What should healthy poo look like?

Our expert view on what poo should look like could have a positive impact on your wellbeing and even save your life, says editor Anna Magee

2019 is set to be the year our health and medical choices become more tailored to our needs than ever.

From high tech scanning devices to smart jewellery that tracks your emotions, we’ll be looking closer at our biology and behaviour in order to achieve bespoke solutions.

If you think that means any part of you will be kept private, think again. Artificial Intelligence (AI) company Micron Technology now claims the next target for health analysis will be – wait for it – your poo.

‘Medicine is going toward precision medicine and precision health,’ he told an audience at the Techonomy 2018 conference recently being held along the coast south of San Francisco.

In the future, AI systems will scan your poo before telling you maybe you should eat less red meat

‘You don’t need to be going to visit a physician every six months – if any sign of disease starts showing up, you’ll be able to catch it much faster because of urine analysis and stool analysis.’

Think of AI systems that actively scan your poo and transmit that data elsewhere to be analysed and stored before telling you that maybe you should eat less red meat.

Can’t wait.  But until the dawn of AI stool analysis becomes reality, our best weapon is our eyes.

In fact, according to experts, looking at your poo regularly and being aware of any changes is as important as checking your breasts or testes.

Why you should be looking at your poo

‘I spend a lot of time trying to diagnose early bowel cancer,’ says Dr Edward Seward, consultant gastroenterologist at University College Hospital, London and also Kind Edward VII’s Hospital, London.

‘I don’t want to make people obsessive about what is bobbing around the toilet bowel, but I think people should be having a quick peek.

‘Any change in bowel habits can be a source of something more serious, and having a regular look at your poo helps you understand what is normal for you – a bit like checking your breasts or testes’.

In Germany, toilets have a little shelf that catches solid matter so you can have a little peek before it goes down

In Germany, the toilets are designed with a little shelf that actually catches solid matter before it falls into the water so you can have a little peek before it goes down, asserts Enid Taylor, a US-trained naturopathic doctor who founded London’s Taymount Clinic (where they specialise in faecal transplants).

‘There, it’s very much a part of the German psyche to turn around and inspect what has just come out of you and it’s something more of us should be doing so we can get used to what our bowel habits are really like, then spot and report any changes,’ she says.

What if there is blood in your poo?

Blood in your stool is a red flag as it can be an early sign of bowel cancer, which is the fourth most common cancer in the UK and accounts for 12 per cent of all cancers.

The good news is that with early detection and the UK bowel cancer screening programme for the over-60s, death rates for bowel cancer are almost half what they were in the 1970s. That’s all the more reason to get more poo aware because the sooner you report any changes, the sooner you can get treated.

But if you see blood in your poo, how can you know it’s not just a haemorrhoid? You don’t, so tell your doctor, says Dr Seward.

The textbooks tell you that if you’re bleeding from the back passage and the blood is bright red, that’s reassuring and that if you’re bleeding higher up, blood comes out darker and that’s meant to be more worrying, asserts Dr Seward.

‘But I’ve seen people with more serious diagnoses like polyps [abnormal tissue growths in the bowel that can be early signs of cancer] or cancer and their only symptom has been bright red bleeding,’ he asserts.

The key is to report any blood to your doctor who will make a choice as to whether you need to be referred for a colonoscopy which will photograph your bowel or a stool test that can identify microscopic traces of blood and help confirm or rule out a diagnosis.

Be persistent if your doctor doesn’t pursue the matter though.  Research by Bowel Cancer UK has found that one in five patients with bowel cancer had visited their GP three or more times with the same symptoms before finally being diagnosed.

‘Doctors can’t be ruling out a diagnosis on the basis of symptoms alone’, Dr Seward asserts. ‘If a patient is over 50 and having any bleeding from the back passage, they probably need to be referred for further tests.

‘The reason people die from bowel cancer is because it usually presents late, which is why symptoms cannot be ignored’.

The expert view on your poo

Google ‘Bristol Stool Chart’ and you will get lots of images of different shapes, sizes and textures of poo, categorizing them into seven categories.

Also called the Bristol Stool Chart (BSC), it’s a diagnostic medical tool created by experts at Bristol University and is now used by doctors to help their patients describe their stools and to assist them in explaining why certain stools look and feel a certain way.

In order to convey the different types of poos on the BSC, Healthista commissioned illustrator Harriet Burns to create the following images and spoke to experts about what they may indicate.

Type 1: You’re constipated

what-should-poo-look-like-bristol-stool-chart-Type-1

‘There’s no normal regularity in terms of how often you should poo,’ says Dr Seward. ‘If you go twice a week or five times a day may not matter, it’s whether your bowel habits are interfering with your life, for example by also giving you bloating or pain or they come with other symptoms such as anaemia or sudden weight loss which should always be checked out.’

‘Describing your stools to your doctor is important as some people will report they go five times a day but when you show them the stool chart, they will point to the tiny pellets of Type 1, which means that however often they’re going in a day, if it’s only tiny pellets, they’re still constipated.’

If you have constipation that’s upsetting your life, there are three ways to manage it, suggests Dr Seward.

First make sure you get your five a day. Then, ‘exercise – especially jogging – is great for constipation.

‘You’ll never meet a constipated marathon runner because jogging jiggles the bowels around and that stimulates peristalsis [the involuntary constriction and relaxing of the intestine that helps shift waste through it] – it’s much more effective for easing constipation than swimming or cycling.’  Drinking 2-3 litres of water a day is often helpful.

If that doesn’t work, natural remedies for constipation may include senna tea, syrup of figs as well as flaxseeds which can be taken in a glass of water as they behave like a broom in the intestine (all from health food stores).

The third option is laxatives, which people often worry about taking because they might end up reliant on them.

‘But the laxatives we often use first are called osmotic laxatives and that means the chemical in them is not absorbed by the rest of the body. They work like a sponge, sucking water into the bowel which helps dilute the poo and break it up, allowing it to pass more easily.’

Some foods such as bananas can have a constipating effect, as can medications such as beta-blockers, a blood pressure medicine,. Stress can also a huge impact on people’s bowel habits, says Dr Seward.

Mindfulness and yoga can help along with Cognitive Behavioural Therapy (CBT) – the latter can often be prescribed in association with other bowel measures, though with poor NHS funding, the waiting list is often long.

Type 2: You’re probably straining (or stressed)

what-should-poo-look-like-bristol-stool-chart-type-2

The stool scale is a spectrum, says Dr Seward. ‘So, while we try to think of numbers 3 and 4 on the stool scale as normal, if you’re passing this Number 2 type you’re probably still a bit bunged up but if you have no bloating or pain, you’re probably okay, says Dr Seward.

However, if you are straining and have this kind of poo, well, stop straining.

Straining can cause haemorrhoids, explains Dr Seward. ‘In the old days people would sit on the loo with the newspaper, now they take their phones in and chat to their mates,’ says Dr Seward.

‘But that is a long time to leave your back passage unsupported and can risk the health of the delicate blood vessels in your back passage, leading to haemorrhoids. You shouldn’t be trying to force poo out, wait until you’re ready to release it before you go into the loo.

‘If you’re straining and there is also blood in the poo, tell your doctor.’

‘Poo that looks like this can also be a sign of a ‘compound situation,’ that is your poo compounding and leading to constipation, says Taylor.  ‘It may be caused by not having the right balance of gut bacteria, but it can also be caused by anxiety and stress or simply not being relaxed when you eat.

‘We sometimes find taking tryptophan, which is an amino acid that has a calming effect on the nervous system, can also help calm the bowel down, and assist sluggishness like this,’ Taylor asserts. Biocare’s NT Intensive contains 200mg tryptophan per sachet £2.10.

A useful type of fibre for constipation is resistant starch, says Taylor.  These are carbohydrates that don’t break down into sugars and are not absorbed by the small intestine.  They’re found in whole grains, legumes and pulses and also potatoes that have been left to go cold in the fridge!

Similar to insoluble fibre, resistant starches pass through most of the digestive system unchanged, usually fermenting in the colon.

By decreasing the pH level in the colon and assisting the body in increasing its production of short-chain fatty acids, resistant starches help to create an environment in which beneficial bacteria thrive in the gut – and help keep you regular.

Another form of resistant starches is known as inulin, a substance extracted from vegetables such as chicory and yams and available as a powder from health food stores. 

Type 3: Normal

what-is-poo-supposed-to-look-like-Bristol-Stool-Chart-Type-3

There is a wide variation of normal when it comes to stools, Dr Seward re-iterates. ‘While this general look of sausage like and brown is considered normal, people get worked up over things such as passing more pencil-like stools – I would always check it but it’s rarely anything to be worried about.’

Likewise, colour changes may be important to note, but only if they are dramatic. ‘For example, there are medical conditions that can cause black stools, which is suggestive of bleeding further up the intestine and must be checked out while very pale, chalky stools may be suggestive of a blockage with the bile ducts and a potential problem with the pancreas,’ says Dr Seward.  ‘But don’t get too worked up about subtle changes in stool appearance and colour.’

What if there is always food in there?  ‘Some people have faster intestinal transit than others,’ says Dr Seward. ‘All of us are used to seeing a bit of sweetcorn poking around in their poo, and other types of fibre such as pulses and grains are tough so if you’re eating a lot of lentils, seeds or oats you will probably see bits of them in your poo – but it’s nothing to get worked up about unless you’re anaemic or losing weight as well.’

Indeed, things like sweetcorn are notoriously difficult to break down, but if you’re regularly seeing things like chunks of apple and other identifiable foods look at how quickly you’re eating, Enid Taylor advises.  ‘Are you taking massive bites and not chewing properly; swallowing great chunks of food? This is not going to give your body a chance to digest your food because your digestive juices need food in small chunks.’

So, how much poo is enough? ‘If you have a very healthy microbiome [gut bacteria] and you’re eating a lot of vegetable fibres to feed all that good bacteria and make it grow, you will also be releasing a lot of poo – and the more vegetable fibres you eat, the bigger the pile of poo you produce,’ says Taylor.

‘As long as it comes out without strain or pain, and it looks healthy, a large volume is good!’ she says.

Type 4: Normal

what-should-poo-look-like-Bristol-Stool-Chart-Type-4

‘This too is considered normal and most people considered healthy would vascillate between types three and four, depending on what they had been eating,’ says Taylor.

What about cracks in the side? ‘Cracks in your poo come from solid matter drying on the outside and the stool having a wetter core, then being flexed and moved around the colon, it’s just a mechanical thing and totally normal.’

So, we have to ask – what does the perfect poo look like?

‘The perfect bowel movement would be one smooth, large piece that is softly and easily delivered and folds up on itself in the toilet, almost like a snake,’ Taylor asserts.

‘It would also leave your anal sphincter relatively clean – one wipe and it’s done. If you were in the wild as our ancestors were, they didn’t have reams of toilet paper to polish their bottoms off with, they would just squat, go and then get on with their hunting or gathering.

‘Moreover, if your faecal matter is very sticky, very difficult to wipe clean, it suggests an imbalance of bacteria in your gut,’ says Taylor.

What about smell? ‘Gas and faeces should smell like a freshly turned compost heap; kind of peaty and organic,’ she explains.

Type 5 : Normal, but sloppy

What-should-poo-look-like-Bristol-stool-chart-by-healthista-Type-5

‘I wouldn’t call this particularly unhealthy,’ says Taylor.  If it’s easy to pass and it doesn’t cause damage, tears or straining, then you’re probably fine.  But if you’re passing excessively moist stools (see below), then just watch that you’re not losing too much fluid.

‘if your stool is excessively wet and sloppy, it’s a sign you’re losing water, check your urine output.  If you’re losing a lot of water in the stool, your urine output might be down.

‘Make sure you’re drinking a lot of water – 2-3 litres a day – to keep yourself hydrated.’

Type 6: Diarrhoea

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‘If there is a very sudden onset of runny diarrhoea, there may be an infection there,’ says Dr Seward.

If it is building up slowly and the patient is younger, it could be Inflammatory Bowel Disease [IBD] or diarrhoea predominant Irritable Bowel Syndrome [IBS], you may have coeliac disease which is an autoimmune reaction to gluten, or you could be allergic to wheat or reacting to medication – in any case see your doctor.

‘When you have any kind of sloppy poo or diarrhoea, you’re not only losing water but also electrolytes and this is very dangerous as you can dehydrate very quickly,’ says Taylor.

‘Even if you know it’s food poisoning or a virus, if you’re having diarrhoea more than one or two times, get some rehydration salts from the chemist.’ Dioralyte costs £3.79 from Boots.

Type 7: Watery diarrhoea

What-should-poo-look-like-by-healthista-bristol-stool-chart-Type-7

A constipated person may in fact occasionally also pass only liquid, Enid Taylor asserts.  ‘As more and more faecal matter compounds in the colon, it becomes like furring up a pipe, sticking to the sides of the colon, making the intestinal lining get thicker and thicker with compounded faces until in the middle you only have a tiny ball going through the centre – those small pellets of poo. Sometimes though, when constipation is severe, only liquid can get through’.

‘It’s important that all diarrhoea – whether runny poo or watery diarrhoea – is checked out as there are more serious things that can cause it such as IBD, an umbrella term for diseases called ulcerative colitis and Crohn’s Disease,’ says Dr Seward.

‘Essentially, IBD is a condition where the body’s immune system – rather than doing useful things like killing off bad bacteria and viruses – turns in on itself and attacks the bowel and we don’t know exactly why but it’s probably a complex interplay between genes, environmental stressors such as smoking and the bacteria that live inside your bowel.’

Though treatments for these diseases are currently available, they often may carry risk of significant side effects and so, one of the more recent exciting developments in the area is the use of faecal transplantation, which takes the healthy bowel bacteria of a donor and transplants it into the person with the disease, Dr Seward asserts.

‘There’s lots of data that faecal transplants can improve ulcerative colitis and it’s the focus of intense study right now – we are going to be talking about this more in the future, not only for bowel issues but also for potentially for problems like Parkinson’s disease or even obesity because so many conditions could be related to your gut bacteria.’

Illustrations by Harriet Burns

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