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Squat Toilets and Rising Fracture Rates

By Dr. Susan E. Brown, PhD

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 descendents 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.



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We created the Better Bones blog as our forum to express opinions and educate the public about natural means of supporting and improving bone health and overall wellness. As part of this forum, we sometimes discuss medical issues and medications, and their effects on bone health in general. However, we cannot advise readers about specific medical issues in this forum. If you wish to obtain advice from Susan E. Brown, PhD, about your specific bone health and nutritional concerns, please visit our Consultations page. Other specific medical questions should be referred to your healthcare provider.


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We created the Better Bones blog as our forum to express opinions and educate the public about natural means of supporting and improving bone health and overall wellness. As part of this forum, we sometimes discuss medical issues and medications, and their effects on bone health in general. However, we cannot advise readers about specific medical issues in this forum. If you wish to obtain advice from Susan E. Brown, PhD, about your specific bone health and nutritional concerns, please visit our Consultations page. Other specific medical questions should be referred to your healthcare provider.


December 11. 2010 19:42

Very interesting article.I never though in something like that but make a lot of sense. Now we have to do exercises that mimic these people behavior to gain similar skills. I am from Guatemala.The Mayan Quiche's people do the same. Also girls learn very young to carry water on their heads. You see there woman walking with perfect balance with big"tinajas" (recipients made of clay) full of water.

Margarita Rivera Swank

December 17. 2010 17:01

Saludos Margarita,
Thanks for the comment.  When thinking about this topic I was struck by all the traditional lifeways that support bone strength and all the modern ways that seem to limit it.  Perhaps you have noted some other traditional indigenous lifestyle factors that favor bone health? There was an interesting study showing that traditional Mayan women did not loose much bone as they aged, nor did they experience the menopausal symptoms common among Caucasian women.  Be well, Susan (PS, I have the fondest memories of Antigua).

Susan Brown

December 20. 2010 14:15

Thanks so much for this blog post!  I've been struggling with stiff knees lately--and this was NEW for me. Not long ago, I was VERY strong and flexible!

Your post reminded me that my knees felt less painful and were more flexible when I was doing yoga including sitting crosslegged and other knee flexed positions!  In our culture --think about it-- there is almost never a need to fully flex our knees! That evening after I read the post, I started yoga postures again--focusing especially on knee flexing and I my knees are feeling so much better!  Thanks again!
Happy Holiday--Love your site!


March 24. 2011 16:10

I’m so glad to read this article advocating something that so many say is dangerous! I’m a kettlebell instructor and functional movement specialist, certified with the RKC (Russian Kettlebell Challenge) and CK-FMS (Certified Kettlebell-Functional Movement Specialist) and I have Osteopenia and formerly bad knees.  As said in both of my certifications, “rock bottom” squatting is a primitive pattern we were all born with that we lose if we don’t practice it. Both certifications advocate learning how to deep squat for the very reasons you mentioned; strength, flexibility and balance. It’s a little known fact that a deep squat uses also lots of core strength. I teach people how to squat again from a functional movement perspective, and then I load the movement with a kettlebell to create true functional strength. Since I started using kettlebells (along with following an alkaline diet), I have almost completely reversed the Osteopenia in my lumbar spine. My hip has been a slower go of it but my t-score now increases with each Dexa! Squatting is definitely not bad for your knees or hips, it’s quite the opposite and everyone should re-learn how to do it!

Shari Wagner

March 24. 2011 16:41

I've actually started thinking about this when traveling in Italy recently!  I came back and told my fitness instructor that I sure wish I had worked a little harder and squatted a little lower in class before my trip!


March 24. 2011 17:24

They are touting a full squat with your earlobes held with hands crossed a brain booster.A bone and brain booster seems a no brainer.
Thanks for the insight.

Asha Bajaj

March 24. 2011 18:32

That was a great article!  Thank you Dr. Brown for all you do!
I am a 55yr old woman and I have been exercising for 30yrs now.  I was an aerobic instructor and a personal trainer for 16yrs and then became a massage therapist.
I can't stress to you enough, the importance of exercise and especially squats, to keep yourselves fit and our bones strong.
It really is not that hard. One just has to look at it as part of their life. Just like bathing and eating, exercise  must be a part of what we do. Why is this so hard to do??  Right? I know what this is all about.
I stopped exercising between 2001 through 2003. I got remarried and got distracted. I felt the difference and choose to put it back in my life, so I hired a personal trainer and got back into it.
Women, we must exercise, please don't let yourselves go. Make sure to squat everyday!

Nejie Sylvester

March 24. 2011 19:27

There is a relationship between low Vitamin D3 levels and strength of the thighs...More industrialized... outside less and fewer squats mean more balance and fracture issues...

Rick Plumb

March 25. 2011 00:23

i totally agree - use it or lose it.

as a student of the feldenkrais method (beginning 2nd yr of 4 yr course) i am re-learning how to use my body (and brain) in a more effective way with many more options and possibilities.

since i fractured the upper femur right leg almost 2 years ago, i have re-invigorated my bones and now move, walk, sit, lie with far more awareness than i did even in my 20's - i'm 65 now.

and squatting regularly is definitely something that uses many of the body's structural systems and invites muscles to work appropriately if the skeleton is aligned and functioning as it should.

bone density then seems to be less important if flexibility and appropriate choices of use are available.

stephanie stone

March 25. 2011 00:54

Thanks for the article.    A few years ago when I started doing yoga -a couple of power classes and a couple of hot classes every week - I found the squat pose - that's not what it's called but I can't remember the name -I found it very challenging and could not get very far down.  Holding the position was just downright uncomfortable.   Now it's easy and I quite enjoy hanging out there.    The point I'm trying to make is that our bodies can become more flexible.    

Shelley Madsen

March 25. 2011 07:38

Thank you, Dr. Brown, for this great article.
I only recently got back to doing yoga and couldn't believe how difficult to hold the squads had become. As a longtime yoga practitioner and teacher I can't stress enough how important it is to not only get stronger but also more flexible. And as Shelley mentions, our bodies can become strong and flexible at any age. Another great weight bearing exercise are squads with weights. Leslie Sansone has a great DVD were she mixes indoor walking with weight training (plenty of squads included).

Padma O'Mara

March 25. 2011 07:44

great points, all and don't forget that in addition to strengthening and improving flexibility of bone & muscle, these types of moves (stretches, squats, exercises) also improve the condition/ function of the lower intestine and elimination issues.
our bodies were designed to move & work, not sit and stagnate!

Chris Johns

March 25. 2011 08:14

Sounds great but I have a lot of cartilage damage to my knees and the ortho told me squats are bad for my knees. Who to believe? Maybe had I done squats early in life I would not have knee problems, but now they might make my condition worse than better. Don't know.


March 25. 2011 13:06

I'm hoping you are right!  Currently, at 60-plus years of age, I am taking a ballet class, for the purpose of increasing strength, flexibility and balance.  Learning to do the exercises properly is important, to keep from doing damage.  My husband has noticed a difference.

We lived in Asia twice and liked the squat toilets for cleanliness, too.

Linda D

March 26. 2011 18:25

When I was 36 I and my family (6 in all) spent a month in Collioure on the Mediterranean coast. We had a porcelain squat toilet (called a la Turque) and we all found it comfortable.
Better still, it had a pull chain and an overhead tank of water for flushing as well as a pipe that brought in instantaneous hot water from the nearby kitchen for a "telephone" shower. A wooden pallet would be placed across the porcelain of the squat toilet and after our showers we'd rinse the walls with hot water. This was a roofless outhouse open to the sunlight. We admired the French adaptation.

I'm think at 84 I'd no longer be able to appreciate it, alas.  

H. Elias

March 26. 2011 21:11

Hi from Susan Brown to everyone who has responded to this blog. I really appreciate your comments, and am excited that you share my appreciation for squatting as an exercise. I also loved the stories about using squat toilets around the world... more sanitary, less likely to cause straining and constipation and a great exercise to boot!  As for substitutes exercises since we don't have many squat toilets?  Well, I think the "cross brain squatting" exercise Asha speaks of is a great replacement exercise we can easily do daily (it is also known as "Brain Yoga", you can find it on the internet). I try to do this each day. All of the other ideas are great too--like yoga postures, kettlebell.
Be well, keep squatting and keep giving me feedback on my blogs.  Best to all, Susan E. Brown

Susan E Brown

March 27. 2011 12:45

I am a 58 year old yoga instructor.  I agree so much with the squat toilets. They help with the hips, knees, elimination, and balance.

In the western culture, we get out of bed, sit at the breakfast table, sit on the toilet, go sit in a car, to go sit at a job, then may walk, but go sit to watch TV.

When I travel to countries with eastern style toilets, I use them over the Western toilets.  I just wish they would put P traps in them.  


June 21. 2011 17:04

Of course when traveling, those who can manage to use the toilet without touching the seat--not a squat exactly, more like a hover.  I really feel the challenge to my legs when doing that, so I've been trying to do it at home too, at least a few times a day.  Hint:  it helps to put the seat up.  :-]


October 19. 2011 06:59

I so want to join in on this squatting but because I am now disabled after back surgery I cannot balance or me relied on not falling.
Have severe Osteoporosis I cannot afford the falls.
Cnot ge on & off the fall. any suggestions please

Alicia Simcock

October 21. 2011 11:36

Alicia, have you had a vitamin D test? When both osteoporosis and balance are an issue, that suggests that vitamin D might be low. We have a collection of articles about fall prevention that you may find helpful http://www.betterbones.com/bonefracture/healthandsafety.aspx but certainly we'd suggest checking out the vitamin D levels if you haven't already done so. Be well!

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