Health promotion and prevention of bowel disorders through toilet designs: A myth or reality?
Sudip Bhattacharya1, Vijay Kumar Chattu2, Amarjeet Singh3
1 Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun, India
2 Public Health Unit, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
3 Professor, Department of Community Medicine, School of Public Health, PGIMER, Chandigarh, India, India
|Date of Submission||30-Jun-2018|
|Date of Acceptance||14-Nov-2018|
|Date of Web Publication||15-Feb-2019|
Dr. Vijay Kumar Chattu
Public Health Unit, Faculty of Medical Sciences, University of the West Indies, St. Augustine
Trinidad and Tobago
Source of Support: None, Conflict of Interest: None
Now, lifestyle diseases are quite common globally. The risk factors of lifestyle diseases such as sedentary habits, lack of physical exercise, and lack of fiber result in the development of noncommunicable diseases. However, when the point of discussion slightly shifted toward toilet habits, it is always seems to be a secret affair. In fact, the discussion of defecation-related matter openly is considered a taboo. This is not uncommon even in medical fraternity. In fact, during the early 1980s, some researches on the association between the diarrhea prevalence, open-air defecation, and latrine use rate were documented. However, nobody acknowledges it socially desirable, now, to discuss defecation-related issues. The public health experts completely ignored the discussion of ill-effects of the use of pedestal latrine on human health. It is evident from scientific studies over a period, that many of the abdominal disorders of the human due change in his toilet habits from a squatting-to-sitting posture using a pedestal latrine. That disease correlation was ignored at that time. The increase in disease burden is due to nonmaintaining the ergonomic design during the construction of this kind of toilets. Squatting posture for the defecation is the most appropriate way, as in this case, abdominal muscles work actively and complete evacuation takes place. To conclude, the time has come to reacquaint people with their natural habits and put this unfortunate experiment to an end.
Keywords: Defecation, health promotion, pedestal toilet, squatting, toilet
|How to cite this article:|
Bhattacharya S, Chattu VK, Singh A. Health promotion and prevention of bowel disorders through toilet designs: A myth or reality?. J Edu Health Promot 2019;8:40
|How to cite this URL:|
Bhattacharya S, Chattu VK, Singh A. Health promotion and prevention of bowel disorders through toilet designs: A myth or reality?. J Edu Health Promot [serial online] 2019 [cited 2019 Sep 22];8:40. Available from: http://www.jehp.net/text.asp?2019/8/1/40/252325
| Introduction|| |
Now, lifestyle diseases are quite common globally and a hot topic of discussion and research among public health researchers. Mostly, such discussion-rotated around on risk factors of lifestyle diseases such as sedentary habits, lack of physical exercise, fast foods, and lack of fiber in the diet. Later, it resulted in the occurrence of noncommunicable diseases such as cardiovascular diseases, diabetes, and obesity. In general discussions, nonacademic such topics are common, and sometimes people discuss this issue openly such as “the cerebral stroke” suffered by their “relatives” or about the “last stage cervical cancer” faced courageously by their “aunts.” However, when the point of discussion slightly shifted toward toilet habits, it is always seems to be a secret affair. In fact, the discussion of defecation-related matter openly is considered a taboo.
This is not uncommon even in public health community in medical colleges of India, where, during 1960s–1970s, debates/discussions on latrines, water seal, and methods of refuse disposal was in vogue. In fact, during the 1970s and early 1980s, some researches on the association between the diarrhea prevalence, open-air defecation, and latrine use rate were documented. However, nobody acknowledges it socially desirable, now, to discuss defecation-related issues. Sadly, despite the recent emphasis on “Public Health” in these departments, the research and discussion on latrines do not find priority. Instead, they have usually limited themselves in heated debates on P value, health economics, universal health coverage etc. It is not surprising; that the public health experts completely ignored the discussion of ill-effects of the use of pedestal latrine on the human health.
It is evident from scientific studies over a period, that many of the abdominal disorders (gastrointestinal diseases such as hemorrhoids, ulcerative colitis, irritable bowel syndrome, and colon cancer) of the human due change in his toilet habits from a squatting-to-sitting posture using a pedestal latrine. These diseases are quite common in developed countries. The disease prevalence is higher among the urban people of South Africa, compared to the rural people with a traditional lifestyle.
| Materials and Methods|| |
The current paper aimed at comparing the two types of toilet designs and literature search was done using PubMed, Google scholar, and Scopus databases for the key terms “toilet designs,” “pedestal latrine,” “squatting posture,” and/or bowel disorders. All the relevant articles were included to support the argument for this narrative review.
| Results|| |
Historically, in Britain royal families and the disabled only used the chair-like toilets. However, later, the practice spread to the common people. For rest of the globe, pedestal toilets denoted, yet an additional symbol of British supremacy. The general impression was the British were successful in improving the “primitive” cultural practices by advocating the pedestal toilets which was followed by the common people in the third world. Hence, within a few decades, most of the industrialized world, for example, Europe, Canada, and United States adopted pedestal toilets-”The Emperor's New Throne.”,
Scientists observed in the late nineteenth century, the sudden emergence of pelvic diseases which was correlated with the change of toilet habits. That disease correlation was ignored at that time. Many scientists rejected the hypothesis, which change in the defecation posture can cause bowel diseases. In fact, from the early days of civilization, human has continuously used squatting position to defecate. Even, children of every civilization automatically learn squatting for defecation. Human body was designed to function by this natural posture.
In India also, it continued till 1980s. With the fast pace of globalization, people have changed their language, dress, food, and even changed their toilet habits also! It has been witnessed in Indian cities in the last two decades, that, pedestal toilet construction took the shape of an epidemic. Whether it is in public or private building, pedestal toilets are constructed without considering the adverse health consequences.
Ergonomic design was not maintained during the construction of this kind of toilets which may be due to a communication gap between the designers/manufacturers of pedestal toilets and the medical knowledge-related to the human physiology or anatomy.
It is evident from the study that defecation by sitting position is a not only difficult process but also it is incomplete one and against nonconsonance with the human physiology and anatomy. This process compels one to exert strain on evacuation. On the traditional pedestal toilet, the intra-abdominal pressure is exerted by pushing the diaphragm down resulted in relaxed abdominal muscle and dysfunctional ileocecal valve. As a consequence of unsupported abdominal muscles, our body suffers later.
Squatting posture for the defecation is the most appropriate way, as in this case, abdominal muscles work actively and complete evacuation takes place as shown in [Figure 1]. There are some health benefits described in the literature.
|Figure 1: Comparison of sitting versus squatting positions. Source: Image credit www.Relfe.com|
Click here to view
Advantages of squatting
- It makes evacuation faster and more convenient
- It prevents “fecal stagnation,” a causative factor for irritable bowel syndrome, inflammatory bowel disease, and appendicitis even colon cancer
- It guards the pelvic nerves from becoming stretched and damaged which control the urogenital organs such as prostate, bladder, and uterus
- It blocks the ileocecal valve temporarily, between the colon and the small intestine, and hence, there is a minimal or no chance of contaminating the small intestine
- It maintains continence by relaxing the puborectalis muscle (which usually chokes the rectum)
- The colon is supported by the thighs which prevent straining which, in turn, prevent hernias and pelvic organ prolapse
- It is a strongly recommended noninvasive treatment in the case of hemorrhoids
- Squatting is also useful for pregnant females by avoiding the pressure exerted on the uterus when using the toilet
- Regular squatting is beneficial for natural delivery.
In fact, it is mentioned in the scientific literature that there may be a relation between the development of hemorrhoids with defecation pattern. The clinicians often advised to the patients suffering from hemorrhoids is to squat for bowel evacuation regularly. Due to the straightening of the anorectal angle during squatting, it reduces the defecation time (i.e., 1 min as compared to 4–15 min in the sitting position) and frequency of straining episodes. Thus, allows smooth evacuation of feces with minimum straining effort., It is also evident that diseases such as hemorrhoids are very uncommon in countries where people squat for defecation, although a causal relationship has not fully established. Majority of our population belong from rural areas, where the predominant mode of defecation still is squatting. In the Indian cities, sitting type of latrine seats is now dominating. Unfortunately, the pedestal latrines installed in public toilets are not found in usable condition due to mishandling. Sometimes, the seat is broken or soiled by urine, even toilet papers are usually missing. Moreover, due to cultural lag, we are still not comfortable with the total package deal, that is, proper use of Western latrine. In fact, not much homework was done for installing pedestal toilets everywhere in India. Biologically, the consistency of fecal matter in India is different as compared to the Westerners, that small volume and hard consistency of fecal matter (due to cold weather) allows the appropriate use of napkin. Even otherwise, chemical-containing toilet papers can create trouble in the piles patients.
Dr. Bernard Cohen, the director of pediatric dermatology at Johns Hopkins Children's Center, and colleagues expressed his concern about developing toilet seat dermatitis to the children. Even, they offered some tips to avoid toilet seat dermatitis (Johns Hopkins Children's Center, News Release, January 25, 2010).
| Discussion|| |
In fact, many people are very shy of their defecation habits. Hence, they prefer their latrines to follow to their culture. For example, traditional squat toilets are well-matched for Indians because of their sense of hygiene and cultural acceptance than pedestal latrines. In this context, it is difficult for people when they are forced to change their defecation habits. Sometimes, defecation-related factors do not remain in their control, for example, it is difficult to get a room with squatting type of latrine in big hotels. Most Indians prefer to wash their bottoms after defecation which is sometimes not possible with the “Western” latrines. As there may not any provision for that except using tissue paper.
Moreover, during the menstruation, pedestal latrines are inconvenient to use for females. Despite numerous medical advantages of squatting, culturally also, squat toilets do suit the Indian people. Further, this has been compared in a tabular form [Table 1] and [Table 2].
|Table 1: Comparison of defecation process in squatting and pedestal type of latrines|
Click here to view
Apart from toilet habits, the pedestal design also affects the women's health. Pelvic floor injury due to the stretching of nerves is the most important cause of the pelvic disease, which affects women more commonly. One probable mechanism is that the gap in the vaginal canal is more prone to stress when women use the sitting toilet. The pressure created by the diaphragm during the defecation and apparent relaxation of abdominal muscles in the sitting toilet pushed pelvic organs into this gap. These results in hernias and other complications such as, uterine prolapse, cystocele, rectocele, and enterocele.
In a broad sense, they are termed as “pelvic organ prolapse.” During later pregnancy and childbirth, the risks of prolapse increase at that time because gravid uterus put extra force to that gap during the defecation in a sitting toilet. Henceforth, the pedestal toilet is to be held responsible again, because it has desalinated women from the natural birthing posture. Simply squatting virtually eliminates the need for the high pressure as it fully opens the birth canal. Surprisingly, clinicians as well as by common women labeed uterine prolapse as a part of an unavoidable set of disorders. This “Unavoidable” ailment means income, so clinicians are reluctant to initiate any promotive health strategies to prevent this “female troubles.” It is also due to huge amounts of their income are at risk, creating an apparent conflict of interest. Fortunately, some clinicians have a more ideological perspective, as they are strongly advocating the squatting posture/squatting exercise for strengthening pelvic floor muscles to prevent any prolapse. Many physicians have worried about the harm caused by their contemporaries in performing needless surgery. Te Linde stated in his book (Textbook on Gynecological Surgery) “-In the practice of gynecology, one has ample opportunity to observe countless women who have been advised to have hysterectomies without proper indications. I am inclined to believe that the greatest single factor in promoting unnecessary hysterectomy is a lack of understanding of gynecologic pathology.” Almost every clinician advocates squatting as the most natural way for defecation. A study was conducted by Alexander Kira, Professor of Architecture at Cornell University regarding the design of the modern toilet and also advocated the same.
The design of the pedestal toilet is an example of absolute neglect of human anatomy. From the last centuries, people from developed countries were compelled to adopt pedestal toilets, while the others (”control group”) used the squatting toilets.
Although the results of this unintentional experiment have been clear and unambiguous. As a result, the experimental group has suffered dramatically higher rates of intestinal and urological disorders. Unfortunately, the findings were misinterpreted by the Western scientists, and they blamed on the bad food habits, that is, “using a highly refined diet.” Despite their deliberate efforts, they have persistently failed to show the association between the changing diet pattern and increase the incidence of bowel disorders.
| Conclusions|| |
Although the medical scientists have been working meticulously to solve these disease mysteries, their progress is not satisfactory enough. Their isolated clinical research has failed to perceive a notable coincidence. Why so many different uncommon bowel diseases suddenly became common in the late nineteenth century? What was a common change in the daily habits of the population? The answer is not very difficult to tell: People changed their squatting posture for routine bodily functions (including childbirth.) The detail anatomical relevance of this change has been explained before. The relevance is also confirmed by the lower incidence of these disorders among the squatting populations.
To conclude, the porcelain throne has caused unnecessary suffering to many. It also wasted billions of dollars of the countries as health-care costs. The time has come to reacquaint people with their natural habits and put this unfortunate experiment to an end.
The authors would like to thank all the authors of those books, articles, and journals that were referred in preparing this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Steyn K, Damasceno A. Lifestyle and related risk factors for chronic diseases. In: Jamison DT, Feachem RG, Makgoba MW, Bos ER, Baingana FK, Hofman KJ, et al.,
editors. Disease and Mortality in Sub-Saharan Africa. 2nd
ed. Washington (DC): World Bank; 2006. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2290/
. [Last accessed on 2018 Apr 07].
Thys S, Mwape KE, Lefèvre P, Dorny P, Marcotty T, Phiri AM, et al.
Why latrines are not used: Communities' perceptions and practices regarding latrines in a Taenia solium
endemic rural area in Eastern Zambia. PLoS Negl Trop Dis 2015;9:e0003570.
Pickering AJ, Djebbari H, Lopez C, Coulibaly M, Alzua ML. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: A cluster-randomised controlled trial. Lancet Glob Health 2015;3:e701-11.
Jacobs EJ, White E. Constipation, laxative use, and colon cancer among middle-aged adults. Epidemiology 1998;9:385-91.
Sikirov D. Comparison of straining during defecation in three positions: Results and implications for human health. Dig Dis Sci 2003;48:1201-5.
Banchoff T. Religious Pluralism, Globalization, and World Politics. USA: Oxford University Press; 2008. p. 359.
Tagart RE. The anal canal and rectum: Their varying relationship and its effect on anal continence. Dis Colon Rectum 1966;9:449-52.
Singh A. Do we really need to shift to pedestal type of latrines in India? Indian J Community Med 2007;32:243. [Full text]
Conlon MA, Bird AR. The impact of diet and lifestyle on gut microbiota and human health. Nutrients 2014;7:17-44.
Schachner LA, Hansen RC. Pediatric Dermatology E-Book. Arizona: Elsevier Health Sciences; 2011. p. 1808.
Kira A. The Bathroom: New and Expanded. New York: Viking Press; 1976.
Kirsner JB. Historical origins of current IBD concepts. World J Gastroenterol 2001;7:175-84.
[Table 1], [Table 2]