If you’ve got problems with regularity, you’re not alone. Whether it’s occasional or chronic, you’re no doubt looking for relief. “There are so many recommendations out there,” says Jacqueline Wolf, a gastroenterologist and associate professor of medicine at Beth Israel Deaconess Medical Center in Boston. “Some of it works, and some is just folklore.”

How do you know if you’re irregular?

“We consider normal anywhere from going three times per day to three times per week,” says Beth Israel Deaconess gastroenterologist Jacqueline Wolf.

But you could have a bowel movement every day and still be constipated. “Constipation also includes straining, having hard, lumpy stools, or not evacuating completely,” says Wolf.¹

What’s to blame?

“Certainly a poor diet can have an impact,” says Lucinda Harris, a gastroenterologist and associate professor of medicine at the Mayo Clinic in Scottsdale, Arizona.

“And if you don’t eat, you don’t stimulate your intestines. Eating too little can be an issue in older people.”

Also check your medicine cabinet. “Opioids can induce constipation,” says Harris. So can some blood pressure meds (diuretics, calcium channel blockers, and beta blockers) and tricyclic antidepressants and MAO inhibitors for depression.

“And as people age, they may lose some of the cells that act as the colon’s pacemaker, so the muscles of the colon don’t contract as well,” says Harris.

Irregularity is also more common in women than men. “I have so many women patients who say, with a touch of envy, ‘My husband always has a bowel movement at the same time every day,’” says Harris. “We haven’t quite figured out why, but most of the data points to a hormonal difference.”

Here’s what may (and may not) improve your trips to the commode.

Fiber Fix?

If you’re irregular, the first step is to up your fiber intake. But to work, the fiber has to increase stool volume, “and it can’t get fermented by gut bacteria or broken down in transit,” says Nicola McKeown of the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University.² (McKeown has received funding from General Mills’s scientific arm and from Metamucil’s manufacturer.)

Fiber comes in two types:

■ Insoluble. “Coarse, insoluble fiber helps move food through the digestive tract by stimulating the lining of the gut to secrete water and mucus, which softens the stool, making it easier to pass,” explains McKeown. “Coarse wheat bran like Kellogg’s All-Bran is a good example.”

■ Soluble. Soluble fiber can boost stool bulk by absorbing water. But not all types of soluble fiber get the job done.

The fiber needs to form a gel, allowing it to hold water on its entire journey through the gut.

Enter psyllium, the laxation-friendly poster child of soluble fibers. It’s in Kellogg’s All-Bran Buds cereal and is the key ingredient in Metamucil.

In contrast, don’t expect much from prebiotic soluble fibers (so-named because they feed gut bacteria). The poster child: inulin—aka chicory root—a processed fiber used in many Fiber One foods, fiber “gummies,” and hundreds of other foods.

In three studies that enrolled a total of 140 people with constipation, only one (funded by an inulin maker) reported more bowel movements in inulin takers than in placebo takers.^3-5 And inulin made people more gassy.

Those results don’t surprise McKeown. “If the fiber gets fermented by gut bacteria, it can’t hold water, so it can’t add to stool bulk.”

“In fact, few of the isolated fibers that are added to foods actually help with regularity,” she adds. Among the duds: soluble corn fiber and wheat dextrin (the main ingredient in Benefiber).

Instead, stick to whole foods. “Eat a variety of fruits, vegetables, beans, whole grains, nuts, and seeds,” says McKeown. That should give you a good mix of soluble and insoluble fiber. (Click here for a chart that lists the grams of fiber per serving of common foods.)

Tip: Add fiber to your diet gradually. “A high-fiber diet may cause gas and bloating at first in people who were on a low-fiber diet,” says McKeown.

If that isn’t enough, try adding psyllium, coarse wheat bran, or prunes.

“Prunes have both fiber and sorbitol,” says Wolf. Sorbitol, a naturally occurring sugar alcohol, helps retain water in the stool.

“But it can cause gas,” adds Wolf. “And too much sorbitol can cause diarrhea.” So introduce prunes slowly.

Coffee to Go?

Coffee wakes up the mind. It may also wake up the gut. “Coffee stimulates the colon to contract,” explains Wolf.

Not a coffee drinker? Eating a meal may have the same impact.

“When food hits the stomach, you get a reflex that stimulates the colon to contract, which is why a lot of people feel the need to go to the bathroom right after eating,” says Wolf.

In one study (funded in part by a coffee industry group) on 12 people without constipation, regular coffee stimulated contractions in the colon similar to a meal, 23 percent more than decaf coffee, and 60 percent more than hot water.⁶

Can coffee help people who are often backed up? No studies have looked.

Drink Up?

“We often recommend that people with constipation drink more water,” says Harris. “But the issue hasn’t actually been well studied.”

If you’re truly dehydrated, that could make you irregular. “Water hydrates and softens the stool, which helps it move through you more easily,” says Wolf.

But if you’re not dehydrated—your urine should be no darker than lemonade—don’t expect more water to help.

When 15 adults without constipation were instructed to double—and then triple—their usual fluid intake for two days each, their stool output didn’t change…though they did urinate more.⁷

There’s no need to guzzle water, Harris explains. “You just need to be adequately hydrated.”

Move to Move?

Can regular exercise keep you regular? Few good studies have looked.

“There just isn’t a lot of evidence to support the idea that exercise is helpful for constipation,” admits Harris. “Anecdotally, my patients always say that if they’re more active, they have better bowel habits. It certainly can’t hurt.”

What’s more, “we know that there are stronger contractions in the colon first thing in the morning. Take advantage of that by doing light exercise or stretching, eating breakfast, and maybe drinking a cup of coffee right when you wake up.”

A Probiotic Push?

Are probiotics the cure for irregularity?

Many people seem to think so. In a survey of 2,557 British adults, roughly 35 percent of those with—versus 10 percent of those without—constipation reported taking probiotics.⁸ And a majority assumed that probiotics had curbed constipation in scientific studies.

Surprise! Most haven’t.

“There are a lot of claims out there for probiotics and regularity without studies to back them up,” says Wolf.

Few probiotics have been tested for regularity in more than one study.

“The studies are often very small and poor quality, so it’s hard to draw conclusions,” says Harris.

Here’s what the best studies have found. Even though all were company funded, none had impressive results.

■ Bifidobacterium lactis DN-173 010. (In Activia yogurt.) Among 126 Chinese women who reported having fewer than three bowel movements per week, those who ate yogurt with 12.5 billion CFU (colony-forming units) daily for two weeks had softer stools and averaged 1½ more bowel movements during the second week than the placebo eaters.⁹

■ Bifidobacterium lactis BB-12.(In Nancy’s yogurt, Good Belly Probiotics bars and cereal, etc.) In 1,248 Europeans who reported having two to four bowel movements per week, those who took either 1 or 10 billion CFUs a day for four weeks had no more bowel movements than placebo takers.¹⁰

■ Bifidobacterium lactis HN019.(In Tropicana Essentials Probiotics drinks, Kellogg’s Happy Inside cereals, etc.) Among 228 French adults with constipation, those who took 1 billion or 10 billion CFU a day for four weeks had no more bowel movements and their stools were no softer than placebo takers.¹¹

A Foot Stool?

“The #1 way to #2,” proclaims the Squatty Potty website.

“Squatty Potty is the original toilet stool that positions your body in a natural, comfy squat. This toilet posture helps you to be healthier and feel better—all while having the best poops of your life.”

When you sit on a standard toilet, your rectum has a bend in it. “Elevating your feet helps straighten that angle, which makes it easier to go,” says Wolf.

That may especially help people avoid straining, which “can lead to hemorrhoids or anal tears,” says Wolf.

Long before the Squatty Potty made its way into millions of American bathrooms, “I told people to put their feet on a stack of telephone books,” says Wolf. “But who has telephone books anymore?”

That said, if you’re looking for robust evidence that a foot stool can help you have “the best poops of your life,” you won’t find it. The few studies that have looked were small, poorly designed, and enrolled people without irregularity.^12,13

“If you’re not struggling or straining, do you need it?” asks Wolf. “Probably not. But it may help you go faster, and people sure are in a hurry these days.”

A trial is currently testing the Squatty Potty in people who are irregular. In the meantime, a foot stool may be worth a try, says Wolf.

“It makes sense that it would help.”

Laxatives for a Smooth Move?

If you’re piling on the beans, whole grains, fruit, and veggies and you still aren’t regular, it may be time to consider an over-the-counter laxative. They come in two main varieties:

■ Osmotic. “Osmotic laxatives draw water into the colon, which softens the stool and makes them easier to pass,” explains Wolf. “Those are the most gentle of the laxatives.”

Polyethylene glycol—the active ingredient in MiraLAX—is the most widely studied laxative.

In the two main studies that compared MiraLAX to a placebo in (roughly 440) adults with chronic constipation, those randomly assigned to take the laxative every day for two weeks to six months had two to three more bowel movements per week and reported less straining.^14,15 (Both studies were funded by MiraLAX’s manufacturer.)

“It’s both safe and effective, so it’s worth a try,” says Harris.

■ Stimulant. Stimulant laxatives move the stool along by helping the colon contract. They include senna (the active ingredient in Ex-Lax) and bisacodyl (in Dulcolax Overnight Relief).

No good trials have tested senna in people with chronic constipation.

In one study funded by the maker of Dulcolax, researchers randomly assigned 356 British adults with chronic constipation to take a placebo or up to 10 milligrams of Dulcolax a day.¹⁶ Over the next four weeks, the Dulcolax takers had roughly five bowel movements per week (and reported less straining) compared with just two per week for the placebo takers.

The downside? Those taking Dulcolax had far more bouts of diarrhea and abdominal pain.

Are laxatives dangerous?

“They’re usually safe if you use them at the dose on the label,” says Harris. “But if you overuse laxatives, you can get chronic diarrhea and can disturb the body’s balance of electrolytes like potassium and magnesium.” That can lead to dehydration and, in extreme cases, heart or kidney failure.

“If you’re taking laxatives daily, consult your doctor,” suggests Wolf. Something else may be going on that a doctor can help you address. Or your doctor may recommend a prescription medication.

“A pill is not necessarily going to make you all better, but it may be helpful along with other lifestyle changes.”

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²J. Acad. Nutr. Diet. 117: 251, 2017.
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¹¹Gut Microbes 9: 236, 2018.
¹²J. Clin. Gastroenterol. 53: 216, 2019.
¹³Low. Urin. Tract Symptoms 2: 16, 2010.
¹⁴Am. J. Gastroenterol. 95: 446, 2000.
¹⁵Am. J. Gastroenterol. 102: 1436, 2007.
¹⁶Clin. Gastroenterol. Hepatol. 9: 577, 2011.

Photos: stock.adobe.com: edan (top), okkijan2010 (left plate), nblxer (right plate), Kate Sherwood & Jennifer Urban/CSPI (beans).