Chronic Constipation and Gut Motility: Functional Medicine Interventions and Solutions

Having regular and complete evacuation of wastes from the body is crucial for well-being and keeping your body healthy. Chronic constipation is a common but often debilitating condition that occurs when there is long-standing difficulty in passing stool.

When constipation occurs on a regular basis, it has significant impacts, impairing quality of life, daily responsibilities, and social interactions. It can also cause pain and other complications. 

The slowing down of stool moving through the digestive tract can occur due to a combination of factors. Common contributors to chronic constipation include impaired gut motility, altered fluid secretion and absorption, and electrolyte abnormalities. These changes can occur due to various health conditions, lifestyle habits, and other factors. Eventually, slowed movement through the intestines due to impaired gut motility, reduced fluid secretion, and/or increased fluid reabsorption can result in chronic constipation.

Since gut motility is impacted by a range of factors, the holistic approach taken by functional medicine offers an effective way to understand this condition. Functional medicine for chronic constitution offers an approach to understanding the physiologic mechanisms underlying normal bowel movements and digestion and utilizes specialty testing to identify contributors to chronic constipation.

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Understanding Chronic Constipation and Gut Motility

Chronic constipation is a multifactorial chronic condition characterized by difficult, infrequent, or inadequate bowel movements. Normally, the ideal stool is passed easily one or two times a day in a soft, formed sausage shape that passes comfortably and without intense effort.

When your digestive tract is functioning normally, gut motility helps ensure a smooth process of digestion and regular bowel movements. Three major movement patterns propel food and waste products through your gastrointestinal tract. These movement patterns include segmentation contraction, peristalsis, and the migrating motor complex (MMC). These processes are coordinated by waves of contraction by the smooth muscles of the gastrointestinal tract, hormones like cholecystokinin, gastrin, and secretin, and the intrinsic enteric nervous system of the GI tract which coordinates activity with the autonomic nervous system.

Impaired gut motility from issues with any of these processes can contribute to constipation. When transport through the colon is slowed down, there is greater reabsorption of water and electrolytes and prolonged retention of intestinal contents that leads to reduced volume and hardening of stools that become more difficult to pass.

In this way, chronic constipation results in long-term difficulty passing stools, less frequent stools, and/or incomplete clearance of stools from the rectum (incomplete defecation). It can also cause chronic abdominal pain, bloating, changes in weight, tears in the anus, nausea, mood changes, and other complications.

This common condition impacts 14–30% of people worldwide. It includes functional constipation and constipation-type irritable bowel syndrome (IBS).

Rome III criteria are used clinically to evaluate bowel movements, requiring at least two of the following criteria be met over a period of at least three months to warrant a diagnosis of functional constipation: straining during at least 25% of defecations, lumpy or hard stools in at least 25% of defecations, a sensation of incomplete evacuation in at least 25% of defecations, a feeling of anorectal obstruction/blockage for at least 25% of defecations, requiring manual maneuvers (e.g., digital evacuation, support of the pelvic floor) to facilitate at least 25% of defecations, and fewer than three spontaneous bowel movements weekly. In addition, loose stools are rarely present without laxative use and criteria for a diagnosis of irritable bowel syndrome are not met.

What Are the Root Causes of Chronic Constipation?

A variety of factors have been associated with chronic constipation. Genetic susceptibility interacts with lifestyle, biological, pharmacological, and/or environmental factors leading to impaired gut motility and issues with absorption. In order to develop an effective personalized approach to managing chronic constipation, it is important to accurately identify and address each individual’s unique root causes.

In addition to assessing underlying health conditions that can impair gut motility such as infections and/or dysbiosis, enteric nervous system dysregulation, altered gut-brain axis function, anatomical issues like pelvic floor dysfunction, and autoimmunity, lifestyle factors like diet and chronic stress can have a significant impact on bowel function and movements. Therefore, a functional approach to constipation considers these factors when assessing and addressing the root causes of constipation.

For example, diets including a high intake of processed foods, animal products, alcohol, and additives with insufficient fiber and deficiencies of micronutrients like vitamin C, magnesium, and potassium, are associated with higher rates of constipation.

Diet and nutrition are also intricately linked to the health and balance of the gut microbiome. Dysbiosis in the microbes within the gut can contribute to constipation. Normally, the microbes inhabiting your gastrointestinal tract help you digest food into absorbable nutrients, contribute to immunity, protect the intestinal mucosal barrier, inhibit the growth of pathogenic bacteria, and produce important metabolites. As such, they influence the balance of water and electrolytes in the intestines and directly influence gut motility. Chronic inflammation due to leaky gut, food allergies and sensitivities, dietary factors, and chronic stress can contribute to these types of imbalances that may result in constipation.

Functional Medicine Testing and Assessment

Functional testing for constipation helps to identify underlying causes so that they can be addressed to bring the body back into balance. Assessment of gut motility, stool analysis, and food sensitivity testing are valuable tools to help guide personalized treatment plans. 

Imaging tests such as X-ray, MRI, and CAT scans and functional motility testing such as anorectal manometry testing, transit studies, and functional imaging studies can help evaluate underlying causes of impaired gastrointestinal motility. These tests can help to reveal inflammation and/or narrowing of the gastrointestinal tract lumen. To evaluate functional motility issues that may be contributing to constipation, anorectal manometry testing can measure the strength of anal muscles and assess the reflexes needed for normal bowel movements. Transit studies are also used to follow how food moves through the digestive tract and how well the bowels are emptied.

A comprehensive stool analysis is an essential test for evaluating factors contributing to chronic constipation. The GI-MAP + Zonulin test screens for intestinal dysbiosis, infections, and leaky gut by measuring markers of digestion and absorption, intestinal inflammation, short-chain fatty acids, and the range of microorganisms inhabiting the large intestine. This can give insights into causes of constipation such as yeast overgrowth and imbalances in gut bacteria.

Other types of dysbiosis such as small intestinal bacterial overgrowth (SIBO) and intestinal methanogen overgrowth (IMO) can also present with chronic constipation in many cases. A breath test can assess the overgrowth of bacteria that do not normally belong in the small intestine. A 3-hour SIBO breath test is a non-invasive way to measure hydrogen and methane gasses to evaluate bacterial overgrowth in the small intestine or methanogenic overgrowth throughout the GI tract that is often associated with constipation.

Testing like the 144 Food Panel: IgG by US BioTek can also help to identify food sensitivities. This can guide personalized dietary approaches like elimination diets that can help to alleviate constipation.

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Dietary Interventions for Improving Gut Motility

Dietary changes for constipation can be tailored to each individual to target specific dysfunctions and imbalances underlying the issue. In general, an anti-inflammatory diet focused on whole foods and excluding highly processed foods, additives, and refined sugars can be adjusted for individual sensitivities, allergies, and needs. Diets rich in plant-based foods like the Mediterranean diet can significantly improve bowel movements. Plant-based anti-inflammatory diets are also rich in antioxidants like vitamins A, C, and E, selenium and manganese, and phytochemicals like flavonoids and carotenoids that help to heal the gut and improve the health of the microbiome.

It is also important to be sure to stay well hydrated by drinking plenty of water with balanced electrolytes from sources like natural sea salt and avoiding alcohol and excessive caffeine. 

Fibers are a type of carbohydrate that the body cannot absorb or digest. They are found in all plant foods such as fruits, vegetables, whole grains, nuts, seeds, beans, and legumes. They play important roles in bulky up the stool and providing food for beneficial gut bacteria. There are different types of fiber. Some fibers are viscous, gel-like, and fermentable and feed bacteria in your gut microbiome bacteria that break them down and ferment them. Others are insoluble and nonfermentable and travel intact into your colon where they can have variable impacts on digestion, some slowing digestion and others having a laxative effect.

Fiber has different effects on each phase of gastrointestinal motility and different preparations of the same fibers can have variable effects. For many people with constipation, adding fiber to the diet can help bulk up and soften stools to increase the frequency of bowel movements. But caution should be taken with those who have slowed gastrointestinal transit and/or a disorder of defecation in whom too much fiber can worsen constipation. Therefore, looking at the underlying causes of constipation and tailoring a management approach to each individual using functional medicine is crucial.

Depending on individual factors, functional constipation may improve with a targeted dietary approach such as a lactose-free, gluten-free, low-carb, or low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet.

The Role of Probiotics and Gut Microbiome

The microbes living in your gastrointestinal tract play a wide range of roles in your health, including helping to digest and metabolize certain nutrients, modulating immunity and inflammation, and protecting the intestinal mucosal barrier. Imbalances in these microbes or dysbiosis can contribute to chronic constipation. For example, studies show that patients with constipation-predominant IBS have a lower level of Actinobacteria, including Bifidobacteria, in their stool with higher levels of Bacteroidetes in their intestinal mucosa.

Given these relationships, interventions targeting the gut microbiome have been studied to help chronic constipation. Research suggests that probiotics, prebiotics, synbiotics, antibiotics, and fecal transplants can effectively improve chronic constipation with few side effects. 

Probiotic consumption via fermented foods and/or supplementation can help to rebalance the intestinal microbiota and improve gut motility. Studies suggest that taking probiotics like bacteroides, bifidobacterium, and lactobacilli improves stool frequency and stool consistency to reduce constipation with very few side effects. 

Short-chain fatty acids (SCFAs) are produced by your gut microbiota when they ferment certain types of fibers or prebiotics. SCFAs increase intestinal contractility to help improve gut motility and constipation.

These impacts are due to the effects that SCFAs have on improving the balance of the microbiome, directly stimulating receptors on the vagus nerve, and regulating the gut-brain axis. Research shows that SCFA produced by the bacteria in your gut can directly stimulate nerves to improve peristalsis and also indirectly stimulate enteroendocrine cells to produce serotonin that triggers peristaltic reflexes.

Lifestyle Modifications and Stress Management

Lifestyle changes for constipation are also an important part of managing this chronic condition. Regular exercise, stress reduction techniques, and adequate sleep are all important lifestyle habits that impact gut motility.

The gut and nervous system are closely connected and communicate with each other bidirectionally via the gut-brain axis. Chronic unmanaged stress slows motility in the gut, contributes to imbalances in gut microflora, increases inflammation, and weakens the intestinal mucosal barrier, increasing the risk of constipation. To coordinate this connection, the parasympathetic division of your autonomic nervous system prepares the body for digestion by communicating with the enteric nervous system located in your gastrointestinal tract. This involves the neurotransmitter serotonin that helps signal the smooth muscles lining your colon to contract and move food along. Prolonged anxiety and stress can alter this signaling and contribute to changes in bowel movements.

You can improve the health of your gut and help regulate intestinal motility by getting regular movement and practicing stress management techniques. Physical activity such as walking or yoga improves constipation by increasing blood flow and reducing stress. Choose regular movement that does not overly stress that body.

Mind-body practices like meditation, tai chi, and breathing practices help to stimulate your parasympathetic nervous system and allow the body to focus more on digestion and repair.

Regular restorative sleep is also important for regular digestion and gut motility. Sleep impacts the microbiome and is very important for overall health. Aim for at least 7-8 hours of sleep and stick to a regular rhythm to keep your gut healthy and moving well.

As part of your lifestyle habits and routine, it is important to listen to your body. When you feel the urge to defecate, do not ignore it. In some cases, it can also be helpful to schedule uninterrupted bathroom time at the same time each day to help your body feel ready to release bowel movements.

Herbal and Nutritional Supplements

Supplements for gut motility can complement dietary and lifestyle approaches to managing chronic constipation. Herbal remedies and nutritional supplements can aid in relieving constipation and enhancing gut motility, such as magnesium, aloe vera, and senna. These may be incorporated as part of an individualized approach to chronic constipation depending on the identified underlying contributing factors and individual needs.

Magnesium is a critical mineral for many processes throughout the body including gut function. Low levels of magnesium are associated with constipation. Magnesium oxide is one form of this mineral that acts as an osmotic laxative, helping to increase the amount of water and stimulating intestinal contractions in the intestines to make bowel movements easier. Magnesium oxide has a laxative effect by pulling water into the bowels and stimulating intestinal contractions. For many, 400-800 mg of magnesium oxide nightly before bed can improve bowel function.

Aloe vera juice is extracted from the leaves of the aloe vera plant and contains a gel-like pulp. It is rich in mucilage that can help soothe inflammation in the digestive tract. The aloe latex in the plant contains anthraquinones which act as natural laxatives by enhancing intestinal motility. Studies suggest that these properties of aloe vera make it an effective treatment for chronic constipation.

Senna is another supplement for gut motility that may help in some cases of chronic constipation. The leaves and fruit of the senna plant stimulate the smooth muscle that lines the intestinal tract, acting as a stimulating laxative. Due to its mechanism of action, it can sometimes cause cramping and diarrhea and should not be used for long-term use to avoid electrolyte imbalances and bowel dependence.

Integrating Conventional and Functional Treatments

Integrating treatments for constipation allows for a personalized approach that combines conventional medicine and functional medicine interventions. This multidisciplinary approach is especially important when managing complex cases of chronic constipation that can cause significant impacts on quality of life.

A holistic approach to gut motility can help to target the identified root causes for each individual. Traditional conventional treatment options can offer medications like laxatives and prokinetics that may help relieve some discomfort. Combining this with a functional approach allows for the underlying cause(s) of the issue to be addressed for long-lasting impacts since most of these medications have potential side effects and may not be appropriate for ongoing use.

Integrative therapies like acupuncture can be an effective part of this type of holistic management plan. Acupuncture is an ancient Chinese Traditional Medicine (TCM) therapy that uses small needles to stimulate meridian points in the body. Acupuncture and electro-acupuncture using electricity to stimulate these meridian points have been shown to effectively treat chronic constipation. One of the ways that these TCM treatments may help chronic constipation is by improving the health of the microbiome.

Biofeedback is another complementary therapy that can help improve constipation as part of a holistic plan. This mind-body therapy uses feedback about bodily functions like muscle contractions and breathing to teach you how to impact the ways your body responds.

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Chronic Constipation and Gut Motility: Key Takeaways

Chronic constipation occurs when the movement of stool through the gastrointestinal tract is impaired for a variety of reasons. Impaired gut motility can occur due to health conditions that impact the muscles of the GI tract, nervous system impairments, dysbiosis in the gut microbiome, nutritional imbalances, lifestyle habits, chronic stress, and other factors. 

A personalized approach to chronic constipation considers the unique needs and underlying contributors for each individual. This allows for an individualized approach to improving gut health in constipation.

Functional medicine considers diet and lifestyle factors, such as dietary factors, excessive caffeine and alcohol consumption, inadequate water intake, and chronic stress, to help bring the body back into balance. In addition, functional medicine testing can help uncover root causes of constipation that can be addressed to improve quality of life.