Don’t Sit, squat!

Posted on 19/02/2011

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Now, here’s a topic that might alarm you, but it really shouldn’t, I mean, everybody uses the bathroom – you did this morning, didn’t you? And as the well-worn barb goes: “Even the Queen uses the bathroom!”

Let’s begin with a story…

Shortly before Christmas in 1978, the President of the United States came down with a severe case of haemorrhoids. The pain was so bad that President Carter had to take a day off from work. A few weeks later, Time Magazine asked a proctologist named Michael Freilich to explain the president’s ailment. “We were not meant to sit on toilets,” he said, “we were meant to squat in the field.” He’s probably right. By the way, proctology is the branch of medicine that deals with the diagnosis and treatment of disorders affecting the colon, rectum, and anus

Michael Freilich isn’t the first doctor to suggest that sitting on toilets—a recent phenomenon, stemming from the invention of the flush toilet in 1591—might be unhealthy. By the 1960s and ’70s, the idea was relatively commonplace. Architect Alexander Kira argued in his 1966 book The Bathroom that human physiology is better suited to the squat. According to Bockus’s Gastroenterology, a standard medical text from 1964, “the ideal posture for defecation is the squatting position, with the thighs fixed upon the abdomen.”

Modern-day squat evangelists make money off the claim that a “more natural” posture wards off all sorts of health problems, from Crohn’s disease to colon cancer. There are many modern inventions of what are generally termed – even if derisively, “pit latrines” in Africa and elsewhere. There is also a Japanese toilet that lets users switch among different squatting and sitting postures, from the “East Asian squat” to the “aft sit.”

Let’s review the mechanics of going to the bathroom. People can control their defecation, to some extent, by contracting or releasing the anal sphincter. But that muscle can’t maintain continence on its own. The body also relies on a bend between the rectum – where faeces builds up, and the anus – where faeces comes out. When we’re standing up, the extent of this bend, called the anorectal angle, is about 90 degrees, which puts upward pressure on the rectum and keeps faeces inside. In a squatting posture, the bend straightens out, like a kink ringed out of a garden hose, and defecation becomes easier.

If you think I’m going on and on about this, please don’t be offended, I think it’s important. Do you know how many ‘silent sufferers’ are out there who spend longer than they should in the bathroom. Are you one? Then please listen on…

Proponents of squatting argue that conventional toilets produce an anorectal angle that’s ill-suited for defecation. By squatting, they say, we can achieve “complete evacuation” of the colon, ridding our bowels of disease-causing toxins. But this isn’t so automatic. If squatting does provide a health benefit, just as Michael Freilich stated in Time, it comes in the form of haemorrhoid prevention.

Haemorrhoids may be brought on by pregnancy, obesity, and receiving anal sex. But the main cause is straining during bowel movement. Straining increases the pressure in your abdomen, causing the veins that line your anus to swell. In haemorrhoid patients, those veins stay swollen and sometimes bleed. In theory, squatting might stave off haemorrhoids by making defecation easier, reducing the need to strain and decreasing abdominal pressure.

An Israeli doctor named Dov Sikirov tested this idea for a 2003 study published in Digestive Diseases and Sciences. He had several dozen patients defecate in each of three positions: sitting on a 16-inch-high toilet, sitting on a 12-inch-high toilet, and squatting over a plastic container. He asked his subjects to record how long each bowel movement took and rate the effort required on a four-point scale ranging from effortless to difficult. Sikirov found that, when squatting, subjects averaged a mere 51 seconds to move their bowels, versus 130 seconds when sitting on a high toilet. And as they moved from a sit to a squat, subjects were more likely to rate the experience as easier.

Then last year, a group of Japanese doctors extended these findings by looking at what happens inside the body while people squat and sit. Six subjects had their rectums filled with a contrast solution and then released the fluid from a squatting or a sitting position while being filmed with X-ray video. Image analysis showed that the anorectal angle increased from 100 degrees to 126 degrees as the subjects moved from a sit to a squat. The researchers also recorded abdominal pressure, and found that the subjects were straining less when they squatted.

Of course, it’s one thing to show that squatting streamlines defecation and reduces haemorrhoid risk. It’s another to actually move your bowels while you squat. But how hard could it be? For most of human history—several hundred thousand years—we’ve squatted. Today, 1.2 billion people squat because they simply don’t have a toilet, while many, many more in Asia, the Middle East, and parts of Europe use toilets designed specifically for squatting.

So, how do we us a modern day sit toilet in a squatting position? Besides tipping over, there’s little danger in squatting over a modern sit toilet. Both American Standard and Kohler say that floor-mounted toilets are designed to hold at least 1,000 pounds. (Although, neither company recommends perching.) But squatting on your toilet seat is not for everybody. I tried it all through last week, and even when I was holding onto a towel rack, the situation felt precarious. A bedpan or a plastic container would have been easier, but I didn’t have the former and the latter seemed gross. So I forged ahead: Bowel movements just seem to happen in a squat. My 10-minute routine dropped to a minute, two at the most, and within a few days my knees stopped complaining.

Although the week is now over, I’ll probably squat again. At the very least, I gained an hour over seven days. It seems doubtful, though, that squatting, even if it helps haemorrhoids, will become a popular sell. Sit toilets, in the short term at least, are more comfortable than any kind of squatting. In fact, since Jimmy Carter’s bout of haemorrhoids, sit toilets have actually grown in height, pushing the anorectal angle further in the wrong direction. The peoples of our modern day world, now fatter than ever, are having trouble standing up from a sit, never mind a squat.

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