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Factors Associated With Persistent and Nonpersistent Chronic Constipation, Over 20 Years

Published:January 30, 2012DOI:https://doi.org/10.1016/j.cgh.2011.12.041

      Background & Aims

      The prevalence of chronic constipation (CC) has been reported to be as high as 20% in the general population, but little is known about its natural history. We estimated the natural history of CC and characterized features of persistent CC and nonpersistent CC, compared with individuals without constipation.

      Methods

      In a prospective cohort study, we analyzed data collected from multiple, validated surveys (minimum of 2) of 2853 randomly selected subjects, over a 20-year period (median, 11.6 years). Based on responses, subjects were characterized as having persistent CC, nonpersistent CC, or no constipation. We assessed the association between constipation status and potential risk factors using logistic regression models, adjusting for age and sex.

      Results

      Of the respondents, 84 had persistent CC (3%), 605 had nonpersistent CC (21%), and 2164 had no symptoms of constipation (76%). High scores from the somatic symptom checklist (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.3–3.4) and frequent doctor visits (OR = 2.0; 95% CI, 1.0–3.8) were significantly associated with persistent CC, compared with subjects with no constipation symptoms. The only factor that differed was increased use of laxatives or fiber among subjects with persistent CC (OR = 3.0; 95% CI, 1.9–4.9).

      Conclusions

      The prevalence of constipation might be exaggerated—the proportion of the population with persistent CC is low (3%). Patients with persistent and nonpersistent CC have similar clinical characteristics, although individuals with persistent CC use more laxatives or fiber. CC therefore appears and disappears among certain patients, but we do not have enough information to identify these individuals in advance.

      Keywords

      Abbreviations used in this paper:

      BDQ (Bowel Disease Questionnaire), BM (bowel movement), BMI (body mass index), CC (chronic constipation), CI (confidence interval), GI (gastrointestinal), IBS (irritable bowel syndrome), OR (odds ratio), SSC (Somatic Symptom Checklist)
      Constipation which is characterized by difficult, infrequent stool passage or feelings of incomplete rectal evacuation is thought to be very common in the community.
      • Pare P.
      • Ferrazzi S.
      • Thompson W.G.
      • et al.
      An epidemiological survey of constipation in Canada: definitions, rates, demographics, and predictors of health care seeking.
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      • et al.
      Functional constipation and outlet delay: a population-based study.
      • Sandler R.S.
      • Jordan M.C.
      • Shelton B.J.
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      Population-based studies have estimated the prevalence of constipation in North America to vary between 2% and 27%, representing 4–56 million adults in the United States alone.
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      Epidemiology of constipation (EPOC) study in the United States: relation of clinical subtypes to sociodemographic features.
      Although only a minority with constipation seek health care, constipation leads to 2.5 million physician visits per year in the United States.
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      • Koch T.R.
      Physician visits in the United States for constipation: 1958 to 1986.
      • Higgins P.D.
      • Johanson J.F.
      Epidemiology of constipation in North America: a systematic review.
      Constipation probably has a clinically significant deleterious effect on health-related quality of life and represents an economic burden for the patient and health care provider.
      • Rantis Jr, P.C.
      • Vernava 3rd, A.M.
      • Daniel G.L.
      • et al.
      Chronic constipation—is the work-up worth the cost?.
      • Irvine E.J.
      • Ferrazzi S.
      • Pare P.
      • et al.
      Health-related quality of life in functional GI disorders: focus on constipation and resource utilization.
      • Dennison C.
      • Prasad M.
      • Lloyd A.
      • et al.
      The health-related quality of life and economic burden of constipation.
      Tertiary care evaluation for constipation has been reported to cost an average of $2752 per patient.
      • Rantis Jr, P.C.
      • Vernava 3rd, A.M.
      • Daniel G.L.
      • et al.
      Chronic constipation—is the work-up worth the cost?.
      Therefore, knowledge of the natural history of constipation is highly relevant to primary care providers, gastroenterologists, and health care policy makers.
      Constipation is seen as a chronic symptom, as many patients have constipation-associated symptoms on a long-term basis.
      • Johanson J.F.
      • Kralstein J.
      Chronic constipation: a survey of the patient perspective.
      • Talley N.J.
      • Weaver A.L.
      • Zinsmeister A.R.
      • et al.
      Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders.
      Johanson and Kralstein
      • Johanson J.F.
      • Kralstein J.
      Chronic constipation: a survey of the patient perspective.
      reported that about 70% of patients had constipation for more than 2 years based on a web-based survey. Talley et al
      • Talley N.J.
      • Weaver A.L.
      • Zinsmeister A.R.
      • et al.
      Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders.
      determined that in the general population, 89% of adults surveyed reported no change in their gastrointestinal (GI) symptoms during an intervening 12–20-month period. However, these data represented only a relatively short period of time that subjects may have constipation. Recently, Halder et al
      • Halder S.L.
      • Locke 3rd, G.R.
      • Schleck C.D.
      • et al.
      Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study.
      showed that the overall prevalence of functional GI disorders including chronic constipation (CC) was stable over time, but the turnover in individual symptom status was high.
      It is therefore unclear if CC is a stable syndrome over a longer period of time in the majority affected. The high prevalence rates of CC published may not reflect chronic persistent cases over time. Moreover, no data exist regarding the characteristics of and risk factors for persistent CC vs nonpersistent CC. Thus, we aimed to estimate the natural history of CC in the community, and specifically characterize the patient population with persistent CC vs nonpersistent CC vs no constipation.

      Methods

      This study is a prospective, population-based longitudinal cohort study of subjects who were sent an initial GI symptom survey including constipation-related questions between 1988 and 1994 and then subsequent surveys until 2009. Data from the individual cross-sectional cohorts have been previously published in part,
      • Talley N.J.
      • Weaver A.L.
      • Zinsmeister A.R.
      • et al.
      Functional constipation and outlet delay: a population-based study.
      • Talley N.J.
      • Weaver A.L.
      • Zinsmeister A.R.
      • et al.
      Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders.
      • Halder S.L.
      • Locke 3rd, G.R.
      • Schleck C.D.
      • et al.
      Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study.
      • Choung R.S.
      • Locke 3rd, G.R.
      • Schleck C.D.
      • et al.
      Cumulative incidence of chronic constipation: a population-based study 1988–2003.
      • Choung R.S.
      • Locke 3rd, G.R.
      • Zinsmeister A.R.
      • et al.
      Epidemiology of slow and fast colonic transit using a scale of stool form in a community.
      • Talley N.J.
      • Fleming K.C.
      • Evans J.M.
      • et al.
      Constipation in an elderly community: a study of prevalence and potential risk factors.
      • Talley N.J.
      • O'Keefe E.A.
      • Zinsmeister A.R.
      • et al.
      Prevalence of gastrointestinal symptoms in the elderly: a population-based study.
      • Talley N.J.
      • Phillips S.F.
      • Melton 3rd, J.
      • et al.
      A patient questionnaire to identify bowel disease.
      • Talley N.J.
      • Phillips S.F.
      • Wiltgen C.M.
      • et al.
      Assessment of functional gastrointestinal disease: the bowel disease questionnaire.
      • Talley N.J.
      • Zinsmeister A.R.
      • Van Dyke C.
      • et al.
      Epidemiology of colonic symptoms and the irritable bowel syndrome.
      and each survey which measured constipation experienced during the past year was included in this current study. This study was approved by the institutional review boards of the Mayo Foundation and the Olmsted Medical Center.

       Subjects

      The Olmsted County population comprises approximately 120,000 persons of whom 90% are white; sociodemographically, the community is similar to the US white population.
      • Melton 3rd, L.J.
      History of the Rochester epidemiology project.
      • Melton 3rd, L.J.
      The threat to medical-records research.
      Eighty percent of the Olmsted County population resides within 5 miles of Rochester, and county residents receive their medical care almost exclusively from 2 group practices: Mayo Medical Center and Olmsted Medical Center. Mayo Clinic has maintained a common medical record system with its 2 affiliated hospitals (St Mary's and Rochester Methodist) for more than 100 years. Recorded diagnoses and surgical procedures are indexed, including the diagnoses made for outpatients seen in office or clinic consultations, emergency room visits, or nursing home care, as well as the diagnoses recorded for hospital inpatients, at autopsy examination or on death certificates.
      • Melton 3rd, L.J.
      History of the Rochester epidemiology project.
      • Melton 3rd, L.J.
      The threat to medical-records research.
      The system was further developed by the Rochester Epidemiology Project, which created similar indexes for the records of other providers of medical care to local residents, most notably the Olmsted Medical Group and its affiliated Olmsted Community Hospital (Olmsted Medical Center). Annually, over 80% of the entire population is attended by 1 or both of these 2 practices, and nearly everyone has an encounter at least once during any given 4-year period.
      • Melton 3rd, L.J.
      History of the Rochester epidemiology project.
      • Melton 3rd, L.J.
      The threat to medical-records research.
      Therefore, the Rochester Epidemiology Project medical records linkage system also provides what is essentially an enumeration of the population from which samples can be drawn.
      As part of previous investigations,
      • Talley N.J.
      • Weaver A.L.
      • Zinsmeister A.R.
      • et al.
      Functional constipation and outlet delay: a population-based study.
      • Talley N.J.
      • Weaver A.L.
      • Zinsmeister A.R.
      • et al.
      Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders.
      • Talley N.J.
      • Fleming K.C.
      • Evans J.M.
      • et al.
      Constipation in an elderly community: a study of prevalence and potential risk factors.
      • Talley N.J.
      • O'Keefe E.A.
      • Zinsmeister A.R.
      • et al.
      Prevalence of gastrointestinal symptoms in the elderly: a population-based study.
      • Talley N.J.
      • Phillips S.F.
      • Melton 3rd, J.
      • et al.
      A patient questionnaire to identify bowel disease.
      • Talley N.J.
      • Phillips S.F.
      • Wiltgen C.M.
      • et al.
      Assessment of functional gastrointestinal disease: the bowel disease questionnaire.
      • Talley N.J.
      • Zinsmeister A.R.
      • Van Dyke C.
      • et al.
      Epidemiology of colonic symptoms and the irritable bowel syndrome.
      we utilized the enumeration of the Olmsted County population as described above to select age- (5-year intervals) and sex-stratified random samples of Olmsted County adult residents. The initial 2 cohorts were middle-aged (20–50 and 30–65 years), then 2 elderly cohorts (age >65) were identified. These samples ranged in size from 800 to 2200 residents. They were mailed valid self-report symptom questionnaires from November 1988 to June 1994 (ie, the “baseline” or initial survey). At the outset, the complete (inpatient and outpatient) medical records of the individuals enumerated in the sample were reviewed. Subjects were excluded if they had significant illnesses which might cause GI symptoms or impair their ability to complete the questionnaire (eg, metastatic cancer, major stroke), had a major psychotic episode, mental retardation or dementia, or had a history of major abdominal surgery.
      Further, revised versions of the study questionnaire and an explanatory letter were then mailed to the original cohort in follow-up surveys in 2003–2004 and 2008–2009. Subjects who had died, moved from Olmsted County, or denied authorization to use their medical records for research, as required by Minnesota law, were excluded from these mailings. However, passive nonresponders to the initial surveys were included. Reminder letters were mailed at 2, 4, and 7 weeks. Subjects who indicated at any point that they did not wish to complete the survey were not contacted further. Otherwise, nonresponders were contacted by telephone at 10 weeks to request their participation and verify their residence within the county.
      Among a total of 4850 subjects who were mailed at least 2 surveys over the 20 years, a total of 2853 subjects (59%) responded to a minimum of 2 surveys. A total of 60% of females responded and 57% of males, with the overall mean (± SD) age of respondents being 53 ± 15 years, and in nonrespondents, 53 ± 17 years. Based on a logistic regression model for response (yes or no), females had a slightly greater odds for response relative to males (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0–1.3; P = .053), but age was not associated with response (OR, 1.0; 95% CI, 0.96–1.04; per 10 years of age, P = .95).

       Questionnaire

      The Talley Bowel Disease Questionnaire (BDQ)
      • Talley N.J.
      • Phillips S.F.
      • Melton 3rd, J.
      • et al.
      A patient questionnaire to identify bowel disease.
      • Talley N.J.
      • Phillips S.F.
      • Wiltgen C.M.
      • et al.
      Assessment of functional gastrointestinal disease: the bowel disease questionnaire.
      • Talley N.J.
      • Zinsmeister A.R.
      • Van Dyke C.
      • et al.
      Epidemiology of colonic symptoms and the irritable bowel syndrome.
      was designed as a self-report instrument to measure symptoms experienced over the prior year and to collect the past medical history. Previous testing has shown this instrument to be reliable, with a median κ statistic for symptom items of 0.78 (range, 0.52–1.00); reliability was assessed by asking subjects to complete the survey on 2 occasions 2 weeks apart in the outpatient setting. It has also been demonstrated to have adequate content, predictive, and construct validity.
      • Talley N.J.
      • Phillips S.F.
      • Melton 3rd, J.
      • et al.
      A patient questionnaire to identify bowel disease.
      • Talley N.J.
      • Phillips S.F.
      • Wiltgen C.M.
      • et al.
      Assessment of functional gastrointestinal disease: the bowel disease questionnaire.
      • Talley N.J.
      • Zinsmeister A.R.
      • Van Dyke C.
      • et al.
      Epidemiology of colonic symptoms and the irritable bowel syndrome.
      The original BDQ contained 46 GI symptom-related items including constipation-related questions; 25 items that measure past illness, health care use, and sociodemographic variables; and a valid measure of non-GI somatic complaints, the Somatic Symptom Checklist (SSC).
      • Attanasio V.
      • Andrasik F.
      • Blanchard E.B.
      • et al.
      Psychometric properties of the SUNYA revision of the psychosomatic symptom checklist.
      The SSC consists of 12 non-GI and 5 GI symptoms or illnesses. Respondents are instructed to indicate how often each symptom occurred (on a scale of 0, indicating not a problem, to 4, indicating occurs daily) and how bothersome each was (on a scale of 0, not a problem, to 4, extremely bothersome when occurs) during the past year, using separate 5-point scales. SSC score also has been shown to be a reliable and valid measure of somatic complaints.
      • Attanasio V.
      • Andrasik F.
      • Blanchard E.B.
      • et al.
      Psychometric properties of the SUNYA revision of the psychosomatic symptom checklist.
      • Choung R.S.
      • Locke 3rd, G.R.
      • Zinsmeister A.R.
      • et al.
      Psychosocial distress and somatic symptoms in community subjects with irritable bowel syndrome: a psychological component is the rule.
      Further, the original BDQ was modified for the elderly
      • O'Keefe E.A.
      • Talley N.J.
      • Tangalos E.G.
      • et al.
      A bowel symptom questionnaire for the elderly.
      and derivatives created for specific conditions.
      • Locke G.R.
      • Talley N.J.
      • Weaver A.L.
      • et al.
      A new questionnaire for gastroesophageal reflux disease.
      • Reilly W.T.
      • Talley N.J.
      • Pemberton J.H.
      • et al.
      Validation of a questionnaire to assess fecal incontinence and associated risk factors: fecal incontinence questionnaire.
      These versions were also tested before implementation. The BDQ has been further refined and retested with excellent results.
      • Rey E.
      • Locke 3rd, G.R.
      • Jung H.K.
      • et al.
      Measurement of abdominal symptoms by validated questionnaire: a 3-month recall time frame as recommended by Rome III is not superior to a 1-year recall time frame.
      • Locke 3rd, G.R.
      • Pemberton J.H.
      • Phillips S.F.
      American Gastroenterological Association medical position statement: guidelines on constipation.
      Modifications of the original BDQ with the non-GI SSC questions were used in the follow-up surveys to measure GI symptoms including constipation symptoms experienced over the prior year.

       Definition

      CC was defined according to modified Rome II criteria by 2 or more of the following 4 symptoms in the last year: (1) <3 defecations per week; (2) straining on at least 25% of defecations; (3) hard stools on at least 25% of defecations; and (4) feelings of incomplete rectal evacuation on at least 25% of defecations. In addition, subjects with CC did not meet the criteria of irritable bowel syndrome.

       Classification of CC

       Persistent CC

      Subjects with constipation who met the constipation criteria on all surveys they returned were classified as having persistent CC.

       Nonpersistent CC

      Subjects with constipation who met the constipation criteria on at least 1 survey but not all surveys were classified as having nonpersistent CC.

       Statistical Analysis

      The overall univariate associations between constipation status and demographic, clinical, and symptom characteristics at baseline (eg, age, gender, body mass index [BMI], SSC score, and GI symptoms) were assessed using a nonparametric (ie, the Kruskal–Wallis test) approach for quantitative characteristics and contingency table methods (ie, a χ2 test or Fisher exact test as warranted) for discrete characteristics. The ORs for specific constipation groups (persistent vs none, nonpersistent vs none, and persistent vs nonpersistent) associated with each characteristic were estimated from the coefficients in a logistic regression model (generalized logit link function), after adjusting for age and sex.
      In order to allow for missing data, SSC scores for both often or bothersome for each non-GI symptom were averaged. Then the average often score and the average bothersome score were summed to create a total SSC score.

      Results

      A total of 2853 subjects responded to a minimum of 2 surveys over the 20-year period, and the overall median follow-up was 11.6 years (range, 10 months to 20.2 years). The mean (±SD) age of responders was 53 (±15) years, and 53% were female.
      Among a total of 2853 respondents, 84 subjects (3%; 95% CI, 2–4), had persistent CC, 605 subjects (21%; 95% CI, 20–23) nonpersistent CC, and 2164 subjects (76%; 95% CI, 74–77) without CC (Figure 1) . The average interval between surveys was 7.0 years in the group of subjects without CC, 6.6 years in the nonpersistent CC group, and 6.2 years in the persistent CC group, but no association of group with between survey interval was detected. The survey frequency proportions in each group differed, with, for example, 75% of persistent CC responding to 2 surveys but 49% of nonpersistent CC and 57% of no CC subjects responding to 2 surveys.
      Figure thumbnail gr1
      Figure 1Proportion of those with persistent CC, nonpersistent CC, or no CC.
      Table 1 shows the demographic characteristics according to constipation status. Those with overall CC including persistent and nonpersistent CC had a mean age of 54 (±15) years, and 39% were male. Significant univariate associations with constipation group were observed for age, sex, SSC score, education level, and several clinical characteristics (Table 1). Notably, higher SSC scores were observed in those with persistent or nonpersistent CC compared with those with no constipation with the highest somatic symptom scores in the nonpersistent CC group. In addition, a larger proportion of patients with persistent CC or nonpersistent CC had visited physicians (>5 times in the last year) and reported more frequent laxative/fiber use than those without CC.
      Table 1Characteristics of the Subjects in Olmsted County, Minnesota, by CC Subgroup Status
      Persistent CC (n = 84)Nonpersistent CC (n = 605)No constipation symptoms (n = 2164)P value
      Based on Kruskal–Wallis test or contingency table analysis.
      Age, y55 ± 1554 ± 1553 ± 14.12
      Female sex (n = 1509)49 (58)370 (61)1090 (50)<.01
      BMI28 ± 629 ± 729 ± 7.44
      SSC score0.6 ± 0.40.7 ± 0.50.5 ± 0.4<.01
      Smoking, current (n = 228)5 (6)55 (9)168 (8).78
      Alcohol use
       1–6 drinks/wk (n = 644)13 (16)150 (25)481 (22).10
       ≥7 drinks/wk (n = 199)7 (8)39 (6)153 (7)
      Married (n = 1624)43 (51)347 (57)1234 (57).79
      Education level
       Less than high school (n = 143)3 (4)39 (6)101 (5).002
       High school/some college (n = 1605)53 (63)372 (62)1180 (55)
       College graduate or higher (n = 1077)28 (33)191 (32)858 (40)
      Cholecystectomy (n = 144)3 (4)36 (6)105 (5).59
      Appendectomy (n = 516)20 (24)133 (22)363 (17).06
      Visiting a physician >5 times in the last year (n = 227)11 (13)66 (11)150 (7).002
      Laxative or fiber use in the last year (n = 391)44 (52)168 (28)179 (8)<.01
      Dyspepsia (n = 96)4 (5)41 (7)51 (2)<.01
      Gastroesophageal reflux symptoms (n = 443)20 (24)132 (22)291 (13)<.01
      NOTE. Data are presented as n (%) or mean ± SD.
      a Based on Kruskal–Wallis test or contingency table analysis.

       Gastrointestinal Symptoms

      Table 2 summarizes the distributions of GI symptoms at 6 months and each item of the SSC by constipation subgroup. As would be expected, all constipation-related symptoms such as infrequent bowel movements, hard stools, straining, and incomplete evacuation were more frequently reported by those with constipation (persistent and nonpersistent) than in those without constipation. Interestingly, those with CC had more dyspepsia and reflux symptoms, and loose bowel movements were least frequently reported in those with persistent CC. Pain-related symptoms including frequent and severe abdominal pain were most often reported in those with nonpersistent CC among the 3 groups. In particular, among 605 with nonpersistent CC, 202 (33%) met the criteria for irritable bowel syndrome (IBS) on 1 or more surveys. Among 2164 with no CC, 552 (26%) met the criteria for IBS on 1 or more surveys. However, no person with persistent CC met the criteria for IBS.
      Table 2Distribution of GI Symptoms and Individual SSC Items by CC Subgroup Status
      Persistent CC (n = 84)Nonpersistent CC (n = 605)No constipation symptoms (n = 2164)P value
      Based on Kruskal–Wallis test or contingency table analysis.
      Mucus (n = 286)18 (21)87 (14)181 (8)<.01
      Bloating (n = 555)36 (43)212 (35)307 (14)<.01
      Abdominal pain (n = 1227)43 (51)335 (55)849 (39)<.01
      Pain severity
       Mild (n = 326)10 (12)90 (15)226 (10)<.01
       Moderate (n = 727)28 (33)210 (35)489 (23)
       Severe or very severe (n = 142)3 (4)32 (5)107 (5)
      Urgency (n = 471)11 (13)124 (21)336 (16).01
      Pain frequency
       <1 per wk (n = 920)31 (37)234 (39)655 (30)<.01
       ≥1 per wk (n = 304)12 (14)100 (17)192 (9)
      Any blood in stool (n = 158)9 (11)64 (11)85 (4)<.01
      More than 3 BMs per d (n = 139)5 (6)34 (6)100 (5).46
      Loose BM (n = 486)5 (6)103 (17)378 (18).02
      More BM with pain (n = 411)5 (6)91 (15)315 (15).08
      SSC
       Headaches1.0 ± 1.01.0 ± 1.10.7 ± 0.9<.01
       Backaches0.9 ± 1.11.3 ± 1.31.0 ± 1.1<.01
       Asthma (wheezing)0.1 ± 0.30.1 ± 0.50.1 ± 0.5.82
       Insomnia1.0 ± 1.10.9 ± 1.10.6 ± 0.9<.01
       Fatigue (tiredness)1.3 ± 1.11.3 ± 1.20.8 ± 1.0<.01
       General stiffness1.1 ± 1.11.2 ± 1.40.9 ± 1.1<.01
       Heart palpitations0.3 ± 0.60.3 ± 0.70.2 ± 0.5<.01
       Eye pain associated with reading0.2 ± 0.50.3 ± 0.80.2 ± 0.5<.01
       Dizziness0.3 ± 0.80.3 ± 0.80.2 ± 0.5<.01
       Weakness0.3 ± 0.70.3 ± 0.80.1 ± 0.5<.01
       High blood pressure1.2 ± 0.60.4 ± 0.90.3 ± 0.7.07
      NOTE. Data are presented as n (%) or mean ± SD.
      a Based on Kruskal–Wallis test or contingency table analysis.

       Association Between Clinical Features and Constipation Status

      The odds ratios for specific constipation subgroups associated with demographic and clinical characteristics are given in Table 3. Greater SSC scores, frequent physician visits, and laxative or fiber use were associated with greater odds for persistent CC compared with those without CC. Similarly, greater SSC scores, frequent doctor visits, and laxative/fiber use were significant predictors of those with nonpersistent CC vs those without CC. However, most characteristics were not significant discriminators of persistent CC vs nonpersistent CC, except increased laxative or fiber use was associated with increased odds for persistent CC (vs nonpersistent, Table 3).
      Table 3Associations Between Clinical Characteristics and CC Subgroups
      Persistent CC vs no CCNonpersistent CC vs no CCPersistent CC vs nonpersistent CCP value
      From logistic regression models, overall test for the 3 constipation subgroups.
      Age per 10 y1.1 (1.0–1.3)1.1 (1.0–1.1)1.0 (0.9–1.2).09
      Female sex1.4 (0.9–2.2)1.6 (1.3–1.9)0.9 (0.6–1.4)<.01
      BMI
      Models adjusted for age and sex.
      1.0 (0.9–1.0)1.0 (1.0–1.0)1.0 (0.9–1.0).50
      SSC score
      Models adjusted for age and sex.
      2.1 (1.3–3.4)2.9 (2.2–3.4)0.8 (0.5–1.3)<.01
      Smoking, current
      Models adjusted for age and sex.
      0.7 (0.3–1.8)1.0 (0.7–1.4)0.7 (0.3–1.8).75
      Alcohol
      Models adjusted for age and sex.
       None2.0 (1.0–4.1)1.2 (0.9–1.5)1.7 (0.8–3.6).09
       ≥7 drinks/wk1.8 (0.7–4.7)0.9 (0.6–1.3)2.0 (0.7–5.5).39
      Married
      Models adjusted for age and sex.
      1.3 (0.6–2.8)1.0 (0.7–1.3)1.3 (0.6–2.9).86
      Education level
      Models adjusted for age and sex.
       Less than high school0.6 (0.2–2.1)1.3 (0.9–1.9)0.5 (0.2–1.7).35
       College graduate or higher0.8 (0.5–1.2)0.7 (0.6–0.9)1.0 (0.6–1.7).008
      Cholecystectomy
      Models adjusted for age and sex.
      0.7 (0.3–2.1)1.2 (0.8–1.7)0.6 (0.2–1.9).59
      Appendectomy
      Models adjusted for age and sex.
      1.2 (0.7–2.1)1.3 (1.0–1.6)0.9 (0.5–1.6).11
      Visiting a physician >5 times
      Models adjusted for age and sex.
      2.0 (1.0–3.8)1.6 (1.2–2.1)1.2 (0.6–2.5).004
      Laxative or fiber use
      Models adjusted for age and sex.
      12.1 (7.5–19.4)4.0 (3.2–5.1)3.0 (1.9–4.9)<.01
      Dyspepsia2.0 (0.7–5.8)2.9 (1.9–4.5)1.1 (0.6–1.9)<.01
      Gastroesophageal reflux symptoms2.0 (1.2–3.3)1.8 (1.4–2.3)0.7 (0.2–2.0)<.01
      NOTE. Data are given as OR (95% CI).
      a From logistic regression models, overall test for the 3 constipation subgroups.
      b Models adjusted for age and sex.
      The association between constipation status and lower GI symptoms is shown in Table 4.
      Table 4Associations Between Individual GI Symptoms and CC Status
      Persistent CC vs no CCNonpersistent CC vs no CCPersistent CC vs nonpersistent CCP value
      From logistic regression models, overall test for the 3 constipation subgroups.
      Mucus
      Models adjusted for age and sex.
      3.1 (1.8–5.4)1.8 (1.4–2.4)1.7 (1.0–3.1)<.01
      Bloating
      Models adjusted for age and sex.
      4.4 (2.8–6.9)3.1 (2.5–3.8)1.4 (0.9–2.2)<.01
      Abdominal pain
      Models adjusted for age and sex.
      1.7 (1.1–2.7)2.0 (1.6–2.4)0.9 (0.5–1.4)<.01
      Pain severity
      Models adjusted for age and sex.
       Mild1.5 (0.7–3.1)2.0 (1.5–2.7)0.7 (0.4–1.5)<.01
       Moderate1.9 (1.2–3.2)2.1 (1.7–2.6)0.9 (0.5–1.5)<.01
       Severe or very severe1.0 (0.3–3.1)1.5 (1.0–2.3)0.6 (0.2–2.2).17
      Urgency
      Models adjusted for age and sex.
      0.8 (0.4–1.5)1.3 (1.1–1.7)0.6 (0.3–1.1).04
      Pain frequency
      Models adjusted for age and sex.
       <1 per wk1.6 (1.0–2.6)1.8 (1.5–2.2)0.9 (0.5–1.5)<.01
       ≥1 per wk2.1 (1.1–4.0)2.6 (1.9–3.4)0.8 (0.4–1.6)<.01
      Any blood in stool
      Models adjusted for age and sex.
      3.2 (1.4–7.1)2.8 (1.9–4.0)1.1 (0.5–2.6)<.01
      More than 3 BMs per d
      Models adjusted for age and sex.
      1.2 (0.5–3.0)1.2 (0.8–1.8)1.0 (0.4–2.6).60
      Loose BM
      Models adjusted for age and sex.
      0.3 (0.1–0.8)1.0 (0.8–1.2)0.3 (0.1–0.8).04
      More BM with pain
      Models adjusted for age and sex.
      0.4 (0.2–0.9)1.0 (0.8–1.3)0.4 (0.1–0.9)<.01
      NOTE. Data are given as OR (95% CI).
      a From logistic regression models, overall test for the 3 constipation subgroups.
      b Models adjusted for age and sex.
      Most of the lower GI symptoms, including any blood in stool, were associated with greater odds for those with persistent CC or nonpersistent CC compared with those without CC except diarrhea-related symptoms (Table 4). Interestingly, most of the GI symptoms were not significant discriminators of persistent CC vs nonpersistent CC, though loose bowel movements and more bowel movements with pain had significantly decreased odds for persistent CC compared with nonpersistent CC.

      Discussion

      This is to our knowledge the first population-based longitudinal study to present US data on the chronicity of constipation over a 20-year time frame. We observed the prevalence of persistent CC over a 20-year period was only 3%. In contrast, the prevalence of nonpersistent CC over a 20-year period was 21%. Those with persistent or nonpersistent CC were more likely to report higher SSC scores and frequent physician visits relative to those without constipation. However, those with persistent CC were similar to those with nonpersistent CC, except for fiber or laxative use, in terms of demographic features and other GI symptoms.
      The prevalence of constipation has been reported to be as high as 27% of the population depending on demographic factors, sampling, and definition, but only a minority visits the clinic.
      • Stewart W.F.
      • Liberman J.N.
      • Sandler R.S.
      • et al.
      Epidemiology of constipation (EPOC) study in the United States: relation of clinical subtypes to sociodemographic features.
      • Sonnenberg A.
      • Koch T.R.
      Physician visits in the United States for constipation: 1958 to 1986.
      • Cook I.J.
      • Talley N.J.
      • Benninga M.A.
      • et al.
      Chronic constipation: overview and challenges.
      • Sonnenberg A.
      • Koch T.R.
      Epidemiology of constipation in the United States.
      • Suares N.C.
      • Ford A.C.
      Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis.
      In our study, we also observed the prevalence of overall CC including persistent and nonpersistent CC over a 20-year period was about 24%, which is similar to other prevalence data. However, we observed only 3% of the population had persistent CC over a 20-year period, which might be a truer indication of the chronicity of constipation. By the recent Rome criteria,
      • Longstreth G.F.
      • Thompson W.G.
      • Chey W.D.
      • et al.
      Functional bowel disorders.
      functional constipation is defined by having constipation-related symptoms with symptom onset at least 6 months prior to diagnosis. Traditionally, the symptom of CC has been considered to persist over a very prolonged period of time, perhaps lifelong. Talley et al
      • Talley N.J.
      • Weaver A.L.
      • Zinsmeister A.R.
      • et al.
      Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders.
      reported that 89% of adults surveyed reported no change in their GI symptoms during an intervening 12 to 20 months in the general population.
      • Talley N.J.
      • Weaver A.L.
      • Zinsmeister A.R.
      • et al.
      Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders.
      Johanson and Kralstein
      • Johanson J.F.
      • Kralstein J.
      Chronic constipation: a survey of the patient perspective.
      also showed that about 70% of patients had constipation for more than 2 years by the web-based survey. Moreover, a random sample survey in Sweden in 1988, 1989, and then 1995 showed that among those with IBS at baseline, 55% continued to report IBS at both follow-up surveys.
      • Agréus L.
      • Svärdsudd K.
      • Talley N.J.
      • et al.
      Natural history of gastroesophageal reflux disease and functional abdominal disorders: a population-based study.
      In another study, Halder et al
      • Halder S.L.
      • Locke 3rd, G.R.
      • Schleck C.D.
      • et al.
      Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study.
      evaluated the natural history of functional GI disorders using multiple surveys over a 12-year period in a community and observed that 40% of people with a GI symptom at baseline had different symptoms at follow-up. Moreover, among people with constipation at the initial survey, only about 22% still had constipation on the follow-up survey. This study showed only 3% of people had persistent CC in a community over a longer 20-year period. Thus, it can be concluded that CC is less frequent in a community over a longer period of time, and the estimated prevalence of CC in previous cross-sectional studies is likely to have been exaggerated. Others have highlighted that only a minority of those with constipation who have chronic or severe symptoms seek health care.
      • Sonnenberg A.
      • Koch T.R.
      Physician visits in the United States for constipation: 1958 to 1986.
      • Longstreth G.F.
      • Thompson W.G.
      • Chey W.D.
      • et al.
      Functional bowel disorders.
      Like many other studies have shown,
      • Suares N.C.
      • Ford A.C.
      Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis.
      • Harari D.
      • Gurwitz J.H.
      • Avorn J.
      • et al.
      Bowel habit in relation to age and gender Findings from the national health interview survey and clinical implications.
      • Everhart J.E.
      • Go V.L.
      • Johannes R.S.
      • et al.
      A longitudinal survey of self-reported bowel habits in the United States.
      • Brandt L.J.
      • Prather C.M.
      • Quigley E.M.
      • et al.
      Systematic review on the management of chronic constipation in North America.
      we observed that older age and a high SSC score were associated with CC regardless of chronicity (persistent or nonpersistent), relative to subjects without constipation. The association of CC with advancing age might reflect the increased prevalence of secondary causes of constipation (eg, an increased prevalence of Parkinson's disease, diabetes mellitus, constipating medication use, or the increasing prevalence of other disabling conditions).
      • Brandt L.J.
      • Prather C.M.
      • Quigley E.M.
      • et al.
      Systematic review on the management of chronic constipation in North America.
      In addition, there is a considerable body of evidence supporting an association between psychological distress, environmental stress, and functional GI disorders, including constipation.
      • Suares N.C.
      • Ford A.C.
      Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis.
      • Koloski N.A.
      • Boyce P.M.
      • Talley N.J.
      Somatization an independent psychosocial risk factor for irritable bowel syndrome but not dyspepsia: a population-based study.
      • Rao S.S.
      • Seaton K.
      • Miller M.J.
      • et al.
      Psychological profiles and quality of life differ between patients with dyssynergia and those with slow transit constipation.
      Rao et al
      • Rao S.S.
      • Seaton K.
      • Miller M.J.
      • et al.
      Psychological profiles and quality of life differ between patients with dyssynergia and those with slow transit constipation.
      showed that patients with constipation had significant evidence of increased psychological distress compared with control subjects, irrespective of the underlying pathophysiology such as slow colonic transit or dyssynergic defecation. Thus, both older age and high somatization trait may be causally linked with constipation.
      An interesting hypothesis explored in the current study is whether those with persistent CC are different from those with nonpersistent CC or whether these 2 forms of CC exist as a temporal spectrum of the same condition. We evaluated for differences between persistent CC and nonpersistent CC, and observed that there were no distinct differences in terms of demographic features between these 2 groups aside from laxative or fiber use. Certain constipation-related symptoms such as infrequent, hard stools, straining, or feelings of incomplete evacuation, were more commonly reported in those with persistent CC, while pain and diarrhea-related symptoms such as loose bowel movements and increased bowel movements with abdominal pain were more commonly reported by those with nonpersistent CC. Thus, it could be inferred that those with persistent constipation are a more homogenous group, with more constipation symptoms and less diarrhea symptoms. Interestingly, the characteristics of those with nonpersistent CC might reflect some portion of underlying unrecognized IBS. Further study of outcomes according to chronicity of constipation status may provide a better understanding of these 2 groups and such work is now needed.
      The strengths of the current study include the investigation of a random community sample that was not seeking health care for their bowel complaints, which should have minimized selection bias. The fact that we employed a previously validated self-report symptom questionnaire also increases confidence in the results.
      • Talley N.J.
      • Phillips S.F.
      • Melton 3rd, J.
      • et al.
      A patient questionnaire to identify bowel disease.
      This study also had limitations. In particular, this study did not assess the whole study period of CC, because subjects could have developed and then lost symptoms between surveys; the current study is limited to the survey responses. However, this study is in fact novel; no previous work has quantified constipation over a 20-year period of time in the general population. These data cannot be generalized outside the white US population because the racial composition of this community is predominantly Caucasian.
      • Melton 3rd, L.J.
      History of the Rochester epidemiology project.
      The prevalence of constipation may vary across different countries and cultures, but at a minimum, our data are probably generalizable to the US Caucasian population.
      We conclude from this population-based study that the proportion with persistent CC in the community is 3%. Persistent CC has similar clinical characteristics to nonpersistent CC.

      Acknowledgments

      The authors thank Lori R. Anderson for her assistance in the preparation of the manuscript.

      Video Abstract

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