Each and every one of us poop. What does your poop say about you? Your poop, stool, feces, or a bowel movement can teach a lot about the health of your whole body. The ancient Ayurvedic medicine and Greek physician and philosopher, Hippocrates, said that all disease begins in the gut. Your bowels are your body’s way of getting rid of wastes and toxins. Your bowels must be completely emptied, not just partially eliminated.
Pooping should not be a painful exercise though. Some degree of urgency to poop, straining, and incomplete evacuation is considered natural. The normal stool frequency is defined as between three per week and three per day (Walter, Kjellstrom, Nyhlin, Talley, & Agreus, 2010). According to Ayurveda, the Indian healing system of medicine, having at least one complete bowel movement a day provides an ideal evacuation. Hippocrates thought that one should poop twice to thrice a day. Some people will have two or three bowel movements a day, and that is absolutely fine. These individuals may have a faster metabolism, they might eat more plant fiber, or have a better bacterial count in their gut. Healthy poop is an indicator of the overall health of your body.
The Perfect Stool
Here are some of the requirements for a perfect stool:
- One complete elimination in the morning
- A brown color
- A banana shape or figure of 8
- Does not stick to the toilet
- Easy to wipe – no mess
- Minimal effort, odor, and gas
- You feel lighter after bowel movement
Let’s examine some published research studies on poop.
Health effects of pooping in sitting, squatting, or leaning positions
When compared to rural Africans who are eating traditional plant-based diets, white South Africans, as well as black and white Americans, have fifty times more heart disease, ten times more colon cancer, and fifty times more gallstones and appendicitis. They have twenty-five times the rate of “pressure diseases,” such as diverticulitis, hemorrhoids, varicose veins, and hiatal hernia (Greger, 2015).
Our poop should come effortlessly. When we have to strain our poop, the raised pressure between sites of luminal obstruction forces diverticulum out between our muscle fibers, causing diverticulitis. The hemorrhoids in our anal region become inflated. The valves and the veins in our legs fail, causing varicose veins. The intra-abdominal pressures raised by straining of poop forces the gastroesophageal junction upwards through the diaphragm, causing a hernia. Straining of stool forces part of the stomach up into the chest, causing acid reflux disease. This is one reason hiatus hernia is uncommon amongst those eating diets rich in fiber, which acts as a natural stool softener (Burkitt, 1975).
What is the best position for pooping: whether you should sit, squat, or lean while pooping
Initially, scientists blamed the pressure diseases on straining while pooping, caused by a lack of fiber in the diet. They later explained that an alternative reason for pressure diseases might be associated with the sitting position while passing a stool. Research shows that adopting a traditional squatting position for defecation might protect the veins of the lower limb from intra-abdominal pressures. For instance, in rural Africa or India, they used traditional squatting position while pooping, and this takes off some of the pressure (Burkitt D. P., 1972).
For hundreds of thousands of years, everybody used the squatting position for the evacuation of stool. This position is helpful in relaxing the rectal muscles and straightens the anorectal angle (Raahave, 2015). At rest, this angle is 80 to 90 degrees. This recto-anal angle is a significant factor in anal continence and thereby keeps us from pooping in our pants while we are walking. When we sit on a Western toilet seat in a common sitting defecation posture, that angle only slightly straightens out. The maximum straightening out of the recto-anal angle takes place in a squatting posture, allowing smoother elimination of poop (Sikirov, 1989).
In a study in the 1960s, ten volunteers with normal anal function were chosen. Latex tubes were filled with radiopaque fluids and inserted into the rectum. Some x-rays were taken with the hips of the volunteers flexed at different angles. The researchers concluded that flexing the knees towards the chest through squatting straightens out the anorectal angle and opens the anal canal. This lowers the amount of pressure necessary to empty the rectum (Tagart, 1966).
Cultural habits can also impact the evacuative function of the rectum. In 2002, scientists used defecography and other radiologic modalities to understand this phenomenon further. The purpose of the investigation was to understand the Iranian and European habits of emptying poop through defecographic measurements. Thirty Iranian patients participated in the study. The patients were told to poop in an unraised, ground-level style toilet requiring squatting (common in developing countries like Iran and India) and a conventional Western style toilet. The x-rays of each participating patient were taken while pooping into both types of toilets. Squatting while pooping in a traditional, non-Western style toilet increased the anorectal angle from 90 degrees to 140 degrees, easing the complete emptying of the bowels (Rad, 2002).
The next question that arises is whether in the Western world we should get a stool to put in front of our Western toilets to place our feet on, as a means to increase the anorectal angle. Research shows that the stools may not work the best as compared to actual squatting. Scientists tried adding foot stools to lower sitting height, but it neither significantly affected the time spent for satisfactory bowel emptying nor decreased difficulty in defecating unlike the squatting posture (Sikirov D. , 2003). Hence, the actual squatting while pooping may be most advantageous, but not convenient in civilized countries such as the United States where we have only the Western toilet seats available in contrast to developing countries such as India where the traditional unraised, ground-level style toilet seats are still available. In the West, a similar effect can be achieved if a person leans forward while sitting on the Western toilet seat, with hands on or close to the floor. Those who suffer from constipation are advised to adopt this forward leaning position while pooping (Tagart, 1966).
It is thought that when the weight of the torso presses against the thighs, it squeezes the colon. This event is opposed while sitting on a Western toilet seat and straining occurs, leading to retention of poop (Raahave, 2015). The major reason for straining is the effort necessary to pass unnaturally firm feces. When we manipulate the anorectal angle by squatting or leaning forward, we can more effectively pass unnaturally firm feces (Burkitt D. , 1975).
Nevertheless, we must not forget to treat the root cause of unhealthy poop. We have to eat enough fiber-containing whole plants to form poop that is large and soft so that it can be passed easily. Bowel function was assessed in fifty-one people. The subjects were divided into three groups according to their diet: omnivores (23g of fiber), vegetarians (37g of fiber), or vegans (47g of fiber). Bowel function was directly correlated to the intake of dietary fiber. The vegans had a much greater frequency of defecation and passed softer poop as compared to vegetarians and omnivores (Davies, Crowder, Reid, & Dickerson, 1986).
Squatting alone while pooping does not statistically significantly lower the pressure gradient that may cause a hiatal hernia (Fedail, Harvey, & Burns-Cox, 1979). Squatting was also no better than sitting in preventing pressure transmission to the leg veins that may lead to varicose veins, according to one study (Martin & Odling-Smee, 1976). Protracted straining can cause cardiac rhythm disturbances as well as reduction of coronary and cerebral blood flow, sometimes creating defecation-related fainting and death (Kapoor, Peterson, & Karpf, 1986). Fifteen seconds of straining to poop can cut blood flow to the brain by 21% (Greenfield, Rembert, & Tindall, 1984). Straining to poop can cut blood flow to the heart by almost 50% (Benchimol, Wang, Desser, & Gartlan, 1972). This provides a mechanism for “bed pan death” syndrome in the hospitals where some patients must have a bowel movement while lying down. This can raise your blood pressure and lead to sudden and unexpected deaths of patients while using bed pans in hospitals (McGuire, et al., 1948).
The pH of our poop and colon cancer
Colorectal cancer causes over 45,000 deaths per year in the United States. Research shows that a high colonic pH promotes colorectal cancer. A high colonic pH indicates the degradation of bile acids and cholesterol into carcinogens by the colonic bacteria, a process that is inhibited once you get a pH below 6.5 (Thornton, 1981). Bile acids should be eliminated from the body in a timely manner so that they are not reabsorbed.
Studies indicate that those at a higher risk for colon cancer have a higher stool pH. South Indians are a high-risk group (pH greater than 8) as compared to North Indians (pH less than 6). Colon cancer is almost twice as common in South Indians than North Indians. This is related to dietary patterns and eating habits. South Indians eat low-fiber foods and a diet low in short-chain fatty acids of milk and fermented dairy products, and might not be chewing their foods properly like North Indians. The North Indian population eats more wheat, a diet rich in fiber, and foods high in fermented milk products such as yogurt and ghee that is created through fermentation. Fiber in the diet makes the stool bulky and fastens transit time, lowering the contact time with chemical carcinogens. Since North Indians consume more fiber in their diet, their risk of colon cancer is lower than the South Indian population. Moreover, the dietary short-chain fatty acids of dairy products in the nutritional plan of North Indians promote acidity in the gut, another factor lacking in South Indian diets. This explains why South Indians get more colon cancer than North Indians (Malhotra, 1982).
There is a 50-fold lower rate of colon cancer in Africa in comparison to America. This is because of the difference in our diets. The bacteria in our gut depends on what we eat. When we eat more fiber like the Africans do, we feed the fiber-eating bacteria, which in return gives us health-promoting substances such as short-chain fatty acids that have anti-inflammatory and antioxidant properties. In America, a higher consumption of animal protein could be one plausible factor for higher stool pH values and hence, a higher rate of colon cancer (Ou, et al., 2013).
The pH of stool in white and black school children in South Africa was studied. Amongst rural black school children, who eat a high fiber, plant-based diet, 90% were able to poop upon request. The mean fecal pH of rural black children was much lower than the fecal pH of white school children who ate a diet high in animal fats. Removing whole plant foods in the diets of rural children increased their fecal pH, and then adding more plant foods like extra servings of fruits decreased fecal pH again (Walker, Walker, & Segal, 1979).
Our intestinal microbiota represents the largest microbial community in the human body. Scientists assessed the fecal samples of vegetarians and omnivores. The vegetarians had a lower stool pH. Now, what about fermented plants? When we consume sour, fermented plants, they increase good bacteria in our gut like Bifidobacterium and Lactobacillus which in turn produce organic acids such as lactic acid or acetic acid, lowering fecal pH. A low fecal pH through a high dietary fiber intake translates into lower counts of bad bugs such as E. coli (Zimmer, et al., 2012). When we eat lots of plants, we have more healthy bacteria in our system and a lower stool pH (Maukonen & Saarela, 2013).
You can bring fecal pH down on a vegetarian diet in two weeks. Twelve healthy white males participated in a study. They consumed three different diets for 20 days each: a mixed western diet, a lactovegetarian diet, and a vegan diet. The effect of diet on mineral metabolism and colonic function was examined. In two weeks, there was a significant drop in fecal pH by eating a complete plant-based diet (Dokkum, de Boer, Faassen, Pikaar, & Hermus, 1983). However, it is important to understand that a beneficial vegetarian diet should not be composed of refined, processed foods. Instead, it ought to contain whole grains, beans, fruits, and vegetables which are high in fiber to nourish the fiber-friendly bacteria in the gut. A decrease in fecal pH lowers the risk of colon cancer (Greger, Stool pH & Colon Cancer, 2015).
Link between constipation and breast cancer
Constipated women are at a higher risk for breast cancer. Studies suggest that there is a link between an increased risk of breast cancer and a decreased frequency of bowel movements along with firm stool consistency. This could be due to the fact that when we are constipated, the contact time between toxins and our intestines increases, which in turn increases the formation and absorption of fecal mutagens (or cancer-causing substances) into the blood circulation and ultimately into breast tissue (Micozzi, Carter, Albanes, Taylor, & Licitra, 1989). Women who poop three or more times a day cut down their risk of breast cancer by almost 50% (Maruti, Lampe, Potter, Ready, & White, 2008).
About 1500 white women participated in a study that looked at the association between frequency of passing a stool and pre-cancerous changes in the breast. There was four times higher risk of breast cancer in women having two or fewer bowel movements in a week as compared to women having more than one bowel movement daily. They found out that non-lactating breast actively takes up and secretes into breast fluid certain chemical substances found in blood. Therefore, it is most probable that many chemical substances in the colon could potentially enter the bloodstream and go into the breast tissue. Since there are mutagens in our poop, toxins from our colon can cause cancer in the breast (Petrakis & King, 1981).
The toxins in our colon that affect the breast health might be bile acids. Bile acids can damage our DNA and are potential carcinogens, as discussed earlier. Bile acids are formed to rid of excess cholesterol. Our liver secretes bile acids into the intestines for disposal, with the assumption that we have sufficient fiber available in the intestines to flush bile acids out of our bodies. When we do not eat enough fiber from whole plant foods, bile acids can be reabsorbed back into the body and reach the breasts (Bernstein, Bernstein, Payne, Dvorakova, & Garewal, 2005).
There is a breast-gut connection that modulates the breast health. The breast cyst fluid can contain carcinogenic bile acids (normally found in the intestines) in concentrations over 100 times greater than those in the bloodstream. The intestinal bile acids are quick to access breast cyst fluid, creating an estrogen-like carcinogenic effect on breast tumor cells (Javitt, et al., 1994). How do we get rid of the bile acids from our body? We can make the oroanal transit time quicker. The oroanal transit time is the pace at which food goes from mouth to poop. A slowed colonic transit can increase bile absorption (Lewis & Heaton, 1999). Again, we can increase the speed of oroanal transit time by consuming lots of fiber in our diet which speeds up the excretion of bile acids (Greger, Breast Cancer & Constipation, 2014).
An interesting correlation between childhood constipation and cow’s milk
Chronic constipation is a common health concern in children. In the 1950s, it was suggested that constipation in children could be due to the intake of cow’s milk. Babies allergic to cow’s milk had no relief from medications but cured immediately as soon as cow’s milk was eliminated from their nutritional regimen (Clein, 1958). Four decades later, this theory was tested. Twenty-seven infants (average age, 20.6 months) with chronic constipation participated in a study. When cow milk protein was removed from their diet, within three days, 21 out of the 27 children were cured. There was a significant improvement: the poop was softer, the frequency of poop increased, and none of the 21 infants had any discomfort in pooping. Once again when the cow’s milk was added to the diet of these patients, symptoms reappeared within 24 to 48 hours, and all of the above 21 patients had a painful pooping experience. A diet free of cow’s milk protein cured constipation, and eczema and wheezing symptoms also disappeared. The scientists concluded that many cases of chronic constipation in infants are because of an allergy to cow milk protein (Iacono, et al., 1995).
Often fiber and laxatives are prescribed to children with chronic constipation. Several laxatives at progressively higher dosages are used, but it does not cure the problem in many cases. One of the very commonly used laxatives is “Miralax”, which is a polyethylene glycol, very similar to antifreeze we put in our cars. I will not use Miralax for my kids. In fact, at the end of a 5-year follow up study, 35-45% of the children on laxatives were still constipated. Research shows that childhood constipation can continue into adulthood. About one-third of the children followed up beyond puberty persisted with the issue of constipation. Surprisingly, eliminating cow’s milk protein from diet often relieves the problem (Irastorza, Ibanez, Delgado-Sanzonetti, Maruri, & Vitoria, 2010).
A double-blind, crossover study was published comparing the effects of cow’s milk and soy milk in children with chronic constipation. A total of 65 children (ages, 11 to 72 months) with chronic constipation (passing a stool every 3 to 15 days) participated in the study. They all took laxatives, which did not help. 49 out of 65 children had anal fissures (a tear in the anus) with inflammation and swelling. They were kept under observation for about two weeks, and thereafter, received cow’s milk or soy milk for another two weeks and then swapped it around. In 44 out of 65 children (68%), constipation resolved while they received soy milk instead of cow’s milk. Anal fissures and pain during pooping became cured on a diet free of cow’s milk and reappeared within 2-10 days when cow’s milk was reintroduced into their nutrition plan (Iacono, et al., 1998). Children drinking more than a cup of milk a day have an eightfold risk of developing constipation and anal fissures (Andiran, Dayi, & Mete, 2003).
For all those children with constipation who do not respond to laxatives and a boost in dietary fiber, removing cow’s milk in their nutritional guidelines ought to be tried. In a 2013 study, researchers took constipated children off of all the dairy products in their diet, and 100% were cured (Crowley, Williams, Roberts, Dunstan, & Jones, 2013). Sometimes, removing not just cow’s milk from the diet but also all other dairy products is important in relieving constipation (Greger, Childhood Constipation & Cow's Milk, 2014).
Eat a fiber-rich, plant-based diet, and avoid processed foods. Supplement with probiotics and fermented foods to maintain a low fecal pH, an important factor in preventing colon cancer. Do not be constipated, as constipation can cause many other diseases including breast cancer. Studies show that chronic constipation can be usually relieved in children by eliminating cow’s milk in their diet. Exercise routinely. Use Indian-style toilet or practice forward leaning while defecating to allow proper emptying of your poop. Enjoy a healthy bowel movement daily.
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