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Many people are familiar with, or have adopted, daily oral and sleep hygiene regimens to improve their health. Now the idea of taking a similar approach to gut health, dubbed bowel hygiene by some, is catching on in clinical practice. 

This concept is gaining momentum as evidence increasingly shows that the microbiome and the mind-gut connection are powerful drivers of functional bowel conditions, Asma Khapra, MD, assistant clinical professor at the University of Virginia School of Medicine, Charlottesville, told Medscape Medical News.

A recent review article published in the Indian Journal of Gastroenterology laid out a “Bowel Hygiene Quintet” that aims to improve gut motility, stool consistency, microbial diversity, and stress resilience. If adopted widely, the model could reduce the burden of chronic gastrointestinal and functional bowel disorders, wrote Manas Kumar Panigrahi, MD, a specialist in gastroenterology at the All India Institute of Medical Sciences in Bhubaneswar, and colleagues.

The five pillars of this multifaceted approach are gut-friendly diet and adequate hydration, physical activity, healthy toileting habits, mind-body practices, and routine timing for eating, sleeping, exercising, and toileting. 

The framework is evolving, and a holistic bowel hygiene model has not been scientifically validated, the authors wrote. However, it is “promising and timely,” given the increased attention to mind-gut connections, they added.

Khapra said she’s seeing a wider shift toward incorporating lifestyle elements, toileting, and mind-body practices into gut health counseling. The framework described in the review article provides a simple guide physicians could use to discuss bowel hygiene with patients and a practical approach to improving gut health at the micro and macro levels, she noted.

Bowel Hygiene in Practice

The multifactorial nature of gut health has been recognized for at least a decade, Yuying Luo, MD, a gastroenterologist at the Mount Sinai Center for Gastrointestinal Physiology & Motility, New York, told Medscape.

“We are recognizing more and more that chronic GI symptoms can be shaped by diet, daily habits, and how the gut and brain communicate,” she said. “Many patients still struggle with GI issues despite medications, or do not want to be on lifelong medications, which has pushed our attention toward what other lifestyle and behavioral factors could be contributing to their GI problems.”

Most clinicians already incorporate many of the review’s bowel hygiene concepts, such as lifestyle counseling and a diet enriched in fiber and low in ultraprocessed foods, in their patient encounters, Luo said.

Each case and patient is different, and issues related to diet and stress may not be present in every patient with GI symptoms; therefore, a personalized approach is needed, she added.

“We don’t necessarily call it ‘bowel hygiene,’ as it can be broadly applicable to other symptoms and disorders of gut-brain interaction,” Luo said. However, explaining the multifactorial nature of gut health is helpful for patients because it makes it clear that factors such as diet and stress can affect GI symptoms, she said.

Taking a multifaceted approach reminds clinicians to assess the variety of factors that can impact GI symptoms, Luo said. For chronic bowel symptoms and constipation in particular, “attention to toileting habits, such as using a squatty posture, are part of what gastroenterologists do assess for and recommend,” she said.

For constipation, Ziad F. Gellad, MD, associate professor of medicine in the Division of Gastroenterology at Duke University Medical Center, Durham, North Carolina, also advises several concepts in the review article, namely adequate fiber, regular toileting, increased hydration and exercise, and behavioral changes such as elevating the feet during defecation, he told Medscape.

Khapra said she has been using the term bowel hygiene for a while to indicate the importance of toilet habits, especially for women with pelvic floor problems or those with hemorrhoidal/anorectal problems.

She gives her patients bowel hygiene tips, including using a stool to achieve a squatting posture at the toilet, avoiding straining (sitting for no more than 5 minutes), and using a bidet, which she described as “life-changing” for many patients with anorectal issues.

Incorporating the lifestyle aspects of bowel hygiene into practice is more challenging, given the increasing demands on physicians and the limited time of an office visit, she said.

“I will provide basic education, but we also have referrals/resources set up for nutrition counseling, GI psychology practitioners, pelvic floor physical therapy, and even a gut directed yoga specialist,” Khapra said.

Lifestyle modification is part of the American College of Gastroenterology’s current clinical guidelines for managing irritable bowel syndrome (IBS). In addition to medications, the guidelines support the use of soluble fiber and gut-directed psychotherapies such as cognitive behavioral therapy and gut-directed hypnotherapy as treatment options.

Although the quality of evidence for these interventions is limited, available data show that they can improve IBS symptom severity as an adjunct to medication by targeting the cognitive and affective factors that impact patients’ experience of symptoms, the guideline authors wrote.

A Public Health Matter?

The global prevalence of constipation, IBS, and other functional bowel disorders is on the rise, fueled by sedentary lifestyles, diets high in processed foods, and chronic stress, Panigrahi and colleagues noted in their review. To address the problem, education about proper bowel hygiene should occur not just at the clinical practice level, but at the public health level, they suggested. 

“By promoting bowel hygiene as a distinct and teachable practice at the home, school, and public health levels, healthcare systems can encourage a preventive culture based on daily behavior,” they wrote.

Additional research is needed to better understand how to most effectively share basic concepts of bowel health and hygiene with the general population,” Gellad said.

One resource the public may turn to for advice is the federal government’s Dietary Guidelines for Americans. The effect the latest version of the guidelines may have on gut health is difficult to determine, Khapra told Medscape.

The guidelines recommend that protein be prioritized at every meal with a target of 1.2-1.6 grams a day; recommend against consumption of highly processed foods; promote consumption of dairy, fruits, and vegetables; and note that fermented foods support a diverse microbiome.

“For an improved microbiome and prevention of chronic disease, we really emphasize high-fiber foods, fermented foods, and a plant-forward diet including whole grains,” Khapra said. Of course, protein is important, Khapra said, but she recommends leaner meats and also endorses plant-forward protein sources if possible, as they have less fat and put less strain on the digestive system. 

Although the new guidelines emphasize protein intake more than previous editions of the guidelines and don’t recommend specific levels of fiber intake, they do call out the importance of a healthy, well-balanced diet for maintaining gut health, Gellad noted.

“Continuing to recommend increased hydration, exercise, and dietary fiber remains a cornerstone of counseling for patients with constipation and should not change with the release of new guidelines,” he added.

As for advising patients on diet, especially in the wake of the updated dietary guidelines for Americans, “everything in moderation is my motto,” Luo said. “Eating a consistently exclusive high-protein diet, especially when low in fiber, can make certain GI symptoms worse.”

Guidelines are meant to offer broad advice, but patients looking to modify their diet to help specific GI symptoms should work with a nutritionist, if possible, and/or their gastroenterologist, Luo added. In general, “a Mediterranean-leaning diet enriched in fiber and fermented foods is considered healthiest for gut health,” she said.

The study received no outside funding. Gellad had no relevant financial relationships to disclose. Luo disclosed research funding from Ardelyx. Khapra disclosed serving as a consultant for Janssen Pharma and is co-founder and chief medical officer of Pandora Health.