Optimal Evacuation

I’m often asked my opinion about a diet or a disease is. Who cares what my or anyone else’s opinion is? All we should care about is what the science says. What does the best available balance of evidence published in the peer-reviewed medical literature have to say right now?

Welcome to the NutritionFacts Podcast – I’m your host Dr. Michael Greger.

Today, we examine the best way to have the most regular and otherwise agreeable – bowel movements. And we’re going to start with the best pooping position.

While squatting continues to be the traditional position in populations of Asia and Africa, Westerners have become accustomed to sitting on toilet seats. And when we do that, when we sit upright, our poop is forced to make a nearly 90-degree turn, the so-called recto-anal angle. Now, that’s a good thing in terms of keeping us from pooping our pants every time we sit down. But when it comes to doing our business, the sitting toilet posture defeats the purpose of our body’s brilliant design—like trying to drive a car without releasing the parking brake. Yet, many physicians are hesitant to discuss such an unmentionable bodily function or may just be ignorant. Doctors don’t know squat.
Of course, this is coming from someone who owns a company selling people squatting platforms for their toilets. In a previous video, I talked about those little footstools you can use to raise your knees when you assume a pooping position, but they were not found to make a difference in terms of self-described difficulty in defecating or the average time spent emptying one’s bowels. But those stools give only a measly 4-inch boost. The so-called Squatty Potty is twice that height, and while you have to admire their graphics, from booty blockage to fecal fiesta, complete with little rainbow poops, it had never been put to the test, until now.
The implementation of a Defecation Posture Modification Device, i.e., Squatty Potty, and…it worked! Increased feelings of bowel emptiness, reduced straining, and about a minute off of their on-the-pot reading time. The only downside is the discomfort, even just a 6-inch riser was found to cause such extreme discomfort in research subjects in a previous trial they abandoned even trying to study it.
How else can we get that same change in angle you get from raising your feet? How about just tipping forward? It’s like that famous sculpture by Rodin, The Thinker. And indeed, Cleveland Clinic researchers set out to study “The Thinker” position for defecation, and were able to show an opening of the ano-rectal angle, as measured using cinedefecography, your SAT word for the day—meaning basically x-ray poop movie—opening to more than 130 degrees, better than what you can get just raising your feet, which is only around 90 degrees. So, ‘‘The Thinker’’ position may be a more efficient method for defecation, it may help with constipation, but it has not yet been formally put to the test.
As an aside, you can imagine how the worst position might be flat on your back using a bedpan, because of the spike in blood pressure in your heart and brain when you bear down, straining at stool is associated with sudden death from heart attack and stroke. In fact, it has been found to be the most common activity of daily living being performed at the time of death in Japan, and those who can’t get out of bed would seem to be especially at risk. That’s why, if at all possible, it can help to sit people up in bed to cause less strain on the system.
It’s important to take a step back, though, in this sitting vs. squatting debate, as this commentary did, nearly 50 years ago. Yes, the squatting position is said to be natural, since it is used by so-called primitive peoples who pass large stools easily, such that squatting advocates blame the porcelain throne for all manner of Western maladies, but does the position really make a difference if you’re eating the right foods? The man who squats because he has no modern plumbing also tends to eat more natural foods that haven’t had the fiber processed out. Adding fiber to the diet can enable constipated patients to poop effortlessly without having to squat over some hole in the ground. So, maybe if we just change the design of our diets, we don’t have to change the design of our plumbing.

In our next story, we look at how most people have between 3 bowel movements a day and 3 a week! But normal doesn’t necessarily mean optimal.

Ancient Egypt was one of the great civilizations, lasting for 3,000 years, its knowledge of medicine vastly underestimated. They had medical subspecialties. The pharaohs, for example, had access to physicians dedicated to be guardians of the royal bowel movement, a title alternately translated from the hieroglyphics to mean Shepherd of the Anus. How’s that for a resumé builder?
Today, the primacy of its importance continues, with some calling for bowel habits to be considered a vital sign of how the body is functioning, along with blood pressure, and heart and breathing rates. Although we may not particularly like hearing the details of someone else’s bowel movement, it is a function that nurses and doctors need to assess.
Surprisingly, the colon remained relatively unexplored territory, one of the body’s final frontiers. For example, current concepts of what “normal” stools are like primarily emanate from the detailed records of 12 consecutive bowel movements in 27 healthy subjects from the United Kingdom, who boldly went where no one had gone before. Those must have been really detailed records.
The reason we need to define normal, when it comes to bowel movement frequency, for example, is how else can we define concepts like constipation or diarrhea if we don’t know what normal is. Standard physiology textbooks may not be helpful in this regard, implying that anything from one bowel movement every few weeks or months to 24 a day can be regarded as normal. Once every few months?
Of all human bodily functions, defecation is perhaps the least understood and least studied. Can’t you just ask people? Turns out people tend to exaggerate. There’s a discrepancy between what people report and what researchers find when they actually have them recorded. It wasn’t until 2010 when we got the first serious look, defining normal stool frequency as between three per week and three per day, based on the fact that that’s where 98% of people tended to fall. But normal doesn’t necessarily mean optimal.
Having a “normal” salt intake can lead to a “normal” blood pressure, which can help us die from all the “normal” causes, like heart attacks and strokes. Having a “normal” cholesterol level in a society where it’s “normal” to drop dead of heart disease—our #1 killer, is not necessarily a good thing. And indeed, significant proportions of people with “normal” bowel function reported urgency, straining, and incomplete defecation, leading the researchers to conclude that that kind of thing must just be normal. Normal, maybe, if you’re eating a fiber-deficient diet. But not normal for our species. Defecation should not be a painful exercise. This is readily demonstrable. For example, the majority of rural Africans eating their traditional fiber-rich, plant-based diets can usually pass, without straining, a stool specimen on demand. See, the rectum may need to accumulate four or five ounces of fecal matter before the defecation reflex is fully initiated, and so if you don’t even build up that much over the day, you’d have to strain to prime the rectal pump.
Hippocrates thought bowel movements should ideally be two or three times a day, which is what you see in populations on traditional plant-based diets, on the kind of fiber intakes you see in our fellow great apes, and what may be more representative of the type of diets we evolved eating for millions of years. It seems somewhat optimistic, though, to expect the average American to adopt a rural African diet. We can, however, eat more plant-based and bulk up enough to take the Hippocratic oath to go two to three times a day.
No need to obsess about it. In fact, there’s actually a “bowel obsession syndrome,” characterized in part by ideational rambling over bowel habits, but three times a day makes sense. We have what’s called a gastrocolic reflex, which consists of a prompt activation of muscular waves in our colon within 1 to 3 minutes of the ingestion of the first mouthfuls of food. Even just talking about food can cause your brain to increase colon activity. This suggests the body figured that one meal should be just about enough to fill you up down there. So, maybe we should eat enough unprocessed plant foods to get up to three a day, a movement for every meal.

In our final story today – prunes, figs, and exercise are put to the test as natural home remedies for constipation.

The act of defecation involves a very private sphere and is the object of cultural taboos, so much so that it’s rarely thought of, even by physicians—but it should be. Constipation accounts for three million annual visits to doctors in the United States and 800,000 emergency room visits. Depending on how you define it, up to 80 percent of the population may be suffering. Even people who don’t think they’re constipated may very well be clinically constipated. A quarter of their so-called healthy subjects reported experiencing incomplete emptying, and approximately half indicated increased straining. In fact, more than half had found blood on their toilet paper within the past year. In severe cases, the blood pressure spike associated with straining at stool can even trigger a heart attack or a stroke.
There are drugs for it. There are always drugs, resulting in side effects like headache, nausea, diarrhea, and abdominal pain, leaving most patients unsatisfied. So, why not instead just try to treat the cause? Common causes of chronic constipation include lack of adequate whole plant foods or insufficient water intake, and so making changes in the patient’s diet and lifestyle is the preferred method for relieving constipation. Such nonpharmacological clinical effective interventions include engaging in physical activity for about 30 min a day.
A systematic review and meta-analysis found aerobic exercise interventions help, starting at about 140 minutes a week. And then, of course, a diet centered around whole plant foods, which are the only naturally concentrated sources of fiber. Any plants in particular?
If you give elderly women with severe constipation about a dozen prunes a day they experience significant improvement within the first week. The control group in the study wasn’t told to do anything though. And any time you have one group doing something and the other doing nothing, you can’t discount the placebo effect. And the placebo response for constipation trials can range up to 44 percent, meaning up to nearly half of the people given a sugar pill claimed to experience an improvement. So, that’s why we need studies like this.
Subjects were randomized to about 8 prunes a day plus a large glass of water; 12 prunes and water; or just the water alone; so, even the control group got an intervention they were told might help with constipation. Previous studies mostly assigned 10 prunes or so a day, so the researchers wanted to see if more was better or less was sufficient and…they found a significant improvement in stool bulk on the prunes and a significant increase in bowel movement frequency, though no real difference between 8 and 12; so, 8 a day seems sufficient. Prunes even appear superior to psyllium, sold as Metamucil, beating it out in terms of improved stool frequency and consistency.
We used to think it was just all the fiber in prunes that was helping, but prune juice evidently works too, which, like most juices, has had the fiber removed. Other potential active components include a natural sugar alcohol known as sorbitol that’s used in some sugar-free gum. Once you eat more than a dozen or so large prunes a day, however, the dose of sorbitol could start reaching laxative levels in susceptible individuals. So, be careful.
If you don’t have constipation, should you avoid prunes? That’s been put to the test, and…most people should be able to eat a dozen or so a day without any issues. In fact, it’s interesting to note that prunes have been traditionally used as both a laxative and an antidiarrheal remedy.
What about dried figs, one of the few medicinal plants mentioned explicitly in the Bible. Researchers took patients with the type of irritable bowel syndrome characterized by constipation and randomized them to one fig with breakfast and one fig with lunch, each with a glass of water, and there was a significant improvement in frequency of defecation and a significant drop in the frequency of hard stools, compared to control. Ah, but what was the control? The control group was just asked to continue their normal diet. In other words, to do nothing special. The placebo response for irritable bowel is infamous. Give people with IBS a fake sugar pill, and sometimes 72 percent say they magically feel better. That’s why we need this kind of study: a randomized, double-blind, placebo-controlled trial. Researchers made a gross-sounding placebo fig paste placebo that supposedly had the same taste, smell, and appearance as the real deal. Those who got the real figs, about six a day, seemed to improve colon transit time, stool consistency, and abdominal discomfort compared to the placebo. Researchers measured transit time by having people swallow little beads that would show up on x-rays so they could track the progress thorough their digestive system. They found that those eating the real figs sped up their gut movement by a full 24 hours. Defecation frequency per week didn’t beat out placebo though, and in fact, they tested so many different outcomes even the stool consistency and tummy discomfort results may have been statistical flukes. So, it looks like prunes would be the better treatment choice.
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