Constipation

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Constipation

Need to Know

Constipation
Find comfort from constipation, a change in normal bowel habits characterized by a decrease in frequency and passage of hard, dry stools. According to research or other evidence, the following self-care steps may be helpful.
  • Try a bulk laxative

    For results within 12 to 24 hours, take 5 to 10 grams per day of psyllium husk or 3 to 4 grams per day of glucomannan mixed in water, followed by a second glass of water

  • Get more fiber and water in your diet

    To increase stool bulk, include more vegetables, beans, bran, flaxseed, and whole grains in your diet; don’t forget to drink more water when you increase fiber intake

  • Get a checkup

    Constipation that starts suddenly should be evaluated by a doctor to make sure no serious diseases are the cause

About

About This Condition

Constipation is a condition in which a person experiences a change in normal bowel habits, characterized by a decrease in frequency and/or passage of hard, dry stools. Constipation can also refer to difficult defecation or to sluggish action of the bowels.

The most common cause of constipation is dietary, which is discussed below. However, constipation may be a component of irritable bowel syndrome or other conditions ranging from drug side effects to physical immobility. Serious diseases, including colon cancer, may sometimes first appear as bowel blockage leading to acute constipation. However, constipation itself does not appear to increase the risk of colon cancer, contrary to popular opinion.1

Although dietary and other natural approaches discussed below are often effective, individuals with constipation should be evaluated by a doctor to rule out potentially serious causes.

Symptoms

Symptoms of constipation include infrequent stools, hard stools, and excessive straining to move the bowels. Frequency of bowel movements and severity of symptoms may vary from person to person.

Holistic Options

Anecdotal reports have claimed that acupuncture is beneficial in the treatment of constipation.2 , 3 , 4 , 5 However, a small, controlled study of eight people with constipation concluded that six acupuncture treatments over two weeks did not improve bowel function during the course of the study.6 Placebo-controlled trials of longer duration are needed to determine whether acupuncture is a useful treatment for constipation.

Biofeedback techniques have been shown to significantly increase the frequency of bowel movements among women with chronic constipation.7

Eating Right

The right diet is the key to managing many diseases and to improving general quality of life. For this condition, scientific research has found benefit in the following healthy eating tips.

Recommendation Why Get started
Get more fiber and water in your diet To increase stool bulk, include more vegetables, beans, bran, flaxseed, and whole grains in your diet, don’t forget to drink more water when you increase fiber intake.

Get more fiber and water in your diet

Fiber , particularly insoluble fiber, is linked with prevention of chronic constipation.8 Insoluble fiber from food acts like a sponge, pulling water into the stool and making it easier to pass. Insoluble fiber comes mostly from vegetables, beans, brown rice, whole wheat, rye, and other whole grains. Switching from white bread and white rice to whole wheat bread and brown rice often helps relieve constipation. It is important to drink lots of fluid along with the fiber—at least 16 ounces of water per serving of fiber. Otherwise, the fiber may actually worsen the constipation.

In addition, wheat bran may be added to the diet. Doctors frequently suggest a quarter cup or more per day of wheat bran along with fluid. An easy way to add wheat bran to the diet is to put it in breakfast cereal or switch to high-bran cereals. Wheat bran often reduces constipation, although not all research shows it to be successful.9 Higher amounts of wheat bran are sometimes more successful than lower amounts.10
Uncover your food allergies Chronic constipation in infants may be due to an intolerance to cow’s milk, adults may experience constipation triggered by other food allergies. An elimination diet can help uncover allergies.

Uncover your food allergies

A double-blind trial found that chronic constipation among infants and problems associated with it were triggered by intolerance to cows’milk in two-thirds of the infants studied.11 Symptoms disappeared in most infants when cows’ milk was removed from their diet. These results were confirmed in two subsequent, preliminary trials.12 , 13 Constipation triggered by other food allergies might be responsible for chronic constipation in some adults. If other approaches do not help, these possibilities may be discussed with a physician.

Supplements

What Are "Star" Ratings?

a7_3star   Reliable and relatively consistent scientific data showing a substantial health benefit.

a7_2star   Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.

a7_1star   For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support.

Our proprietary “Star-Rating” system was developed to help you easily understand the amount of scientific support behind each supplement in relation to a specific health condition. While there is no way to predict whether a vitamin, mineral, or herb will successfully treat or prevent associated health conditions, our unique ratings tell you how well these supplements are understood by the medical community, and whether studies have found them to be effective for other people.

For over a decade, our team has combed through thousands of research articles published in reputable journals. To help you make educated decisions, and to better understand controversial or confusing supplements, our medical experts have digested the science into these three easy-to-follow ratings. We hope this provides you with a helpful resource to make informed decisions towards your health and well-being.


Supplement Amount Why
Aloe
 50 to 200 mg of aloe latex once per day for a maximum of ten days 3 stars   Aloe is considered a stimulant laxative because it stimulates bowel muscle contractions. Aloe is very potent and should be used with caution.

3 stars  Aloe

50 to 200 mg of aloe latex once per day for a maximum of ten days

For constipation, a single 50 to 200 mg capsule of aloe latex can be taken each day for a maximum of ten days.

The laxatives most frequently used world-wide come from plants. Herbal laxatives are either bulk-forming or stimulating.

Stimulant laxatives are high in anthraquinone glycosides, which stimulate bowel muscle contraction. The most frequently used stimulant laxatives are senna leaves, cascara bark, and aloe latex. While senna is the most popular, cascara has a somewhat milder action. Aloe is very potent and should be used with caution. Other stimulant laxatives include buckthorn, alder buckthorn (Rhamnus frangula), and rhubarb (Rheum officinale, R. palmatum).

Supplement Amount Why
Cascara
 20 to 30 mg of cascarosides per day for no more than ten days 3 stars   Cascara is considered a stimulant laxative because it stimulates bowel muscle contractions. Cascara has a milder action compared to other stimulant herbs.

3 stars  Cascara

20 to 30 mg of cascarosides per day for no more than ten days

Only the dried form of cascara should be used. Capsules providing 20 to 30 mg of cascarosides per day can be used. However, the smallest amount necessary to maintain soft stool should be used.14 As a tincture, 1/4 to 1 teaspoon (1–5 ml) per day is generally taken. It is important to drink eight 6-ounce (180 ml) glasses of water throughout the day while using cascara. Cascara should be taken consecutively for no longer than eight to ten days.15

The laxatives most frequently used world-wide come from plants. Herbal laxatives are either bulk-forming or stimulating.

Stimulant laxatives are high in anthraquinone glycosides, which stimulate bowel muscle contraction. The most frequently used stimulant laxatives are senna leaves, cascara bark, and aloe latex. While senna is the most popular, cascara has a somewhat milder action. Aloe is very potent and should be used with caution. Other stimulant laxatives include buckthorn, alder buckthorn (Rhamnus frangula), and rhubarb (Rheum officinale, R. palmatum).

Supplement Amount Why
Flaxseed
 1 Tbsp (15 ml) whole or ground with a full glass of water, one or two times per day 3 stars   Flaxseed is a mild bulk-forming laxative that’s best suited for long-term use in people with constipation.


3 stars  Flaxseed

1 Tbsp (15 ml) whole or ground with a full glass of water, one or two times per day

The laxatives most frequently used world-wide come from plants. Herbal laxatives are either bulk-forming or stimulating.

Bulk-forming laxatives come from plants with a high fiber and mucilage content that expand when they come in contact with water; examples include psyllium, flaxseed, and fenugreek. As the volume in the bowel increases, a reflex muscular contraction occurs, stimulating a bowel movement. These mild laxatives are best suited for long-term use in people with constipation.

Supplement Amount Why
Glucomannan
 3 to 4 grams daily in water, followed by a second glass of water 3 stars   Glucomannan is a water-soluble dietary fiber that has shown to be effective as a bulk-forming laxative.


3 stars  Glucomannan

3 to 4 grams daily in water, followed by a second glass of water

Glucomannan is a water-soluble dietary fiber that is derived from konjac root. Like other sources of fiber, such as psyllium and fenugreek, glucomannan is considered a bulk-forming laxative. A preliminary trial16 and several double-blind trials17 , 18 , 19 , 20 have found glucomannan to be an effective treatment for constipation. The amount of glucomannan shown to be effective as a laxative is 3 to 4 grams per day. In constipated people, glucomannan and other bulk-forming laxatives generally help produce a bowel movement within 12 to 24 hours.

Supplement Amount Why
Psyllium
 5 to 10 grams daily in water, followed by a second glass of water 3 stars   Psyllium is a mild bulk-forming laxative that’s best suited for long-term use in people with constipation.

3 stars  Psyllium

5 to 10 grams daily in water, followed by a second glass of water

The laxatives most frequently used world-wide come from plants. Herbal laxatives are either bulk-forming or stimulating.

Bulk-forming laxatives come from plants with a high fiber and mucilage content that expand when they come in contact with water; examples include psyllium, flaxseed, and fenugreek. As the volume in the bowel increases, a reflex muscular contraction occurs, stimulating a bowel movement. These mild laxatives are best suited for long-term use in people with constipation.

Many doctors recommend taking 7.5 grams of psyllium seeds or 5 grams of psyllium husks, mixed with water or juice, one to two times per day. Some doctors use a combination of senna (18%) and psyllium (82%) for the treatment of chronic constipation. This has been shown to work effectively for people in nursing homes with chronic constipation.21

Supplement Amount Why
Senna
 20 to 60 mg of sennosides per day for no more than ten days 3 stars   Senna is considered a stimulant laxative because it stimulates bowel muscle contractions. Senna is the most popular of these stimulant herbs.

3 stars  Senna

20 to 60 mg of sennosides per day for no more than ten days

Senna contains hydroxyanthracene glycosides known as sennosides. These glycosides stimulate colon activity and thus have a laxative effect. Also, these glycosides increase fluid secretion by the colon, with the effect of softening the stool and increasing its bulk.1 Double-blind trials have confirmed the benefit of senna in treating constipation.22 , 23Constipation induced by drugs such as the anti-diarrhea medicine loperamide (Imodium) has also been shown to be improved by senna in a clinical trial.24

The laxatives most frequently used world-wide come from plants. Herbal laxatives are either bulk-forming or stimulating.

Bulk-forming laxatives come from plants with a high fiber and mucilage content that expand when they come in contact with water; examples include psyllium, flaxseed, and fenugreek. As the volume in the bowel increases, a reflex muscular contraction occurs, stimulating a bowel movement. These mild laxatives are best suited for long-term use in people with constipation.

Many doctors recommend taking 7.5 grams of psyllium seeds or 5 grams of psyllium husks, mixed with water or juice, one to two times per day. Some doctors use a combination of senna (18%) and psyllium (82%) for the treatment of chronic constipation. This has been shown to work effectively for people in nursing homes with chronic constipation.25

Stimulant laxatives are high in anthraquinone glycosides, which stimulate bowel muscle contraction. The most frequently used stimulant laxatives are senna leaves, cascara bark, and aloe latex. While senna is the most popular, cascara has a somewhat milder action. Aloe is very potent and should be used with caution. Other stimulant laxatives include buckthorn, alder buckthorn (Rhamnus frangula), and rhubarb (Rheum officinale, R. palmatum).

Supplement Amount Why
Alder Buckthorn
 20 to 30 mg of anthraquinone glycosides (calculated as glucofrangulin A) per day 2 stars   Alder buckthorn is considered a stimulant laxative because it stimulates bowel muscle contractions.

2 stars  Alder Buckthorn

20 to 30 mg of anthraquinone glycosides (calculated as glucofrangulin A) per day

Only the dried form of alder buckthorn should be used. Capsules providing 20 to 30 mg of anthraquinone glycosides (calculated as glucofrangulin A) per day can be used; however, the smallest amount necessary to maintain regular bowel movements should be used.26 As a tincture, 5 ml once at bedtime is generally taken. Alder buckthorn is usually taken at bedtime to induce a bowel movement by morning. It is important to drink eight six-ounce glasses of water throughout the day while taking alder buckthorn, and to consume plenty of fresh fruits and vegetables. Alder buckthorn should be taken for a maximum of eight to ten days consecutively or else it can lead to dependence on it to have a bowel movement.27 Some people take peppermint tea or capsules with alder buckthorn to prevent griping, an unpleasant sensation of strong contractions in the colon sometimes induced by the herb.

The laxatives most frequently used world-wide come from plants. Herbal laxatives are either bulk-forming or stimulating.

Stimulant laxatives are high in anthraquinone glycosides, which stimulate bowel muscle contraction. The most frequently used stimulant laxatives are senna leaves, cascara bark, and aloe latex. While senna is the most popular, cascara has a somewhat milder action. Aloe is very potent and should be used with caution. Other stimulant laxatives include buckthorn, alder buckthorn (Rhamnus frangula), and rhubarb (Rheum officinale, R. palmatum).

Supplement Amount Why
Basil
 Take as tea (2 tsp in 2 cups of water), or as a tincture or capsules (follow label instructions) 2 stars   Basil seed has been found to relieve constipation by acting as a bulk-forming laxative in one preliminary study.

2 stars  Basil

Take as tea (2 tsp in 2 cups of water), or as a tincture or capsules (follow label instructions)

The laxatives most frequently used world-wide come from plants. Herbal laxatives are either bulk-forming or stimulating.

Basil (Ocimum basilicum) seed has been found to relieve constipation by acting as a bulk-forming laxative in one preliminary study.28 A similar study showed the seeds to be useful following major surgery for elderly people with constipation.29Alginic acid, one of the major constituents in bladderwrack (Fucus vesiculosus), is a type of dietary fiber that may be used to relieve constipation. However, human studies have not been conducted on the effectiveness of bladderwrack for this condition.


Supplement Amount Why
Buckthorn
 20 to 30 mg of anthraquinone glycosides (calculated as glucofrangulin A) daily 2 stars   Buckthorn is considered a stimulant laxative because it stimulates bowel muscle contractions.

2 stars  Buckthorn

20 to 30 mg of anthraquinone glycosides (calculated as glucofrangulin A) daily

Only the dried form of buckthorn berries and bark should be used. Capsules providing 20 to 30 mg of anthraquinone glycosides (calculated as glucofrangulin A) per day can be used; however, the smallest amount necessary to maintain regular bowel movements should be used.30 As a tincture, 5 ml once at bedtime is generally taken. Usually buckthorn is taken at bedtime, so it will have time to act and by morning a bowel movement is induced. It is important to drink eight six-ounce glasses of water throughout the day while taking buckthorn, and to consume plenty of fresh fruits and vegetables. Buckthorn should be taken for a maximum of eight to ten days consecutively or else it can lead to dependence on it to have a bowel movement.31 Some people take peppermint tea or capsules with buckthorn to prevent griping, an unpleasant sensation of strong contractions in the colon sometimes induced by buckthorn.

The laxatives most frequently used world-wide come from plants. Herbal laxatives are either bulk-forming or stimulating.

Stimulant laxatives are high in anthraquinone glycosides, which stimulate bowel muscle contraction. The most frequently used stimulant laxatives are senna leaves, cascara bark, and aloe latex. While senna is the most popular, cascara has a somewhat milder action. Aloe is very potent and should be used with caution. Other stimulant laxatives include buckthorn, alder buckthorn(Rhamnus frangula), and rhubarb (Rheum officinale, R. palmatum).

Supplement Amount Why
Probiotics
 6.5 billion colony-forming units of Lactobacillus casei Shirota 2 stars  

Research has shown that the probiotic strain Lactobacillus casei Shirota may help relieve chronic constipation after two weeks of supplementation.



2 stars  Probiotics

6.5 billion colony-forming units of Lactobacillus casei Shirota

In one double-blind study, 70 people (average age, 44 years) with chronic constipation were randomly assigned to receive 65 ml/day of a probiotic beverage or placebo for four weeks.32 The probiotic beverage provided daily at least 6.5 billion colony-forming units of Lactobacillus casei Shirota. The treatment group began showing statistically significant improvements at the end of the second week. At the end of the treatment period, the proportion of patients having moderate or severe constipation was 34% in the active-treatment group and 83% in the placebo group.

Supplement Amount Why
Rhubarb
 Follow label instructions 2 stars   Rhubarb is considered a stimulant laxative because it stimulates bowel muscle contractions.

2 stars  Rhubarb

Follow label instructions

The laxatives most frequently used world-wide come from plants. Herbal laxatives are either bulk-forming or stimulating.

Stimulant laxatives are high in anthraquinone glycosides, which stimulate bowel muscle contraction. The most frequently used stimulant laxatives are senna leaves, cascara bark, and aloe latex. While senna is the most popular, cascara has a somewhat milder action. Aloe is very potent and should be used with caution. Other stimulant laxatives include buckthorn, alder buckthorn (Rhamnus frangula), and rhubarb (Rheum officinale, R. palmatum).

Supplement Amount Why
Bladderwrack
 Refer to label instructions 1 star   Alginic acid, one of the major constituents in bladderwrack, is a type of dietary fiber that may be used to relieve constipation.

1 star  Bladderwrack

The laxatives most frequently used world-wide come from plants. Herbal laxatives are either bulk-forming or stimulating.

Basil (Ocimum basilicum) seed has been found to relieve constipation by acting as a bulk-forming laxative in one preliminary study.33 A similar study showed the seeds to be useful following major surgery for elderly people with constipation.34Alginic acid, one of the major constituents in bladderwrack(Fucus vesiculosus), is a type of dietary fiber that may be used to relieve constipation. However, human studies have not been conducted on the effectiveness of bladderwrack for this condition.

Supplement Amount Why
Chlorophyll
 Refer to label instructions 1 star   Chlorophyll, the substance responsible for the green color in plants, has been shown to ease chronic constipation in elderly people.

1 star  Chlorophyll

Chlorophyll , the substance responsible for the green color in plants, may be useful for a number of gastrointestinal problems. In a preliminary trial, chlorophyll supplementation eased chronic constipation in elderly people.35

Supplement Amount Why
Dandelion
 Refer to label instructions 1 star   The bitter compounds in dandelion leaves and root are also mild laxatives.

1 star  Dandelion

The unprocessed roots of fo-ti possess a mild laxative effect. The bitter compounds in dandelion leaves and root are also mild laxatives.

Supplement Amount Why
Fenugreek
 Refer to label instructions 1 star   Fenugreek is a mild bulk-forming laxative that’s best suited for long-term use in people with constipation.

1 star  Fenugreek

The laxatives most frequently used world-wide come from plants. Herbal laxatives are either bulk-forming or stimulating.

Bulk-forming laxatives come from plants with a high fiber and mucilage content that expand when they come in contact with water; examples include psyllium, flaxseed, and fenugreek. As the volume in the bowel increases, a reflex muscular contraction occurs, stimulating a bowel movement. These mild laxatives are best suited for long-term use in people with constipation.

Supplement Amount Why
Fo-Ti
 Refer to label instructions 1 star   The unprocessed roots of fo-ti possess a mild laxative effect.

1 star  Fo-Ti

The unprocessed roots of fo-ti possess a mild laxative effect. The bitter compounds in dandelion leaves and root are also mild laxatives.

Supplement Amount Why
Psyllium
(Parkinson’s Disease)
 3 to 5 grams taken at night with a one to two glasses of fluid 1 star   Preliminary research has shown that psyllium seed husks improve constipation and bowel function in people with Parkinson’s disease and constipation.


1 star  Psyllium

3 to 5 grams taken at night with a one to two glasses of fluid

Doctors recommend that people with Parkinson’s disease supplement with fiber and maintain adequate fluid intake to reduce constipation associated with this disease.36 Preliminary research has shown that psyllium seed husks improve constipation and bowel function in people with Parkinson’s disease and constipation.37 A typical recommendation for psyllium seed husks is 3 to 5 grams taken at night with a one to two glasses of fluid.

References

1. Dukas L, Platz EA, Colditz GA, et al. Bowel movement, use of laxatives and risk of colorectal adenomatous polyps among women (United States). Cancer Causes Control 2000;11:907–14.

2. Kangmei C, Shulian Z, Ying Z. Auriculoacupuncture therapy—a traditional Chinese method of treatment. J Tradit Chin Med 1992;12:308–10.

3. Xuemin S. Clinical observations on 50 cases of obstipation treated with acupuncture. J Tradit Chin Med 1982;2:162.

4. Fischer MV, Behr A, Reumont J. Acupuncture—a therapeutic concept in the treatment of painful conditions and functional disorders. Report on 971 cases. Acupunct Electrother Res 1984;9:11–29.

5. Shuli C. Clinical application of acupoint tianshu. J Tradit Chin Med 1992;12:52–4.

6. Klauser AG, Rubach A, Bertsche O, Muller-Lissner SA. Body acupuncture: effect on colonic function in chronic constipation. Z Gastroenterol 1993;31:605–8 [in German].

7. Heymen S, Wexner SD, Vickers D, et al. Prospective, randomized trial comparing four biofeedback techniques for patients with constipation. Dis Colon Rectum 1999;42:1388–93.

8. Morais MB, Vítolo MR, Aguirre ANC, Fagundes-Nteo U. Measurement of low dietary fiber intake as a risk factor for chronic constipation in children. J Pediatr Gastroenterol Nutr 1999;29:132–5.

9. Müller-Lissner SA. Effect of wheat bran on weight of stool and gastrointestinal transit time: a meta analysis. BMJ 1988;296:615–7.

10. Marcus SN, Heaton KW. Effects of a new, concentrated wheat fibre preparation on intestinal transit, deoxycholic acid metabolism and the composition of bile. Gut 1986;27:893–900.

11. Iacono G, Cavataio F, Montalto G, et al. Intolerance of cow’s milk and chronic constipation in children. N Engl J Med 1998;339:1100–4.

12. Daher S, Solé D, de Morias MB. Cow’s milk and chronic constipation in children. N Engl J Med 1999;340:891.

13. Shah N, Lindley K, Milla P. N Engl J Med 199918;340:891–2.

14. Blumenthal M, Busse WR, Goldberg A, et al. (eds). *The Complete Commission E Monographs: Therapeutic Guide to Herbal Medicines.* Boston, MA: Integrative Medicine Communications, 1998, 104–5.

15. Bradley PR, ed. British Herbal Compendium, vol 1. Bournemouth, Dorset, UK: British Herbal Medicine Association, 1992, 52–4.

16. Passaretti S, Franzoni M, Comin U, et al. Action of glucomannans on complaints in patients affected with chronic constipation: a multicentric clinical evaluation. Ital J Gastroenterol 1991;23:421–5.

17. Marzio L, Del Bianco R, Donne M, et al. Mouth-to-cecum transit time in patients affected by chronic constipation: effect of glucomannan. Am J Gastroenterol 1989;84:888–91.

18. Marsicano LJ, Berrizbeitia ML, Mondelo A. Use of glucomannan dietary fiber in changes in intestinal habit. G E N 1995;49:7–14 [in Spanish].

19. Signorelli P, Croce P, Dede A. A clinical study of the use of a combination of glucomannan with lactulose in the constipation of pregnancy. Minerva Ginecol 1996;48:577–82 [in Italian].

20. Staianno A, Simeone D, Giudice ED, et al. Effect of the dietary fiber glucomannan on chronic constipation in neurologically impaired children. J Pediatr 2000;136:41–5.

21. Passmore AP, Wilson-Davies K, Flanagan PG, et al. Chronic constipation in long stay elderly patients: a comparison of lactulose and senna-fiber combination. BMJ 1993; 307:769–71.

22. Passmore AP, Davies KW, Flanagan PG, et al. A comparison of Agiolax and Lactulose in elderly patients with chronic constipation. *Pharmacol* 1993;47(suppl 1):249–52.

23. Kinnunen O, Winblad I, Koistinen P, Salokannel J. Safety and efficacy of a bulk laxative containing senna versus lactulose in the treatment of chronic constipation in geriatric patients. *Pharmacol* 1993;47(suppl 1):253–5.

24. Ewe K, Ueberschaer B, Press AG. Influence of senna, fibre, and fibre+senna on colonic transit in loperamide-induced constipation. *Pharmacol* 1993;47(suppl 1):242–8.

25. Passmore AP, Wilson-Davies K, Flanagan PG, et al. Chronic constipation in long stay elderly patients: a comparison of lactulose and senna-fiber combination. BMJ 1993; 307:769–71.

26. Blumenthal M, Busse WR, Goldberg A, et al, eds. *The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines.* Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998:95–8.

27. Blumenthal M, Busse WR, Goldberg A, et al, eds. *The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines.* Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998:95–8.

28. Kocharatana P, et al. Clinical trial of maeng-lak seeds used as a bulk laxative. Maharaj Nakornratchasima Hosp Med Bull 1985;9:120–36.

29. Muangman V, Siripraiwan S, Ratanaolarn K, et al. A clinical trial of Ocimum canum Sims seeds as a bulk laxative in elderly post-operative patients. Ramathibodi Med J 1985;8:154–8.

30. Blumenthal M, Busse WR, Goldberg A, et al, eds. *The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines.* Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998:95–8.

31. Blumenthal M, Busse WR, Goldberg A, et al, eds. *The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines.* Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998:95–8.

32. Koebnick C, Wagner I, Leitzmann P, Stern U, Zunft HJF. Probiotic beverage containing Lactobacillus casei Shirota improves gastrointestinal symptoms in patients with chronic constipation. Can J Gastroenterol 2003;17:655-9.

33. Kocharatana P, et al. Clinical trial of maeng-lak seeds used as a bulk laxative. Maharaj Nakornratchasima Hosp Med Bull 1985;9:120–36.

34. Muangman V, Siripraiwan S, Ratanaolarn K, et al. A clinical trial of Ocimum canum Sims seeds as a bulk laxative in elderly post-operative patients. Ramathibodi Med J 1985;8:154–8.

35. Young RW, Beregi JS Jr. Use of chlorophyllin in the care of geriatric patients. J Am Geriatr Soc 1980;28:46–7.

36. Kempster PA, Wahlqvist ML. Dietary factors in the management of Parkinson’s disease. Nutr Rev 1994;52:51–8 [review].

37. Ashraf W, Pfeiffer RF, Park F, et al. Constipation in Parkinson’s disease: objective assessment and response to psyllium. Mov Disord 1997;12:946–51.

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