Constipation represents a prevalent health concern among individuals. While various factors are commonly believed to contribute to constipation, obtaining real-world evidence to support these associations can be challenging. A recent study published in World Journal of Gastroenterology in 2021 titled “Potential risk factors for constipation in the community” explained some of these potential risk factors which includes demographic, lifestyle, and health-related aspects.
The review examined available evidence, drawing from quantitative data sourced from cross-sectional studies of adults residing in communities over the past three decades. Their findings indicate associations between constipation and factors such as female gender, residential location, physical activity, self-rated health, specific surgeries, certain medical conditions, and medications. However, conflicting or insufficient evidence exists for many other factors. Further research is imperative to validate these associations and classify them as potential risk factors. Comprehensive studies encompassing diverse factors in community populations, along with multivariate analyses to address confounding variables, are recommended. Such efforts will contribute to a more comprehensive understanding of constipation risk factors within communities.
According to the studies, below are the risk factors related to constipation.
- Demographic factors (age, gender, income, education, work status and geography)
- Lifestyle factors and behaviors (physical activity, smoking, and fiber, fluid, alcohol and coffee intakes)
- Health-related factors (medical conditions and medications)
1. Demographic and Socioeconomic Factors
Age
The association between age and both chronic constipation and any constipation appears inconclusive, with conflicting findings reported in various studies. Some literature reviews and epidemiological studies suggest a higher prevalence of constipation in older age groups, while others report either no association or a higher prevalence in younger age groups.
Regarding chronic constipation, one systematic review found no significant differences in prevalence between younger and older age groups. However, reviews of Chinese and Iranian studies suggested an increased prevalence with age. Among epidemiological studies, six indicated a higher prevalence in younger age groups, while only four reported higher prevalence in older age groups. Additionally, four studies did not demonstrate any clear trends in the association between chronic constipation and age groups.
For any constipation (chronic and sporadic), one systematic review noted an increased prevalence after the age of 60, with the largest increase after 70. Three reviews observed increasing prevalence with age, but one review of North American studies concluded that the relationship between age and any constipation could not be established. While some epidemiological studies from various countries reported an increase in any constipation with age, others showed a decrease or no clear association.
Female Gender
The prevalence of constipation tends to be consistently higher among females compared to males, as indicated in all systematic reviews and nearly all epidemiological studies included in their analysis. Most studies that report gender disparities utilize female/male (F/M) ratios to express the findings, with only a minority reporting odds ratios. Based on the available data, it suggests that females are approximately twice as likely as males to report chronic constipation and more than twice as likely to report any constipation.
In terms of chronic constipation, systematic reviews have documented mean F/M ratios ranging from 1.4 to 1.89, and 1.75. Comparable ratios are observed across most epidemiological studies, with F/M ratios varying from 1 to 10 in 24 studies conducted across different countries. Notably, only one study showed a higher prevalence in males, with an F/M ratio of 0.84. Odds ratios for chronic constipation among females were reported as 2.22 in a global systematic review and ranged from 1.0 to 4.8 in epidemiological studies.
Regarding any constipation, systematic reviews have reported mean F/M ratios ranging from 2.1 to 2.65. Across 26 epidemiological studies conducted in 17 countries, F/M ratios ranged from 1.10 to 6.75, with statistically significant differences between genders reported in 8 of these studies (P < 0.05). Odds ratios for any constipation among females ranged from 2.0 to 3.8 in both systematic reviews and epidemiological studies.
Income level
The connection between constipation and income remains unclear based on their review of the literature. The relationship between income level and constipation appears to vary across countries, and conflicting findings are evident even within individual countries. In numerous countries, there is an observed inverse (negative) correlation between constipation and income, with a higher prevalence of constipation observed among individuals with lower incomes.
For chronic constipation, a Canadian study provided evidence of an inverse relationship, whereas this was not observed in a study conducted in the United States. In Iran and Brazil, a significantly higher prevalence of chronic constipation was found among those with lower incomes, but no inverse relationship was noted in South Korea and Hong Kong. Similarly, an Australian study reported an inverse relationship.
Regarding any constipation, an inverse relationship was observed in the United Kingdom, Germany, Brazil, Colombia, and China. However, no such trend was apparent in France, Italy, South Korea, and Indonesia. Studies conducted in North America suggest that the prevalence of any constipation tends to increase as income decreases.
Educational level
When examining chronic constipation, evidence of an inverse relationship—indicating a higher prevalence of constipation among individuals with lower educational attainment—was found in studies from the United States, China, Croatia, and Iran. However, other studies did not clearly demonstrate this pattern or any consistent trend.
In North American studies, a majority indicated an inverse relationship between the prevalence of any constipation and years of education. Conversely, studies from other countries displayed mixed findings: while an inverse relationship was observed in the United Kingdom, France, Germany, Italy, and South Korea, the opposite trend was noted in Brazil, China, and Indonesia. No discernible patterns were found in studies conducted in Spain, Argentina, and Colombia.
2. Lifestyle and Behavioral Factors
Physical Activity
There is limited evidence suggesting that low levels of physical activity are linked to a higher prevalence of constipation. Studies from various countries have shown that low exercise levels are significantly associated with increased rates of both chronic and sporadic constipation.
Smoking
Conflicting data exists regarding the association of smoking with the prevalence of constipation, whether chronic or sporadic. While some studies from the United States and Iran propose smoking as a potential risk factor for chronic constipation, others from the United States, Greece, and Taiwan found no significant differences in prevalence between smokers and non-smokers. Interestingly, findings from one study in the United States and another in Norway suggest that smoking might even have a protective effect against chronic and sporadic constipation, respectively.
Fiber
In one Spanish study, both low and high fiber intakes were associated with an increased prevalence of sporadic constipation, while another Spanish study found no significant association with chronic constipation.
Fluid Intake
Only one Spanish study reported an inverse relationship between chronic constipation and fluid intake, defined as daily glasses of liquids consumed. A United States study showed no association between coffee intake and chronic constipation.
Alcohol
Few evidence suggests that alcohol consumption may be associated with a decreased prevalence of chronic constipation. Several studies have explored the link between alcohol intake and chronic constipation, with increasing alcohol consumption being identified as a negative risk factor in studies from the United States and Norway. Similar trends were observed in Taiwan and other United States studies, although an opposite trend was noted in Iran, with no significant relationships found.
3. Health-related Factors
Self-Rated Health
Two European studies have shown a significant association between fair or poor self-rated health and an increased prevalence of chronic constipation.
Medical Conditions
Various medical conditions have been identified as potential factors associated with constipation in epidemiological studies. Gastrointestinal disorders such as dyspepsia, heartburn, gastroesophageal reflux disease (GORD), and nausea/vomiting have commonly been linked with chronic constipation. An association between GORD and constipation has been noted in several epidemiological studies. Similarly, colorectal cancer and diverticulitis have been associated with both chronic and sporadic constipation.
- Anorectal disorders: Anorectal disorders, particularly haemorrhoids, are frequently linked with constipation. Several studies have found a significant association between haemorrhoids and sporadic constipation, with haemorrhoids also commonly associated with chronic constipation. Other anorectal disorders like fistulas, anal fissures, and rectal prolapse have been associated with sporadic constipation.
- Depression, anxiety and insomnia: Depression, anxiety, and insomnia have been linked with both chronic and sporadic constipation, with depression being the most commonly reported psychiatric condition associated with chronic constipation. Neurological diseases such as multiple sclerosis and Parkinson’s disease have shown significant odds ratios for chronic constipation.
- Obesity: There is conflicting evidence regarding the association of obesity or body weight with constipation. While some studies have found frequent associations between chronic constipation and obesity, other epidemiological studies have not shown a clear link between body mass index (BMI) and constipation.
- Other Medical Conditions: Diabetes has been frequently associated with chronic constipation in some studies, while the association is not evident in others. Cardiovascular diseases, stroke, musculoskeletal complaints, and urinary tract disorders have also been reported to be associated with constipation.
Surgery
Recent surgery is known to be a risk factor for constipation, with gynaecological, abdominal, and anorectal surgery being significantly associated with an increased risk of chronic constipation in some epidemiological studies.
Medications
Constipation is a common side effect of many drug classes, although population-based studies often fail to report concomitant drug use. The use of one or more medications has been associated with chronic constipation in some studies, with certain medications like aspirin, NSAIDs, digoxin, glyceryl trinitrate, atorvastatin, furosemide, and levo-thyroxine showing significant associations with chronic constipation.
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Conclusion
This article contains a detailing of potential risk factors for adult constipation following a review published in a journal which encompasses 30 years of epidemiological studies on community populations. While cross-sectional studies identify associations, causality remains elusive. Factors like poor self-rated health, depression, and certain medical conditions may contribute to or result from constipation. However, evidence regarding demographic, socioeconomic, and lifestyle factors is inconclusive. Female gender appears strongly associated with constipation, while age’s impact varies. Lifestyle factors like physical activity show some correlation, while others like fluid and fiber intake lack substantial evidence. Smoking, alcohol, and coffee effects remain unclear. Conversely, health-related factors like surgical procedures, medications, and medical conditions show significant associations.