.

    Sincerely,
    Vincent

  40. Paul, I’m astounded you were able to zero in on Vincent’s constipation — due to candida. I’m wondering if I may have the same problem. Like Vincent & Bella, I have fungal toes and a large fungal rash around my knee which I’ve had for 3 years that was confirmed by my dermy as fungal (not psoriasis).

    I also became insulin resistant (Type II diabetes) by eating too much sugar and processed carbs, working 60+ hours and sleeping at odd hours. Constipation ensued immediately when doing 50 grams of carbs for about a year. Developed anal fissues and hemarrhoids, like Vincent, and also very dry skin. However, I lost considerable weight and am now quite lean (13% body fat), thanks to the VLC diet and working out everyday (HIIT).

    6 mos. ago, ran into your site and started the PHD (150g carbs now mainly as yams + sweet potatoes) and antioxidant supplements (Se, Vit C, Zn, Cu, NAC + Choline). Bowel movement is better (improvement in lubrication)- however, hard, small stools still remain, though less fissures due to lubrication. My GI thinks my constipation isn’t due to the gut flora (or lack thereof), as I’ve tried some OTC probiotics, as well as home-made kombucha and fermented foods. He only conducted a routine stool test, though, (Ova + Parasite Exam, certainly not Metametrix GI Effects) to clear me. His only answer is Miralax (not working).

    Do you think my constipation is related to a gut infection (Candida)? My thyroid panels are normal (TSH ~1.0 & midpoint T3/T4), as are Vit D levels (not excessive), and I’ve been supplementing with the above antioxidant minerals for 3 mos. If so, should switching to white rice, olive oil, herbs, & more fermented foods (perhaps fermented sweet potatoes) rid of the remaining constipation? Thanks so much for your insights.

  41. Vincent, I would be curious to know whether your toenails are still fungal. How fungal were they before you started the diet (e.g., completely whitened out and irregular grooves on toenails, often becoming fragile, as mine currently are?) Also, did you suffer from athlete’s foot for many years before they became fully fungal? Thanks.

  42. Hi Randle,

    First of all, if you have a chronic fungal infection with skin manifestations I would definitely treat it. I can’t guarantee that clearing the fungal infection will cure your constipation, but fungal infections can certainly cause constipation, so best to treat the potential cause that we know is there.

    One thing that does seem to be important is fixing any sulfur deficiency. I expect to add this to my recommended supplements for everyone soon, but it seems to be especially important in fungal infections. Try getting some epsom salts that are pure (listed for internal use as a laxative on the package) and drinking 1 teaspoon a day in a cup of water.

    Then the antifungal diet should help re-shape the gut flora in a positive way.

  43. Thanks so much, Paul. I will follow through with Epsom salt and apply the prescribed topical cream (Ciclopirox Olamine Cream USP 0.77%) to my fungal areas, as well as eating some fermented sweet potatoes.

  44. Paul

    I deeply appreciate your commitment to spreading the scientific truth of what is healthy for people to eat.
    I re-read your book after reading this thread and am left with the same conclusion that the book recommends coconut oil and a modified ketogenic or ketone producing diet “In the book we recommend coconut oil and fiber-rich calorie-poor plant foods.”

    It seems that people seek out your diet because of illness or conditions such as candida etc. Could you please simplify your dietary recommendations regarding those with infections or suspected ones.
    Thanks

  45. Hi George,

    Yes, the book will evolve in its next edition. We do need to clarify how infections interact with diet, and create a more systematic approach to diagnosis and dietary therapy.

    I have a greater appreciation for how ketogenic diets promote eukaryotic infections than I did when the book was written. That’s one reason I blog so much, it gives me opportunities to learn.

  46. Randle: Before starting the anti-fungal regimen, most of my toenails were to varying degrees discolored (white or off-white), brittle, and chalky. Because I have been so preoccupied with my digestion, I did not pay close attention to how, if at all, the anti-fungal regimen affected my nails. My toenails have not worsened during the anti-fungal regimen, and it’s possible that some nails have improved, but I have not noticed radical changes. Both before and after my toenails became infected, I’ve only occasionally experienced athlete’s foot.

    I hope that this information helps and that you are able to remedy the health problems you are experiencing.

    Sincerely,
    Vincent

  47. Vincent and Randle,

    My experience so far leads me to believe that in some cases topical treatments may be necessary in addition to dietary and supplement changes to deal with toenail and foot fungus.

    This foot soak resolved a 40 year old case of foot fungus for me ( While following PHD)

    http://www.longcreekherbs.com/nail-fungus-soak-guarantee.php

    people have mentioned various things for their nails..For me a mixture my dermatologist prescribed containing fluconasole worked on one toenail fungus that I had for close to 40 years. He has since added eterbinafine for me to use for the remaining fungus in my other large toenail. But that nail ( what is left of it) is very thick and so far not improving

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