Semaglutide and Severe Constipation

[Anthony Castore]

Some other members have touched on the importance of hydration. I agree hydration is incredibly important. I use Leonard‘s product iCell water with added Taurine (another neutral osmolite) to prevent fatty acids oxidation, further support cardiac function and improve insulin sensitivity. Additionally, lactolose can be a great addition. It has the benefit of decreasing inflammation in colonocytes and also hydrating the colon. I load magnesium at 8mg/kg. During the day around exercise time I use magnesiu  malate to support Krebs cycle energy production and magnesium threonate in the evening to help with perserveration in anxious clients. During the day to make up the rest of the in take I use calms to improve gastric motility (mg citrate). Some additional things I focus on is making sure they are meeting a fiber goal of 40g/ day. For every cup of fruit I use 2 servings of vegetables and add in Sun Fiber for its ability to bind and remove LPS, green banana starch as an added form of resistant starch and to increase butyrate production and pectasol to bind metals. I also support bike production with 500mg of TUDCA/day. The bile production is important to support removal of toxins as fat is being lost. An underrated thing that helps tremendously is making sure the person is getting in 10k steps per day. This seems like an extremely high number but, if they begin their day with a walk outdoors this can knock out 2-3k steps and rebalance circadian rhythm (a forgotten aspect of health and digestion) then I tell clients to park farther everywhere they go and take stairs (another 2-3k steps) I encourage them to stand for every phone call they make or take and pace while talking (this will easily amount to 4-5k steps and hit the goal).

Another strategy I deploy isnswithching briefly to retatritide, the added glucagon modulation leads to increased energy expenditure and I have found this lets me stay at an onboarding dose for both peptides they can return to semaglitide after 2-3 weeks in my experience have success with a lower dose. BPC and KPV can be added in as well for reducing inflammation and improving digestive health. My last trick is using a shake as a meal alternated with solid food. For the shake, I mix the following: 1-2 scoops whey isolate or beef hydrolysate protein, 2 grams colostrum, 1 scoop sun fiber, 1 scoop green banana starch, 1 tablespoon of trelahose for its insulin resensitizong properties and prebiotic benefit and mix this in water I like the combination of walnuts and blue berries with this to potentiate GLP response and for positive effects on bifodo bacteria. Finally, practicing some basic breathing techniques can be helpful. I use a basic 5/5/5/5 box breathing protocol and a 8 second exhale, 1 second pause 3 second inhale, 1 second pause for my 2 go-tos. Tirzapetide is much more mild and has a better effect on lipid dynamics in my experience. Mazdutide (GLP-1/Glucagon combo used commonly in china) is another great option.

[Stephen Matta, DO, MBA, CAQSM]

I echo the comments on tirzepatide.  The GI side effects are much less, including the nausea, which helps compliance.  You also get much more profound weight loss.

[Anthony Castore]

This can be an issue. Some excellent suggestions by people far smarter than me have been listed above. To add to the discussion, I wanted to contribute some things I have found to be helpful.

First: Alternatives

Tirzapetide, in my experience, causes less digestive distress and can be a great alternative.

Specifically, I would consider the following options to replace the benefits you would get from lactulose.

For individuals with extreme lactose intolerance, finding an alternative to lactulose that provides similar prebiotic effects, reduces inflammation in colonocytes, and improves motility is essential. Here are some viable options:

1. Inulin
– Prebiotic Effects:  Inulin is a soluble fiber in many plants, such as chicory root, onions, and garlic. It promotes the growth of beneficial gut bacteria, such as Bifidobacteria and Lactobacilli.
– Anti-Inflammatory: Inulin has been shown to reduce inflammation in colonocytes by promoting the production of short-chain fatty acids (SCFAs) like butyrate, which have anti-inflammatory properties.
– Motility: Inulin can help improve bowel regularity and motility due to its fiber content.

2. Psyllium Husk
– Prebiotic Effects: Psyllium husk is a soluble fiber that can enhance the growth of beneficial gut bacteria.
– Anti-Inflammatory: Psyllium husk has anti-inflammatory properties and can help reduce inflammation in the gut.
– Motility: Psyllium husk helps to bulk up the stool and improve bowel movements, aiding in regularity.

3. Sunfiber (Partially Hydrolyzed Guar Gum)
– Prebiotic Effects: Sunfiber is a soluble dietary fiber that acts as a prebiotic, promoting the growth of beneficial bacteria in the gut.
– Anti-Inflammatory: It has been shown to reduce inflammation and support gut health by increasing the production of SCFAs.
– Motility: Sunfiber improves bowel regularity and can relieve constipation without causing excessive gas or bloating.

-Sun FIber can be especially beneficial for people on a ketogenic diet to bind endotoxins and help with the removal of LPS

4. Resistant Starch
– Prebiotic Effects: Resistant starch is a carbohydrate that resists digestion and reaches the colon intact, feeding beneficial gut bacteria.
– Anti-Inflammatory: Resistant starch increases the production of SCFAs, particularly butyrate, which has potent anti-inflammatory effects on colonocytes.
– Motility: It helps to improve bowel motility and regularity. Examples include Green Bananas, Green Plantains, Cooled Rice or Potato

5. Pectin
– Prebiotic Effects:*Pectin is a soluble fiber in fruits like apples and citrus. It acts as a prebiotic by promoting the growth of beneficial bacteria.
– Anti-Inflammatory: Pectin can help reduce inflammation in the gut by increasing the production of SCFAs.
– Motility: Pectin aids bowel regularity by bulking the stool and promoting peristalsis.

6. **GOS (Galactooligosaccharides)
– Prebiotic Effects: GOS are prebiotic fibers that selectively stimulate the growth of beneficial bacteria in the gut.
– Anti-Inflammatory: They have anti-inflammatory properties and can help reduce inflammation in the colon.
– Motility: GOS can help improve bowel function and regularity.

Choosing the suitable alternative depends on individual tolerance and specific health needs. Inulin, psyllium husk, Sunfiber, resistant starch, pectin, and GOS are excellent options that provide similar prebiotic effects, reduce inflammation, and enhance motility, making them suitable substitutes for lactulose in lactose-intolerant individuals. Consulting with a healthcare provider can help tailor the choice to the individual’s condition and goals.

As previously mentioned, hydration is paramount! I use and recommend NuBioage iCell water. From the pro athletes I have consulted for to the general population I have worked with, it unanimously seems to improve people’s state of hydration and, most importantly, cell volume and polarization.

Another point that often goes overlooked is the importance of movement! I establish an average number of steps before starting a client on a GLP1 and tell them we will increase the total step count by 20% weekly until we get to 8000 steps daily. An example would be if someone starts with an average of 3000 steps, I would have them get 3600 steps daily every day for the first week; I check in with them and hold them accountable. The following week, they will be held responsible for 4320 steps.

Imagine your digestive system as a busy highway. Just as traffic flows smoothly when cars keep moving, your digestion works best when physically active. Movement helps keep the “traffic” (your food and waste) moving efficiently through your digestive tract. Without movement, it’s like a traffic jam – things slow down, leading to discomfort, bloating, and other digestive issues.

1. Stimulates Peristalsis: Walking and other forms of movement stimulate peristalsis, the wave-like muscle contractions that move food through your digestive system. Think of it as giving your digestive highway a gentle push to keep everything flowing smoothly.
2. Enhances Blood Flow: Physical activity increases blood flow to your digestive organs, helping them function more effectively, much like how a well-maintained road network facilitates better traffic movement.
3. Reduces Stress: Movement, especially low-intensity activities like walking, reduces stress and anxiety, which are known to affect digestion negatively. It’s like lowering roadblocks on your digestive highway.
4. Improves Gut Motility: Regular movement helps maintain healthy gut motility, prevents constipation, promotes regular bowel movements, and ensures that your digestive highway is free of blockages.

Simple Ways to Increase Movement and Step Counts Daily

Incorporating more movement into your day doesn’t have to involve drastic changes to your schedule. Here are some easy and practical ways to increase your step count and movement:

1. Park Farther Away:
– When going to work, the store, or any destination, park in the farthest parking spot. This simple change can add a few hundred extra steps each day.

2. Take the Stairs:
– Opt for stairs instead of elevators or escalators whenever possible. Climbing stairs is an excellent way to increase your heart rate and step count.

3. Stand and Move During Phone Calls:
– Stand up and walk around instead of sitting down during phone calls. This habit can easily add extra movement throughout your day.

4. Walk During Meetings:
– If you have phone meetings or casual discussions, consider holding them at walking meetings. Walking and talking can be productive and healthy.

5. Pace While Watching TV:
– During Netflix sessions or while watching TV, pace around the room or march in place. You can also use commercial breaks as a cue to get up and move.

6. Use a Standing Desk:
– Consider using a standing or adjustable desk to alternate between sitting and standing. Standing burns more calories than sitting and encourages you to move more.

7. Set Reminders to Move:
– Set a timer or use an app to remind you to move up every hour. A quick walk or stretch can keep your body active and your digestion on track.

8. Walk to Talk:
– Instead of sending an email or a message, walk to your colleague’s desk. This not only adds steps but also promotes face-to-face interaction.

9. Take Short Walks:
– Incorporate short walks into your routine, such as a 5-10 minute walk after meals. This can aid digestion and help maintain blood sugar levels.

10. Choose Active Hobbies:
– Engage in hobbies that require movement, like gardening, dancing, or playing with pets. These activities can be enjoyable ways to stay active.

Finally, VIP peptide can be a great add-on:

– VIP binds to VPAC1 and VPAC2 receptors on smooth muscle cells, activating adenylate cyclase and increasing cyclic AMP (cAMP) levels. This cascade leads to smooth muscle relaxation, like opening more highway lanes to improve traffic flow.
– VIP promotes the secretion of water and electrolytes into the intestinal lumen, which helps soften stool and prevent constipation. It’s akin to ensuring the roads are well-maintained and debris-free, allowing smooth travel.

–  GLP-1 agonists delay emptying the stomach contents into the small intestine, providing a more gradual release of nutrients. This action is comparable to a traffic light system that regulates the flow of cars to prevent congestion.
– GLP-1 agonists help maintain blood glucose levels by promoting insulin secretion, indirectly influencing GI motility. This effect can be likened to vehicle fuel management, ensuring that the traffic (food) moves efficiently through the system.

– VIP and GLP-1 agonists can work together to enhance GI motility. VIP’s action on smooth muscle relaxation complements the slowing of gastric emptying by GLP-1 agonists. This synergistic effect ensures a steady and coordinated food movement through the digestive system, much like synchronized traffic lights and expanded highway lanes facilitating smooth traffic flow.

– While GLP-1 agonists slow gastric emptying, VIP promotes the secretion of water and electrolytes into the intestinal lumen. This combined action helps maintain optimal stool consistency, preventing constipation. It’s similar to ensuring that roads are well-paved and adequately maintained with proper drainage systems.

– Both VIP and GLP-1 have anti-inflammatory properties. VIP modulates immune responses and reduces cytokine production, while GLP-1 agonists have been shown to reduce inflammation in the GI tract. Together, they act like road maintenance crews that keep the highways clear and repair any damage, ensuring smooth travel.

 

[Flip Troiano]

Anthony,

Thanks for the comprehensive review.

Flip

 

[Mary Ann Butler]

Update:

One of our SSRP colleagues shared with me she puts all her GLP1-RA patients on a Gut Tune Up regimen before starting the GLP1-RA. Not a bad idea.

[Ka Rose]

I had a client on Semaglutide and developed severe constipation.  We found Calm (magnesium powder) worked wonders for her.  You can get it on Amazon or at Costco.

Ka

[Flip Troiano]

Ka,

How much did you have to use?

Flip

 

[Ka Rose]

Hi Flip!

Sorry for the late reply.  Up to 2 tsp (4g)/day.

Best,

Ka

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