Friday, 08 March 2019 / Published in Science Blog

Chronic Constpation – Part 2

Marvin is a 29-year old accountant with a very stressful job, working long hours and then commuting home on a train which is often packed with commuters. He suffers from chronic constipation which he manages by taking laxatives. He is aware that his constipation is exacerbated by his stress levels and lack of physical activity.

Martin’s 5-day food diary revealed that his diet is a typical Western diet high in refined carbohydrates and saturated fats, and alcohol, while lacking in dietary fibre, fruit or vegetables. Marvin does not drink any water either; his only fluid intake is from coffee and a glass of orange juice in the morning.

1^st visit

During his first nutrition consultation we focused on various diet and lifestyle factors contributing to his constipation, including refined carbohydrates, excessive alcohol intake (dehydration), stressful lifestyle and lack of physical activity.

2^nd visit

This time we applied principles of Functional Medicine to address Marvin’s constipation. We identified FOUR direct factors (and their supporting evidence) contributing to his constipation: 1. low stomach acid (HCl) 2. underactive thyroid 3. possible serotonin deficiency and 4. laxative use (discussed below).

Low stomach acid

Marvin’s Metagest challenge test tested positive, which in addition to symptoms such as constipation, bloating, flatulence and belching after a meal confirmed he may not be producing sufficient levels of stomach acid.

Stomach acid is primarily responsible for protein digestion in foods. It also stimulates gall bladder contraction, which, via release of bile salts, stimulates colon motility. While stomach acid deficiency can be treated with supplementation, it is important to identify what might be contributing to Marvin’s low stomach acid in the first place. We identified THREE possible contributing factors:

Chronic stress – during the consultation, Marvin commented that stress is the main trigger for his constipation. The role of stress is also supported by research; studies show that long-term exposure to stress activates increased secretion of the stress hormone cortisol from the adrenal cortex, which, in turn, inhibits gastrointestinal secretions such as stomach acid.

Underactive thyroid – thyroid hormones are known to influence stomach acid secretion, though the exact mechanism is not fully understood. However, research shows that thyroid hormones may alter the number or size of secretory cells in the stomach (e.g. cells responsible for stomach acid secretion). In this way low thyroid hormone activity may indirectly contribute to constipation.

Lack of chewing – Marvin often eats in a hurry and has a tendency not to chew his food properly. The chewing process is vital to stimulate digestion, as both mechanical and chemical stimuli via neural reflexes, result in an increased secretion of salivary enzymes which helps to secrete gastric juice such as stomach acid. Therefore, if we do not chew sufficiently, the brain will not register that the food is coming, and digestive juices like stomach acid will not be released. This will impair subsequent digestive processes, eventually contributing to constipation.

Underactive thyroid function – direct effect on constipation

Despite taking a low dose of thyroxine (25 mg), Marvin’s Genova Functional Profile test flagged up high TSH and low T4, suggesting his thyroid is not functioning optimally. The mechanisms are not fully understood; however, it is believed that thyroid affects neuro-hormonal regulation, contributing to a decreased gut motility. Hence constipation is very often reversible with thyroid replacement therapy. We identified THREE possible factors that could be contributing to Marvi’s underactive thyroid:

High cortisol (a stress hormone) – cortisol and thyroid hormones have a complex relationship; high cortisol, as flagged up on Marvin’s Adrenal Stress Profile test, can contribute to an increase in the inactive thyroid hormone, called reverse T3 (rT3). This can contribute to hypothyroidism, and may, in part, explain Marvin’s poor response to thyroxine and continuing symptoms of underactive thyroid, including constipation. A copy of Marvin’s tests was emailed to his GP with a request to review the dosage of thyroxine, and an explanation how we intend to support his thyroid hormone function nutritionally.

Pesticide exposure – high levels of chemicals, known as PCBs (organic chlorine compounds), which structurally resemble thyroid hormone, may disrupt normal thyroid function in various ways. For example, PCBs can bind to thyroid hormone receptors, blocking thyroxine binding and inactivating thyroid function, which may ultimately contribute to constipation.

Vitamin D deficiency – Marvin’s serum vitamin D is 38 ng/mL (reference range 50 – 100 ng/mL). Research is controversial; however, studies show that there is an association between vitamin D deficiency and hypothyroidism in patients with autoimmune hypothyroidism and in hypothyroidism without antibodies. Research shows that patients with hypothyroidism suffered from vitamin D deficiency, including low calcium levels, suggesting that both nutrients are associated with the condition.

Possibly low serotonin levels

Marvin’s symptoms associated with low serotonin are unexplained depression and constipation.

Serotonin is a polyfunctional signalling molecule, acting as a neurotransmitter in the brain, where surprisingly, only 1% of serotonin is found. The remaining 99% is found in other tissues, (e.g. plasma, the gastro-intestinal tract and immune cells). The gut is the largest producer of serotonin in the human body; almost 90% of serotonin is synthesised in the colonic cells. Gut serotonin plays a crucial role in the regulation of colonic motility, as it initiates peristaltic reflexes. We identified THREE possible factors that could be contributing to his serotonin deficiency:

Underactive thyroid contributing to low serotonin – it is well established that thyroid hormones regulate neurotransmitter release, including serotonin. Studies in hypothyroid patients have shown a reduced serotonin responsiveness to its receptor, which was reversible with thyroid replacement therapy. This suggests that thyroid hormones may increase serotonin receptor sensitivity and therefore serotonin function in the body. Addressing underactive thyroid may therefore have a positive effect on Marvin’s gut motility and constipation.
High cortisol contributing to low serotonin – high cortisol substantially increases serotonin uptake by blood lymphocytes (white blood cells), possibly due to serotonin’s role in regulation of immunity (e.g. serotonin can influence mobility and proliferation of white blood cells). As Marvin experiences frequent colds and infections, constant immune challenges may be depleting his serotonin levels, thereby contributing to symptoms of serotonin deficiency such as constipation.
Vitamin D deficiency – research shows that vitamin D helps to induce serotonin synthesis by inducing expression of an enzyme (TPH2), involved in the biosynthetic of serotonin. Therefore, vitamin D deficiency can also contribute to his constipation via reduced serotonin synthesis.

4. Laxative use

Extensive use of laxatives can lead to reduced concentrations of minerals involved in smooth muscle contraction (peristalsis), such as potassium and magnesium, eventually contributing to ‘lazy colon’ and constipation.

Supplement programme for Marvin’s constipation

Betaine HCl – a supplement that contains an acidifying factor betaine HCl, which compensates for reduced stomach acid production as discussed above.
Apoptogenic herbs – including ginseng, rhodiola and cordyceps, required to “adapt” to various stressors and to help regulate his stress hormone, cortisol levels. This is particularly important as stress is the trigger for his constipation.
Papaya extract – an entirely natural organic product made from the pulp of tree-ripened papaya. Research shows that Caricol ^TMsupplementation benefit constipation.
Vitamin D – to correct deficiency, as tested below normal reference range (50 – 100 ng/mL).

Constipation – Marvin’s Action Plan Summary

Chew food properly and do not eat in a hurry, to help stimulate stomach acid secretion
Avoid high goitrogens (e.g. excess soya foods and raw cruciferous vegetables) and avoid pesticide exposure to support thyroid health
Increase tryptophan rich foods such as low-fat dairy, some meat, poultry, fish, nuts and seeds to provide building blocks for serotonin synthesis
Avoid laxative use – re: ‘lazy colon’
Avoid stress and finding a way to relax. As discussed during the first visit, research shows that mindfulness meditation could be a potential remedy to stress by helping with relaxation and reducing anxiety.
Introduce a regular exercise routine

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