1582 CLINICAL AND SYSTEMATIC REVIEWS
`
`nature publ1sh1nggroup
`
`mJI)
`
`Prevalence of, and Risk Factors for, Chronic Idiopathic
`Constipation in the Community: Systematic Review
`and Meta-analysis
`
`Nicole C. Suares, MBChB1 and Alexander C. Ford, MBChB, MD, MRCP 1
`2
`•
`
`OBJECTIVES:
`
`METHODS:
`
`RESULTS :
`
`Chronic idiopathic constipation (CIC) is a common functional gastrointestinal disorder in the
`community, yet no previous systematic review and meta-analysis has estimated the global
`prevalence, or potential risk factors for the condition.
`
`MEDLINE, EMBASE, and EMBASE Classic were searched (up to December 2010) to identify popu(cid:173)
`lation-based studies reporting the prevalence of CIC in adults (:2'15 years), according to self-report,
`questionnaire, or specific symptom-based criteria. The prevalence of CIC was extracted for all
`studies, and according to country, age, gender, socioeconomic status, and presence or absence of
`irritable bowel syndrome (18S) where reported. Pooled prevalence overall, and according to study
`location and certain other characteristics, as well as odds ratios (ORs), with 95% confidence
`intervals (Cls) were calculated.
`
`Of the 100 papers evaluated, 45 reported the prevalence of CIC in 41 separate study populations,
`containing 261,040 subjects. Pooled prevalence of CIC in all studies was 14% (95% Cl: 12-17%).
`The prevalence of CIC was lower in South East Asian studies, and in studies using the Rome II or Ill
`criteria. The prevalence of CIC was higher in women (OR: 2.22; 95% Cl: 1.87-2.62), and increased
`with age and lower socioeconomic status. The prevalence was markedly higher in subjects who also
`reported IBS (OR: 7.98; 95% Cl: 4.58-13.92), suggesting common pathogenic mechanisms.
`
`CONCLUSIONS: Pooled prevalence of CIC in the community was 14%, and of similar magnitude in most geographical
`regions. Rates were higher in women, older individuals, and those of lower socioeconomic status.
`Presence of IBS was strongly associated with CIC.
`Am J Gastroenterol 20ll; 106:1582-1591; doi:10.1038/ajg.2011.164; published online 24 May 20ll
`
`INTRODUCTION
`Constipation is characterized by the difficult or infrequent
`passage of stool, often accompanied by straining or a sensation of
`incomplete evacuation. It is a common complaint in the general
`population, and contributes considerably to physician visits
`and other costs to the health service (1). Chronic idiopathic
`constipation (CIC) is a functional gastrointestinal disorder
`(FGID), and although its symptoms are similar to the above defi(cid:173)
`nition, there is usually no demonstrable underlying physiological
`abnormality (2). It is thought to be more common in women,
`elderly people, and those of lower socioeconomic status (3,4),
`and sufferers report a degree of impairment in health-related
`quality of life that is comparable with that for some chronic
`organic conditions (5).
`
`The prevalence of constipation has been reported in numerous
`population-based cross-sectional surveys (3,6,7), and the implicit
`assumption in studies such as these is that, as organic disease
`in the community is rare, the majority of individuals reporting
`symptoms compatible with constipation will have CIC. Many of
`these community surveys have used either self-report of symp(cid:173)
`toms or a questionnaire to diagnose the disorder. However, studies
`conducted over the last decade have increasingly used one of the
`three iterations of the Rome criteria (2,8,9), which were developed
`initially to aid recruitment ofhomogenous groups of patients into
`clinical trials, with the diagnosis of the various FGIDs reached
`via symptom-based criteria.
`Another FGID with some symptoms that are common to
`CIC is constipation-predominant irritable bowel syndrome (IBS).
`
`1Leeds Gastroenterology Institute, Leeds General Infirm ary, Leeds, UK; 2Leeds Institute of Molecular Med icine, University of Leeds, Leeds, UK. Correspondence:
`Alexa nder C. Ford , MBCh B, MD, MRCP, Leeds Gastroenterology Institute, Leeds General Infirmary, D Floor, Clarendon Wing, Great George Street, Leeds LSI 3EX,
`UK. E-mail : alexfl 2399@yahoo.com
`Received 8 March 2011; accepted 19 April 2011
`
`The American Journal of GASTROENTEROLOGY
`
`VOLUME 106 I SEPTEMBER 2011 www.amjgastro.com
`
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`Chronic Idiopathic Constipation: Systematic Review and Meta-Analysis
`
`1583
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`s w
`> w
`
`0:::
`
`Each of these is a distinct condition according to the Rome
`criteria (2), with the presence of either abdominal pain or discom(cid:173)
`fort, which are required to meet diagnostic criteria for IBS, used
`as the main features to distinguish between the two. Recently,
`however, there has been some evidence to suggest a degree of
`overlap between the two conditions, and a lack of stability in
`either diagnosis during follow-up, suggesting that IBS and CIC
`are not entirely separate conditions (10) .
`Despite a growing number of cross-sectional surveys examin(cid:173)
`ing the prevalence of CIC, some of which have been conducted
`across several countries worldwide (11,12), the prevalence of
`CIC according to geographical location has not been well studied
`to date. Nor has any single study synthesized all the available
`evidence to examine potential risk factors for CIC, or the degree
`of overlap between CIC and IBS. We have therefore conducted
`a systematic review and meta-analysis of the prevalence of CIC
`in the community to examine these issues.
`
`METHODS
`Search strategy and study selection
`A search of the medical literature was conducted using MED LINE
`(1950 to December 2010), EMBASE, and EMBASE Classic (1947
`to December 2010) to identify population-based cohort studies,
`case-control studies, cross-sectional surveys, or randomized con(cid:173)
`trolled trials that reported the prevalence of CIC in adults aged
`15 years or over. Studies conducted among convenience samples,
`such as university students or hospital employees, were not eligi(cid:173)
`ble for inclusion. The diagnosis of CIC could be on the basis of
`symptoms self-reported by the individual, defined according to
`a questionnaire, based on the Rome I, II, or III criteria (2,8,9),
`or according to a physician's diagnosis. Studies were only eligible
`for inclusion if they contained :2'.50 individuals. Detailed eligibi(cid:173)
`lity criteria for study inclusion, which were defined prospectively,
`are provided in Box 1.
`Studies on CIC were identified using the search terms:
`constipation or gastrointestinal transit (both as medical subject
`headings (MeSH) and as free text terms), as well as functional
`constipation, chronic constipation, or idiopathic constipation
`as free text terms. These were combined with the set operator
`AND with studies identified with the search term prevalence
`as both a MeSH and free text term. There were no language
`restrictions. All abstracts identified by the search were evaluated
`for appropriateness to the study question, and all potentially
`relevant papers were obtained and assessed in detail. A recursive
`
`search of the literature was conducted using the bibliographies
`of all eligible studies. Foreign language papers were translated
`where required. Studies were assessed independently by two
`investigators, using pre-designed eligibility forms, according
`to the eligibility criteria. All disagreements were resolved by
`consensus.
`
`Data extraction
`Data were extracted independently by two investigators
`onto a Microsoft Excel spreadsheet (XP professional edition;
`Microsoft, Redmond, WA), with discrepancies resolved by
`consensus. The following data were collected for each study:
`type of study, year(s) conducted, country and geographi(cid:173)
`cal region, method of data collection (postal questionnaire,
`interview-administered questionnaire, face-to-face interview,
`telephone interview), criteria used to define CIC, symptom
`duration used to define the presence of CIC, total number of
`subjects recruited, and number of subjects with CIC. We also
`extracted the number of subjects with CIC according to age
`group, gender, socioeconomic status, and IBS symptom status,
`in order to examine any effect of these factors on the prevalence
`of CIC.
`
`Data synthesis and statistical analysis
`The proportion of individuals with CIC in each study was
`combined to give a pooled prevalence of CIC for all studies.
`Heterogeneity between studies was assessed using the P statistic
`with a cutoff of 50% (13), and the x2 test with a P value <0.10,
`used to define a statistically significant degree of heterogeneity.
`We planned to conduct sensitivity analyses according to geo(cid:173)
`graphical region, criteria used to define the presence of CIC,
`study publication year, validation status of the questionnaire
`(where used), symptom duration used to define the presence of
`CIC, age, gender, and IBS symptom status to examine whether
`this had any effect on the pooled prevalence of CIC. The preva(cid:173)
`lence of CIC was also compared according to age group, gender,
`socioeconomic status, and IBS symptom status using an odds
`ratio (OR), with a 95% confidence interval (CI).
`Data were pooled using a random effects model (14), to give
`a more conservative estimate of the prevalence of CIC and the
`odds of CIC in these various groups. StatsDirect version 2.7.2
`(StatsDirect, Sale, Cheshire, UK) was used to generate Forest plots
`of pooled prevalences and pooled ORs with 95% Cis. We planned
`to assess for the evidence of publication bias by applying Egger's
`test to funnel plots of ORs (15).
`
`Box 1. Eligibility criteria
`
`Cohort studies, case-control studies, cross-sectional surveys, or randomized controlled trials
`Recruited adults (>90% of participants aged ;::,:15 years)
`Participants recruited from the general population/community (convenience samples excluded)
`Reported prevalence of chronic idiopathic constipation (according to self-report, questionnaire data, specific diagnostic criteria
`(Rome I, II, or Ill criteria), or a physician's opinion)
`Sample size of ;::,:50 participants
`
`© 2011 by the Ameri can College of Gastroenterology
`
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`1584
`
`Suares and Ford
`
`Studies identified in literature
`search (n = 3,278)
`
`s w
`> w
`
`0::::
`
`Studies retrieved for evaluation
`(n= 100)
`
`Excluded (title and abstract revealed
`not appropriate) (n = 3,178)
`
`Excluded (n = 55) because:
`Convenience sample= 21
`Prevalence of chronic
`idiopathic constipation not
`reported = 13
`Duplicate publication = 7
`Database study = 4
`Data not extractable = 4
`Not population-based = 3
`Not all participants adults = 2
`Birth cohort = 1
`
`Population-based studies
`reporting prevalence of chronic
`idiopathic constipation (n = 45)
`
`Figure 1. Flow diagram of assessment of studies identified in the
`systematic review and meta-analysis.
`
`RESULTS
`The search strategy identified 3,278 citations (Figure 1). From
`these we identified 100 papers that appeared to be relevant to the
`study question. Of these, 45 studies reported the prevalence of
`CIC in 41 separate adult study populations (3,6,7,11,12,16-55).
`Agreement between investigators for assessment of study eligibil(cid:173)
`ity was excellent (K statistic= 0.88). Detailed characteristics of all
`included studies are provided in Table 1.
`Most studies were cross-sectional surveys, but two were case(cid:173)
`control studies conducted among diabetic patients and non(cid:173)
`diabetic controls from the general population (33,41). For the
`purposes of the present analysis, only data for the non-diabetic
`controls were extracted from these two studies. Three of the studies
`were multi-national surveys (11,12,25), and two of these also pro(cid:173)
`vided data according to each individual country studied (11,12).
`The pooled prevalence of CIC in all 41 studies containing 261,040
`participants, using the primary definition for CIC in each study,
`was 14.0% (95% Cl: 12.0-17.0%), with statistically significant
`heterogeneity between studies (P = 99. 7%, P < 0.001).
`
`Global prevalence of CIC
`The majority of studies were conducted in North America or
`Northern Europe. There were no identified studies conducted in
`
`South Asia, Africa, or Central America, and only a few studies
`from South America and the Middle East (11,12,18,40,44). The
`pooled prevalence of CIC according to geographical location of
`the study is provided in Table 2. There was statistically signifi(cid:173)
`cant heterogeneity between studies in all of these analyses, but the
`prevalence was remarkably similar in all of the regions studied,
`with the lowest prevalence occurring in South East Asia (11.0%)
`and the highest in South America (18.0%). The prevalence accord(cid:173)
`ing to individual country studied is shown in Figure 2.
`
`Prevalence of CIC according to criteria used to define its
`presence
`The majority of studies used a questionnaire to define the presence
`of CIC. Eleven studies used the Rome II criteria (18-20,23,26,28,
`32,34,35,37,43), 10 used self-report of symptoms (7,28-30,37,42-
`45,51), six used the Rome I criteria (3,7,24,28,38,43), and only
`two used the Rome III criteria (42,44). The pooled prevalence of
`CIC according to the various criteria used to define its presence
`is provided in Table 3. The prevalence of CIC was similar with all
`definitions, with the exception of when the Rome II or III criteria
`were used to define its presence, with a prevalence of 11.0 and
`6.8%, respectively.
`
`Prevalence of CIC according to study year
`Of the identified and eligible studies, seven were conducted between
`1981 and 1990 (3,6,16,29,30,33,50), 16 between 1991 and 2000
`(17,20,22,24,25,27,28,31,36,38,40,43,45-48), and 18 between 2001
`and 2010 (l l,12,18,21,23,26,32,34,35,37,39,41,42,44,49,51,52,54).
`The prevalence of CIC was generally lower in studies conducted
`between 1981 and 1990 (11.0%), compared with those conducted
`from 1991 to 2000, and from 2001 to 2010 (15.0%) (Table 3).
`
`Prevalence of CIC according to questionnaire validation status
`Of the 41 studies, 40 used a questionnaire to capture CIC symptom
`data, and 27 of these used a validated instrument (3,6,16-18,20-
`27,31,32,34-37,39,42-44,46,47,49,50). The prevalence of CIC was
`almost identical in studies that used a validated, compared with
`a non-validated questionnaire (Table 3).
`
`Prevalence of CIC according to duration of symptoms
`Twenty-six studies reported the duration of symptoms required
`to meet diagnostic criteria for CIC, with eight using 3 months
`(3,16,17,20,21,25,37,45), 16 using 12 months (7,11,12,23,28,29,
`31,32,35,36,38,46-48,52,54), and two using both 3 and 12 months
`(42,43). The prevalence of CIC was only slightly higher, 15.0 vs.
`13.0%, in studies that used 12 months compared with those that
`used 3 months (Table 3).
`
`Prevalence of CIC according to age
`There were 12 studies reporting the prevalence of CIC according
`to age, which provided extractable data (3,11,12,16,17,21,23,28,
`29,32,42,43). However, due to different age bands used to report
`the prevalence of CIC, data available for pooling were limited.
`Three studies used identical age bands to report prevalence
`(11,12,42), and these studies were therefore pooled accordingly.
`
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`
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`Chroni c Idiopathic Constipation: Systematic Review and Meta-Analysis
`
`1585
`
`Table 1. Characteristics of i ncluded studies
`
`Study
`
`Talley et al. (6)
`
`Talley et al. (7)
`
`USA
`
`Postal questionnaire"
`
`Questionnaire-defined
`
`Self-reported
`
`Rome I
`
`Jones and Lydeard (36)
`
`Walker et al. (50)
`
`Drossman et al. (3)
`
`Heaton et al. (30)
`
`UK
`
`USA
`
`USA
`
`UK
`
`Postal questionnaire•
`
`Questionnaire-defined
`
`Interview-administered questionnaire"
`
`Questionnaire-defined
`
`Postal questionnaire•
`
`Rome I
`
`Interview-administered questionnaire
`
`Self-reported
`
`Janatuinen et al. (33)
`
`Finland
`
`Postal questionnaire
`
`Questionnaire-defined
`
`Agreus et al. (16)
`
`Country
`
`Method of data collection
`
`Criteria used to
`define CIC
`
`Sample
`size
`
`Number with
`CIC (%)
`
`s
`w
`> w
`
`0:::
`
`835
`
`690
`
`690
`
`1,620
`
`18,571
`
`5,430
`
`1,892
`
`588
`
`1,156
`
`140 (16.8)
`
`86 (12.5)
`
`126 (18.3)
`
`333 (20.6)
`
`1,794 (9.7)
`
`197 (3.6)
`
`452 (23.9)
`
`107 (18.2)
`
`92 (8.0)
`
`Talley et al. (46)
`
`Harari et al. (29)
`
`Frexinos et al. (27)
`
`Ho et al. (31)
`
`Talley et al. (47)
`
`Enck et al. (25)
`
`Sweden
`
`Australia
`
`USA
`
`France
`
`Singapore
`
`Australia
`
`Postal questionnaire"
`
`Postal questionnaire•
`
`Questionnaire-defined
`
`Questionnaire-defined
`
`99
`
`Interview-administered questionnaire
`
`Self-reported
`
`Postal questionnaire•
`
`Questionnaire-defined
`
`Interview-administered questionnaire"
`
`Questionnaire-defined
`
`Postal questionnaire•
`
`Questionnaire-defined
`
`42,375
`
`4,817
`
`696
`
`726
`
`Multi-national
`
`Interview-administered questionnaire"/
`telephone interview
`
`Questionnaire-defined
`
`5,581
`
`23 (23.2)
`
`1,433 (3.4)
`
`1,686 (35.0)
`
`29 (4.2)
`
`103 (14.2)
`
`564 (10.1)
`
`Stewart et al. (45)
`
`USA
`
`Telephone interview
`
`Self-reported
`
`10,018
`
`1,466 (14.6)
`
`Chen et al. (22)
`
`Choo et al. (24)
`
`Singapore
`
`Interview-administered questionnaire"
`
`Questionnaire-defined
`
`South Korea
`
`Interview-administered questionnaire"
`
`Rome I
`
`271
`
`420
`
`16(5.9)
`
`102 (24.3)
`
`Koloski et al. (38)
`
`Koloski et al. (53)
`
`Boyce et al. (19)
`
`Bytzer et al. (20);
`Bytzer et al. (55)
`
`Fang et al. (26)
`
`Pare et al. (43)
`
`Australia
`
`Postal questionnaire
`
`Australia
`
`Postal questionnaire"
`
`Rome I
`
`Rome II
`
`Rome II
`
`China
`
`Canada
`
`Self-administered questionnaire"
`
`Rome II
`
`Postal questionnaire•
`
`Self- reported
`
`Rome I
`
`Rome II
`
`2,910
`
`227 (7.8)
`
`762
`
`8,608
`
`1,952
`
`1,149
`
`1,149
`
`1,149
`
`1,610
`
`3,282
`
`242
`
`22 (2.9)
`
`313 (3.6)
`
`73 (3.7)
`
`312 (27.2)
`
`192 (16.7)
`
`171 (14.9)
`
`2,248 (3.7)
`
`232 (14.4)
`
`458 (14.0)
`
`76 (31.4)
`
`Tangen Haug et al. (48)
`
`Walter et al. (51)
`
`Cheng et al. (23)
`
`Mjornheim et al. (41)
`
`Norway
`
`Sweden
`
`Postal questionnaire
`
`Postal questionnaire
`
`Hong Kong
`
`Telephone interview with questionnaire•
`
`Rome II
`
`Questionnaire-defined
`
`Questionnaire-defined
`
`60,998
`
`Self-reported
`
`Garrigues et al. (28)
`
`Sweden
`
`Spain
`
`Postal questionnaire
`
`Postal questionnaire
`
`Self-reported
`
`Rome I
`
`Rome II
`
`Wang et al. (52)
`
`Locke et al. (39)
`
`Aro et al. (17)
`
`Howell et al. (32)
`
`Jun et al. (37)
`
`China
`
`USA
`
`Sweden
`
`Australia
`
`Interview-administered questionnaire
`
`Questionnaire-defined
`
`Postal questionnaire•
`
`Questionnaire-defined
`
`Self-administered questionnaire"
`
`Questionnaire-defined
`
`Postal questionnaire•
`
`Rome II
`
`South Korea
`
`Interview-administered questionnaire"
`
`Self-reported
`
`Mendoza-Sassi et al. (40)
`
`Brazil
`
`Interview-administered questionnaire
`
`Questionnaire-defined
`
`Rome II
`
`349
`
`349
`
`349
`
`2,532
`
`643
`
`1,001
`
`1,673
`
`1,029
`
`1,029
`
`1,259
`
`103 (29.5)
`
`67 (19.2)
`
`49 (14.0)
`
`292 (11.5)
`
`109 (17.0)
`
`239 (23.9)
`
`514 (30.7)
`
`170 (16.5)
`
`95 (9.2)
`
`268 (21.3)
`
`Contin ued on following page
`
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`
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`1586
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`Suares and Ford
`
`Table 1. Continued
`
`Study
`
`Country
`
`Method of data collection
`
`Siproudhis et al. (54)
`
`France
`
`Postal questionnaire
`
`s w
`> w
`
`0:::
`
`Chang et al. (21)
`
`Johanson et al. (35)
`
`USA
`
`USA
`
`Criteria used to
`define CIC
`
`Questionnaire-defined
`
`Questionnaire-defined
`
`Postal questionnaire'
`
`Self-administered questionnaire•
`
`Rome II
`
`Basaranoglu et al. (18)
`
`Turkey
`
`Interview-administered questionnaire'
`
`Rome II
`
`Jeong et al. (34)
`
`South Korea
`
`Interview-administered questionnaire'
`
`Rome II
`
`van Kerkhoven et al. (49)
`
`Holland
`
`Postal questionnaire'
`
`Questionnaire-defined
`
`Sample
`size
`
`7,196
`
`523
`
`24,090
`
`707
`
`1,417
`
`1,616
`
`Number with
`CIC(%)
`
`1,611 (22.4)
`
`93 (17.8)
`
`4,680 (19.4)
`
`173 (24.5)
`
`37 (2.6)
`
`230 (14.2)
`
`Wald et al. (11)
`
`Multi-national
`
`Interview-administered questionnaire/
`telephone interview
`
`Questionnaire-defined
`
`13,879
`
`1,712 (12.3)
`
`Papatheoridis et al. (42)
`
`Greece
`
`Self-administered questionnaire•
`
`Self-reported
`
`Sorouri et al. (44)
`
`Iran
`
`Interview-administered questionnaire'
`
`Self-reported
`
`Rome Ill
`
`Wald et al. (12)
`
`Multi-national
`
`Interview-administered questionnaire/
`telephone interview
`
`CIC, chronic idiopathic constipation .
`'Validated questionnaire.
`
`Rome Ill
`
`Questionnaire-defined
`
`1,000
`
`1,000
`
`18,180
`
`18,180
`
`8,100
`
`140 (14.0)
`
`132 (13.2)
`
`1,145 (6.3)
`
`445 (2.4)
`
`1,293 (16.0)
`
`The prevalence of constipation increased modestly with increas(cid:173)
`ing age in these three studies (Table 4).
`We also dichotomized the reported age groups for all studies.
`Five studies provided data according to age < 45 years, or ~45
`years (3,11,12,32,42). The prevalence of CIC in those aged ~45
`years was not significantly higher than in those aged < 45 years
`(OR: 1.10; 95% Cl: 0.93-1.29), with significant heterogeneity
`between studies (P=74.6%, P=0.003), but no evidence of funnel
`plot asymmetry (Egger test, P=0.59). Seven studies provided data
`according to an age threshold of ~50 years compared with < 50
`years (16,17,21,23,28,29,43). Again, there was no significant
`difference detected between the prevalence of CIC in those aged
`~50 years compared with those aged <50 years (OR: 1.16; 95%
`CI: 0.87-1.54), with significant heterogeneity between studies
`(P = 87.6%, P<0.001), and evidence of funnel plot asymmetry or
`other small study effects (Egger test, P=0.03).
`
`Prevalence of CIC according to gender
`There were 26 studies that reported the prevalence of CIC
`according to the gender of participants (3, 11, 12, 16-19,21-24,28-
`34,37,42-45,47,49,5 l). Overall, the pooled prevalence of CIC
`was higher in women compared with men (17.4% (95% Cl: 13.4-
`21.8%) vs. 9.2% (95% CI: 6.5-12.2%)). The OR for CIC in women
`was 2.22 (95% Cl: 1.87-2.62) (Figure 3), with significant hetero(cid:173)
`geneity between studies (P =90.4%, P<0.001), but no evidence
`of funnel plot asymmetry (Egger test, P = 0.83 ).
`
`Prevalence of CIC according to socioeconom ic status
`There were six studies reporting the prevalence of constipation
`according to socioeconomic status (11,12,23,32,43,55). When
`
`data from these studies were pooled, there was a modest increase
`in the prevalence of CIC in those of lower socioeconomic status,
`compared with those of higher socioeconomic status, but no dif(cid:173)
`ference between those of medium socioeconomic status and those
`of higher socioeconomic status (Table 5).
`
`Prevalence of CIC according to 18S symptom status
`There were five studies that collected data on both IBS and CIC
`and that reported the prevalence of CIC according to the IBS
`symptom status of participants (6,36,39,44,53). Two studies used
`the Manning criteria to define IBS (6,36), two the Rome I crite(cid:173)
`ria (39,53), and one the Rome II criteria (44). Overall, the pooled
`prevalence of CIC was higher in individuals with IBS (44.0%; 95%
`Cl: 36.0-53.0%) compared with those without (9.0%; 95% CI:
`7.0-12.0%). The OR for CIC in those with IBS was 7.98 (95% Cl:
`4.58-13.92) (Figure 4), with significant heterogeneity between
`studies (P=92.2%, P<0.001), but no evidence of funnel plot
`asymmetry (Egger test, P=0.95).
`
`DISCUSSION
`This is the first systematic review and meta-analysis of studies, to
`our knowledge, examining the global prevalence of CIC, risk fac(cid:173)
`tors for CIC, and relationship between CIC and IBS in the com(cid:173)
`munity. We have demonstrated a pooled prevalence of CIC across
`all included studies of 14%. The pooled prevalence of CIC was
`remarkably stable according to geographical location, though was
`slightly lower in South East Asian studies, and generally higher
`in South American studies. There were a paucity of data from
`the Middle East, Africa, and Central America. Similar pooled
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`Chronic Idiopathic Constipation: Systematic Review and Meta-Analysis
`
`1587
`
`Table 2. Pooled prevalence of CIC according to geographical location
`
`All studies
`
`North American studies
`
`North European studies
`
`South European studies
`
`Middle Eastern studies
`
`South East Asian studies
`
`South American studies
`
`Austra lasian studies
`
`Multinational studies
`
`Number of
`studies
`
`41
`
`10
`
`14
`
`3
`
`2
`
`11
`
`4
`
`5
`
`3
`
`Number of
`subjects
`
`261,040
`
`105,634
`
`88,615
`
`3,349
`
`18,887
`
`17,699
`
`7,259
`
`14,016
`
`27,560
`
`Pooled
`prevalence
`
`95% Confidence
`interval
`
`f2(%)
`
`P value for 12
`
`14.0
`
`14.0
`
`16.0
`
`16.0
`
`14.0
`
`11.0
`
`18.0
`
`14.0
`
`13.0
`
`12.0-17.0
`
`9.0-20.0
`
`10.0-24.0
`
`7.0 - 27.0
`
`2.0 - 36.0
`
`7.0-15.0
`
`15.0-22.0
`
`5.0-27.0
`
`10.0-16.0
`
`99.7
`
`99.8
`
`99.8
`
`98.1
`
`NIA
`
`98.3
`
`94.1
`
`99.6
`
`98.2
`
`<0.001
`
`<0.001
`
`<0.001
`
`<0.001
`
`N/A
`
`<0.001
`
`<0.001
`
`<0.001
`
`<0.001
`
`s w
`> w
`
`0:::
`
`CIC, chronic idiopathic constipation.
`N/A, not applicable, too few studies to assess heterogeneity.
`
`0--4.9%
`5.0-9.9%
`10.0-14.9%
`15.0-19.9%
`~20.0%
`
`-
`
`Figure 2. Prevalence of chronic idiopathic constipation according to country.
`
`prevalence rates were also found according to definition of CIC,
`with the exception of the Rome III criteria, for which the preva(cid:173)
`lence was lower at around 7%. This lower prevalence with Rome
`III was driven by one study (44), which reported a prevalence
`of only 2.4%, compared with 13.2% in the other study that used
`these criteria (42). Studies performed in the 1980s demonstrated
`a slightly lower pooled prevalence of CIC, but duration of symp(cid:173)
`toms and validation status of the questionnaire used appeared to
`have little impact on pooled prevalence of CIC in our analyses.
`Data for pooled prevalence of CIC according to age, gender, and
`socioeconomic status support previous assertions that the con(cid:173)
`dition is commoner in females, older individuals, and those of
`lower socioeconomic status, although ORs were only modestly
`increased in these groups. Finally, and most strikingly, the odds
`
`of CIC in those with JBS were almost eightfold greater than that of
`individuals without JBS.
`This study was strengthened by our rigorous methodology.
`The literature search, judging of study eligibility, and data extrac(cid:173)
`tion were carried out by two investigators independently, with
`discrepancies resolved by consensus. Foreign language papers
`were translated where required. Use of a random effects model to
`pool data provided a more conservative estimate of prevalence of
`CIC, and publication bias was assessed using funnel plots. We were
`careful to include only population-based studies conducted with
`participants recruited from the community, who were therefore
`representative of the general population in each study country, in
`order not to inflate the pooled prevalence of CIC. This was done to
`ensure that the results are generalizable to the general population.
`
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`1588
`
`Suares and Ford
`
`s w
`> w
`
`0:::
`
`Table 3. Pooled prevalence of CIC according to criteria used to define its presence, study year, validation status of questionnaire, and
`duration of symptoms
`
`All studies
`
`Criteria used to define CIC
`
`Questionnaire-defined
`
`Rome II
`
`Self-reported
`
`Rome I
`
`Rome Ill
`
`Study year
`
`1981-1990
`
`1991-2000
`
`Number of
`studies
`
`41
`
`22
`
`11
`
`10
`
`6
`
`2
`
`7
`
`16
`
`Number of
`subjects
`
`261,040
`
`Pooled
`prevalence
`
`95% Confidence
`interval
`
`14.0
`
`12.0-11.0
`
`132,949
`
`45,018
`
`78,292
`
`10,948
`
`19,180
`
`70,847
`
`100,522
`
`15.0
`
`11.0
`
`15.0
`
`14.0
`
`6.8
`
`11.0
`
`15.0
`
`11.0- 20.0
`
`6.0-18.0
`
`10.0-21.0
`
`18.0-22.0
`
`0.3-20.9
`
`6.0-16.0
`
`/2(%)
`
`99.7
`
`99.7
`
`99.6
`
`99.7
`
`98.9
`
`N/A
`
`99.7
`
`P value for / 2
`
`<0.001
`
`<0.001
`
`<0.001
`
`<0.001
`
`<0.001
`
`NIA
`
`<0.001
`
`2001-2010
`
`Validation status of questionnaire
`
`Validated
`
`Not validated
`
`Duration of symptoms
`
`3 months
`
`12 months
`
`18
`
`27
`
`13
`
`10
`
`18
`
`89,671
`
`107,092
`
`143,930
`
`35,495
`
`173,364
`
`15.0
`
`14.0
`
`15.0
`
`13.0
`
`15.0
`
`CIC, chronic idiopathic constipation .
`N/A, not applicable, too few studies to assess heterogeneity.
`
`10.0-22.0
`
`12.0-19.0
`
`11.0- 18.0
`
`11 .0-20.0
`
`8.0-18.0
`
`11.0-20.0
`
`99.8
`
`99.5
`
`99.6
`
`99.8
`
`99.4
`
`99.8
`
`<0.001
`
`<0.001
`
`<0.001
`
`<0.001
`
`<0.001
`
`<0.001
`
`Table 4. Pooled prevalence of CIC according to age
`
`Pooled prevalence of
`Number of CIC (95% confidence
`interval)
`subjects
`
`Odds ratio for CIC
`(95% confidence
`interval)
`
`7,153
`
`7,092
`
`5,314
`
`3,443
`
`12.0 (10.0-14.0)
`
`1.0
`
`15.0 (12.0-19.0)
`
`1.20 (1.09-1.33)
`
`16.0 (11.0-21.0)
`
`1.31 (1.09-1.58)
`
`17.0 (13.0-22.0)
`
`1.41 (1.17-1.70)
`
`Age band
`
`<29 years
`
`30-44 years
`
`45-59 years
`
`~years
`
`CIC, chronic idiopathic constipation .
`
`Limitations ofthis study arise from the available studies and the
`reporting of data within them. When calculating pooled preva(cid:173)
`lence, there was a notable absence of studies conducted in certain
`geographical regions making it difficult to accurately estimate true
`global prevalence. There was also considerable heterogeneity across
`all the analyses we conducted, which our pre-specified sensitivity
`analyses did not reveal any clear explanation for. The reasons for
`this, therefore, remain speculative, but may relate to individual
`inconsistencies and variations in the definition of constipation
`used in studies that defined CIC according to either self-report
`or on the basis of questionnaire data, differences in demographic
`characteristics of recruited individuals, or cultural differences.
`
`There have been two previous systematic reviews of the
`epidemiology of constipation conducted (56,57). The earlier of
`these restricted its focus to population-based studies conducted
`in North America, and only included 10 English language
`publications (56). The authors reported prevalence rates between
`2 and 27%, with an average of 14.8%, and a higher prevalence with
`self-reported symptoms than with either the Rome I or II criteria.
`They also reported a higher prevalence in females (median female(cid:173)
`to-male ratio of 2.2:1) and those of lower socioeconomic status,
`while data according to age were conflicting across the various
`studies they identified. The second systematic review, conducted
`in 2008, included epidemiological studies conducted in Europe
`and Oceania (57). However, the authors employed less stringent
`inclusion criteria, accommodating convenience samples in their
`review. They reported a mean prevalence of constipation in all
`studies of 22%, while the mean prevalence in Europe was 17%, and
`that in Oceania was 15% and, as with our study, there was a female
`preponderance of symptoms. Other potential risk factors were not
`analyzed systematically by the authors.
`While relatively few of the studies identified in our literature
`search collected data on prevalence of CIC according to IBS symp(cid:173)
`tom status, the five studies that did report these data showed a
`marked increase in prevalence of CIC in those with IBS compared
`with those without (6,36,39,44,53). The issue of overlap between
`constipation-predominant IBS and CIC has been examined in
`
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`Chronic Idiopathic Constipation: Systematic Review and Meta-Analysis
`
`1589
`
`Odds ratio meta-analysis plot [random effects]
`
`s w
`> w
`
`0:::
`
`2.06(1.51, 2.84)
`
`2.61 (2.06, 3.32)
`
`1.24 (0.79, 1.93)
`
`2.96(1.81, 4.96)
`
`3.90 (3.38, 4.52)
`
`2.06 (0.89, 5.03)
`
`3.99 (2.37, 6.96)
`
`1.40 (1.23, 1.58)
`
`3. 10(1.04, 11.11)
`
`2.31 (1 .41, 3.82)
`
`2.56(1.93, 3.40)
`
`2.73(1.99, 3.78)
`
`0.99(0.81, 1.21)
`
`3.06(1.82, 5.20)
`
`2.59(1.88, 3.5"1)
`
`0.27 (0.08, 0. 78)
`
`1.67 (1.34, 2.08)
`
`2.55 (1.77, 3.69)
`
`1.00(0.62, 1.61)
`
`2.15 (1.47, 3. 14)
`
`10.05 {3.54, 39.23)
`
`2.95 (2.03, 4.37}
`
`2.39(2. 14, 2.67)
`
`2.26 (1.57, 3.30)
`
`3. 1