Symptoms and Prevalence of Constipation among Adult Population of Bangladesh

INTRODUCTION

The contemporary lifestyle has led to huge changes in diseases pattern and it became more noticeable with the entrance of the current century.¹ Constipation is one of the most common gastrointestinal disorders faced in Inpatients and Outpatient Departments.²

Constipation is used to express a person’s perception of altered bowel movement that includes hard stools, difficulty with defecation, and a sense of incomplete evacuation. Chronic constipation is defined as when a person reports symptoms of constipation for at least three consecutive months. Chronic constipation may cause severe health issues regarding economic load for the patients and the healthcare service systems.^3,4 The prevalence of constipation is rising day by day worldwide.⁵ But it is still underappreciated and consulted only when severely sick.^6,7

There is wide variation of prevalence of the constipation from one region to another worldwide.⁸ In Europe, prevalence ranges from 1 to 81% in different ethnicity with a mean prevalence of 17%.⁹In the West, chronic constipation affected nearly 2–27% in Canada. In the United States, overall prevalence is 16%.^3,10 In Asia, China, India, and Japan reported a prevalence of 8, 17, and 28% respectively.^11–13Considering the wide variation of the prevalence of constipation, recent studies are using Rome criteria of constipation, which are standardized for diagnosing functional gastrointestinal disorders. The latest version of this is Rome IV criteria and it was released in May 2016.¹⁴

There are different causes of chronic constipation. Among them, metabolic and endocrine derangement, electrolyte imbalance, neurological and myopathic disturbances, colorectal mechanical obstructions, and use of specific medications are the secondary causes of constipation.¹⁵In clinical practice, a small number of patients have these secondary causes. Among the types of constipation, functional constipation (FC) is the most common and it is diagnosed after the exclusion of alarm symptoms of constipation which includes anemia, significant weight loss, per rectal bleeding, or positive occult blood test (OBT), acute constipation, positive family history of colorectal carcinoma etc., and exclusion of secondary causes. There are three subgroups of functional constipation based on the pathophysiology. These are normal colonic transit (NCT), slow colonic transit (SCT), and rectal evacuation disorders.¹⁶

There are different factors associated with constipation. Previous studies revealed that female gender, poor diet habits, and lower socioeconomic status in addition to certain geographic regions, race, and ethnicity have associations with constipation. Data on constipation are scarce in Bangladesh. One population-based study trying to determine “Functional constipation - prevalence and lifestyle factors in a district of Bangladesh” showed 4.9% of the respondents experienced functional constipation.¹⁷ Due to lacking uniform diagnostic criteria; there is a discrepancy in the reported rates. Bristol’s chart and Rome III criteria are commonly used among gastroenterologists to diagnose constipation while some prefer using self-perception for constipation diagnosis in surveys.^18,19

There is little data on the symptoms, prevalence and risk factors of constipation among adult population of Bangladesh. So, the present study evaluated the symptoms and prevalence of constipation among adult population of Bangladesh.

MATERIALS AND METHODS

The study was conducted at Savar, one of the largest Upzilla of Dhaka district in Bangladesh with technical support from the Department of Gastroenterology of Shaheed Suhrawardy Medical College and Hospital. Total 1,550 participants were randomly selected from July 2019 to December 2019. This area, Savar has a large industrial base and it is a leading export processing zone (EPZ) the country. People from all over the country stay and work in different garments, industrial and other installations in this area. It is therefore assumed that the study population was representative of the Bangladeshi population. All the apparently healthy individuals of either sex aged 18 years or above in mentioned area were included in this study. The data collected was done by face-to-face interviews of the respondents who met the selection criteria. The instruments for data collection were a validated structured questionnaire and a checklist (Rome III criteria, Bristol criteria and Self-reporting). Data collected was done by four trained personnel and medical officers. The researchers rechecked randomly selected data to verify the collected data. Informed written consent was obtained from every respondent and interviews were held in private. Collected relevant data were compiled on a master table first and then statistical analysis was done by using window-based software with Statistical Packages for Social Sciences (SPSS-25). Results were exhibited in tables, figures, and diagrams. The research protocol was approved by the National Research Ethics Committee (NERC) of Bangladesh Medical Research Council (BMRC) before starting the study.

RESULT

The study population consisted of 1,550 respondents, 41.61% male, and 58.39% female. The majority (45%) of the study population belonged to the young age-group (<30 years) and the mean age was 32.71 ± 9.72 years. The male-to-female ratio was 1:1.4. Nearly 82.3% of the sample population was married, among them 79.1% were male and 84.6% were female. In regard to the occupation of the respondents majority was from non-government employees (40%), about 24% from housewife, and about 12% from business and the rest 24% constituted other occupations like students, government employees, drivers, farmers, agri-laborers and others. On educational background 9.2% graduate and above, 19.7% secondary education completed, 36.9% of the respondents were secondary education not completed, 12.1% primary education completed, and 22% are illiterate. Most of the study populations are Muslims (90.9%) and the rest are Hindu (6.8%) and Christian (2.3%). About 70% of the respondents reported to earning a monthly income of taka less than 10,000 (Table 1).

DISCUSSION

The study estimated the prevalence and symptoms of constipation among the general population of Bangladesh. Constipation can be defined as a decreased number of defecations per week, other symptoms, for example, sensation of incomplete evacuation, abdominal bloating, straining, elongated or failed attempts to defecate, hard stools, and sometimes necessity of digital disimpaction.²⁰ Constipation is usually subjective and is termed when people have reduced frequency of stools or strain during defecation.

In this study, the majority of the study population was in the younger age-group (<30 years). Studies from Singapore raveled that constipation in the form of hard stool was more in older adults over 40 years, but constipation in the sense of straining was more in the younger age-group, 18–29 years.²¹ Older age-group are more affected by constipation due to their different comorbidities and side effects of different medication.²²

Regarding gender, males were 41.61% and females were 58.39%. Females were more prevalent than males. In the USA, Females were 2.2 times more likely to be affected by constipation than males.²³Association of constipation with the female gender is well established in the literature.²⁴However, it is difficult to establish the exact causative mechanism, but contributing factors like hormonal causes and dietary patterns have been illustrated.^23,25

There are many clinical diagnostic criteria for constipation resulting in a huge variation in its prevalence.²⁶The present study obtained a self-reported prevalence of constipation of 12.2%. On application of the Rome III criteria, the rate was 11.2%, while estimation through the Bristol stool chart, obtained a lower rate of 10.3%. These statistics show little variation. However, since there is no single gold standard diagnostic method available, there is a need to discuss the pros and cons of the other methods used. Self-reporting method is especially individual-based and depends on the extent of the self-perception of people in the frequency of stools and the amount of straining depending on one’s bowel habits as the reference standard. Hence, there is a risk of over-reporting the symptoms although it might be considered to be normal resulting in an overestimation of results. Johanson in his review of the epidemiology of constipation demonstrated a prevalence ranging from 3 to 27%, mostly from NHS and NHANES surveys using either self-reported or Rome I/II criteria and thereby attributed the variance to the different diagnostic criteria and concluded by stating self-reporting method has a risk of attaining higher prevalence rates.²⁷

There are different etiological and risk factors for constipation. In this study, Logistic regression analysis showed a significant risk for constipation with betel nut chewers, alcohol consumption, diabetes mellitus, hypertension, GI Surgery, and bronchial asthma (p < 0.05).

Betel nut chewing is very common in this Southeast Asia. In our study, the study population was mostly from an industrial region, where most of them are workers. Betel nut chewing and alcohol consumption increased the capacity to work. So betel nut chewing and alcohol consumption is comparatively more prevalent in this population group. There is no clear evidence that betel nut chewing and alcohol consumption causes constipation, rather betel nut chewing improves bowel movement.^28,29Surgery is a known risk factor for constipation. This may be due to a different medications, opioid analgesics, and a sedentary lifestyle after surgery. Epidemiological studies revealed that abdominal and anorectal surgery were significantly associated with an increased risk of chronic constipation.³⁰

From the perspective of comorbidities, diabetes mellitus was associated with chronic constipation (4.7–11.8%).³¹ Diabetes mellitus may cause constipation by complications like autonomic neuropathy. Hypertensive patients use different medications including calcium channel blockers and patient suffering from bronchial asthma lead a sedentary life and use medications that contribute to developing constipation.³²

CONCLUSION

Chronic constipation is a common problem globally. The study findings suggest a high prevalence of constipation among the general population of Bangladesh. Decreasing modifiable risk factors of constipation can reduce its prevalence and burden of the disease. Bangladesh is markedly deficient in literature citing constipation prevalence and determinants. The findings of this study have important implications for future research. It has highlighted the magnitude of the disorder and has provided a pathway for designing larger population-based studies to assess its epidemiology, etiological characteristics, environmental risk factors, and the quality of life of people with constipation in Bangladesh.

ACKNOWLEDGMENTS

The Author expresses gratitude to BMRC for the funding of this project. The patients and colleagues in the Gastroenterology Department of Shaheed Suhrawardy Medical College and Hospital are acknowledged for their cooperation.

ORCID

Parash Ullah https://orcid.org/0000-0001-6397-9736

REFERENCES

1. Egger G, Dixon J. Beyond obesity and lifestyle: A review of 21st century chronic disease determinants. Bio Med Research International, 2014;731685:12. DOI: https://doi.org/10.1155/2014/731685.

2. Johanson JF, Kralstein J. Chronic constipation: A survey of the patient perspective. Aliment Pharmacol Ther 2007;25(5):599–608. DOI: 10.1111/j.1365-2036.2006.03238.x.

3. Chang JY, Locke GR 3rd, McNally MA, et al. Impact of functional gastrointestinal disorders on survival in the community. Am J Gastroenterol 2010;105(4):822–832. DOI: 10.1038/ajg.2010.40.

4. Sommers T, Corban C, Sengupta N, et al. Emergency department burden of constipation in the United States from 2006 to 2011. Am J Gastroenterol 2015;110(4):572–579. DOI: 10.1038/ajg.2015.64.

5. Trinkley KE, Porter K, Nahata MC. Prescribing patterns for the outpatient treatment of constipation in the United States. Dig Dis Sci 2010;55(12):3514–3520. DOI: 10.1007/s10620-010-1196-3.

6. Johanson JF, Sonnenberg A, Koch TR. Clinical epidemiology of chronic constipation. J Clin Gastroenterol 1989;11(5):525–536. DOI: 10.1097/00004836-198910000-00008.

7. Enck P, Leinert J, Smid M, et al. Prevalence of constipation in the German population - A representative survey (GECCO). United European Gastroenterol J 2016;4(3):429–437. DOI: 10.1177/2050640615603009.

8. Alhusainy YA, Tarakji AR, Alhowaish NY, et al. Symptoms and prevalence of constipation among adult population of Riyadh city: An internet based survey. Egypt J Hosp Med 2018;70(8):1317–1322. DOI: 10.12816/0044641.

9. Peppas G, Alexiou VG, Mourtzoukou E, et al. Epidemiology of constipation in Europe and Oceania: A systematic review. BMC gastroenterology 2008;8:5. DOI: 10.1186/1471-230X-8-5.

10. Sanchez MIP and Bercik P. Epidemiology and burden of chronic constipation. Can J Gastroenterol 2011;25 Suppl B(Suppl B):11B–15B. DOI: 10.1155/2011/974573.

11. Tamura A, Tomita T, Oshima T, et al. Prevalence and self-recognition of chronic constipation: Results of an internet survey. J Neuro gastroenterol Motil 2016;22(4):677–685. DOI: 10.5056/jnm15187.

12. Chu H, Zhong L, Li H, et al. Epidemiology characteristics of constipation for general population, pediatric population, and elderly population in China. Gastroenterol Res Pract 2014;2014:532734. DOI: 10.1155/2014/532734.

13. Rajput M, Saini SK. Prevalence of constipation among the general population: A communitybased survey from India. Gastroenterol Nurs 2014;37(6):425–429. DOI: 10.1097/SGA.0000000000000074.

14. Simren M, Palsson OS, Whitehead WE. Update on Rome IV criteria for colorectal disorders: Implications for clinical practice. Curr Gastroenterol Rep 2017;19(4):15. DOI: 10.1007/s11894-017-0554-0.

15. Basilisco G, Coletta M. Chronic constipation: A criticalreview. Dig Liver Dis 2013;45(11):886–893. DOI: 10.1016/j.dld.2013.03.016.

16. Mearin F, Ciriza C, Minguez M, et al. Clinical practice guideline: Irritable bowel syndrome with constipation and functional constipation in the adult. Rev Esp Enferm Dig 2016;108(6):332–363. DOI: 10.17235/reed.2016.4389/2016.

17. Parveen l, Rahman MM, Saha MM, et al. Functional constipation - prevalence and life style factors in a district of Bangladesh. Mymensingh Med J 2015; 24(2):295–304.PMID: 26007257.

18. Olesen AE, Drewes AM. Validated tools for evaluating opioid-induced bowel dysfunction. Adv Ther 2011;28(4):279–294. DOI: 10.1007/s12325-011-0006-4.

19. Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterology 2006 130(5):1480–1491. DOI: https://doi.org/10.1053/j.gastro.2005.11.061.

20. Włodarczyk J, Waśniewska A, Fichna J, et al. Current overview on clinical management of chronic constipation. J Clin Med 2021;10(8):1738. doi: 10.3390/jcm10081738.

21. Gwee KA, Setia S. Demographics and health care seeking behavior of Singaporean women with chronic constipation: Implications for therapeutic management. Int J Gen Med 2012;5:287–302. DOI: 10.2147/IJGM.S29011.

22. Cardin F, Minicuci N, Droghi AT, et al. Constipation in the acutely hospitalized older patients. Arch Gerontol Geriatr 2010;50(3):277–281. DOI: 10.1016/j.archger.2009.04.007.

23. Jung HK, Kim DY, Moon IH. Effects of gender and menstrual cycle on colonic transit time in healthy subjects. Korean J Intern Med 2003;18:181–186. DOI: 10.3904/kjim.2003.18.3.181.

24. Higgins PD, Johanson JF. Epidemiology of constipation in North America: A systematic review. Am J Gastroenterol 2004;99(4):750–759. DOI: 10.1111/j.1572-0241.2004.04114.x.

25. Chiarelli PA, Brown W, McElduff P. Constipation in Australian women: Prevalence and associated factors. Int Urogynecol J Pelvic Floor Dysfunct 2000;11(2):71–78. DOI: 10.1007/s001920050073.

26. Garrigues V, Galvez C, Ortiz V, et al. Prevalence of constipation: Agreement among several criteria and evaluation of the diagnostic accuracy of qualifying symptoms and self-reported definition in a population-based survey in Spain. Am J Epidemiol 2004; 159(5):520–526.DOI: 10.1093/aje/kwh072.

27. Johanson JF. Definitions and epidemiology of constipation. Constipation 2006;67:1–8. DOI: https://doi.org/10.1007/978-1-84628-275-1_1.

28. Chu NS. Neurological aspects of areca and betel chewing. Addict Biol 2002;7(1):111–114. DOI: 10.1080/13556210120091473.

29. Werth BL, Christopher SA. Potential risk factors for constipation in the community. World J Gastroenterol 2021;27(21):2795–2817. DOI: 10.3748/wjg.v27.i21.2795.

30. Schmidt FM, de Gouveia Santos VL, de Cássia Domansky R, et al. Constipation: Prevalence and associated factors in adults living in londrina, Southern Brazil. Gastroenterol Nurs 2016;39:204–211. DOI: 10.1097/SGA.0000000000000224.

31. Nellesen D, Chawla A, Oh DL, et al. Comorbidities in patients with irritable bowel syndrome with constipation or chronic idiopathic constipation: A review of the literature from the past decade. Postgrad Med 2013; 125(2):40–50.DOI: 10.3810/pgm.2013.03.2640.

32. Choung RS, Rey E, Richard Locke G 3rd, et al. Chronic constipation and co-morbidities: A prospective population-based nested case-control study. United European Gastroenterol J 2016;4(1):142–151. DOI: 10.1177/2050640614558476.