Fluid Intake, Fiber Consumption and Physical Activity Related to Constipation among Elderly, Which One Is More Important? A cross sectional study from Iran

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Fluid Intake, Fiber Consumption and Physical Activity Related to Constipation among Elderly, Which One Is More Important? A cross sectional study from Iran

https://doi.org/10.21203/rs.3.rs-3235582/v1

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Background: Chronic constipation is a common, self-reported, symptom-based disorder which can significantly impact an individual’s health-related quality of life [1]. Constipation affects the quality of life of a person with social problems and imposes many financial costs on the person

The prevalence of constipation is estimated at 1 to 80% around the worldods: Inadequate fluid consumption is touted as a common culprit in constipation, and increasing fluid intake is a frequently recommended treatment. Evidence suggests, however, that increasing fluids is only of usefulness in individuals in a hypo hydrated state, and is of little utility in EU hydrated individuals".There is a strong association between obesity and constipation . Although obesity is also associated with constipation; it is not recognized as a causal factor of constipation. Another investigation indicated constipation and obesity have common risk factors. However, little is known about constipation in individuals with severe obesity and the associated factors

The current study was conducted to investigate the effect of Water consumption, fiber intake, and PA on Constipation and which one is more critical by considering Mediating effect of BMI

Methods: The study was a cross-sectional study performed on 400 older adults in 2019 referring to the comprehensive health service centers in Karaj, the capital of Alborz province,several instruments included demographic and antro pometric traits , PASE,fluid intakes, FFQ و WHO Qol, wexner cospitation were used to collect data.ُSPSS and lizrelsoftwares were used to analysize data

Results: Based on the final fitted model, PA is the most critical factor related to constipation compared to fluid intake and fiber consumption. The finding of the present study was in line with several studies.Based on the final fitted model, fiber consumption is the second most factor affecting constipation, and there is a negative association between constipation and fiber intake.

Conclusions: As price is one of the barriers to fiber consumption in the elderly, the recommendation to do Physical activity such as walking to solve the problem of constipation is efficient and inexpensive advice for people with different socioeconomic statuses.

Physical activity

wexner constipstion

quality of life

Elderly

Chronic constipation is a common, self-reported, symptom-based disorder which can significantly impact an individual’s health-related quality of life [1]. Constipation affects the quality of life of a person with social problems and imposes many financial costs on the person [2].

The prevalence of constipation is estimated at 1 to 80% around the world [3]. The prevalence increase with age [4]. Older people suffered more from constipation than their counter partner [5]. Constipation affects 17–40% of the elderly and reduces the quality of life (QOL) [6, 7].

Chronic constipation is a symptom-based disorder characterized by unsatisfactory defecation due to infrequent stools, difficult stool passage, or both [8]

According to Rome Criteria III, having two or more of the following symptoms for at least 12 weeks in 12 months determines constipation: 1. Two or fewer bowel movements per week; 2. Strain during defecation; 3. lumpy or hard stools; 4. sensation of incomplete [9].

The prevalence in older adults above 65 years old in Iran assessed by the criteria of Rome III was 50% [10].

Constipation is related to multiple factors, and when it is untreated or not adequately treated, it results in complications, such as compression or perforation and death [11]. Constipation represents an economic burden for the patient and healthcare provider [12, 13].

Elderly healthcare providers need to be aware of constipation, and be prepared to care to reduce complications [14].

Lifestyle correction is of global worry and is suggested to prevent and handle several diseases [15] including constipation.

Low fluid intake, low fiber consumption, and impaired mobility are relevant factors that increase constipation in the elderly [16, 17].

Of all the advantages of Dietary fiber, probably the most commonly known and appreciated influences constipation alleviation. Several research support such efficacy, which appears indisputable based on the available evidence. In a randomized controlled, double-blind related study regarding the effects of ‘vege-powder’ (consisting of chicory, broccoli, and whole grains) on the constipation prevention in ninety percent of the participants, compared with the control group, those who received vege-powder had a significant reduction in the symptoms of constipation at 2 and 4 weeks [18]. Further supportive evidence comes from a systematic review reported by Rao et al. [19]. Dietary fibre was effective on constipation in five of the seven studies. This evidence would appear to support the positive effects of dietary fibre on constipation.

Physical activity has positive effects on the health of Gastrointestinal tract (GIT) [20]. Compared to physically inactive individuals, physically active individuals have demonstrated a lower prevalence of constipation [21].

There is limited evidence that lifestyle changes resolve constipation, but it is universally accepted as a first-line approach. Studies assessing the effect of Physical activity on constipation in the elderly were unable to show an improvement in bowel movements; however, exercise has been shown to enhance the quality of life in this population [22].

Appropriate Physical activity should be considered may improve symptoms of constipation, but strong evidence in this regard is lacking [23].

Related to fluid intake, it should notice that high fiber foods and enough water intake are essential for general health and the dietary treatment of constipation and obesity [24].

Promoting fluid intake to improve symptoms of constipation is not supported by the literature [25]. Evidence shows low fluid intake has been associated with constipation in nursing home residents [26]. But, some researchers highlight in their study that the prevalence of constipation was higher in those who did not consume whole grains, fresh fruits, and raw salad daily, which are high fiber foods and those with inadequate water intake [27].

Another study indicated two groups with similar fiber consumption. Higher fluid intake led to higher stool frequency compared to lower fluid intake (P < 0.001).

"Inadequate fluid consumption is touted as a common culprit in constipation, and increasing fluid intake is a frequently recommended treatment. Evidence suggests, however, that increasing fluids is only of usefulness in individuals in a hypo hydrated state, and is of little utility in Euhydrated individuals" [28].

There is a strong association between obesity and constipation [29]. Although obesity is also associated with constipation; it is not recognized as a causal factor of constipation [30]. Another investigation indicated constipation and obesity have common risk factors. However, little is known about constipation in individuals with severe obesity and the associated factors [31, 32, 33, 34].

A recent study showed that obese individuals have several other risk factors for constipation, such as physical inactivity, low quality of their diet, and low consumption of fibers and vegetables in general [35].

The current study was conducted to investigate the effect of Water consumption, fiber intake, and PA on Constipation and which one is more critical by considering Mediating effect of BMI [Figure1]

Procedure

The study was a cross-sectional study performed on 400 older adults in 2019 referring to the comprehensive health service centers in Karaj, the capital of Alborz province, located in the west of Tehran province (capital of Iran). To select the studied samples, the multi-stage sampling method was used. Thus, in the first stage, the city of Karaj was divided into four parts based on the socio-economic status of the city (good socio-economic status, moderate upward socio-economic status, medium-down socio-economic status, low socio-economic status). Then, from each section, 2 health centers were selected, and subjects were selected by convenience sampling.

For determining, the sample size, the following formula was considered with the prevalence of 18% prevalence of constipation [36], 95% confidence interval and precision (d) of 4%.

Inclusion criteria were: age above 60 consent to participate in the study (filling conscious and voluntary consent). At last, 400 elderly persons were studied related to water consumption, fiber intake, and physical activity and constipation.

Instruments

We used several instruments to collect data. The reliability of all instruments was assessed among a sub-sample of 20 older individuals using Cronbach’s alpha coefficient. The instruments and findings are explained as follows:

Demographic and anthropometric questionnaire: The demographic section of the questionnaire included age, gender, education, income, marital status, gastrointestinal diseases (having or not), BMI (Body Mass index). The same calibrated digital scales were used for Weighing. Standing tape was used to measure height while the study subjects were standing and not wearing shoes with the normal shoulders position. BMI was calculated by divided weight / (heigh)², and income status was measured by asking the participants related to monthly income (due to Iranian currency). Based on society context, the individuals are divided into three (low, medium, high).

Constipation assessment: Constipation in the current study assessed by the Wexner score [37]. Wexner's score compromised 8 items which are scored based on five-point Likert scale except for one item, which is scored from 0 to 2. The first item is the frequency of bowel movements, which is 0 means "1–2 times in 1–2 days", 1 means "2 times in week", a score 2 means "once in week", 3 means "less than once in week", and 4 means "less than once in month". Painful evacuation endeavors, unsatisfied evacuation, and belly pain are the second, third, and fourth items, respectively, as well as, scores from 0 to 4 mean "never", "rarely", "sometimes", "usually", and "always", respectively. The fifth item is the time spent in the toilet for each effort for which a score of 0 equivalent "less than 5 min", a score of 1 equivalent "5–10 min", a score of 2 equivalent "10–20 min", a score of 3 equivalent "20–30 min", and a score of 4 equivalent "more than 30 min". The sixth item is the type of help for which a score of 0 equivalent "without helping ", a score of 1 equivalent "stimulative laxatives", and a score of 2 equivalent "digital helping or enema". The seventh item is unsuccessful efforts for evacuation in 24 hours for which scores of 0 to 4 equivalent "never ", "1–3", "3–6", "6–9", and "more than 9", respectively. The eighth item is the duration of constipation (yrs.) for which scores of 0 to 4 equivalent "0 (yrs.)", "1–5 (yrs.)", "5–10 (yrs.)", "10–20 (yrs.)", and "more than 20 (yrs.)", respectively. Based on the grading of the questionnaire, grading ranges from 0 (normal) to 30 (severe constipation), and a score of 15 is the cut-off point. The psychometric properties of the Wexner questionnaire was assessed among Iranian Population [38]

Total fluid consumption: To assess total fluid intake, the participants were asked to determine the average number of water glasses (including plain water intake, water from beverage) they usually consume per day and their usual intra-meal fluid intake [39]. Standard containers were provided as visual aids to help participants recall water intake accurately. The internal consistency of the questionnaire was assessed using Cronbach’s alpha coefficient, and it was found to be 0.79.

Dietary fiber intakes: This variable assessed by two methods:

Food Frequency Questionnaire: Dietary fiber intakes of study participants were examined using a validated 106-item semi-quantitative food frequency questionnaire, as described elsewhere in detail [40]. The FFQ was administered in combination with a photo album of foods for more reliable data Daily intakes of fibers for each participant were estimated based on the US Department of Agriculture food-composition database, modified for Iranian foods.

A 24-hour recall: Subjects were asked to estimate their daily intake of fiber ( whole grains, fruit and vegetable, and legumin ) at breakfast, lunch, dinner, and between meals as snacks or desserts following a nutrition guideline card.

5. Physical Activity: The modified version of PASE was used to measure self-reported PA. It is a brief and easily scored questionnaire designed specifically to assess PA over a week in epidemiologic studies of the elderly [41]. The questionnaire contains three sections regarding the frequency and duration of leisure-time activities, household activities, and work-related activities. The overall PASE score ranges from 0 to 400 or more [41]. This instrument has been translated and validated in Iran [42].

Ethical Consideration:

This research has been approved by the Ethics Committee of Alborz University of Medical Sciences, (Ethical code no. IR.ABZUMS.REC. 1398.223)

Data analysis

Data related to the descriptive part were analyzed using SPSS26 software and the part related to path analysis was analyzed using LISRELS software version 8. First, the normality of the data was assessed by using Kolmogorov–Smirnov test (P > 0.05). Correlations between variables were calculated for path analysis. Fluid intake, fiber consumption, physical activity, as predictor variables, BMI as mediating variables, and constipation as dependent variables. In order to fit the model from chi-square indices to the degree of freedom X2 / df, root error index of mean RMSEA squares, NFI normalized fit index, non-softened fit index NNFI, CFI adaptation fit index, GFI goodness-fit index AGFI Modified was used.

The mean age of participants was 66.54. The largest sample size (236) was between 66–70. years old, and 52.75% of the participants were employed. In terms of education, most of the sample group (42%) had education at the diploma level. In terms of income, 50.75 had the middle income.

There is no difference between constipated and non-constipated patients related to demographic characteristics. (P > 0.05). Demographic characteristics are shown in Table 1.

Table 1

The characteristics of study sample (n = 400)
	Total	Constipated Patients (n = 238)	Non- constipated patients (n = 162)	P*
Age (n (%)				0.867
60–65	121 (30.25)	72(3.03)	49
66–70	236 (59)	142(59.66)	94
> 70	43 (10.75. 5)	24(10.08)	19
Mean ± SD	66.54 ± 3.58	66.63 ± 3.41	66.41 ± 3.82	0.545
Gender				0.396
Male	207 (51.75)	119(50)	88(54.32)
Female	193 (48.25)	119(50)	74(45.68)
Education				0.361
< 12	157(43.75)	92(38.66)	65(40.12)
12	168(42)	96(40.34)	72(44.44)
12>	75 (18.8)	50(21.01)	25(15.43)
Marital status				0.448
Married	218 (54.5)	126(52.94)	92(56.79)
Widowed/divorce	182 (45.5)	112(47.06)	70(43.21)
Income				0.569
Low	126)31.5)	72(30.25)	54(33.33)
Intermediate	203(50.75)	120(5.42)	83(51.23)
High	71(17.75)	46(19.33)	25(15.43)
Employment status				0.127
Employed	211(52.75)	117(49.16)	94(58.02)
Retired	127(31.75)	78(32.77)	49(30.25)
Housewife	62(15.5)	43(18.07)	19(11.73)
Smoking				0.351
Yes	152(38)	86(2.05)	66(40.74)
No	248(62)	152(63.87)	96(59.26)
Gastrointestinal disease				< 0.001
Yes	84(21)	70(29.41)	14(8.64)
No	316(79)	168(70.59)	148(91.36)
BMI				0.713
< 25	162(40.5)	94(39.5)	68(41.98)
26–30	169(42.25)	100(42.01)	69(42.59)
> 39	69(17.25)	44(18.49)	25(15.43)
X^2, independent t- test*

Table 1

The mean of fiber intake, Fluid consumption, and physical activity are 8.60, 4.65 ± 1.63, and 126.83 ± 88.39, respectively. The mean and standard deviation of the variables are reported in constipated patients versus non -constipated patients in Table 2.

Table 2

comparison fiber intake, fluid consumption and physical activity between conspited and non – conspited pstients
	Constipated Patients (n = 238)	Non- constipated patients (n = 162)	P
Fiber Intake(g/day)	7.54 ± 3.17	10.16 ± 3.49	< 0.001
Fluid consumption (Glass)	4.31 ± 1,70	5.15 ± 1.37	< 0.001
Physical activity(day)	107.07 ± 82.36	155.86 ± 7.01	< 0.001
*ANOVA

Table 2:

The correlation between the variables is shown in (Table 3). There is the significant negative correlation between fiber consumption, fluid intake and physical activity with constipation ion.

Table 3

Correlation between fiber, fluid, PASE, BMI and constipation:
	fiber	fluid	PASE	BMI	constipation
fiber	1
fluid	.307^**	1
PASE	.253^**	.169^**	1
BMI	− .298^**	− .242^**	− .156^**	1
Constipation	− .373^**	− .292^**	− .314^**	.251^**	1
**. Correlation is significant at the 0.01 level (2-tailed).

Table 3

Before testing the model, the correlation between constipation, fiber consumption, fiber intake and body mass index was evaluated, which was shown.

Model structure:

Due to the final fitted model (Fig. 2), among the variables, only BMI directly affects constipation; other variables through both direct and indirect routes were associated with constipation. Physical activity (β = 1) is the most influential variable on constipation; Fiber consumption is the second important factor related to constipation (Table 4). The final path model fitted well (CFI = 1, RMSEA = 0.00, GFI = 1), the Goodness of fit Indices for the model indicated in Table 5.

Table 4

Path Coefficients for study predictors on constipation among elderly
Variables	Direct effect	Indirect effect	Total effect	R2
BMI	0.33	----	0.33	0.99
Physical Activity (PA)	0.67	0.33	1
Fiber intake	0.03	0.013	0.043
Fluid consumption	0.01	0.003	0.013

Table 5

Goodness of fit Indices for the model
Fitting index	X2	df	RMSEA	GFI	NFI	CFI	NNFI
Model Index	5.55	5	0.0	1	1	1	0.99
Acceptable Range	X2/df < 5		< 0.05	> 0.90	> 0.90	> 0.90	> 0.90
IFI: Incremental fit indices, NFI: Normed-fit index, GFI: Goodness-of-fit statistic, RMSEA: Root mean square error of approximationX²:chi-square

Figure2:

Table 5

Based on the final fitted model, PA is the most critical factor related to constipation compared to fluid intake and fiber consumption. The finding of the present study was in line with several studies [43. 44]. An interventional study conducted on 125 obese premenopausal women who had chronic constipation showed that 12 weeks of PA positively affects constipation [45].

physical activity Furthermore, Jumping, standing position, gravity, and belly muscle contraction incitement the gut transmit and push stools to the rectum, and increasing the stimulation and the augmentation of energy expenditure during physical activity was found to influence energy intake, need for increasing dietary fiber intake [46, 47, 48] .

physical activity Based on the final fitted model, fiber consumption is the second most factor affecting constipation, and there is a negative association between constipation and fiber intake. Increased dietary fiber intake can result in diminished colonic transit times and increased stool mass [49, 50],

Studies have revealed that a high-fiber diet can enhance stool weight, resulting in a decline in colon passage time, while a low-fiber diet cause constipation [51]. Soluble fiber (e.g., psyllium) has better results than insoluble fiber (e.g., bran) and is recommended [52], and fiber should be increased gradually to ovoid side effects [53].

Based on recent study results,” Increasing DF intake was associated with stool consistency-related constipation among physically active participants, but not among non-active participants. However, increasing DF intake is not significantly associated with stool frequency in different physical activity groups.” [54]

Fluid intake alongside the PA and fiber consumption affect constipation in our study. High fiber food and proper fluid intake are essential factors in general health and the non-medical treatment of constipation and obesity [55]

As in this study, constipation was evaluated based on both stool consistency and stool frequency. We could not assess physical activity effects on stool consistency and stool frequency separately.

Furthermore, based on current study results, PA affects constipation through BMI. Another study indicated that physical activity and weight reduction improve constipation in middle-aged, premenopausal women with constipation in the short term [56].

Despite the association between obesity and constipation, obesity is not distinguished as a causal element of constipation. Based on a study in this regard, obese people have several other risk factors for constipation; for example, obese individuals are less physically active, lower fiber intake, and poorer quality diets [57].

By considering the effect of several factors such as age [58],gender [59],Education [60],smoking [61], Martial status [62] occupation[63], and income [64], we assessed our participants related to these factors between constipated and non-constipated individuals, and two groups were homogeneous in this regard.

Limitation

This study was conducted among older adults in the urban area of Karaj, so caution should be taken in extending the finding to other communities. Second, it should be noticed that constipation in the present study was assessed by the subjective assessment, therefore is a need for objective assessment (Like defecography) in the future studies. Finally, as the data were collected in the form of self-report questionnaires, the recall bias should be considered.

Based on the findings, PA has a powerful effect on constipation, which is better considered in intervention studies. Given that price is one of the barriers to fiber consumption in the elderly, the recommendation to do PA such as walking to solve the problem of constipation is efficient and inexpensive advice for people with different socioeconomic statuses.

Dietary fiber

QOL

quality of life

GIT

goucose tolerance test

physical activity

BMI

Body Mass index

fiber intake

PASE

The physical activity scale for the elderly.

Acknowledgement

We thank all the participants and staff of the comprehensive health service centers in Karaj who helped us in this research.

Ethics approval and consent to participate

Ethical Committee of Alborz University of Medical Sciences approved the study (approval number: IR.Abzums.1398.223). All the participants signed the informed written consent forms. All the participations were assured regarding their privacy in this study and informed about volunteer entering in the study and willingness to exclude from the study at any time.All methods in the current study were carried out in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare that there is not any conflict of interest.

Funding

This study conducted without any funding.

Authors’ contributions

MS:Worte manuscript and contributed in perform the study, , M Gh : collected the study data and contributed to statistical analysis and interpreted the findings.ZM : analysized data study.

LS: supervised the study; contributed to the study design and conducted the analysis and write the manuscript

Availability of data and materials

The current study datasets and analysis sheets are available and will be provided due to reasonable request.

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Fluid Intake, Fiber Consumption and Physical Activity Related to Constipation among Elderly, Which One Is More Important? A cross sectional study from Iran

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