Exclusive Dr. Hyman+ Functional Medicine Deep Dive: Constipation

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Hello and welcome to the Dr. Hyman Plus exclusive Functional Medicine Deep Dive. I'm Dr. Mary Pardi and we're going to talk about constipation today. So I'm a naturopathic medical doctor. I'm also a certified functional medicine doctor through the Institute of Functional Medicine. And I'm the founder of Modern Men, which is a virtual telehealth company based in Los Angeles, California. I've put down some of my Instagram handles there. I do a ton of gut health related content on Instagram @dr.marypardi is my main handle. And then our Institution's Instagram is @modernmed. So when we're talking about constipation, we first want to talk about what a normal stool should look like in comparison. And so the big thing here is consistency as well as frequency with constipation. And we'll look at consistency over here in a little bit, but in terms of frequency, we want to make sure that you're having one bowel movement per day minimum. some doctors will say you can have less than that. Most people will feel best if they're having a normal bowel movement every single day. The next thing is how much quantity is coming out as well, because if you're having a really small bowel movement that can still feel uncomfortable. And so a normal amount of stool is going to be about the length of your forearm from your wrist to your elbow throughout a day. And so that's through a whole day, you may have several smaller bowel movements or one large bowel movement. In terms of color, the color of stool is determined by red blood cells being broken down into a substance called bilirubin that's excreted into the intestines through the gallbladder. And that's really what gives stool the brown color. It's not the only normal color of stool. And I talked about this in the other deep dive that I did around gut health in general. So I'm not going to go too far into it, but your stool can change colors. based on which foods you're eating more of. Eating a ton of leafy greens, you can see a greener type stool. Beets can cause the stool to become a red color, but red in general is never normal for a stool unless you're consuming beets, 'cause you really wanna make sure that there is no blood in the stool, which is never normal. Gas and bloating, also normal for humans to have gas and bloating. It should just be at a amount that doesn't interfere with the quality of life. And so we see that between 10 to 20 times of passing gas throughout the day is actually considered normal. I usually go on the lower end, closer to 10 as being more ideal. But again, really looking at does it cause pain? Does it interfere with daily activities that are the biggest things there? And when we're talking about constipation, we really wanna look at the consistency of the stool. And so this is called the Bristol Stool Chart. like my holy grail to what does your poop look like? Because it's hard to describe, but it's easier to pick out which of these is more consistent with your stool type. And so when we look at constipation, we're looking at type one and type two on the Bristol Stool Chart. These are harder stools. They look like rabbit pellets. They can be stuck together rabbit pellets, which is more the type two that we see here, but they are hard. And we'll talk about why they're hard in a little bit, but it's really important as part of the physiology of of the gut and how it works and how constipation actually comes to be about. A normal stool is closer to this type four here. So this is a smooth kind of log shaped stool that is easier to pass compared to these type one and type twos which are harder. So how does constipation happen? We want to look at how does the intestines work in the first place and then what can cause constipation if things go wrong. So you have two parts of the intestines. You've got your small intestine, which is right here, and then you have the large intestine or the colon here. And all in all, both of those together make up about 15 feet of intestinal contents. And the surface area is actually more impressive than that. So if we cut open the intestines and we spread it out, it would actually equate to about half of a badminton court in terms of the surface area. And the reason why we have so much surface area to the intestines is because of these things that we you see on the right here called your villi and then your microvilli. And so instead of the intestines just being a flat surface, instead it has these little bumps or I like to call them fingers that kind of stick out into the intestines called villi. And on top of these little villi, in addition to that, there's also little brush border microvilli. So there's little hairs that stick on to these little finger projections in the intestines. And this this is what really increases the surface area of the intestines and the reason why we want a ton of surface area in the intestines, because this is where digestion and absorption. So it's really for the absorption of nutrients, the absorption of water that happens in the intestines that we need all of this surface area or else we would not be able to absorb everything that we need to from our food. And so that's why we have all the surface area in our villi and our microvilli projections. so in terms of constipation, we're looking at peristalsis as a big factor. And so peristalsis is the movement that happens in the gut. And this is a wave-like contraction that you can kind of see forming here, contraction and propulsion of the intestinal contents through. And this peristalsis makes sure that the food that we consume ends up being stool and passes through the intestinal contents at a normal rate. Constipation is really the slowing of the intestines. Why are things not moving through fast enough so we're not having normal bowel movements on a regular basis? And so with that we're looking at those two things. We're looking at the absorption of water that happens because of the increased surface area with the villi and microvilli, and then also peristalsis and if anything is going wrong there. Other movements of the GI tract, we've got the migrating motor complex. The migrating motor complex happens in the small intestines. This is a series of electrical currents that pass through the small intestines when we're fasting. That's really the key there is that it's electrical waves that propel contents through during the fasting state, not the fed state. And so what happens is that after we're fasting for a period of time, the small intestine starts to initiate this migrating motor complex that moves contents through and kind of acts as the sweeping mechanism while we're fasting so that we can have normal regular bowel movements. It's also going to push through gas. It's going to make sure that we are regular. So the big factor when we look at small intestinal bacterial overgrowth or intestinal methanogen overgrowth, which I've also talked about in the past. this migrating motor complex, you have to be fasted. And so we'll talk about in the treatment section why fasting is important to preventing constipation and why spacing out meals is. But it's really due to this migrating motor complex physiology in that when you start to eat food, anything with a calorie, it shuts off this migrating motor complex. So you don't have those normal waves of propulsion that can happen when you're in that fasted state. And the migrating motor complex is going to repeat about every 120 about every two hours. And so ideally we're having good chunks of fasting between our meals that we can have a few waves of the migrating motor complex come in and ensure normal movement of contents. All right. Constipation. So in order to diagnose constipation, there's got to be a couple things in place. But I want to look at the different types of constipation. And so constipation can be in the form of IBS, irritable bowel syndrome that's constipation. constipation predominant, so we call that IBSC. We can also have functional constipation, which does not fall under the IBS category. We can have opioid-induced constipation, and then there can also be some issues with defecation that can happen, which we're not going to focus a ton on today. But I want to focus on IBSC and more of the functional constipation types as the most common. About 20% of people have IBS in general, and then a subset of those are going to have IBS that's constipation predominant. and what that means is that 25% or more of the bowel movements are those type 1 or type 2 on the Bristol Stool Chart. The other factor with IBS is that there's recurrent abdominal pain at least one day per week in the last three months, and that is related to either having a bowel movement or the pain is relieved by having a bowel movement or bowel movement frequency. So discomfort because you're not having many bowel movements throughout the week. And so really that's the big thing with constipation is that when it's IBS, there is that abdominal pain that exists. With functional constipation, there is not necessarily that abdominal pain. So it's straining during 25% or more of bowel movements. It is that type 1 or type 2 on the Bristol stool chart for more than 25%. Another factor can be that it feels like you're not fully voiding about a quarter of the bowel movements you're having and then can feel like there's an obstruction or a blockage in the anorectal area. Sometimes people will use their finger to manually maneuver the stool out of the colon and so if that is happening then that is one of the criteria. And then having fewer than three bowel movements per week is also a diagnostic criteria for functional constipation. There's rarely loose stools present, so you're not having that type 6 or type 7 unless there's laxative use in place. And I'll see that really commonly. And people say, okay, well, sometimes I'm type 1 or type 2 on the Bristol stool chart, these harder stools. But then sometimes I'll have type 7. And I'll say, okay, are you using MiraLAX? Are you using magnesium? And they'll say yes. And so. And I said, if you weren't taking those, would you ever have the loose stools? And they would say, no, I wouldn't have them if I and taking those laxatives. And then the other thing with functional constipation is that you don't meet the criteria for irritable bowel syndrome. So you're not having that pain piece of the irritable bowel syndrome. So for functional constipation, you're looking at two or more of these diagnostic criteria in the last 12 weeks, for at least 12 weeks of the year. So it's not going to be that you're constipated, you know, two days out of the year. But instead it's happening for about 12 weeks of the year. And then opioid induced constipation is pretty straightforward in terms of it's when people are taking opioids for pain and then that can lead to constipation. Causes. So why do we get IBSC or functional constipation? Those are the two that we'll be focusing on. Low fiber intake, really, really common. So the average American consumes about 15 grams of fiber per day. Recommended daily allowance for fiber is closer to 25 to 30 grams per day. so it's about half of what the average American is consuming. Also dehydration or lack of water intake. This is really big. If you're not consuming about half of your body weight in ounces of water, then water intake alone could resolve the constipation. A sedentary lifestyle, movement makes movement of the GI too, and so being sedentary can cause constipation. intestinal methanogen overgrowth. We're going to go into that. I've also done a full Deep dive on small intestinal bacterial overgrowth, which the IMO Falls underneath that. We'll talk about it a little bit today as well. Anxiety, depression and stress have been linked to constipation and IBS in general. And so our mental health can affect our gut health, and the reverse is true, too. And so we want to remember that the gut and the brain are bidirectional. It's a two-way street. So things that are affecting our gut health can also affect our mental health, but our mental health can also affect our gut health. Some people, especially when you see children, ignoring the urge to pass stool, it can cause constipation. And so sometimes there's an issue with the communication between the gut and the brain in that there's stool in the rectum and people are either very consciously ignoring the urge to pass the stool or subconsciously ignoring it. They're not sensing it or they don't know what the sensor actually is. And so there's biofeedback that people will sometimes do when we see this pelvic floor dysfunction occur. And so that's another cause of constipation. Changes of routine. How common is this? When we go traveling, you know, say you're on vacation and what you want to do is just relax and you can't go to the bathroom for a week, that change in routine signals to the brain that there's a change in our environment. And it sends the sub really subtle cue that, you know, are we safe? And so this is something that I talked with a lot of my patients about is that our brains are actually simply at a lot of levels in terms of sometimes they're just scanning for the cue of being safe or not. And when we have a new environment, they were in a hotel room or you know, you're at a resort or anywhere that may be enjoyable, your brain is still not fully sure if it's safe or not. And when we talk about how the gut works, we have to be in that parasympathetic state. We have to be in that rest and digest state where our body fully knows that we are safe. And so any change of routine, including travel, but other things as well, can signal to the brain, hey, we're not sure if we're safe anymore. It can down regulate that parasympathetic nervous system and it can cause constipation, unfortunately. abnormalities of the enteric nerves. And so this is one cause of constipation, which we're still looking at. But the enteric nerves are the nerves that reside in the gut. And, you know, we see issues with this, especially after surgery. And so if a woman goes through a hysterectomy or even childbirth, it doesn't have to be surgery, but anything that could be traumatic to those pelvic nerves can affect the enteric nerves and potentially reduce the ability of the colon and the intestines to move normally and potentially lead to constipation. And so if symptoms are starting right after childbirth or right after a hysterectomy or a pelvic surgery, then we want to think, is this actually an issue with the enteric nerves that are there? Diabetes can also affect the nerves in the GI tract, and this is why in diabetes there can be constipation. And so diabetes is potentially a cause or a culprit for constipation that we want to look out for. and so in people that are overweight or we see insulin resistance or, you know, prediabetes where the HbA1c is elevated, then we wanna be seeing, you know, should we be targeting blood sugar regulation as the main cause? Often gastroparesis can be caused by diabetes and that's the slowing of the stomach. And so we can also see it further down in the intestines leading to constipation. And finally medications. And so medications can cause constipation. We talked about opioid induced constipation, but also just taking iron if you're anemic, calcium, if you're taking a calcium supplement because you want to protect your bones, that can be constipating. Tums have calcium in them. They also have other ingredients. I think it's an aluminum salt that can cause constipation with Tums. Diuretics, so if there's any edema that you're treating or heart disease you're treating with a diuretic, that can cause constipation because we need water in the intestines for normal regular bowel movements. Some of the antidepressant Constipation can cause constipation, as well as medications to treat schizophrenia.

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Hi everyone. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, seek out a qualified medical practitioner If you're looking for a functional medicine practitioner, you can visit ifm.org and search their Find a Practitioner database. It's important that you have someone in your corner who's trained, who's a licensed healthcare practitioner, and can help you make changes, especially when it comes to your health.