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Orgnal Artcle | 22
Address for Correspondence: Atahan Durba, Acıbadem Mehmet Al Aydınlar Unversty School of Medcne, Istanbul, TURKEY
e-mail: atahan.durbas@gmail.com
Recieved: 27.11.2020 Accepted: 11.12.2020 • DOI: 10.4274/tmsj.galenos.2021.08.01.06
Available at https://tmsj.trakya.edu.tr/
ORCID iDs of the authors: NK: 0000-0003-2359-1432 ; AD: 0000-0001-5236-2212; HK: 0000-0002-9949-3188; ÇHS: 0000-0002-6937-8410; ÖE: 0000-0002-9317-8523
Cite this article as:
Nsanur K, Atahan D, Hüseyn K et al. Evaluaton of tolet habts and self-awareness of constpaton statuses among young adults from derent facultes at Acıbadem Unversty. Turksh Med Stud J 2021;8(1):22-7.
Copyrght@Author(s) - Avalable onlne at https://tmsj.trakya.edu.tr
Moreover, women are 1.5 times more likely to be constipated than
men (3). Insucient uid intake can also be one of the causative
factors for constipation by forming a hard stool (15).
e study conducted by Dehn et al. (16) demonstrated the re-
lationship between toilet habits and the risk of hemorrhoids. Gold-
stein et al. (17) attempted to examine the relationship between
constipation and reading habits during defecation. However, this
study included many bowel diseases besides constipation, and only
toilet reading was questioned. In a recently published paper, Ber-
ney (18) stated that over the last few years they have been getting
a lot of complaints from young adults with no signicant risk fac-
tors referred to them with symptomatic hemorrhoidal disease. He
found that the patients mostly reported prolonged sitting time on
the toilet due to frequent smartphone usage therefore decided to
ask patients presenting with gastrointestinal symptoms about their
smartphone usage during their time on the toilet (18). In his paper,
he named this situation the “Smartphone Lavatory Syndrome” (18).
e study by Çelik (19) attempted to investigate the relationship
between hemorrhoid incidence and smartphone use in Turkey,
however, the study is not yet completed.
is study aims to evaluate Acıbadem University students’
self-awareness of their constipation statuses and investigate whether
INTRODUCTION
Constipation can be dened as infrequent defecation or hard
passage of stools (1). e prevalence of constipation is 8.3% in Tur-
key (2) and approximately 20% around the world (3-5), being one
of the most common gastrointestinal complaints. However, it is still
dicult to determine the exact prevalence of constipation since
self-reported constipation is a subjective complaint dependent on
the self-awareness and the denition used to identify “constipation”.
It has also been shown that self-reported constipation ndings are
neither sensitive nor specic compared to constipation diagnosis
made with symptom-based criteria (5-7). e Rome IV Diagnostic
Criteria are expert consensus criteria that have long been used by
gastroenterologists for the diagnosis and classication of functional
gastrointestinal disorders (8, 9). One of the criteria for the diagnosis
of functional constipation is lumpy or hard stool defecation which
is classied as Type 1 and Type 2 according to the Bristol Stool Form
Scale is widely used in clinical practice for stool form measurement
(10, 11). Additionally, many factors alter the prevalence of consti-
pation such as age, gender, eating habits, water consumption, and
physical activity (12-14). e prevalence of constipation increases
in the elderly since the colonic transit time slows down with age.
EVALUATION OF TOILET HABITS AND SELF-AWARENESS OF
CONSTIPATION STATUSES AMONG YOUNG ADULTS FROM
DIFFERENT FACULTIES AT ACIBADEM UNIVERSITY
Nsanur Kaygısız , Atahan Durba , Hüseyn Karaman ,
Çağla Hamde Solman , Özdal Ersoy
Acıbadem Mehmet Al Aydınlar Unversty School of Medcne, Istanbul, TURKEY
Department of Gastroenterology, Acıbadem Internatonal Hosptal, Istanbul, TURKEY
ABSTRACT
Aims: To evaluate Acıbadem University students’ self-awareness of their constipation statuses and investigate whether there is an association between consti-
pation and prolonged sitting time in the toilet aected by toilet habits. Methods: is cross-sectional study was conducted from March 7 to April 3, 2019, at
Acıbadem Mehmet Ali Aydınlar University. e questionnaire consists of 3 parts and a total of 16 questions. e rst part asked about the participants’ gender,
age, faculty, and school year to collect their demographic information. e second part investigated participants' awareness of constipation and factors aecting
constipation. e last part included questions about toilet habits and their sitting time in the toilet. e constipation status of participants was evaluated using
the Rome IV Diagnostic Criteria and the self-awareness of participants about their constipation statuses was assessed. Results: 293 students from 5 dierent
faculties (Medicine, Pharmacy, Medical Engineering, Nutrition and Dietetics, and Psychology) of Acıbadem University participated in our study. Our results
showed that 22.54% of students were appeared to be constipated. Out of all the students, 24.45% of them were unaware that they were constipated. e use of
smartphones was the most common toilet habit, and it increased the time spent sitting on the toilet. Constipation was seen at higher rates among students who
spent a longer time on the toilet. Conclusion: Our study demonstrated that having toilet habits increased the time spent sitting on the toilet. Our study also found
that as the time spent on the toilet increased, the prevalence of constipation among participants increased accordingly. Poor eating habits and sedentary lifestyles
of young adults may have a cumulative eect on constipation. Raising public awareness regarding proper defecation routines and limiting toilet habits and sitting
time on the toilet seems essential to prevent constipation. Keywords: Constipation, toilets habits, lifestyle, smartphone, young adult
OPEN ACCESS
23
Questions Answe rs
1st Part: Demographics of Participants
1) Gender
2) Age
3) Which faculty are you enrolled in?
4) Which year are you enrolled in?
2nd Part: Awareness of Constipation and Factors Aecting Constipation
5) Which of the following do you think describes constipation? a) Using the toilet less oen
b) Having diculty in defecation
c) Sitting on the toilet for a long time
d) Bleeding while defecating
e) Formation or palpation of hemorrhoids
f) Lack of urge to defecate
g) Bloating and excess gas in the intestines
h) Other
6) Do you think you are constipated? Yes / No / No idea
7) Please mark the criteria below that you have in at least 1 of every 4 stools
(≥25%):
a) Straining during defecation
b) According to the Bristol Stool Form Scale:
Type 1 (separate, ball-like stools) or,
Type 2 (lumpy, sausage-shaped stool)
c) Sensation of incomplete evacuation aer defecation
d) Sensation of anorectal obstruction/blockage during defecation
e) Use of drugs that facilitate defecation (laxatives)
f) I do not experience any of the above
8) Choose the one that suits you from the following accommodation types: With family / Dormitory or shared house / Other
9) Do you think you are eating a healthy and balanced diet? Yes / No / No idea
10) How oen do you consume ber-rich foods such as fruits, vegetables, legumes,
and cereals?
Every day / Few times a week / Once a week / Few times in a month / Once a month
11) How much water do you drink in a day approximately? (1 glass of water is
about 200 mL)
<1 L / 1-2 L / 2-3 L / >3 L
12) When you think about your normal day, how active do you think you are? I go on a walk every day / I go on a walk every other day / I go on a walk at least 3 days
a week / I go on a walk once a week / I do not go on a walk routinely / Other (you can
write down other sports you practice)
3rd Part: Toilet Habits and Sitting Time on the Toilet
13) How oen do you defecate? More than once a day / Every day / More than 3 times a week / Less than 3 times a week
14) Do you have abdominal pain and/or abdominal bloating, discomfort that
you feel relieved of when you go to the toilet?
Yes / No
15) Approximately how long do you stay on the toilet when you go to defecate?
(in minutes)
<5 / 5-10 / 10-15 / 15-20 / >20
16) Are you being busy with something else while defecating? a) Smoking
b) Reading newspaper/ magazine
c) Solving puzzle/sudoku
d) Using cellphone/tablet
e) Other
f) None
there is an association between constipation and prolonged sitting
time on the toilet induced by toilet habits.
MATERIAL AND METHODS
Research design
Our study was approved by the Acıbadem University Medical
Research Ethics Committee (Protocol Code: ATADEK 2019-4/7).
Informed consent was obtained from the students before they par-
ticipated in the study. is study was conducted from March 7 to
April 3, 2019, at Acıbadem Mehmet Ali Aydınlar University. e
questionnaire in the Turkish language was carried out as hand-
outs and distributed to participants via an interviewer. e ques-
tionnaire consists of 3 parts and a total of 16 questions (Table 1).
Table 1: e questionnaire used in the study.
e participants were able to choose more than one option for the 5th, 7th and 16th questions.
e rst part asked about the participants’ gender, age, faculty, and
grade to collect their demographic information. e second part
investigated participants' awareness of constipation and factors
aecting constipation (accommodation, water and ber consump-
tion, physical activity). e last part included questions about toilet
habits (what they do on the toilet during defecation) and their sit-
ting time on the toilet. Participants had to complete at least half of
the questionnaire to be included in the study. e participants who
completed less than half of the questionnaire were excluded from
the study. Moreover, participants who completed more than half of
the questionnaire but did not answer particular questions were ex-
cluded for only the questions that they did not answer. Additionally,
participants were able to choose more than one option for the last
question which asked about their toilet habits.
24
Figure 1: Bristol Stool Form Scale (11).
(© 2016 Rome Foundation, Inc. All Rights Reserved. Reprinted with
permission from the Rome Foundation; all rights reserved.)
Data analysis
e data were analyzed using Microso Excel (2016). e vari-
ables were tested for normal distribution by the Shapiro-Wilk Test.
A p-value <0.05 was set for statistical signicance. Numbers, per-
centages, mean, and standard deviation were used as the descrip-
tive statistics for this study. Categorical variables were compared by
using the Chi-squared test. e multivariate linear regression anal-
ysis was used to predict the value of constipation on the value of
variables such as gender, age, accommodation, ber consumption,
water consumption, and physical activity.
RESULTS
s study was conducted on 293 students from the most po-
pulated 5 facultes of Acıbadem Mehmet Al Aydınlar Unversty.
e results of ths study were evaluated based on the answers of
291 students snce 2 partcpants were excluded from the statstcal
analyss as they dd not meet the ncluson crtera. A total of 80
medcal students, 63 nutrton and detetcs students, 82 psychology
students, 29 medcal engneerng students, and 39 pharmacy stu-
dents were ncluded n the study. e mean age of the students was
20.43 ± 1.73 years. Demographcs of the partcpants are presented
n Table 3.
Table 2: Rome IV Diagnostic Criteria for functional constipation.
Must include two or more of the following:
1. Lumpy or hard stools (Bristol Stool Form Scale 1-2) more than ¼
(25%) of defecations
2. Sensation of incomplete evacuation more than ¼ (25%) of defeca-
tions
3. Sensation of anorectal obstruction/blockage more than ¼ (25%) of
defecations
4. Manual maneuvers to facilitate more than ¼ (25%) of defecations
(e.g., digital evacuation, support of the pelvic oor)
5. Fewer than three spontaneous bowel movement per week
6. Loose stools are rarely present without the use of laxatives
7. Insucient criteria for irritable bowel syndrome
Criteria fullled for the last 3 months with symptom onset at least 6
months prior to diagnosis.
In the questionnaire, the Rome IV Diagnostic Criteria (Table 2)
was used to diagnose whether participants are constipated or not
(12). Furthermore, the Bristol Stool Form Scale (Figure 1) was add-
ed to the questionnaire to classify the participants' shape of stool
(13). Besides, participants were asked to dene constipation and in-
dicate whether they think they are constipated or not to determine
the participants’ self-awareness of constipation. e 5th question
aimed to determine the level of personal knowledge of constipation
based on how well the participant knew the denition of constipa-
tion. If the participants who chose the correct denition of con-
stipation here chose themselves as constipated in question 6 and
were evaluated as constipated according to the Rome IV Diagnostic
Criteria in question 7, this participant was considered to be "self-
aware" of their constipation status, and the opposite situation was
also valid. erefore, the participant’s self-awareness was a complex
outcome that has emerged as a result of the analysis of the answers
to more than one question. e participants’ toilet habits were also
investigated in the questionnaire. According to expert opinion, it
is not recommended to sit on the toilet for more than 5 minutes.
However, a span of 5 minutes may not be a very long time for the
participants to notice that they have been sitting on the toilet for
too long. erefore, to ask if the participants had been sitting on the
toilet for too long, the 10 minutes was deemed more appropriate to
be included in the questionnaire.
Table 3: Demographics of participants.
Number of Students [n (%)]
Gender
Male
Female
Not specied
67 (23.0)
223 (76.6)
1 (0.3)
Age Group (years)
18 – 20
21 – 23
> 23
169 (58.1)
117 (40.2)
5 (1.7)
Grade
1
2
3
4
87 (29.8)
120 (41.2)
63 (21.6)
21 (7.2)
Facult y
Medicine
Nutrition and Dietetics
Pharmacy
Medical Engineering
Psychology
80 (27.5)
62 (21.3)
38 (13.1)
29 (9.9)
82 (28.2)
Accordng to the Rome IV Dagnostc Crtera, 64 (22.54%)
partcpants were found constpated. Out of 291 partcpants, 45
(15.46%) of them descrbed themselves as constpated. Out of 45
partcpants who descrbed themselves as constpated, 34 (75.56%)
of them were truly constpated accordng to the Rome IV Dag-
nostc Crtera. Moreover, 17 of 291 partcpants (5.84%) dd not
have an dea about ther constpaton statuses. e self-awareness
of students on ther constpaton statuses s presented n Fgure 2
and Fgure 3. Medcal students had the hghest rate of awareness
wth 94.26% whereas nutrton and detetcs students were found
to have the lowest awareness wth 69%. Pharmacy, medcal engne-
erng, and psychology students’ awareness rates were 85%, 82.96%,
and 80.14%, respectvely.
25
Table 4: Results of multivariate analysis with gender, age, accommodation type, ber consumption, water consumption and physical
activity as independent variables and constipation as the dependent variable.
Independent variables Beta
coecients
Standard
Error
t Stat P-value
Intercept -0.077 0.100 -0.768 0.443
Gender Female / Male 0.159 0.062 2.547 0.011
Age >20 / =<20 -0.002 0.050 -0.041 0.967
Accommodation type Dormitory / House 0.150 0.049 3.062 0.002
Fiber consumption Everyday / Not everyday 0.023 0.052 0.436 0.663
Water consumption => 2L / Less than 2 L -0.119 0.059 -2.038 0.042
Physical activity At least 3 times a week / Less 3 times a week -0.003 0.053 -0.051 0.960
Figure 3: e comparison of students (Faculties of Medicine,
Nutrition and Dietetics, Pharmacy, Medical Engineering, Psy-
chology, respectively) according to their self-awareness on their
constipation statuses (i.e. who was not diagnosed as constipated
and also did not dened themselves constipated as well).
Figure 2: e comparison of students (Faculties of Medicine, Nu-
trition and Dietetics, Pharmacy, Medical Engineering, Psycholo-
gy, respectively) according to their self-awareness on their consti-
pation statuses (i.e. who was diagnosed as constipated and also
dened themselves constipated as well).
e multivariate linear regression analysis of dierent vari-
ables that could play a role in constipation is presented in Table 4.
A signicant regression equation was found (F(8.273) =4.066025,
p<0.001) with an R2 of 0.11. According to participants’ character-
istics and preferences; gender, water consumption, and types of ac-
commodation were signicant predictors of the constipation status
of participants (p=0.01, p=0.04, p=0.002, respectively). 28.24% of
participants who were staying in a dormitory or a shared house
were found to be constipated, while only 14.51% of participants
who lived with their families were found to be constipated. Fiber
consumption and physical activity were not signicant factors for
determining constipation status (p=0.66 and p=0.95, respectively).
Smartphone/tablet use (69.76%) was the most common toilet habit
among participants, whereas the rates of smoking, reading newspa-
per/magazines, and solving puzzles/sudoku were 5.5%, 4.12%, and
2.41%, respectively. 79 participants (27.15%) stated that they had no
toilet habits. 81 of the participants who had at least one toilet habit,
also had prolonged sitting time (>10 minutes) on the toilet. Table
5 shows that having toilet habits and prolonged sitting time on the
toilet were signicantly associated, (χ2(1, N=291) =12.569, p-val-
ue<0.001). Furthermore, 26 of the participants who were diagnosed
as constipated according to Rome IV Diagnostic Criteria also had
Table 6: e relationship between time spent on the toilet and state
of constipation presented as numbers of participants
(p-value =0.001).
Diagnosed as
constipated
(n)
Not diagnosed
as constipated
(n)
Tot a l
Sits on the toilet more
than 10 minutes 26 46 72
Sits on the toilet less
than 10 minutes 38 174 212
Tot a l 64 220 284
prolonged sitting time on the toilet. As shown in Table 6, being
constipated and having a prolonged sitting time on the toilet had
a signicant association (χ2(1, N=284) =10.183, p-value =0.001).
60 participants who were diagnosed as constipated also had toilet
habits. However, as shown in Table 7, there was no signicant as-
sociation between being constipated and having toilet habits (χ2(1,
N=284) =3.293, p-value =0.07).
(7 participants were excluded from the statistical analysis due to the
incomplete lling of the questionnaire.)
Table 5: e relationship between participants’ toilet habits and their time spent on the toilet presented as numbers of participants
(p-value <0.001).
Toilet Habits
Time spent on the toilet Phone/tablet (n) Newspaper/ magazine (n) Puzzle (n) Smoking (n) Other (n) None (n) Tot a l
More than 10 minutes 63 6 4 5 3 10 91
Less than 10 minutes 141 6 3 11 2 69 232
Tot a l 204 12 7 16 5 79 323
(Participants were allowed to choose more than one toilet habit.)
26
Table 7: Relationship of toilet habits and state of constipation presented as numbers of participants. Participants could choose more than
one answer about their toilet habits if they have (p-value =0.07).
DISCUSSION
Although the use of smartphones and tablets on the toilet is
very common, there are not many studies on the eects of using
smartphones on the toilet on defecation disorders in the light of
the literature. To our knowledge, this is the rst study to present
the frequency of toilet habits and the self-awareness of constipation
statuses among young adults. Our study showed that having toilet
habits was fairly common and was present in 72.85% of our par-
ticipants. A study by Goldstein et al. (17) evaluated the prevalence
of toilet reading habits in the Israeli adult population and found
that toilet reading was prevalent in 52.7% of adults. In comparison,
our study questioned several toilet habits such as the use of smart-
phones, solving puzzles, and smoking in addition to reading print-
ed materials such as books, newspapers, and magazines. In con-
trast to the results of the aforementioned study, smartphone/tablet
(69.76%) was found to be the most prominent habit in our study.
According to the literature, people with relatively unhealthy
lifestyles and bad eating habits are more likely to experience con-
stipation (13). However, our study did not show any signicant as-
sociation between constipation and ber consumption or physical
activity. On the other hand, types of accommodation and water
consumption were signicantly associated with constipation. Par-
ticipants who stated that they live with families were found to be
less constipated. is may be attributed to having more organized
lifestyles and nely regulated circadian rhythm which controls gut
motility (20, 21). Since less uid consumption can increase the
likelihood of constipation, the recommendation to increase uid
intake for patients with constipation will be appropriate. Conse-
quently, the type of accommodation and water consumption are
signicantly related to constipation. erefore, to prevent and treat
constipation in young adults, it is important for them to consume
sucient water and accommodate in a regular place that supports
their circadian rhythms.
Another key nding in our study was that participants who had
at least one toilet habit were found to be more constipated. 25.7%
of participants who had toilet habits were constipated while only
15.5% of participants who did not have any toilet habits were con-
stipated. However, our study did not nd any signicant associa-
tion between toilet habits and constipation. It seems that extensive
smartphone use during defecation (69.76%) is not a distinctive fac-
tor in our study population due to its popularity among both con-
stipated and non-constipated participants. Since young adults lead
smartphone use in the general population, further studies may be
conducted in a broader age group to provide more accurate results
(22). Since the rate of smartphone use is lower in other age groups,
this could act as a distinctive factor (22).
Our study showed that having toilet habits was signicantly as-
sociated with prolonged sitting time (>10 minutes) on the toilet.
Having constipation and prolonged sitting time on the toilet was
also found to be signicantly associated. Such a result can be at-
tributed to the expulsion of hard and lumpy stools, which requires
more time since it takes more force and coercion to expel the hard
stools. However, prolonged sitting on the toilet can lead to hemor-
rhoids and exacerbate constipation (16). Based on these ndings,
it seems necessary to raise public awareness by training on reduc-
ing the prevalence of anorectal disorders and limiting toilet habits
and the time spent on the toilet. Medical students were the group
with the highest awareness of constipation in our study, possibly
more familiar with the symptoms that contribute to constipation,
given their medical education. Similarly, if constipation becomes
more recognized by the public, adjusting some routines on their
own, such as increasing water intake, limiting toilet habits, and time
spent on the toilet, will help alleviate patients' symptoms and com-
plaints.
Our study provided an integrated approach to constipation that
includes many independent variables. However, several potential
limitations arose due to the demographics of our population. e
fact that women were in the majority at the Acıbadem University at
the time of the survey may have created a gender imbalance. Fur-
ther studies may involve a wider age group and a more balanced
gender distribution.
In conclusion, having toilet habits is a common trait that may
increase the time spent sitting on the toilet, which can lead to issues
in the anorectal system. Moreover, young adults with toilet habits
tend to be more constipated, although a signicant association has
yet to be shown. Constipation status and time spent on the toilet
were found to be signicantly associated. Water intake and type
of accommodation were found to be signicantly associated with
constipation. Raising public awareness regarding proper defeca-
tion routines and limiting toilet habits and sitting time on the toilet
seems essential to prevent constipation.
Ethics Committee Approval: is study was approved by the Acıbadem
University Medical Research Ethics Committee (Protocol Code: ATADEK
2019-4/7).
Informed Consent: Written informed consent was obtained from the par-
ticipants of this study.
Conict of Interests: e authors declared no conict of interest.
Author contributions: Concept: NK, AD, HK, CHD. Design: NK, AD, HK,
CHD. Supervision: OE. Resources: NK, AD, HK, CHD. Materials: NK, AD,
HK, CHD. Data Collection and/or Processing: NK, AD, HK, CHD. Analysis
and/or Interpretation: NK, AD, HK, CHD. Literature Search: NK, AD, HK,
CHD. Writing Manuscript: NK, AD, HK, CHD. Critical Review: NK, AD,
HK, CHD, OE.
Financial disclosure: e authors declared that this study received no -
nancial support.
Toilet Habits
Phone/Tablet (n) Newspaper/Magazine (n) Puzzle (n) Smoking (n) Other (n) None (n) Total
Diagnosed as
constipated 50 2 3 5 0 12 72
Not
diagnosed as
constipated
149 9 3 10 3 65 239
Tot a l 199 11 6 15 3 77 311
27
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