LIFESTYLE FACTORS CONTRIBUTING TO HEMORRHOIDS

1. Low fibre intake and constipation
   Haemorrhoids are associated with straining during bowel movements, a feeling of incomplete bowel movements, and having hard or lumpy stools at least 25% of the time.^3,4
2. Dehydration
   Inadequate fluid intake worsens constipation⁵. Without enough moisture, the body draws water from the stool to maintain hydration, leading to dry, hard stools that are more difficult to pass⁶.
3. Prolonged sitting and sedentary lifestyles
   Sitting for more than five hours a day may increase the risk of developing haemorrhoids. This risk is associated with prolonged sitting in any context — whether at work (eg drivers), during study, or at leisure. Prolonged sitting increases pressure and reduced blood flow in the anal canal.⁷
4. Obesity and elevated BMI
   Increased body mass index, body fat percentage, waist circumference, and waist-to-hip ratio are linked to a higher risk of haemorrhoids⁸. Excess adiposity raises intra-abdominal pressure, impairing venous return and causing venous engorgement in the distal rectum⁸. Additionally, adiposity is associated with chronic inflammation and oxidative stress, which can damage supporting tissues through the release of oxygen radicals, inflammatory cytokines, and tissue-remodelling proteins, ultimately impairing the structure of anal cushions and promoting haemorrhoid development⁸.
5. Pregnancy
   Haemorrhoids often worsen during pregnancy, particularly in the third trimester and postpartum, reducing quality of life⁹. The growing uterus increases abdominal pressure and compresses the rectum, inferior vena cava, and portal vein, leading to venous stasis and reduced blood flow to the internal anal sphincter. Circulating blood volume also increase by 25-40%, further contributing to vascular dilation and congestion. Hormonal changes, especially increased progesterone, relax vein walls, increasing susceptibility to swelling and the development of haemorrhoids.⁹
6. Poor bowel habits and chronic straining
   Poor bowel habits, particularly prolonged time spent on the toilet, are a stronger predictor of haemorrhoids than straining.¹⁰ This extended duration is often associated with passive smartphone use, which can lead to prolonged sitting and increased pressure on the haemorrhoidal cushions¹⁰. Chronic straining increases intra-abdominal pressure to overcome the resistance faced by the descending stool⁴, resulting in the persistence of prolapsed anal cushions.⁴
7. Physical activity
   Given the broad health benefits of physical activity, it should never be discouraged, however, patients should receive proper guidance on safe exercise practices¹¹. For example, strenuous activities like heavy lifting may increase the risk of haemorrhoids and should be approached with caution.¹¹
8. Chronic conditions
   Pre-existing conditions such as inflammatory bowel disease, including Crohn’s disease and ulcerative colitis¹², as well as lower extremity chronic venous insufficiency¹³ – commonly associated with varicose veins¹³ – can increase a patient’s risk of developing haemorrhoids.¹³ These conditions contribute to increased intra-abdominal pressure, which can lead to conditions such as constipation.¹³ Chronic pressure exacerbates both venous insufficiency and haemorrhoid disease.¹³

PREVENTION AND MANAGEMENT STRATEGIES

Preventive counselling can empower patients in lifestyle-modifiable risk factors:

1. Encourage high-fibre diets
   • Recognising insufficient dietary fibre as a major risk factor³ allows pharmacists to highlight emphasising its role in bowel health. Good dietary sources of fibre include legumes, nuts, whole grains, bran products, fruits, and non-starchy vegetables. Among these, legumes (eg dry beans and peas), nuts, seeds, and whole grains are generally more concentrated in fibre than fruits and vegetables.¹⁴ Adequate total fibre intake is 38g/day for men and 25g/day for women aged 50 and younger. For adults over 50, the recommendation decreases to 30g/day for men and 21g/day for women.¹⁴ Supplementation with psyllium (7g/day for 6 weeks) improves stool consistency and regularity, reduced the use of laxatives in patients with haemorroids.¹⁴
2. Promote adequate hydration
   • A daily intake of at least 1.5-2 litres of water supports softer stools and better bowel function.¹⁵
3. Encourage healthy physical activities
   • Encourage regular moderate-intensity exercise – such as walking, cycling, or yoga – has been linked to improved gastrointestinal function in conditions like constipation.¹⁶ These benefits are largely due to enhanced intestinal motility, reduced systemic inflammation, and improved gut barrier integrity.¹⁶
   • Educate patients on avoiding prolonged sitting⁷, and encourage breaks for light mobility.
4. Counsel on bowel habits
   • Emphasise correct toilet behaviours, limit defecation time to 1-2 minutes and avoid straining where possible.¹⁷
   • Encourage individuals to respond promptly to the urge to defecate, as delaying can lead to the accumulation of stool and increase the risk of straining.¹⁸ Maintaining proper anorectal function relies on intact sensory awareness and coordinated muscle activity.¹⁸
5. Highlight weight management
   • Managing body weight alleviates intra-abdominal pressure and contributes to reduced venous congestion.⁸
6. Educate on pregnancy-specific interventions
   • For pregnancy-related internal haemorrhoids that can present with sudden and severe pain, initial management should be conservative. Recommend adequate pain relief, oral and topical flavonoid preparations, and warm sitz baths to improve anal circulation and reduce internal sphincter tone.⁹ While most pregnant women respond well to these measures, surgical intervention may be necessary in cases where symptoms persist or worsen.⁹
7. Recommend conservative treatments when needed
   • For patients where lifestyle adjustments have not been successful in addressing constipation, the use of laxatives (eg docusate sodium)¹⁹ or OTC topical agents (eg gels, or wipes)²⁰ may be recommended.