Editor’s Note: This article is a reprint. It was originally published September 22, 2018.
If you live in the U.S., there’s a good chance you don’t put much thought into the best position in which to poop. You simply sit down on the toilet and let nature take its course. Except, for some people, this process isn’t simple at all. Up to 27% of adults may be chronically constipated,1 which can lead to other problems like anal fissures, rectal prolapse, fecal incontinence and urologic disorders.2
Meanwhile, so-called “pressure diseases,” such as hemorrhoids, varicose veins, diverticulitis and hiatal hernia (in which part of your stomach pushes up through your diaphragm), which may relate to straining excessively to have a bowel movement, are about 25 times more common in the U.S. than they are in rural Africa.3 What’s different? Many things, such as much of the African population eating a traditional, nonprocessed and fiber-rich diet, and using a squatting position to poop.
This latter item may seem inconsequential, but it’s the way humans have been pooping for hundreds of thousands of years. The flush toilet wasn’t even invented until 1596 and didn’t become widely used until 1851.4
Prior to this, elimination took place via chamber pots, outhouses or simply outdoors, sometimes using holes in the ground. As the variety of latrine changed, so, too, did the pooping position, and this swap of sitting for squatting could be having negative consequences on human health.
The Problem With Sitting to Poop
Your puborectalis muscle is an important one, helping you to control elimination during a bowel movement and prevent incontinence when you’re standing. However, when you sit on a typical toilet, this muscle cannot fully relax, which is why you may need to push or even strain in order to have a bowel movement. While squatting, however, the muscle relaxes fully, making elimination easier. Dr. Michael Greger explained via Nutrition Facts:5
“For hundreds of thousands of years, everyone used the squatting position, which may help by straightening the ‘anorectal angle.’ There’s actually a kink at almost a 90-degree angle right at the end of the rectum that helps keep us from pooping our pants when we’re just out walking around.
That angle only slightly straightens out in a common sitting posture on the toilet. Maximal straightening out of this angle occurs in a squatting posture, potentially permitting smoother defecation.”
That the anorectal angle straightens out via squatting is not a fact based on hearsay. In 1966, researchers conducted a study involving latex tubes filled with fluid that showed up on X-rays. Using volunteers, the tubes were inserted and X-rayed as the participants moved in various positions.6 In 2003, researchers conducted a study to compare how long it took people to eliminate while using different positions: sitting on a standard toilet, sitting on a lower toilet or squatting.
Compared to either sitting position, squatting significantly reduced both the time needed for elimination as well as the self-reported amount of straining necessary. “[S]ensation of satisfactory bowel emptying in sitting defecation posture necessitates excessive expulsive effort compared to the squatting posture,” the researchers concluded.7
Again in 2010, researchers examined the influence of body position on defecation in humans. The study was small — only six participants — but it also revealed that “the greater the hip flexion achieved by squatting, the straighter the rectoanal canal will be and, accordingly, less strain will be required for defecation.”8
Could Squatting Reduce the Risk of Certain Diseases?
If squatting makes it easier to eliminate and thereby reduces rates of constipation, it could lead to significant benefits to overall health. For instance, chronic pushing and painful stools may predispose you to large hemorrhoids, which are irritating and painful.
Your colon was designed to hold a few pounds of stool, but when constipated your colon may hold up to 10 pounds of dry, hard feces. Just the sheer volume of stool can stretch your colon, irritate the lining of the colon (mucosa) and produce toxins while waiting to be eliminated from the body.
Chronic constipation can also lead to tearing of the anus, called an anal fissure. These fissures are caused by trauma to the inner lining of the anus, often before a large, dry stool.9 Chronic constipation can also affect the genital and urinary health of women.
Because the colon and female reproductive organs are structurally close in the body, pressure from large amounts of stool in the colon can lead to rectal prolapse in the vagina,10 and increase the potential that the bladder will not empty completely or result in reflux of urine from the bladder back into the kidneys, called vesicoureteral reflux.11
This reflux causes permanent kidney damage and increases the risk of kidney infections. Pushing large, hard stool from the rectum can also result in some of your intestines protruding from the anus, called rectal prolapse. Chronic constipation is a recurring problem in 30% to 67% of patients who suffer from rectal prolapse.12
This requires surgery to repair. When people decide to postpone the surgery, they risk stretching the anal sphincter even further and increasing the amount of intestines that protrude from the body. Chronic constipation has even been linked to rectal cancer, gastric cancer, diverticulitis and ischemic colitis.13 Writing in the journal Lower Urinary Tract Symptoms, researchers further noted:14
“Historically, man has squatted in order to defecate. In Western countries, the dissemination of the sitting toilet took place during the 19th century when sewage systems were developed to improve sanitation. In contrast to Western countries, in Asian and African countries, their dietary habits and use of a squatting posture might contribute to the very low incidence of hemorrhoids, constipation and diverticulosis.
In addition, lower abdominal pressure on squatting defecation might reduce the risk of defecation syncope, deep vein thrombosis and stroke. Therefore, a new toiletry commode incorporating both Western and Eastern approaches is anticipated.”
Do Potty Stools Work?
There are a number of stools on the market designed to help you squat while using a toilet. Do they work? Greger explained:15
“[T]hey don’t seem to work. Researchers tried adding a footstool to decrease sitting height, but it didn’t seem to significantly affect the time it took to empty one’s bowels or decrease the difficulty of defecating. They tried even higher footstools, but people complained of extreme discomfort using them. Nothing seemed to compare with actual squatting, which may give the maximum advantage.”
If you live in the U.S., you can achieve this advantage by squatting on top of your toilet, which does require strength, flexibility and balance, especially if you’re not used to this method. Another option is use of a simple footstool to help you get into a more “squatty” position.
Greger also suggested leaning forward as you sit on the toilet, with your hands on or near the floor. “[R]esearchers advise all sufferers from constipation to adopt this forward-leaning position when defecating, as the weight of our torso pressing against the thighs may put an extra squeeze on our colons,” he said.16
Indeed, if your bowel habits are normal you may feel less inclined to try a new pooping position, but you may be pleasantly surprised if you do so. If you have trouble with bowel movements, especially constipation, I urge you to give the squat position a try and get closer to the ideal position even if you’ve been sitting for decades.
Having Trouble Eliminating? Address Your Lifestyle
Squatting can help you to eliminate if you’re constipated, but it won’t address the reasons why you’re struggling with constipation in the first place. And this is extremely important for optimal health. First off, be sure you are well hydrated, drinking plenty of pure water daily.
The best way to determine how much water you need is to listen to your body and let thirst be your guide. Water is important because as the stool travels through your intestines your body removes water. If you are well hydrated, less water may be removed, leaving the stool softer and easier to pass.
The fiber in your stool will help to draw more water and keep the stool soft. This is why your doctor probably recommends increasing the amount of fiber in your diet to help relieve constipation. However, be aware that if you’re eating a high-fiber diet but not staying hydrated the stool will still get hard and be more difficult to pass. A general recommendation is to make sure you get 20 to 30 grams of fiber per day, but I believe about 25 to 50 grams per 1,000 calories consumed is ideal.
Skip loading up on grains for their fiber content, choosing primarily vegetables instead. Many whole foods, especially fruits and vegetables, naturally contain both soluble and insoluble fiber, which serve as excellent fodder for the microorganisms living in your gut.
Organic whole-husk psyllium is another great fiber source, as are sunflower sprouts and fermented vegetables, the latter of which are essentially fiber preloaded with beneficial bacteria. Regular exercise can also help reduce constipation.
The movement helps increase the motility in your digestive tract and can stimulate the urge to have a bowel movement. When you do feel the urge, don’t wait. The longer the stool sits in your colon, the more water is removed and the more difficult it is to pass. Ignoring the urge to go is also problematic because eventually you may stop feeling the urge.
Certain medications, like antidepressants, antacids (like calcium), blood pressure medications and iron supplements, may also contribute to constipation, as can certain medical conditions (Parkinson’s disease, hypothyroidism, diabetes and more), so be sure to rule out these other contributing factors.
What Does a Healthy Stool Look Like?
If you’re constipated, the bloated feeling and need to strain to have bowel movements will probably tip you off. However, you can also look at the shape and texture of your stool for clues. Separate, hard lumps that are difficult to pass are indicative of constipation. In fact, if you need to push or strain, something is off, as moving your bowels should take no more effort than urinating or passing gas.
Many people get caught up in believing they should be having a certain number of bowel movements, but the ease of elimination is more important than the frequency.
If you move your bowels every other day, but the elimination is easy, you’re within a normal range, more so than someone who moves their bowels more often but has to strain to do so. What’s important is what’s regular for you; in general, three bowel movements per day to three per week is considered the normal range.
As for appearance, healthy stool should be smooth and soft, formed into one long shape and not a bunch of pieces. The Bristol Stool Chart is a handy tool to help you learn what healthy stool looks like. Your stool should approximate types 3, 4 and 5, but type 4 is considered ideal.17 If you’ve addressed your lifestyle and are still straining or having trouble eliminating, it’s time to adjust your position and adopt a squatting position instead of sitting.
