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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 2  |  Page : 56-60

Defecation frequency and stool form in rural and urban african settings


Department of Medicine, University of Nigeria Teaching Hospital Ituku, Ozalla, Enugu State, Nigeria

Date of Submission05-Jan-2020
Date of Decision08-Mar-2020
Date of Acceptance16-Mar-2020
Date of Web Publication22-May-2020

Correspondence Address:
Dr. Ekenechukwu Esther Young
Department of Medicine, University of Nigeria Teaching Hospital Ituku, Ozalla, Enugu State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJGH.NJGH_2_20

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  Abstract 


Background: Evaluation of patients who present with diarrhea and constipation requires a good knowledge of what constitutes normal defecation frequency and stool form. This study was designed to determine the normal defecation frequency and normal stool form in adult rural and urban dwellers in Southeast Nigeria.
Materials and Methods: This was an observational, descriptive, cross-sectional, questionnaire-based study of adults in rural and urban settings in Southeast Nigeria. Defecation frequency was recorded as number of bowel motions per week, while stool form was determined with the use of the Bristol stool scale. Variables included in the questionnaire were age, sex, occupation, level of education, use of alcohol, cigarette smoking, use of kolanut, use of coffee, and body mass index. Data were analyzed with SPSS v 23.
Results: There were 670 participants (61.6% females and 56.7% rural dwellers). The 25 and 75 percentiles of the stool form were Bristol types 3 and 4, while the 25 and 75 percentiles of defecation frequency were 7 and 14. Defecation frequency was higher in males than females (P = 0.006), while stool form was significantly affected by age (P = 0.001), sex (P = 0.041), and place of abode (P = 0.001).
Conclusion: In Southeast Nigeria, normal defecation frequency is between 7 and 14 bowel motions per week, while normal stool forms are Bristol types 3 and 4. Age, sex, and place of abode significantly affect defecation frequency and stool form.

Keywords: Africa, defecation frequency, stool form


How to cite this article:
Nwokediuko SC, Ijoma UC, Obienu O, Young EE, Anigbo G, Onyia C, Nwoko U. Defecation frequency and stool form in rural and urban african settings. Niger J Gastroenterol Hepatol 2019;11:56-60

How to cite this URL:
Nwokediuko SC, Ijoma UC, Obienu O, Young EE, Anigbo G, Onyia C, Nwoko U. Defecation frequency and stool form in rural and urban african settings. Niger J Gastroenterol Hepatol [serial online] 2019 [cited 2020 Jun 5];11:56-60. Available from: http://www.njghonweb.org/text.asp?2019/11/2/56/284716




  Introduction Top


Diarrhea and constipation are common symptoms of gastrointestinal disease. An assiduous evaluation of patients who present with these symptoms requires an in-depth knowledge of what constitutes normal stool frequency and form.

The normal act of defecation arises from reflex contraction of muscles of the rectum, relaxation of internal anal sphincter, and an initial contraction of the skeletal muscle of the external anal sphincter. If the condition and environment are not conducive, the urge is not acted upon and the rectal content is returned to the colon through a process of reverse peristalsis. This allows for more water to be reabsorbed, until the next mass peristalsis from the proximal transverse and descending colon. Prolonged delay of defecation leads to hardening of fecal matter, resulting in constipation. On the other hand, if defecation occurs too fast before excess water is absorbed, diarrhea may occur.

An association between constipation and risk of colorectal cancer has long been noted.[1],[2] Prolonged intestinal transit time might not only increase the duration of contact between carcinogens in the stool and the gut wall, but it could also concentrate carcinogens by increasing colonic water absorption.

Bowel habits of different populations may vary widely due to several factors, including dietary habit, quantity of fiber intake, age, gender, and difference in gut transit time.[3],[4] In the Western population, a stool frequency between 3 and 21/week is considered normal.[5],[6] There is a paucity of research data on the stool form and frequency among healthy subjects in Nigeria. The studies carried out so far on this subject are mainly from the northern part of the country.[7],[8]

This study was designed to determine normal stool frequency and stool form in Nigerians from the southeastern part of the country resident in rural and urban areas, using the Bristol stool scale.[9]


  Materials and Methods Top


This was a cross-sectional, questionnaire-based evaluation study of urban and rural dwellers using the Bristol stool scale. Defecation frequency was recorded as number of bowel motions per week.

Out of five states in Southeast Nigeria, two were picked by simple random sampling, and from each state, two local government areas (LGA) were picked, and from each LGA, two communities or clusters were picked, all by simple random sampling. A pilot survey was carried out in two communities during which the study questionnaire was validated. Advocacy visits were arranged to traditional rulers, market leaders, and religious leaders, who eventually facilitated data collection. On the appointed day, the research team went to the study site (markets, village squares, or places of worship). All participants who showed up and consented to participate were included. All those who took laxatives within 1 week of the study were excluded. Data collection lasted from October 1, 2018, to December 20, 2018.

Questions captured by the questionnaire included age, gender, occupation, level of education, cigarette smoking, and use of alcohol, cola, and coffee. Height, weight, body mass index (BMI), waist circumference, hip circumference, and waist: hip ratio were determined for each participant. Statistical analysis was carried out with SPSS v 23 (IBM Corp.). The data were subjected to normality test. The 25 and 75 percentiles were used to determine the normal stool frequency and stool form. Parametric numerical variables were expressed as means ± standard deviation, while nonparametric and categorical variables were expressed as medians and frequencies. Student's t-test was used to determine the difference between means in quantitative variables, while Mann–Whitney test was used to determine the difference between medians in categorical variables. A P < 0.05 was considered statistically significant.


  Results Top


A total of 670 subjects participated in the study; 257 males (38.4%) and 413 females (61.6%). There were 380 rural (56.7%) and 290 urban (43.3%) participants. Their ages ranged from 18 to 90 years (mean = 52.0 ± 15.9). The mean age of the rural dwellers was 55.9 (15.6) years, while that of the urban participants was 46.8 (14.8) years (P < 0.0001).

There were 208 (31.4%) young adults (18–44 years), 298 (45%) in the 45–64 years of age group, and 156 (23.6) in the age group of 65 years and above [Table 1]. There was no vegetarian among the study participants.
Table 1: Characteristics of study participants

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The BMI of the participants ranged from 17.0 to 63.4 kg/m[2] (Mean = 27.5 ± 5.3 kg/m[2]). The mean BMI of male participants was 26.8 ± 3.9 kg/m[2] while the mean BMI of the female participants was 27.9 ± 5.9 kg/m[2] (P = 0.007). The mean BMI of the rural participants was 26.5 ± 4.5 kg/m[2] while the mean BMI of the urban subjects was 28.7 ± 5.9 kg/m[2] (P < 0.001).

[Table 2] illustrates the stool form in the study participants. The 25 and 75 percentiles were Bristol stool types 3 (sausage-shaped stool with cracks on the surface) and 4 (looking like a smooth, soft sausage or snake) [Figure 1]. [Table 3] illustrates the stool frequency in the study participants. The 25 and 75 percentiles were 7 and 14, corresponding to 7–14 bowel motions per week.
Table 2: Bristol stool form in study population

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Figure 1: Defecation frequency and stool form in the study population

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Table 3: Stool frequency in the study population

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Using stool form, 76.5% of the population reported Bristol stool forms 3 and 4 which are the normal forms, 11.7% had stool forms 1 and 2 (constipated stool), while 11.8% had stool forms 5, 6, and 7 (more watery stools). Using defecation frequency, 92.9% reported frequencies within the normal range (7–14 times per week), 3.3% had reduced defecation frequency, while 3.9% had increased defecation frequency.

Defecation frequency was significantly higher in males than females (Mann–Whitney = 46074.5000, P = 0.006). Rural and urban dwellers did not have any significant difference in defecation frequency (Mann–Whitney = 51640.000, P = 0.105).

Stool forms were significantly different between the males and females (Chi-square = 13.12, df = 6, P = 0.041). The most common stool form overall was type 4. Type 4 stool form was present in 57.9% of the females and 62.5% of the males. Similarly, type 3 stool form was present in 17.4% of males and 16.1% of females. Stool types 1 and 2 were more common in females with 3.9% versus 1.6% in comparison with males and 10.8% versus 5.5% respectively.

Stool forms were also significantly different between the rural and urban dwellers (Chi-square = 21.1, df = 6, P = 0.001); 68.3% of the urban dwellers had type 4 stool form, while 53.4% of rural dwellers also had type 4. Stool type 2 was more in the rural dwellers than the urban dwellers; 10.5% versus 6.2%.

Stool forms also differed significantly among the age groups (P = 0.001). Type 4 stool form was seen in 67.6% of young people, 60.3% of the middle-aged participants, and 48.7% of the elderly. Type 3 was reported in 22.8% of the elderly, 17.2% of the middle-aged people, and 11.4% of the young people. Type 6 and Type 1 were all more common in the elderly

Stool frequency and form did not differ significantly across different occupations and different levels of education. [Table 4] summarizes the inferential statistics.
Table 4: Summary of inferential statistics

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  Discussion Top


In this study, the normal defecation frequency was between 7 and 14 bowel motions per week, while normal stool forms were Bristol types 3 and 4. The frequency range is narrower than what has been reported in the developed world (3–21/week).[5],[6] With defecation frequency, 92.9% of the population are normal. Two previous studies from Northern Nigeria used only defecation frequency without factoring stool form in the definition of constipation and diarrhea.[7],[8]

With stool form, 76.5% of the population was classified as normal. Stool form is, therefore, more restrictive in defining normal bowel habit. However, a population survey in Olmsted (Minesota), USA, showed that stool types 3, 4, and 5 constitute normal transit time.[10] This suggests that type 5 stool (soft blobs with clear-cut edges, lacking fiber) may be normal in some populations, especially where the diet is deficient in fiber.

The introduction of Bristol stool scale has made the definition of diarrhea and constipation more robust because both defecation frequency and stool form are now factored into the definitions. The scale measures fecal shape and consistency and is able to differentiate individuals with a fast transit time (loose stools) from those with a slow transit time (hard stools) in healthy subjects[11],[12] and in patients with irritable bowel syndrome.[13] The scale has become a very useful diagnostic tool for the evaluation of samples of human feces with reasonable objectivity. Based on the shape and consistency of stool, a number (1–7) is assigned and that corresponds to descriptions on the scale. With such a chart, people with diarrhea or constipation can clearly describe to their doctor what their stool looks like without bringing it physically.

This study also showed that constipated stool, which corresponds to slow transit time, was more common in females compared to males. Similarly, males had higher defecation frequency compared to females. This pattern has also been reported from other parts of the world including Asia[14] and the western world.[6],[15],[16],[17] This may be explained by the fact that males tend to be more physically active than females and physical activity has been associated with increased defecation frequency.[18] Furthermore, female sex hormones tend to slow gut transit time;[19] however, after menopause, slow transit time may be related to disorders of defecation, resulting from parturition-induced pelvic floor dysfunction.[20]

Another important finding in this study is the effect of age on stool form. Abnormal stool forms were more common in the elderly (Types 1 and 6). This may be explained by the more likelihood of comorbidities and consequent use of drugs in the elderly. It may also be related to the higher tendency to sedentary lifestyle and gastrointestinal infections in the elderly.


  Conclusion Top


Stool frequency and form are the major determinants of defecation-related complaints. The normal stool frequency in rural and urban populations in Southeast Nigeria is 7–14 motions per week, while the normal stool forms are Bristol Types 3 and 4. Constipated stools are more common in females, rural dwellers, and the elderly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Sonnenberg A, Müller AD. Constipation and cathartics as risk factors of colorectal cancer: A meta-analysis. Pharmacology 1993;47 Suppl 1:224-33.  Back to cited text no. 1
    
2.
Kojima M, Wakai K, Tokudome S, Tamakoshi K, Toyoshima H, Watanabe Y, et al. Bowel movement frequency and risk of colorectal cancer in a large cohort study of Japanese men and women. Br J Cancer 2004;90:1397-401.  Back to cited text no. 2
    
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Cummings JH, Bingham SA, Heaton KW, Eastwood MA. Fecal weight, colon cancer risk, and dietary intake of nonstarch polysaccharides (dietary fiber). Gastroenterology 1992;103:1783-9.  Back to cited text no. 3
    
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Gwee KA, Lu CL, Ghoshal UC. Epidemiology of irritable bowel syndrome in Asia: Something old, something new, something borrowed. J Gastroenterol Hepatol 2009;24:1601-7.  Back to cited text no. 4
    
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Heaton KW, Radvan J, Cripps H, Mountford RA, Braddon FE, Hughes AO. Defecation frequency and timing, and stool form in the general population: A prospective study. Gut 1992;33:818-24.  Back to cited text no. 5
    
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Connell AM, Hilton C, Irvine G, Lennard-Jones JE, Misiewicz JJ. Variation of bowel habit in two population samples. Br Med J 1965;2:1095-9.  Back to cited text no. 6
    
7.
Fakunle YM, Ajagbonna O, Ani OE, Awofeso O. Diarrhea, constipation and intestinal transit in a Northern Nigerian population. J Trop Med Hyg 1978;81:137-8.  Back to cited text no. 7
    
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Daniyam CA, Malu AO, Okeke EN, Lawal OO. Bowel habits of urban and rural populations on the Jos, Plateau, Nigeria. West Afr J Med 2011;30:182-7.  Back to cited text no. 8
    
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Choung RS, Locke GR 3rd, Zinsmeister AR, Schleck CD, Talley NJ. Epidemiology of slow and fast colonic transit using a scale of stool form in a community. Aliment Pharmacol Ther 2007;26:1043-50.  Back to cited text no. 10
    
11.
Probert CJ, Emmett PM, Heaton KW. Intestinal transit time in the population calculated from self made observations of defecation. J Epidemiol Community Health 1993;47:331-3.  Back to cited text no. 11
    
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Degen LP, Phillips SF. How well does stool form reflect colonic transit? Gut 1996;39:109-13.  Back to cited text no. 12
    
13.
Heaton KW, O'Donnell LJ. An office guide to whole-gut transit time. Patients' recollection of their stool form. J Clin Gastroenterol 1994;19:28-30.  Back to cited text no. 13
    
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Panigrahi MK, Kar SK, Singh SP, Ghoshal UC. Defecation frequency and stool form in a coastal eastern Indian population. J Neurogastroenterol Motil 2013;19:374-80.  Back to cited text no. 14
    
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Everhart JE, Go VL, Johannes RS, Fitzsimmons SC, Roth HP, White LR. A longitudinal survey of self-reported bowel habits in the United States. Dig Dis Sci 1989;34:1153-62.  Back to cited text no. 15
    
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Sanjoaquin MA, Appleby PN, Spencer EA, Key TJ. Nutrition and lifestyle in relation to bowel movement frequency: A cross-sectional study of 20630 men and women in EPIC-Oxford. Public Health Nutr 2004;7:77-83.  Back to cited text no. 16
    
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Talley NJ, Weaver AL, Zinsmeister AR, Melton LJ 3rd. Functional constipation and outlet delay: A population-based study. Gastroenterology 1993;105:781-90.  Back to cited text no. 17
    
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Heaton KW, Ghosh S, Braddon FE. How bad are the symptoms and bowel dysfunction of patients with the irritable bowel syndrome? A prospective, controlled study with emphasis on stool form. Gut 1991;32:73-9.  Back to cited text no. 18
    
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Bhatia SJ, Reddy DN, Ghoshal UC, Jayanthi V, Abraham P, Choudhuri G, et al. Epidemiology and symptom profile of gastroesophageal reflux in the Indian population: Report of the Indian Society of Gastroenterology Task Force. Indian J Gastroenterol 2011;30:118-27.  Back to cited text no. 19
    
20.
Kepenekci I, Keskinkilic B, Akinsu F, Cakir P, Elhan AH, Erkek AB, et al. Prevalence of pelvic floor disorders in the female population and the impact of age, mode of delivery, and parity. Dis Colon Rectum 2011;54:85-94.  Back to cited text no. 20
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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