Is exercise effective for constipation?

I recently had a clinical scenario about one of my patients named Brenda in Constipation and Cramps: A Slam Dunk Diagnosis? This 35-year-old woman came to me with symptoms that had been present for a year. I asked for reader comments on my dealings with Brenda.

I appreciate the comments I received on this case. The most common suggestion was to encourage Brenda to exercise, and a systematic review of randomized clinical trials published in 2019 supports this recommendation. This review included nine studies totaling 680 participants, and the overall effect of exercise was a two-fold improvement in symptoms associated with constipation. Walking was the most common exercise intervention, and together with qigong (which combines posture, breathing, and meditation), these two types of exercise were effective in improving constipation. However, the one study that looked at resistance training failed to show a significant effect. Importantly, the reviewers considered the collective research to be at high risk of bias.

Exercise will likely help Brenda, although some brainstorming might be needed to help her fit exercise into her busy schedule. Another suggestion focused on their risk for colon cancer, and Drs. Cooke and Boboc both astutely noted that colon cancer is becoming more prevalent in adults in their early middle years. This contrasts with a steady decline in the prevalence of colorectal cancer among US adults aged 65 years and older. While colorectal cancer among older adults in the US declined 3.3% annually from 2011 to 2016, this favorable trend reversed in those aged 50 to 64, with rates increasing 1% annually.

The increase in colorectal cancer incidence in adults aged 50 to 64 was outpaced by the increase in adults under 50 years of age, who saw a 2.2% annual increase in colorectal cancer incidence between 2012 and 2016. The increase in colorectal cancer in early middle-aged adults was due to higher rates of rectal cancer, but more recently this trend has also been accompanied by higher rates of tumors of the proximal and distal colon. In 2020, 12% of new cases of colorectal cancer were expected to be in people under the age of 50.

So in the case of Brenda, how do we go about this? Her history suggests no obvious warning signs of cancer. The medical history did not address a family history of gastrointestinal symptoms or colon cancer, which is an important omission.

Although the number of cancer cases can increase in those under 50 years of age, the overall prevalence of colorectal cancer in younger adults is well below 1%. At the age of 35, there is no need to screen Brenda for colon cancer. However, persistent or worsening symptoms at a later date may result in a referral for a colonoscopy.

Finally, let’s talk about how to practically handle Brenda’s case, since there are many options available. I would start with recommendations on her lifestyle, including regular exercise, getting enough sleep, and anything she can achieve on the FODMAP diet. I would also recommend psyllium as a soluble fiber and expect these changes would help her constipation. But they might be less effective for stomach cramps, so I’d also recommend peppermint oil at this point.

If Brenda follows these recommendations, she will most likely improve. When she doesn’t, I worry more about anxiety and depression complicating her illness. Treating these disorders can make a big difference.

In addition, if there is an insufficient response to the initial therapy, I will start with linaclotide or lubiprostone. Plecanatide is another reasonable option. At this point I will also consider a referral to a gastroenterologist for a recalcitrant case and will certainly refer if Brenda fails any of these specific treatments. Conditions such as pelvic floor dysfunction can mimic irritable bowel syndrome with constipation and should be considered.

However, I really think Brenda will feel better. Thanks for all the insightful and interesting comments. It’s easy to see how we all work to improve patients’ lives.

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