Probiotics for Constipation

In this article we will be looking at the following areas:

• The gut microbiome and constipation
• Probiotics for constipation
• The best probiotic strains for constipation
• Can prebiotics help constipation?
• What is constipation?
• What causes constipation?
• How to manage constipation
• How do probiotics help with constipation?
• Constipation in the elderly
• Dietary sources of probiotic bacteria
• Summary of probiotics for constipation

Probiotics can play a key role in helping to relieve constipation, but it can be confusing trying to choose the correct and most effective one. Here we aim to demystify some of the confusion surrounding probiotics, and help you get the most out of your friendly bacteria. The majority of bacteria found in the large intestine are of the Bifidobacteria and Lactobacillus species, therefore it makes sense that probiotics with specific strains belonging to these species are generally regarded as the most beneficial in helping to alleviate constipation.

How do probiotics help with constipation?

Although the exact mechanisms have not yet been fully established ⁷, several suggestions by which probiotics can help with constipation include:

• Production of SCFAs (Short Chain Fatty Acids). SCFAs are produced as a result of the bacterial fermentation of carbohydrates in the gut by both Bifidobacteria and Lactobacilli ⁸. SCFAs are suggested to enhance colonic motility by stimulating neural receptors in the gut wall smooth muscle causing peristalsis. They have also been suggested to increase serotonin concentration in the colon which is an excitatory neurotransmitter and also can stimulate peristalsis ⁷.  
• Decreased colonic pH due to increased production of lactic acid and SCFAs by both Lactobacillus and Bifidobacteria species. Increased acidity of the gut luminal contents stimulates peristalsis and reduces colonic transit time ⁹.
• Increased bile salt metabolism by strains of both Bifidobacteria and Lactobacilli in the gut stimulates peristalsis as there is an increased level of deconjugated bile salts which can stimulate colonic motility¹⁰. 

A review of 14 randomised control trials revealed that constipation probiotics significantly reduced gut transit time by over 12 hours, as well as increasing average stool frequency per week and improving the consistency of the stool¹⁹.

No specific strains were mentioned in the meta-analysis but the researchers found that one specific species of probiotic, Bifidobacterium lactis, had a greater efficacy than others. The Bifidobacterium lactis species was more effective in all categories measured; gut transit time, stool frequency and consistency.

There are many possible triggers for constipation, and as a result there is no 'one size fits all' solution, fortunately though, there is good evidence to show that probiotics can be effective. It is important to be aware that each probiotic strain is different from the next. To meet your needs, it is always recommended that you select a strain that has been clinically trialled with a proven health benefit.

The best probiotic strains for constipation

There are several strains of friendly bacteria that have been shown to be beneficial in helping to alleviate constipation in various clinical studies. The best probiotic for constipation should contain strains which have been specifically researched for constipation including:  

• Bifidobacterium lactis BB-12^®
• Bifidobacterium lactis HN019 
• Bifidobacterium lactis DN-173 010
• Lactobacillus rhamnosus GG^®

Bifidobacterium lactis BB-12®

Bifidobacterium lactis BB-12^® ® is an extensively researched probiotic strain shown to be effective in alleviating constipation. In a clincial trial assessing the effects of a probiotic strain, supplementation with B. lactis BB-12® was assessed in those suffering with constipation 11. A large multi-centre double-blind randomised placebo-controlled trial was conducted by Eskesen et al involving 1000 subjects with low defecation frequency of 2 to 4 episodes per week. They were divided into 3 groups: one group were given 10 billion CFU of B. lactis BB-12® daily, the second group were given 1 billion CFU of B. lactis BB-12® daily and the third group were given a placebo, for 4 weeks. In the B. lactis BB-12® groups, there was a statistically significant increase in average defecation frequency compared with the placebo group from on average 3 episodes per week to 4 episodes per week at week 4.

B. lactis BB-12^® has also been trialled successfully in specific groups of individuals more vulnerable to constipation such as the elderly and pregnant women. It has also been trialled in those with regular bowel movements and didn't increase defaecation rate - showing that it has a normalising effect. 

Bifidobacterium lactis HN019

There have been several clinical studies to date assessing the effects of B.lactis HN019 in those with constipation.

In a gold standard trial (double blind, randomised controlled trial) by Ibarra et al, 228 adults diagnosed with constipation by their physician, according to the ROME III guidelines, were divided into 3 groups ¹². Each group were given either 10 billion of B. lactis HN019, 1 billion of B. lactis HN019 or a placebo daily for 28 days. Symptoms of constipation were monitored during and after the trial. In the intervention groups, there was a statistically significant increase in stool frequency in comparison with the placebo group. However, there was no alteration to colonic transit time in the probiotic groups.

In a triple-blind gold standard trial by Waller et al in which the effects of B. lactis HN019 on whole gut transit time constipated individuals was assessed ¹³. Participants chosen had functional gastrointestinal symptoms and a reduced stool frequency of 1 to 3 bowel movements per week. In total 88 participants completed the trial. They were divided into 3 groups: placebo group, low dose B. lactis HN019 group (1.8 billion CFU daily) and the high dose B. lactis HN019 group (17.2 billion CFU daily) for 14 days. Whole Gut Transit Time (WGTT) was assessed at day 0 and day 14 as each participant ingested radio-opaque markers followed by abdominal x-rays. Statistically significant reductions in WGTT were seen in the high dose (from 49 hours to 21 hours on average) and low dose (60 hours to 41 hours on average) B. lactis HN019 groups, which was not evident in the placebo group.

Of note, in a meta-analysis by Miller et al of 15 eligible randomised controlled trials assessing the effects of various probiotic strain supplementation on intestinal transit time, B. lactis HN019 was particularly noted to have medium to large treatment effects, suggesting that this strain is a viable option to consider to relieve constipation ¹⁴.

Bifidobacterium animalis subsp. lactis DN-173 010

B. lactis DN-173 010 is another Bifidobacterium lactis strain shown to be effective at helping to relieve constipation in several clinical studies. In a double-blind parallel study in 70 healthy adults, drinking a daily combination of 375g of milk fermented with the specific Bifidobacterium lactis strain DN-173 010 (containing minimum 50 to 500 million CFU per dose) for 11 days reduced colon transit time by 20%. Interestingly, the effect was more pronounced in women ¹⁵.  In another similar study, this time a gold standard trial, 12.5 billion CFU of B. lactis DN-173 010 was administered in yoghurt form to 34 individuals with IBS-constipation daily for 4 weeks. B. lactis DN-173 010 was demonstrated to significantly reduce colonic transit time from baseline (-12.2 hours) which was statistically significant comparted with placebo ¹⁶.

Lactobacillus rhamnosus GG®

Lactobacillus rhamnosus GG^® (or LGG^® as it is more commonly known) is a very well-known and well-researched strain of probiotic bacteria with a range of known health benefits, some of which are suggested to include reducing constipation. Supplementation with LGG^® has had some positive results in clinical trials in increasing stool frequency in constipated individuals, but was usually administered alongside another treatment such as fructo-oligosaccharides (a prebiotic fibre), which renders the true efficacy of LGG^® alone, difficult to assess ¹⁷. Of note, a gold standard trial by Banaszkiewicz et al. failed to demonstrate significant benefits in the alleviation of constipation using LGG^® alone. Ideally, further clinical studies would be performed to accurately assess its efficacy ¹⁸.

Can prebiotics help constipation?

In addition to probiotics, it is worth mentioning that prebiotics may also be helpful in relieving constipation. Prebiotics act as a food source for the probiotics and help to stimulate the activity of beneficial colonic bacteria. They are thought to have a small laxative effect, but with no risk of dependency. A combination of the probiotic Bifidobacterium lactis BB-12 and prebiotic fibres are widely recognised as an effective remedy to help alleviate constipation and maintain normal bowel function.

What is constipation?

Subjectively, constipation can have different meanings for different people. Symptoms can be reported as any of the following:

• Reduced stool frequency (typically less than 3 stools passed per week)
• Lumpy or hard stool consistency
• Difficulty passing stool or straining
• Sensation of incomplete evacuation
• Abdominal pain or cramping associated with defecation – typically indicative of constipation subtype of Irritable Bowel Syndrome ²

It’s important to remember that everybody’s natural bowel habits are different, and there is no such thing as a ‘normal’ frequency. Some people go three times a week, and some people might go three times a day. However, what is normal is that you’re consistent and regular, and when you do go, that you don’t need to strain more than usual. All you have to do is listen to your body, and you’ll know whether your unique rhythm has changed.

What causes constipation?

• Poor diet – low in fibre and plant-based foods
• Dehydration or insufficient water intake
• Medications – iron supplements, opioid analgesics
• Pregnancy
• Sedentary lifestyle and inactivity
• Stress
• Abnormal functioning/structural abnormality of the gastrointestinal tract – pelvic floor dysfunction, mass obstruction
• Secondary to medical conditions for example hypothyroidism, Parkinson’s disease ³

How to manage constipation?

For some people, managing their constipation is a daily undertaking. Common therapeutic options include dietary supplementation with fibre, such as psyllium husks or flax seeds, use of over-the-counter laxatives such as bisacodyl or senna-based stimulant laxatives and in severe cases, the use of prescription medication such as lactulose or lubiprostone.

Almost half of patients who suffer with chronic constipation are dissatisfied with conventional measures used to increase their stool frequency including laxatives and fibre supplements ⁴. In the same population-based survey, 52% of those suffering with constipation reported that it significantly affected their quality of life. Therefore, many of those who suffer are looking for alternative options, including being more active and taking regular exercise, to help alleviate their symptoms. Probiotics for constipation are becoming an increasingly popular choice.

The gut microbiome and constipation

Trillions of bacteria reside in the gut in what is known collectively as the gut microbiome. These microbes live in an ideally harmonious equilibrium, with a balance between beneficial and pathogenic bacteria. However, certain lifestyle factors can disturb this balance leading to what is known as dysbiosis. Dysbiosis has been often noted to be present in constipation ^{5 6}. Addressing this imbalance with a probiotic can help to restore normal bowel function and increase stool frequency.

Constipation in the elderly

Constipation in the elderly, like in the young, can be caused by a diet lacking in fibre, or a low fluid intake, lack of movement or exercise, and sometimes by emotional stress. Often medications such as antacids, tablets for high blood pressure, antidepressants and some pain killers can also upset the digestive system.

When you are eating less food than you used to do and maybe drinking less fluid than before your bowel movements will slow down. When stools remain in the large intestine for long periods, they can dry out and become hard, making them more difficult to pass. If you have less than three bowel movements a week, or have to strain when going, this could indicate you are suffering from constipation.

During later years it's common that you won't be exercising as much as before. Also, muscle tone will not be as strong as it used to be, and we know that bowel movements depend on good muscular contractions. Exercise really does benefit the digestive process, in the elderly and for everyone; because it stimulates the passage of food through the system, thereby helping to prevent constipation. Regular walks and getting out in the fresh air, or even movement around the house and garden is good for digestion, as well as for your general health and well-being.

Dietary sources of probiotic bacteria

There are also certain foods you can include in your diet which may help to boost levels of beneficial bacteria and support digestive health. Probiotic foods such as natural live yogurt and fermented foods (e.g sauerkraut and kimchi) are rich in Lactobacillus bacteria.

Summary of probiotics for constipation

• Constipation is a very common issue that can significantly affect the quality of life of those that suffer.
• Although conventional laxatives and fibre supplements are commonly used to increase stool frequency, many people are left dissatisfied and are seeking other options to help manage their symptoms.
• Dysbiosis or an imbalance in our gut bacteria can lead to constipation.
• Probiotics for constipation are an increasingly popular supplement choice and can be very helpful in managing constipation.
• Probiotics help with constipation by increasing short-chain fatty acid production, reducing the pH of the colon and increasing bile salt metabolism, all of which helps stimulate peristalsis.
• Some probiotic strains are better than others at improving symptoms of constipation. Notable strains include B. lactis BB-12, B. lactis HN019 and B. lactis DN-173 010.

If you found this article relevant to you, you may like to read ‘Constipation in babies’, ‘Constipation in the elderly’ and ‘Constipation in pregnancy’.

This article was written by Dr Aisling Dwyer MB BCh BAO (Medicine, Surgery and Obstetrics), MSc (Personalised Nutrition)​ in collaboration with Kerry Beeson BSc (Nut. Med.) Nutritional Therapist and was last updated on 18th September 2020.

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23. This article was written by Dr Aisling Dwyer MB BCh BAO (Medicine, Surgery and Obstetrics), MSc (Personalised Nutrition)​ in collaboration with Kerry Beeson BSc (Nut. Med.) Nutritional Therapist and was last updated on 24th April 2020.