Optimal Bowel Movement Position

Image Credit: Sally Plank

Optimal Bowel Movement Position

Compared to rural African populations eating traditional plant-based diets, white South Africans and black and white Americans have more than 50 times more heart disease, 10 times more colon cancer, more than 50 times more gallstones and appendicitis, and more than 25 times the rates of “pressure diseases”—diverticulitis, hemorrhoids, varicose veins, and hiatal hernia.

As I discussed in my Should You Sit, Squat, or Lean During a Bowel Movement?, bowel movements should be effortless. When we have to strain at stool, the pressure may balloon out-pouchings from our colon, causing diverticulosis; inflate hemorrhoids around the anus; cause the valves in the veins of our legs to fail, causing varicose veins; and even force part of the stomach up through the diaphragm into our chest cavity, causing a hiatal hernia (as I covered previously). When this was first proposed by Dr. Denis Burkitt, he blamed these conditions on the straining caused by a lack of fiber in the diet. He did, however, acknowledge there were alternative explanations. For example, in rural Africa, they used a traditional squatting position when they defecated, which may have taken off some of the pressure.

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. (I remember sitting in geometry class wondering when I’d ever use the stuff I was learning. Little did I know I would one day be calculating anorectal angles with it! Stay in school, kids :)

How did they figure this out? Researchers filled latex tubes with a radiopaque fluid, stuck them up some volunteers, and took X-rays with the hips flexed at various angles. They concluded that flexing the knees towards the chest like one does when squatting may straighten that angle and reduce the amount of pressure needed to empty the rectum. This idea wasn’t directly put to the test until 2002, when researchers used defecography (which are X-rays taken while the person is defecating) on subjects in sitting and squatting positions. Indeed, squatting increased the anorectal angle from around 90 degrees all the way up to about 140.

So, should we all get one of those little stools for our stools, like the Squatty Potty that you put in front of your toilet to step on? No, they 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. However, in developed nations, it may not be convenient. But, we can achieve a similar effect by leaning forward as we sit, with our hands on or near the floor. The researchers 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.

Instead of finding ways to add more pressure, why not get to the root of the problem? “The fundamental cause of straining is the effort required to pass unnaturally firm stools.” By manipulating the anorectal angle through squatting or leaning, we can more easily pass unnaturally firm stools. But why not just treat the cause and eat enough fiber-containing whole plant foods to create stools so large and soft that you could pass them effortlessly at any angle?

Famed cardiologist Dr. Joel Kahn once said that you know you’re eating a plant-based diet when “you take longer to pee than to poop.”

In all seriousness, even squatting does not significantly decrease the pressure gradient that may cause a hiatal hernia. It does not prevent the pressure transmission down into the legs that may cause varicose veins. And, this is not just a cosmetic issue. Protracted straining can cause heart rhythm disturbances and reduction in blood flow to the heart and brain, resulting in defecation-related fainting and death. Just 15 seconds of straining can temporarily cut blood flow to the brain by 21% and blood flow to the heart by nearly one-half, thereby providing a mechanism for the well-known “bed pan death” syndrome. If you think you have to strain a lot while sitting, try having a bowel movement on your back. Bearing down for just a few seconds can send our blood pressure up to nearly 170 over 110, which may help account for the notorious frequency of sudden and unexpected deaths of patients while using bed pans in hospitals. Hopefully, if we eat healthy enough, we won’t end up in the hospital to begin with.

Wondering How Many Bowel Movements Should You Have Every Day? Watch the video to find out!

The “forcing part of your stomach up through the diaphragm into our chest cavity” phenomenon is covered in my video Diet and Hiatal Hernia. The “ballooning of out-pouchings from our colon” is called diverticulosis. There’s a video I did about 6 years ago (Diverticulosis & Nuts), but I have some new and improved ones available: Diverticulosis: When Our Most Common Gut Disorder Hardly Existed and Does Fiber Really Prevent Diverticulosis?

 More on that extraordinary African data here:

So excited to be able to slip in a plug for Dr. Kahn’s work. His brand of “interpreventional cardiology” can be found at www.drjoelkahn.com.

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:


Michael Greger M.D., FACLM

Michael Greger, M.D. FACLM, is a physician, New York Times bestselling author, and internationally recognized professional speaker on a number of important public health issues. Dr. Greger has lectured at the Conference on World Affairs, the National Institutes of Health, and the International Bird Flu Summit, testified before Congress, appeared on The Dr. Oz Show and The Colbert Report, and was invited as an expert witness in defense of Oprah Winfrey at the infamous "meat defamation" trial.

32 responses to “Optimal Bowel Movement Position

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  1. Hi, I would like to know Dr. Greger’s opinion about the ketonic diets and cancer. And if one can follow this diet on a longter basis

    1. Ketogenic diet is a no no on this site because it is high fat. Don’t bother to ask because the answer will be NO (from an old misconception about fat).

      1. So-called low-carb “Eco-Atkins” diet that are plant-based might be OK for you. It would be best to avoid animal proteins. Treating cancer the ketogenic diet are merely based on anecdotes, however, it may be useful for children with epilepsy and another way to lose weight.

    1. I simply use a small footstool to elevate my knees. It makes everything work much better, even on a vegan diet. Seldom have constipation anyway by giving up meat and dairy.

        1. I think you are correct Jerry. It is the lack of fibre that causes constipation. The point is that when we include meat and dairy in our diet it usually replaces a whole plant which contains fibre and this may lead to constipation.

    2. you must have missed Dr Gregor saying: So should we all get one of those little stools for our stools, like the Squatty Potty that you put in front of your toilet to step on? No, they don’t seem to work.

  2. The most difficult bowel movement I ever experienced was the first one following a three-day water-only fast. I think fasting clinics such as TrueNorth routinely use enemas in such situations.

  3. Hi, I tend to eat lots of beets in my diet, I love them! Raw or cooked – I find my stool is red and my urine is somewhat darker after eating. Should I be concerned in any way?
    Thank you for sharing your passion with the world :)

  4. Thank you, Dr. G., for putting out this important information! Especially the info on diverticulitis. I have a couple of friends who suffer from it. One in particular had part of her colon removed. I’ll be sure to share this with them.

      1. Unfortunately many vegans are vegan to protect the animals and not the planet or their own health. So they eat a lot of junk food (eg sugar, oil & white flour) and not whole plants. This means they can be overweight and suffer from many of the chronic diseases including constipation.

        1. Thanks for sharing this important information Dr. G.
          I eat mostly whole food plant based diet. Very rarely some white bread. And I get constipated very easily. If I had a bad night sleep for example next day I’m constipated. Or If i had any white bread at all it does the same. I find that when I eat more whole plant based raw food I don’t have this problem.

  5. Your knowledge never ceases to amaze, educate and entertain me all at once. I loved you on the many Holistic cruises I have enjoyed, I have your DVDs and your great new “How Not to Die”, which is currently out on loan. Thank you for your work and the fabulous way you present it. I learned so much of this way too late for my huge varicose veins that started in my teens, but otherwise you have helped me be much healthier.

  6. I use my grandchildren’s step stool when I am on the toilet. Initially I tried it to ease the process of defalcating but when my back pain went away I was so impressed that I stuck with it. I stopped using it for awhile and my back pain came back. I looked into it and learned that physical therapy for the back for people who sit a lot is basically stretches and that is what I am getting when I use a step stool on the potty, without taking me any extra time. Of course another alternative is just to lean forward

  7. Personally, I get the same angle without raising my legs up and spending that money on a stool to hold my legs up to produce the movement. I just lower my body down to my thighs and that gives my colorectal structures the same >90 degrees position. Easy Peasy as they say because it works for me.

  8. For a sad example of how such basic issues affect us all, rich and poor, famous and unknown, note that the first announcements of the death of Elvis Presley appearing in the New York Times, stated that the cause of death was “straining at stool.”

    Later editions of the Times removed this information, for obvious PR reasons. Lives and disabilities of thousands of people might have been spared had there been this sort of inquiry and public discussion of the issue instead of hushing it up for fear of the publicity.

    Thank you, Dr. Greger, for bringing this issue, like so many other ignored, but vital, health issues, to the public’s attention.

  9. While camping in Florence, Italy in 1973, I was quite surprised to discover the most unusual toilet when I walked into one of the bathroom stalls: There is was, two concrete slabs spaced about eighteen inches apart a hole in the ground. It didn’t take me too long to figure the position I needed to assume to eliminate my bowel. The process was extremely fast and comfortable, and I have ever since questioned why this is not a more popular method?

  10. I have something called “Nature’s Platform.” http://www.naturesplatform.com/ It’s not like the Squatty Potty, because it fits on top of the toilet bowl with the seated portion raised up to accommodate it (as you’ll see in the picture if you click on the link), so you do a full squat, just as if you were going outside over a hole in the ground.

    It helps if you can do the Asian squat — a full squat with feet flat on the ground. I can do it, but most Caucasians don’t have the flexibility to do it, because the rear heels of their feet rise up when they try it, which tips them forward a bit, so it’s awkward. I’m not sure why I can do it so easily. I guess my Achilles tendons are pretty flexible. It also helps if your knee joints are not too stiff or arthritic. I’m 77 and I can still squat that way, but for some people, especially as they get older, it may be too much of a strain on the knees.

    I would think that if you grow up squatting that way, you should still be able to do it late in life. I grew up using a regular sitting toilet bowl, but I can still squat pretty easily. It probably has something to do with one’s natural biomechanics, which you’re born with.

    The recommendation for using the platform is to completely remove your pants or trousers, which can be a bit time consuming and inconvenient, but I found that when I’m on top of the platform, I can simply drop my pants down around my ankles as I normally would when going on a seated toilet, and go without making a mess. It can take some getting used to, and you have to be able to step up on top of the platform without too much difficulty, which may also be problem for some older folks. But it does make pooping a lot easier, as Dr. Greger indicates.

  11. I can just see (no….please…no!) the typical obese/overweight Murcan trying to “stoop”.

    Main thing would be to watch your weight. Watch your elimination process…do not get in a hurry…let it happen naturally.

    If you have constipation there are always prunes…eaten judiciously 2 at a time. Triphala as a supplement also helps.

    Eat your veggies…watch those peanut binges. Pay attention to which foods cause issues…avoid them and/or take a couple of prunes after.

    As this video explains….straining is a health risk…don’t do it…period. The poop doctor. ;-)

  12. Does this have any significance with how women birth? My mom was made to lay flat on her back when she birthed me and ended up with back spasms and incontinence. I feel like (from birthing two kids myself) that you use the same muscles as when you poop… Has birth position ever killed a women like death by straining? I birthed on my side mostly- holding my knees up kinda like I was squatting only laying down and didn’t have any ill effects. Any thoughts?

    1. Unfortunately, Mikale, the treatment for fistula in ano requires surgical repair. This is not like a fissure that can be treated with other medical options, including keeping stool softer, etc. I have included a link which describes the procedure. Certainly “going under the knife” is not something to be done lightly, but I would schedule an appointment with a doctor you trust to learn more. You can certainly ask about non-surgical treatment, if you haven’t already, but I’m afraid that’s not an option for this condition;

  13. What exactly is the rural African diet? Seems like it might be the best diet ever. Sure, it’s some kind of porridge, but it’s never told exactly what that is. Sure, it’s not a lot of meat. Sure, it’s corn or beans or whatever. But I have yet to see any of you guys, this doc included, say exactly what it is, what’s in it, how to cook it, how much to eat, etc. It’s this nebulous great thing that no one actually knows what it is. I think it’s a the mystery diet that makes people keep thinking this doc has something special up his sleeve. The secret diet. If it’s great, why does no one publish the actual rural african diet? Every meal, every day, that we can make here in the USA? I don’t think these guys, this doc included, actually know the answer to that question. They simply keep mentioning studies from here and wide, none of which say exactly what people ate, just the nebulous “porridge” etc. It’s really weird and far from science. Buy hey, I don’t have a diet to sell either.

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