Squat toilets and rising fracture rates

You might have heard it said that it’s not what we do “once in a while” that matters, but what we do most of the time that is most important. You know, I think this is true, and we can see it when we look at how different cultures perform some of the most basic tasks. And right now, I’m going to talk about a really basic task and how it affects bone health — humor me for a moment so I can tell you about the difference between Western “throne” toilets and Asian squat toilets.

At a recent international bone meeting (ASBMR), there was extended discussion of the rising hip fracture rates in newly developing countries, particularly in Asia. High on the list of concerns is an expected tsunami of hip fractures in China as that country industrializes. This happened in Hong Kong, Singapore, and Japan, where hip fracture rates among the elderly are now often similar to Western rates, where in pre-industrial times they were less common.

The question of why Asian fracture rates dramatically increase with industrialization was open to speculation. Some saw it as a result of the move from field to factory, which reduced physical activity. Some suggest lower vitamin D levels were responsible, while others pointed at higher rates of smoking, more people drinking colas and eating fast food instead of traditional food and drinks, and so on. But then, one researcher suggested that the increasing fracture rates could be attributed in part to the move from traditional “squat” toilets — basically, a simple hole in the floor with a cover and a pipe leading to the sewer outflow — to modern “throne” toilets. Now this got me thinking about simple activities like squatting, and I wondered just how many of us here in the West could even get down to, and up from, a squat toilet just once, much less several times a day?

Musing on this, I remembered the Mexican Aztec descendants I worked with decades ago in remote areas of Acapulco. They had little furniture and would spend much of their “time off” squatting (with heels on the ground) while chatting, drinking a homemade cactus brew, and just relaxing. In a similar fashion, the Japanese traditionally sat on the floor. A traditional Japanese housewife could move with grace and fluidity from a standing position to bended knees, without spilling, to serve tea to a companion sitting on the floor. Even today in Pakistan, the tradition is to sit on the floor to eat and, of course, to use a squat toilet, as I was told by a Pakistani doctor at the ASBMR meeting. Now, if you were to undertake any of these habits for some time, you will note the strength, balance and flexibility required — and most of us in the West just don’t have it any more.

So how does all this relate to increasing fracture rates in China? Here’s a hint. As hip fractures increased in Hong Kong, so did the rate of fragility and falls (there’s been a 50% increase in falls over the last three decades, in fact). My bet is that while many factors are at play, the most predominate drivers are declines in physical strength, flexibility, and balance, leading to more falls and thus more fractures. What do you think? Let me know.