The association between body roundness index and constipation: a cross‑sectional survey of NHANES 2005–2010

The association between body roundness index and constipation: a cross‑sectional survey of NHANES 2005–2010 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The association between body roundness index and constipation: a cross‑sectional survey of NHANES 2005–2010 Chaofan Guo, Qibo Peng, Qi Ao, Zhangqiang Zheng, Xiangyang Yu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5082782/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Obesity, particularly visceral fat, is linked to constipation. And Body Roundness Index (BRI) offers a precise evaluation of visceral fat levels. Nevertheless, the risk of developing constipation is not yet known to be connected with BRI. Methods From the National Health and Nutrition Examination Survey (NHANES), 8,388 individuals aged 20 years or older were recruited for the study. The primary strategy employed to examine the relationship between BRI and the possibility of constipation was logistical regression, which encompassed multivariable regression analysis, smoothing curve fitting, and subgroup analysis. Results These findings revealed a negative correlation between elevated BRI values and the likelihood of constipation. After adjusting for variables, persons in the uppermost quartile (Q4) of BRI showed a 0.574-fold reduced likelihood of constipation in contrast to people who were in the bottom quartile (Q1), as shown in Table 2. The 95% confidence interval (CI) for this risk was 0.464–0.710, where P < 0.001. These findings support the negative correlation between increased BRI and reduced likelihood of constipation. Conclusions An elevated BRI ratio was linked to a reduced likelihood of developing constipation. Our findings suggest that maintaining a certain level of visceral fat may have a preventive and alleviating effect on constipation. However, additional prospective investigations are necessary to validate this hypothesis. Body roundness index Visceral fat Constipation NHANES Obesity Figures Figure 1 Figure 2 Figure 3 Background Constipation is a common condition, with a prevalence ranging from 9–20% in the U.S. [ 1 ]. Patients suffering with persistent constipation frequently encounter a substantial deterioration in their standard of living and physical capabilities, which can result in feelings of anxiety and other adverse emotions. In certain instances, these symptoms may progress to the development of depressive disorders [ 2 ]. Moreover, persistent constipation places a significant strain on healthcare resources, as alone, non-prescription remedies incur billions of dollars in annual expenditures in America [ 3 , 4 ]. The causes of constipation are varied and are typically classified as organic, functional, or medication-induced. The relationship between constipation and obesity has been increasingly elucidated in recent years. Epidemiological studies of constipated populations have revealed a close correlation between the two conditions, with a particularly strong association observed between visceral obesity and constipation. Several studies have indicated an elevated incidence of constipation in adults classified as obese, with BMI ranging from 25 to 39.9 [ 5 ]. In studies such as the one conducted in Iran, approximately 60% of patients with functional constipation were found to have a higher BMI, which may be related to changes in biologically active substances and intestinal flora resulting from the gain or loss of visceral fat [ 6 ]; However, other studies have failed to identify a significant correlation between obesity and constipation [ 7 ]. In some cases, negative correlations were noted, with a reduced incidence of constipation noted in obese individuals in contrast with the whole population. These discrepancies highlight the need for further research in this area [ 8 ]. Both computed tomography (CT) and magnetic resonance imaging (MRI) are very efficient techniques for precisely quantifying fat in the viscera [ 9 , 10 ]. However, their use in routine clinical practice is limited by lengthy processing times, high costs, and lack of flexibility regarding when and where they can be employed. Additionally, bioelectrical impedance analysis (BIA) can be used as a straightforward, economical, and non-invasive method for quantifying body fat content [ 11 ]. Anthropometric indicators provide an easy, affordable, and less invasive way to screen populations for health issues and identify potential dangers at an early stage. Consequently, the bulk of studies that evaluate body fat often use anthropometric indicators [ 12 ]. In order to quantify visceral fat as well as body fat, the Body Roundness Index (BRI) was first introduced in 2013 [ 13 ]. Compared to other anthropometric measures, the BRI may be more beneficial due to its ability to precisely estimate visceral fat. A number of research investigations have shown a strong correlation between BRI and certain human diseases, such as colorectal cancer and stone deposition[ 14 , 15 ]. Despite extensive research, there remains a paucity of data regarding the relationship between BRI and constipation, thereby underscoring the necessity for the present study. This study, based on data from 8,388 individuals drawn from the National Health and Nutrition Examination Survey (NHANES), had two primary objectives: firstly, to examine the link between the BRI and the risk of constipation, and secondly, to suggest methods for further clarifying the connection between visceral fat and constipation. Methods Survey description and study population: An continuing, yearly survey, NHANES evaluates the health and nutritional condition of the population in the United States. Complete data can be accessed by the public on the NHANES website. All participants provided explicit consent in writing. This research comprised individuals from the survey cycles conducted between 2005 and 2010, with the exclusion of those below the age of 20 or those with missing clinical data. There were 8,388 people chosen for the final research. (Figure 1) Data collection and measurements: Data collection and measurements were all acquired from the NHANES database. The database contains an extensive range of information, including demographic data such as race, gender, age, and other relevant details; information about nutrition; anthropometric measurements, including waist circumference (WC) and height; laboratory data, such as fasting blood glucose, glycosylated hemoglobin, and arterial pressure; and questionnaire responses, including information on alcohol consumption patterns, tobacco usage patterns, and existing health issues. Assessment of body roundness index ： BRI served as the independent variable in this research. BRI was calculated following the approach described in prior research. The BRI was determined by the following: 364.2 - 365.5 * ( 1 - [ WC ( m ) / 2π ] 2 / [ 0.5 * height ( m ) ] 2 ) 1 / 2 [13]. Definition of constipation From 2005 to 2010, the NHANES implemented the Bowel Health Questionnaire to record the frequency of bowel movements and stool characteristics. To ascertain stool characteristics, participants were shown vividly colored cards featuring the seven-point Bristol Stool Form Scale (BSFS). Subsequently, participants were instructed to choose the numerical value that corresponded to the stool pattern which was most representative or prevalent on their behalf. Bowel movement frequency was determined through a questionnaire that inquired about participants' bowel movement habits, specifically asking how many bowel movements they typically experienced per week. These data were instrumental in defining the constipated population [16]. Our research established two definitions of constipation, utilizing the standards set by Rome IV and prior NHANES investigations[17]. The first definition was derived from participants' self-reported stool characteristics, which were classified as either type 1 (separate hard lumps, like nuts) or type 2 (sausage-shaped, but lumpy) on the BSFS[18]. In addition, another way to define constipation was determined by considering the frequency of bowel movements reported by the subjects themselves. Individuals reporting a frequency of fewer than or equal to two bowel movements per week were classified as having constipation. Covariates To address potential confounding effects on the correlation between BRI and constipation, we employed multivariate adjustment models that accounted for a range of potential confounding variables. In this study, we considered various factors in the analysis, including sex , age, race, education level, poverty-to-income ratio (PIR), physical activity (defined as either active or inactive), depressive symptoms (classified as non-depressed or depressed), sleep duration (categorized into three groups: <5 hours, 5–6 hours, and ≥9 hours), information regarding the individual's smoking and alcohol use habits, as well as their medical conditions of diabetes and hypertension. Meanwhile, we examined the influence of dietary components, such as calories, protein, carbohydrate, fiber in the diet, fat consumption, magnesium, selenium, and caffeine intake. Participants were categorized according to their physical activity status: physically active was defined as engaging in at least 10 consecutive minutes of vigorous-intensity activity per week. Alcohol consumption was categorized based on participants' intake over the past 12 months, with individuals classified as either nondrinkers or drinkers. Two categories were established for smoking status: participants who had consumed over 100 cigarettes in their lifespan were classified as smokers, alternatively, a nonsmoker. The total intake of dietary factors was calculated by averaging the results of two 24-hour dietary memory tests, which provided detailed information on nutrient consumption. Comprehensive data regarding the measurement and quantification of the research variables can be obtained from the official website www.cdc.gov/nchs/nhanes/. Statistical analyses The statistical analyses were conducted in compliance with the recommendations provided by the Centers for Disease Control and Prevention (CDC), this investigation implemented sophisticated statistical analyses. The methodology entailed the initial division of the BRI into quartiles, with the lowest quartile (Q1) functioning as the reference group. The presentation of categorical data involved reporting frequencies and percentages, whereas measurements of central tendency, such as means and standard deviations, were used to represent continuous variables. A multivariate logistic regression model was used to examine the relationship between BRI and the occurrence of constipation. Model 2 was adjusted for sex, age, and race; Model 3 included additional adjustments for education level, income-to-poverty ratio, physical activity, depressive symptoms, sleep duration, smoking status, drinking status, diabetes, hypertension, and nutritional aspects—specifically energy, protein, carbohydrate, dietary fiber, fat intake, magnesium, selenium, and caffeine—while maintaining adjustments for sex, age, and race. In the subsequent step, the impact of BRI on the occurrence of constipation was evaluated by a segmented linear regression model, while the non-linear correlation between BRI and constipation incidence was analyzed using a smoothed curve-fitting method. A thorough investigation of potential variations in population was carried out using subgroup analysis and interaction tests. The statistical analyses were conducted using EmpowerStats (version 6.0) and R software (version 4.2.0). A significance level of P < 0.05 was used to determine statistical significance. Results Baseline characteristics of participants: Table 1 presents the fundamental characteristics of the participants chosen from the NHANES 2005-2010 cycles. In the investigation, 8,388 participants were enrolled. The group with constipation exhibited significant differences from the non-constipated group in terms of gender, age, ethnicity, educational level, PIR, physical activity, depressive symptoms, sleep duration, smoking status, drinking status, hypertension, and various dietary factors, including energy, protein, carbohydrate, dietary fiber, fat intake, magnesium, selenium, and caffeine. However, the prevalence of diabetes did not differ significantly among the two groups. Relationship between BRI and constipation The current study revealed a negative link between BRI and the likelihood of experiencing constipation. BRI was analyzed as a stratified variable (quartiles), and as shown in Table 2, individuals in the highest quartile (Q4) showed a 0.574-fold decrease in the likelihood of experiencing constipation compared to those in the lowest quartile (Q1) in a fully adjusted model that considered all covariates (95% CI: 0.464–0.710; P < 0.001). This result indicates a potential inverse association between higher BRI and the likelihood of developing constipation. Non-linear relationship between BRI and constipation The study investigated the nonlinear association between BRI and constipation risk, as shown in Figure 2. Through a meticulous analysis of the smoothed curves, we elucidated this relationship. The likelihood ratio test revealed a p-value of 0.007 for the relationship between BRI and constipation occurrence. A biphasic linear model, coupled with a recursive algorithm, was employed to identify the inflection point, which was found to be a BRI of 2.74. Below this threshold, the risk of constipation increased by 71% for every unit rise in BRI (OR: 1.71, 95% CI: 1.07–2.76). However, when BRI exceeded 2.74, the risk declined by 10% per unit increase (OR: 0.90, 95% CI: 0.87–0.94) (Table 3). Subgroup analyses Figure 3 presents the results of the subgroup analysis. The study found that, with the exception of Mexican Americans, other races, individuals with less than a high school education, and those with sleep durations of <5 or ≥9 hours, the association between BRI and constipation was positive across all subgroups. Notably, there was a significant interaction between BRI and race in relation to constipation risk (interaction p = 0.025), while no significant interaction was observed for other subgroups (interaction p > 0.05). Additionally, a stronger inverse association was observed among females (OR 0.91, 95% CI: 0.87–0.94), which may be related to the distinct pelvic anatomy of women. Discussion The aim of this study was to assess the relationship between BRI and constipation risk using data from the NHANES dataset. This investigation of 8,388 participants revealed an overall negative association between BRI and constipation risk, as well as a nonlinear correlation. A clear correlation between BRI and the likelihood of constipation was observed on both sides of the inflection point (BRI = 2.74). Each unit increase in BRI resulted in a 171% increase in the risk of constipation for BRIs less than 2.74, while the risk decreased by 10% for BRIs greater than 2.74. Moreover, a rise in BRI was linked to a heightened likelihood of chronic constipation, but only when BRI is less than 2.74. BRI values below 2.74 fall within the lowest quartile. Therefore, it may be deduced that an elevation in BRI is related to an augmented likelihood of chronic constipation in a relatively minor segment of the population. On the other hand, among the majority of individuals who have higher amounts of visceral fat and a BRI greater than 2.74, a consistent increase in BRI is linked to a decreased likelihood of experiencing chronic constipation. As far as we know, this is the very first investigation to evaluate the correlation between BRI and the likelihood of experiencing constipation. The association between bowel symptoms and body fat has been a subject of debate in the scientific literature. In a study of the Iranian population, Mohamad and colleagues observed that up to 60% of patients with constipation had a BMI greater than or equal to 25, proposing a possible correlation between BMI and a heightened susceptibility to constipation[6]；Xiang et al. analyzed the relationship between several measures of obesity and the occurrence of constipation by utilizing data from the NHANES. Their research revealed that lower BMI, waist-to-stature ratio (WSR), lipid accumulation product (LAP), and waist circumference were linked to a decreased likelihood of experiencing constipation. Conversely, elevated waist-to-waist index (WWI) levels correlated with a reduced incidence of constipation[19]; Additionally, a research study executed by Naotaka and associates reported a significant reduction in BMI among men with constipation compared to men without constipation. However, there was no discernible distinction between the two categories in the female population[20]；A recent study conducted in New Zealand also revealed a negative correlation between being overweight and constipation[8]；Furthermore, Michel et al. discovered that rectosigmoid transit time (RSTT) and colonic transit time (CTT) were shorter in obese patients compared to those with a normal BMI. BMI and RSTT also exhibited a negative correlation (P<0.001)[21]. Our clinical observations have also revealed a negative connection between visceral obesity and the incidence of constipation. The fundamental processes of this negative association are, however, ambiguous. The association between visceral obesity and persistent constipation is probably intricate and not entirely comprehended, particularly regarding its precise mechanistic basis. This study aims to investigate the inverse relationship between these two parameters, emphasizing the structural effects of visceral fat on the rectum. We hypothesized that a high visceral fat load may stabilize the rectum, thereby reducing the likelihood of anterior rectal herniation, especially in the female population. The probability of developing constipation due to outlet obstruction is relatively low. Moreover, elevated visceral fat may lead to a shallower Douglas pouch, which further reduces the risk of intestinal herniation and, consequently, the risk of constipation[22]; Additionally, an increase in visceral fat may reduce pelvic floor muscle laxity, thereby limiting the descent of the anorectal plate and subsequently lowering the likelihood of developing constipation [23]. Moreover, the prevalence of constipation is frequently associated with intestinal dysbiosis. Individuals with obesity are susceptible to small intestine bacterial overgrowth (SIBO) characterized by hydrogen (H₂)-producing dysbiosis, potentially resulting in an elevated frequency of bowel movements [24]. Furthermore, individuals with a high BMI frequently exhibit insulin resistance [25]. Certain research indicates a possible positive association between the onset of insulin resistance and chronic diarrhea. Specifically, the risk of constipation appears to be relatively lower in obese individuals [26]. Moreover, individuals with obesity may exhibit hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, leading to elevated cortisol secretion. Elevated cortisol levels have been associated with a statistically significant reduction in the probability of developing constipation, according to research. Consequently, obese individuals may potentially mitigate the risk of constipation through increased cortisol release [27]. The BRI represents an innovative methodology to detecting obesity in humans. It offers a more convenient alternative to CT and MRI for measuring visceral obesity and provides a superior reflection of visceral fat distribution compared to traditional anthropometric indicators such as BMI. The BRI has proven to be an efficient indicator of illnesses including diabetes and metabolic syndrome.[28, 29]. Additionally, BRI is associated with certain functional disorders, including bladder mobility disorders [30] While BMI is a reliable indicator of overall body fat, it does not distinguish between subcutaneous and visceral fat. The BRI may offer a more accurate assessment of visceral adiposity. Our research demonstrates an association between increased BRI and a diminished risk of constipation, implying that sustaining a specific level of BRI may enhance bowel function. Nonetheless, further extensive prospective cohort studies are need to validate our idea. Our study has several strengths, including a well-designed protocol with rigorous quality control, a large and representative sample, and comprehensive data on numerous key covariates obtained through the integration of NHANES data. However, there are some limitations to this study. First, the diagnosis of constipation was based on self-reports, which introduces subjectivity and recall bias. Second, the potential influence of unmeasured or unknown confounders on the study results cannot be entirely ruled out. Additionally, due to the cross-sectional nature of this study, causal relationships between variables cannot be established. Conclusion The study's findings indicated that a higher BRI is negatively associated with the probability of having constipation. This indicates that a suitable rise in visceral fat levels may diminish the likelihood of getting constipation. This study has limitations, and additional prospective medical studies are required to validate the potential influence of visceral adiposity on the onset of constipation. Abbreviations BMI Body mass index BRI Body roundness index BSFS Bristol Stool Form Scale CDC Centres for Disease Control and Prevention CI Confdence interval NHANES National Health and Nutrition Examination Survey OR Odds ratio Declarations Supplementary Information Supplementary Material : Supplementary Figure 1. Flowchart of participant selection from NHANES 2005-2010. Supplementary Figure 2. Non-linear correlation between body roundness index (BRI) and the prevalence of constipation. Supplementary Figure 3. Subgroup analysis for the association between BRI and constipation. Supplementary Table 1. Characteristics of eligible participants Supplementary Table 2. Association between BRI quartiles and the risk of Constipation in participants. Supplementary Table 3. Sensitivity analyses. Ethics approval and consent to participate All study participants signed the consent form. The Ethics Review Committee of the CDC approved the creation and use of NHANES data. Consent for publication Not applicable. Availability of data and materials All the data used in this study are from the open database of NHANES (http://www.cdc.gov/nchs/nhanes.htm). Competing interests The authors declare no competing interests. Funding There is no funding. Authors’ contributions Conceptualization: CG, XY. Methodology: CG, QP Software: CG, QP, XY. Validation: CG, QP, XY. Formal analysis: CG, QA. Investigation: CG, ZZ. Resources: QP. Data curation: CG. Writing-original draft: CG, QP. Visualization: CG,QA. Supervision: XY. All authors have read and agreed to the published version of the manuscript. Acknowledgements Not applicable. References Oh SJ, Fuller G, Patel D, Khalil C, Spalding W, Nag A, Spiegel BMR, Almario CV. Chronic Constipation in the United States: Results From a Population-Based Survey Assessing Healthcare Seeking and Use of Pharmacotherapy. Am J Gastroenterol. 2020;115(6):895–905. Rao SS, Seaton K, Miller MJ, Schulze K, Brown CK, Paulson J, Zimmerman B. Psychological profiles and quality of life differ between patients with dyssynergia and those with slow transit constipation. J Psychosom Res. 2007;63(4):441–9. Benninga MA, Scott SM. Chronic constipation. Preface. Best Pract Res Clin Gastroenterol. 2011;25(1):1–2. Rao SS, Rattanakovit K, Patcharatrakul T. Diagnosis and management of chronic constipation in adults. Nat reviews Gastroenterol Hepatol. 2016;13(5):295–305. Silveira EA, Santos A, Ribeiro JN, Noll M, Dos Santos Rodrigues AP, de Oliveira C. Prevalence of constipation in adults with obesity class II and III and associated factors. BMC Gastroenterol. 2021;21(1):217. Pourhoseingholi MA, Kaboli SA, Pourhoseingholi A, Moghimi-Dehkordi B, Safaee A, Mansoori BK, Habibi M, Zali MR. Obesity and functional constipation; a community-based study in Iran. J Gastrointest liver diseases: JGLD. 2009;18(2):151–5. Delgado-Aros S, Locke GR 3rd, Camilleri M, Talley NJ, Fett S, Zinsmeister AR, Melton LJ. 3rd: Obesity is associated with increased risk of gastrointestinal symptoms: a population-based study. Am J Gastroenterol. 2004;99(9):1801–6. Talley NJ, Howell S, Poulton R. Obesity and chronic gastrointestinal tract symptoms in young adults: a birth cohort study. Am J Gastroenterol. 2004;99(9):1807–14. Xu Z, Liu Y, Yan C, Yang R, Xu L, Guo Z, Yu A, Cheng X, Ma L, Hu C, et al. Measurement of visceral fat and abdominal obesity by single-frequency bioelectrical impedance and CT: a cross-sectional study. BMJ open. 2021;11(10):e048221. Maskarinec G, Shvetsov YB, Wong MC, Garber A, Monroe K, Ernst TM, Buchthal SD, Lim U, Le Marchand L, Heymsfield SB, et al. Subcutaneous and visceral fat assessment by DXA and MRI in older adults and children. Obes (Silver Spring Md). 2022;30(4):920–30. Amano K, Bruera E, Hui D. Diagnostic and prognostic utility of phase angle in patients with cancer. Reviews Endocr metabolic disorders. 2023;24(3):479–89. Fang H, Berg E, Cheng X, Shen W. How to best assess abdominal obesity. Curr Opin Clin Nutr Metab Care. 2018;21(5):360–5. Thomas DM, Bredlau C, Bosy-Westphal A, Mueller M, Shen W, Gallagher D, Maeda Y, McDougall A, Peterson CM, Ravussin E, et al. Relationships between body roundness with body fat and visceral adipose tissue emerging from a new geometrical model. Obes (Silver Spring Md). 2013;21(11):2264–71. Liu X, Shi H, Shi Y, Wei H, Yuan X, Jiao Z, Wu T, Wang Z. Association between a body shape index and prostate cancer: a cross-sectional study of NHANES 2001–2018. Int Urol Nephrol. 2024;56(6):1869–77. Mao X, Yang Y, Yang J, Chen M, Hao Z. Association between body roundness index and prevalence of kidney stone in the U.S: a study based on the NHANES database. BMC Urol. 2024;24(1):93. Markland AD, Palsson O, Goode PS, Burgio KL, Busby-Whitehead J, Whitehead WE. Association of low dietary intake of fiber and liquids with constipation: evidence from the National Health and Nutrition Examination Survey. Am J Gastroenterol. 2013;108(5):796–803. Wilson PB. Associations between physical activity and constipation in adult Americans: Results from the National Health and Nutrition Examination Survey. Neurogastroenterol Motil. 2020;32(5):e13789. Li Y, Tong WD, Qian Y. Effect of Physical Activity on the Association Between Dietary Fiber and Constipation: Evidence From the National Health and Nutrition Examination Survey 2005–2010. J Neurogastroenterol Motil. 2021;27(1):97–107. Xiang N, Xu L, Qian H, Zhang D. Multiple obesity indices suggest a close relationship between obesity and constipation: evidence from NHANES. BMC Public Health. 2024;24(1):1273. Ogasawara N, Kasugai K, Funaki Y, Ebi M, Izawa S, Tamura Y, Kato A, Yamaguchi Y, Adachi K, Sugiyama T, et al. Relationships between body mass index and constipation, gastroesophageal reflux disease, stool forms based on the Bristol Stool Form Scale, and education level: results from an internet survey in Japan. J Clin Biochem Nutr. 2023;73(1):84–90. Bouchoucha M, Fysekidis M, Rompteaux P, Airinei G, Sabate JM, Benamouzig R. Influence of Age and Body Mass Index on Total and Segmental Colonic Transit Times in Constipated Subjects. J Neurogastroenterol Motil. 2019;25(2):258–66. Joubert K, Laryea JA. Abdominal Approaches to Rectal Prolapse. Clin Colon Rectal Surg. 2017;30(1):57–62. Jeong HY, Park DH, Lee JK. Levator plate descent angle in pelvic floor disorders. Tech Coloproctol. 2021;25(9):1011–8. Jung SE, Joo NS, Han KS, Kim KN. Obesity Is Inversely Related to Hydrogen-Producing Small Intestinal Bacterial Overgrowth in Non-Constipation Irritable Bowel Syndrome. J Korean Med Sci 2017, 32(6):948–53. Tarasiuk A, Mosińska P, Fichna J. The mechanisms linking obesity to colon cancer: An overview. Obes Res Clin Pract. 2018;12(3):251–9. Zhu JY, Liu MY, Sun C. Assessment of the triglyceride glucose index in adult patients with chronic diarrhea and constipation. World J Clin cases. 2024;12(6):1094–103. Callan NGL, Mitchell ES, Heitkemper MM, Woods NF. Constipation and diarrhea during the menopause transition and early postmenopause: observations from the Seattle Midlife Women's Health Study. Menopause (New York, NY) 2018, 25(6):615–624. Sadeghi E, Khodadadiyan A, Hosseini SA, Hosseini SM, Aminorroaya A, Amini M, Javadi S. Novel anthropometric indices for predicting type 2 diabetes mellitus. BMC Public Health. 2024;24(1):1033. Rico-Martín S, Calderón-García JF, Sánchez-Rey P, Franco-Antonio C, Martínez Alvarez M, Sánchez Muñoz-Torrero JF. Effectiveness of body roundness index in predicting metabolic syndrome: A systematic review and meta-analysis. Obes reviews: official J Int Association Study Obes. 2020;21(7):e13023. Zhang Y, Song J, Li B, Wu Y, Jia S, Shu H, Liu F, Yang X. Association between body roundness index and overactive bladder: results from the NHANES 2005–2018. Lipids Health Dis. 2024;23(1):184. Tables Table 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table13.docx SupplementaryFigure1.FlowchartofparticipantselectionfromNHANES20052010.jpg SupplementaryFigure2NonlinearcorrelationbetweenbodyroundnessindexBRIandtheprevalenceofconstipation.jpg SupplementaryFigure3SubgroupanalysisfortheassociationbetweenBRIandconstipation.jpg SupplementaryTable1Characteristicsofeligibleparticipants.docx SupplementaryTable2AssociationbetweenBRIquartilesandtheriskofConstipationinparticipants.docx SupplementaryTable3Sensitivityanalyses..docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5082782","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":371286088,"identity":"3419ccfa-069c-46d9-aede-ac5358d47338","order_by":0,"name":"Chaofan Guo","email":"","orcid":"","institution":"Tianjin NanKai Hospital, Tianjin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chaofan","middleName":"","lastName":"Guo","suffix":""},{"id":371286089,"identity":"a6a8f8cd-c92f-4942-856c-d9145d62150a","order_by":1,"name":"Qibo Peng","email":"","orcid":"","institution":"Tianjin NanKai Hospital, Tianjin Medical 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09:25:12","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":204549,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of participant selection from NHANES 2005-2010\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5082782/v1/997ed70958ec98b56b7392a6.jpeg"},{"id":70449642,"identity":"b7376f55-65cc-4e18-a0a5-4ca3d1f0bc90","added_by":"auto","created_at":"2024-12-03 09:25:12","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":115138,"visible":true,"origin":"","legend":"\u003cp\u003eNon-linear correlation between body roundness index (BRI) and the prevalence of constipation\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5082782/v1/2558bc82735fa7c9d8935c75.jpeg"},{"id":70449643,"identity":"b5ad0a91-141e-437d-9e46-40eee513e5cc","added_by":"auto","created_at":"2024-12-03 09:25:12","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":210338,"visible":true,"origin":"","legend":"\u003cp\u003eSubgroup analysis for the association between BRI and constipation\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5082782/v1/78a98974274939b4f646c404.jpeg"},{"id":72447595,"identity":"f592ded6-7ea0-4e48-a5ff-57879c32ba2a","added_by":"auto","created_at":"2024-12-27 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09:25:12","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":16866,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable2AssociationbetweenBRIquartilesandtheriskofConstipationinparticipants.docx","url":"https://assets-eu.researchsquare.com/files/rs-5082782/v1/4cbb0b0d6bdbdb1db8006d96.docx"},{"id":70449648,"identity":"701dde1c-99c8-4a7a-a07e-6be676efb696","added_by":"auto","created_at":"2024-12-03 09:25:12","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":15704,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable3Sensitivityanalyses..docx","url":"https://assets-eu.researchsquare.com/files/rs-5082782/v1/2a410732d32a3454790c46cb.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The association between body roundness index and constipation: a cross‑sectional survey of NHANES 2005–2010","fulltext":[{"header":"Background","content":"\u003cp\u003eConstipation is a common condition, with a prevalence ranging from 9\u0026ndash;20% in the U.S. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Patients suffering with persistent constipation frequently encounter a substantial deterioration in their standard of living and physical capabilities, which can result in feelings of anxiety and other adverse emotions. In certain instances, these symptoms may progress to the development of depressive disorders [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Moreover, persistent constipation places a significant strain on healthcare resources, as alone, non-prescription remedies incur billions of dollars in annual expenditures in America [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The causes of constipation are varied and are typically classified as organic, functional, or medication-induced.\u003c/p\u003e \u003cp\u003eThe relationship between constipation and obesity has been increasingly elucidated in recent years. Epidemiological studies of constipated populations have revealed a close correlation between the two conditions, with a particularly strong association observed between visceral obesity and constipation. Several studies have indicated an elevated incidence of constipation in adults classified as obese, with BMI ranging from 25 to 39.9 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In studies such as the one conducted in Iran, approximately 60% of patients with functional constipation were found to have a higher BMI, which may be related to changes in biologically active substances and intestinal flora resulting from the gain or loss of visceral fat [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]; However, other studies have failed to identify a significant correlation between obesity and constipation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In some cases, negative correlations were noted, with a reduced incidence of constipation noted in obese individuals in contrast with the whole population. These discrepancies highlight the need for further research in this area [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBoth computed tomography (CT) and magnetic resonance imaging (MRI) are very efficient techniques for precisely quantifying fat in the viscera [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, their use in routine clinical practice is limited by lengthy processing times, high costs, and lack of flexibility regarding when and where they can be employed. Additionally, bioelectrical impedance analysis (BIA) can be used as a straightforward, economical, and non-invasive method for quantifying body fat content [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Anthropometric indicators provide an easy, affordable, and less invasive way to screen populations for health issues and identify potential dangers at an early stage. Consequently, the bulk of studies that evaluate body fat often use anthropometric indicators [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In order to quantify visceral fat as well as body fat, the Body Roundness Index (BRI) was first introduced in 2013 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Compared to other anthropometric measures, the BRI may be more beneficial due to its ability to precisely estimate visceral fat. A number of research investigations have shown a strong correlation between BRI and certain human diseases, such as colorectal cancer and stone deposition[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Despite extensive research, there remains a paucity of data regarding the relationship between BRI and constipation, thereby underscoring the necessity for the present study.\u003c/p\u003e \u003cp\u003eThis study, based on data from 8,388 individuals drawn from the National Health and Nutrition Examination Survey (NHANES), had two primary objectives: firstly, to examine the link between the BRI and the risk of constipation, and secondly, to suggest methods for further clarifying the connection between visceral fat and constipation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eSurvey description and study population:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn continuing, yearly survey, NHANES evaluates the health and nutritional condition of the population in the United States. Complete data can be accessed by the public on the NHANES website. All participants provided explicit consent in writing. This research comprised individuals from the survey cycles conducted between 2005 and 2010, with the exclusion of those below the age of 20 or those with missing clinical data. There were \u0026nbsp;8,388 people chosen for the final research. (Figure 1)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection and measurements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection and measurements were all acquired from the NHANES database. The database contains an extensive range of information, including demographic data such as race, gender, age, and other relevant details; information about nutrition; anthropometric measurements, including waist circumference (WC) and height; laboratory data, such as fasting blood glucose, glycosylated hemoglobin, and arterial pressure; and questionnaire responses, including information on alcohol consumption patterns, tobacco usage patterns, and existing health issues.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of body roundness index\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBRI served as the independent variable in this research. BRI was calculated following the approach described in prior research. The BRI was determined by the following: 364.2 - 365.5 * ( 1 - [ WC ( m ) / 2\u0026pi; ]\u003csup\u003e\u0026nbsp;2\u0026nbsp;\u003c/sup\u003e/ [ 0.5 * height ( m ) ] \u003csup\u003e2\u0026nbsp;\u003c/sup\u003e) \u003csup\u003e1 / 2\u0026nbsp;\u003c/sup\u003e[13].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDefinition of\u0026nbsp;constipation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom 2005 to 2010, the NHANES implemented the Bowel Health Questionnaire to record the frequency of bowel movements and stool characteristics. To ascertain stool characteristics, participants were shown vividly colored cards featuring the seven-point Bristol Stool Form Scale (BSFS). Subsequently, participants were instructed to choose the numerical value that corresponded to the stool pattern which was most representative or prevalent on their behalf. Bowel movement frequency was determined through a questionnaire that inquired about participants\u0026apos; bowel movement habits, specifically asking how many bowel movements they typically experienced per week. These data were instrumental in defining the constipated population [16]. Our research established two definitions of constipation, utilizing the standards set by Rome IV and prior NHANES investigations[17]. The first definition was derived from participants\u0026apos; self-reported stool characteristics, which were classified as either type 1 (separate hard lumps, like nuts) or type 2 (sausage-shaped, but lumpy) on the BSFS[18]. In addition, another way to define constipation was determined by considering the frequency of bowel movements reported by the subjects themselves. Individuals reporting a frequency of fewer than or equal to two bowel movements per week were classified as having constipation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCovariates\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo address potential confounding effects on the correlation between BRI and constipation, we employed multivariate adjustment models that accounted for a range of potential confounding variables. In this study, we considered various factors in the analysis, including sex , age, race, education level, poverty-to-income ratio (PIR), physical activity (defined as either active or inactive), depressive symptoms (classified as non-depressed or depressed), sleep duration (categorized into three groups: \u0026lt;5 hours, 5\u0026ndash;6 hours, and \u0026ge;9 hours), information regarding the individual\u0026apos;s smoking and \u0026nbsp;alcohol use habits, as well as their medical conditions of diabetes and hypertension. Meanwhile, we examined the influence of dietary components, such as calories, protein, carbohydrate, fiber in the diet, fat consumption, magnesium, selenium, and caffeine intake.\u003c/p\u003e\n\u003cp\u003eParticipants were categorized according to their physical activity status: physically active was defined as engaging in at least 10 consecutive minutes of vigorous-intensity activity per week. Alcohol consumption was categorized based on participants\u0026apos; intake over the past 12 months, with individuals classified as either nondrinkers or drinkers. Two categories were established for smoking status: participants who had consumed over 100 cigarettes in their lifespan were classified as smokers,\u0026nbsp;alternatively, a nonsmoker. The total intake of dietary factors was calculated by averaging the results of two 24-hour dietary memory tests, which provided detailed information on nutrient consumption.\u003c/p\u003e\n\u003cp\u003eComprehensive data regarding the measurement and quantification of the research variables can be obtained from the official website www.cdc.gov/nchs/nhanes/.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical analyses were conducted in compliance with the recommendations provided by the Centers for Disease Control and Prevention (CDC), this investigation implemented sophisticated statistical analyses. The methodology entailed the initial division of the BRI into quartiles, with the lowest quartile (Q1) functioning as the reference group. The presentation of categorical data involved reporting frequencies and percentages, whereas measurements of central tendency, such as means and standard deviations, were used to represent continuous variables. A multivariate logistic regression model was used to examine the relationship between BRI and the occurrence of constipation. Model 2 was adjusted for sex, age, and race; Model 3 included additional adjustments for education level, income-to-poverty ratio, physical activity, depressive symptoms, sleep duration, smoking status, drinking status, diabetes, hypertension, and nutritional aspects\u0026mdash;specifically energy, protein, carbohydrate, dietary fiber, fat intake, magnesium, selenium, and caffeine\u0026mdash;while maintaining adjustments for sex, age, and race. In the subsequent step, the impact of BRI on the occurrence of constipation was evaluated by a segmented linear regression model, while the non-linear correlation between BRI and constipation incidence was analyzed using a smoothed curve-fitting method. A thorough investigation of potential variations in population was carried out using subgroup analysis and interaction tests. The statistical analyses were conducted using EmpowerStats (version 6.0) and R software (version 4.2.0). A significance level of P \u0026lt; 0.05 was used to determine statistical significance.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline characteristics of\u0026nbsp;participants:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 presents the fundamental characteristics of the participants chosen from the NHANES 2005-2010 cycles. In the investigation, 8,388 participants were enrolled. The group with constipation exhibited significant differences from the non-constipated group in terms of gender, age, ethnicity, educational level, PIR, physical activity, depressive symptoms, sleep duration, smoking status, drinking status, hypertension, and various dietary factors, including energy, protein, carbohydrate, dietary fiber, fat intake, magnesium, selenium, and caffeine. However, the prevalence of diabetes did not differ significantly among the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRelationship between\u0026nbsp;BRI and\u0026nbsp;constipation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe current study revealed a negative link between BRI and the likelihood of experiencing constipation. BRI was analyzed as a stratified variable (quartiles), and as shown in Table 2, individuals in the highest quartile (Q4) showed a 0.574-fold decrease in the likelihood of experiencing constipation compared to those in the lowest quartile (Q1) in a fully adjusted model that considered all covariates (95% CI: 0.464\u0026ndash;0.710; P \u0026lt; 0.001). This result indicates a potential inverse association between higher BRI and the likelihood of developing constipation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNon-linear relationship between BRI and constipation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study investigated the nonlinear association between BRI and constipation risk, as shown in Figure 2. Through a meticulous analysis of the smoothed curves, we elucidated this relationship. The likelihood ratio test revealed a p-value of 0.007 for the relationship between BRI and constipation occurrence. A biphasic linear model, coupled with a recursive algorithm, was employed to identify the inflection point, which was found to be a BRI of 2.74. Below this threshold, the risk of constipation increased by 71% for every unit rise in BRI (OR: 1.71, 95% CI: 1.07\u0026ndash;2.76). However, when BRI exceeded 2.74, the risk declined by 10% per unit increase (OR: 0.90, 95% CI: 0.87\u0026ndash;0.94) (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubgroup analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 3 presents the results of the subgroup analysis. The study found that, with the exception of Mexican Americans, other races, individuals with less than a high school education, and those with sleep durations of \u0026lt;5 or \u0026ge;9 hours, the association between BRI and constipation was positive across all subgroups. Notably, there was a significant interaction between BRI and race in relation to constipation risk (interaction p = 0.025), while no significant interaction was observed for other subgroups (interaction p \u0026gt; 0.05). Additionally, a stronger inverse association was observed among females (OR 0.91, 95% CI: 0.87\u0026ndash;0.94), which may be related to the distinct pelvic anatomy of women.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this study was to assess the relationship between BRI and constipation risk using data from the NHANES dataset. This investigation of 8,388 participants revealed an overall negative association between BRI and constipation risk, as well as a nonlinear correlation. A clear correlation between BRI and the likelihood of constipation was observed on both sides of the inflection point (BRI = 2.74). Each unit increase in BRI resulted in a 171% increase in the risk of constipation for BRIs less than 2.74, while the risk decreased by 10% for BRIs greater than 2.74. Moreover, a rise in BRI was linked to a heightened likelihood of chronic constipation, but only when BRI is less than 2.74. BRI values below 2.74 fall within the lowest quartile. Therefore, it may be deduced that an elevation in BRI is related to an augmented likelihood of chronic constipation in a relatively minor segment of the population. On the other hand, among the majority of individuals who have higher amounts of visceral fat and a BRI greater than 2.74, a consistent increase in BRI is linked to a decreased likelihood of experiencing chronic constipation. As far as we know, this is the very first investigation to evaluate the correlation between BRI and the likelihood of experiencing constipation.\u003c/p\u003e\n\u003cp\u003eThe association between bowel symptoms and body fat has been a subject of debate in the scientific literature. In a study of the Iranian population, Mohamad and colleagues observed that up to 60% of patients with constipation had a BMI greater than or equal to 25, proposing a possible correlation between BMI and a heightened susceptibility to constipation[6]；Xiang et al. analyzed the relationship between several measures of obesity and the occurrence of constipation by utilizing data from the NHANES. Their research revealed that lower BMI, waist-to-stature ratio (WSR), lipid accumulation product (LAP), and waist circumference were linked to a decreased likelihood of experiencing constipation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConversely, elevated waist-to-waist index (WWI) levels correlated with a reduced incidence of constipation[19]; Additionally, a research study executed by Naotaka and associates reported a significant reduction in BMI among men with constipation compared to men without constipation. However, there was no discernible distinction between the two categories in the female population[20]；A recent study conducted in New Zealand also revealed a negative correlation between being overweight and constipation[8]；Furthermore, Michel et al. discovered that rectosigmoid transit time (RSTT) and colonic transit time (CTT) were shorter in obese \u0026nbsp; \u0026nbsp;patients compared to those with a normal BMI. BMI and RSTT also exhibited a negative correlation (P\u0026lt;0.001)[21]. Our clinical observations have also revealed a negative connection between visceral obesity and the incidence of constipation. The fundamental processes of this negative association are, however, ambiguous.\u003c/p\u003e\n\u003cp\u003eThe association between visceral obesity and persistent constipation is probably intricate and not entirely comprehended, particularly regarding its precise mechanistic basis. This study aims to investigate the inverse relationship between these two parameters, emphasizing the structural effects of visceral fat on the rectum. We hypothesized that a high visceral fat load may stabilize the rectum, thereby reducing the likelihood of anterior rectal herniation, especially in the female population. The probability of developing constipation due to outlet obstruction is relatively low. Moreover, elevated visceral fat may lead to a shallower Douglas pouch, which further reduces the risk of intestinal herniation and, consequently, the risk of constipation[22]; Additionally, an increase in visceral fat may reduce pelvic floor muscle laxity, thereby limiting the descent of the anorectal plate and subsequently lowering the likelihood of developing constipation [23]. Moreover, the prevalence of constipation is frequently associated with intestinal dysbiosis.\u0026nbsp;Individuals with obesity are susceptible to small intestine bacterial overgrowth (SIBO) characterized by hydrogen (H₂)-producing dysbiosis, potentially resulting in an elevated frequency of bowel movements\u0026nbsp;[24]. Furthermore, individuals with a high BMI frequently exhibit insulin resistance\u0026nbsp;[25]. Certain research indicates a possible positive association between the onset of insulin resistance and chronic diarrhea. Specifically, the risk of constipation appears to be relatively lower in obese individuals\u0026nbsp;[26]. Moreover, individuals with obesity may exhibit hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, leading to elevated cortisol secretion. Elevated cortisol levels have been associated with a statistically significant reduction in the probability of developing constipation, according to research. Consequently, obese individuals may potentially mitigate the risk of constipation through increased cortisol release\u0026nbsp;[27]. The BRI represents an innovative methodology to detecting obesity in humans. It offers a more convenient alternative to CT and MRI for measuring visceral obesity and provides a superior reflection of visceral fat distribution compared to traditional anthropometric indicators such as BMI. The BRI has proven to be an efficient indicator of illnesses including diabetes and metabolic syndrome.[28, 29]. Additionally, BRI is associated with certain functional disorders, including bladder mobility disorders\u0026nbsp;[30]\u0026nbsp;While BMI is a reliable indicator of overall body fat, it does not distinguish between subcutaneous and visceral fat. The BRI may offer a more accurate assessment of visceral adiposity. Our research demonstrates an association between increased BRI and a diminished risk of constipation, implying that sustaining a specific level of BRI may enhance bowel function. Nonetheless, further extensive prospective cohort studies are need to validate our idea.\u003c/p\u003e\n\u003cp\u003eOur study has several strengths, including a well-designed protocol with rigorous quality control, a large and representative sample, and comprehensive data on numerous key covariates obtained through the integration of NHANES data. However, there are some limitations to this study. First, the diagnosis of constipation was based on self-reports, which introduces subjectivity and recall bias. Second, the potential influence of unmeasured or unknown confounders on the study results cannot be entirely ruled out. Additionally, due to the cross-sectional nature of this study, causal relationships between variables cannot be established.\u003c/p\u003e"},{"header":"Conclusion","content":"\n\u003cp\u003eThe study\u0026apos;s findings indicated that a higher BRI is negatively associated with the probability of having constipation. This indicates that a suitable rise in visceral fat levels may diminish the likelihood of getting constipation. This study has limitations, and additional prospective medical studies are required to validate the potential influence of visceral adiposity on the onset of constipation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI Body mass index\u003c/p\u003e\n\u003cp\u003eBRI Body roundness index\u003c/p\u003e\n\u003cp\u003eBSFS Bristol Stool Form Scale\u003c/p\u003e\n\u003cp\u003eCDC Centres for Disease Control and Prevention\u003c/p\u003e\n\u003cp\u003eCI Confdence interval\u003c/p\u003e\n\u003cp\u003eNHANES National Health and Nutrition Examination Survey\u003c/p\u003e\n\u003cp\u003eOR Odds ratio\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupplementary Material : Supplementary Figure 1. Flowchart of participant selection from NHANES 2005-2010. Supplementary Figure 2. Non-linear correlation between body roundness index (BRI) and the prevalence of constipation. Supplementary Figure 3. Subgroup analysis for the association between BRI and constipation.\u003c/p\u003e\n\u003cp\u003eSupplementary Table 1. Characteristics of eligible participants\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSupplementary Table 2. Association between BRI quartiles and the risk of Constipation in participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSupplementary Table 3. Sensitivity analyses.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eAll study participants signed the consent form. The Ethics Review Committee\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eof the CDC approved the creation and use of NHANES data.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eAll the data used in this study are from the open database of NHANES (http://www.cdc.gov/nchs/nhanes.htm).\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThere is no funding.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eConceptualization: CG, XY. Methodology: CG, QP Software: CG, QP, XY. Validation: CG, QP, XY. Formal analysis: CG, QA. Investigation: CG, ZZ. Resources: QP. Data curation: CG. Writing-original draft: CG, QP. Visualization: CG,QA. Supervision: XY. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOh SJ, Fuller G, Patel D, Khalil C, Spalding W, Nag A, Spiegel BMR, Almario CV. Chronic Constipation in the United States: Results From a Population-Based Survey Assessing Healthcare Seeking and Use of Pharmacotherapy. Am J Gastroenterol. 2020;115(6):895\u0026ndash;905.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRao SS, Seaton K, Miller MJ, Schulze K, Brown CK, Paulson J, Zimmerman B. Psychological profiles and quality of life differ between patients with dyssynergia and those with slow transit constipation. J Psychosom Res. 2007;63(4):441\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenninga MA, Scott SM. Chronic constipation. Preface. Best Pract Res Clin Gastroenterol. 2011;25(1):1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRao SS, Rattanakovit K, Patcharatrakul T. Diagnosis and management of chronic constipation in adults. Nat reviews Gastroenterol Hepatol. 2016;13(5):295\u0026ndash;305.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilveira EA, Santos A, Ribeiro JN, Noll M, Dos Santos Rodrigues AP, de Oliveira C. Prevalence of constipation in adults with obesity class II and III and associated factors. BMC Gastroenterol. 2021;21(1):217.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePourhoseingholi MA, Kaboli SA, Pourhoseingholi A, Moghimi-Dehkordi B, Safaee A, Mansoori BK, Habibi M, Zali MR. Obesity and functional constipation; a community-based study in Iran. J Gastrointest liver diseases: JGLD. 2009;18(2):151\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelgado-Aros S, Locke GR 3rd, Camilleri M, Talley NJ, Fett S, Zinsmeister AR, Melton LJ. 3rd: Obesity is associated with increased risk of gastrointestinal symptoms: a population-based study. Am J Gastroenterol. 2004;99(9):1801\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTalley NJ, Howell S, Poulton R. Obesity and chronic gastrointestinal tract symptoms in young adults: a birth cohort study. Am J Gastroenterol. 2004;99(9):1807\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu Z, Liu Y, Yan C, Yang R, Xu L, Guo Z, Yu A, Cheng X, Ma L, Hu C, et al. Measurement of visceral fat and abdominal obesity by single-frequency bioelectrical impedance and CT: a cross-sectional study. BMJ open. 2021;11(10):e048221.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaskarinec G, Shvetsov YB, Wong MC, Garber A, Monroe K, Ernst TM, Buchthal SD, Lim U, Le Marchand L, Heymsfield SB, et al. Subcutaneous and visceral fat assessment by DXA and MRI in older adults and children. Obes (Silver Spring Md). 2022;30(4):920\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmano K, Bruera E, Hui D. Diagnostic and prognostic utility of phase angle in patients with cancer. Reviews Endocr metabolic disorders. 2023;24(3):479\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFang H, Berg E, Cheng X, Shen W. How to best assess abdominal obesity. Curr Opin Clin Nutr Metab Care. 2018;21(5):360\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas DM, Bredlau C, Bosy-Westphal A, Mueller M, Shen W, Gallagher D, Maeda Y, McDougall A, Peterson CM, Ravussin E, et al. Relationships between body roundness with body fat and visceral adipose tissue emerging from a new geometrical model. Obes (Silver Spring Md). 2013;21(11):2264\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu X, Shi H, Shi Y, Wei H, Yuan X, Jiao Z, Wu T, Wang Z. Association between a body shape index and prostate cancer: a cross-sectional study of NHANES 2001\u0026ndash;2018. Int Urol Nephrol. 2024;56(6):1869\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMao X, Yang Y, Yang J, Chen M, Hao Z. Association between body roundness index and prevalence of kidney stone in the U.S: a study based on the NHANES database. BMC Urol. 2024;24(1):93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarkland AD, Palsson O, Goode PS, Burgio KL, Busby-Whitehead J, Whitehead WE. Association of low dietary intake of fiber and liquids with constipation: evidence from the National Health and Nutrition Examination Survey. Am J Gastroenterol. 2013;108(5):796\u0026ndash;803.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson PB. Associations between physical activity and constipation in adult Americans: Results from the National Health and Nutrition Examination Survey. Neurogastroenterol Motil. 2020;32(5):e13789.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, Tong WD, Qian Y. Effect of Physical Activity on the Association Between Dietary Fiber and Constipation: Evidence From the National Health and Nutrition Examination Survey 2005\u0026ndash;2010. J Neurogastroenterol Motil. 2021;27(1):97\u0026ndash;107.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiang N, Xu L, Qian H, Zhang D. Multiple obesity indices suggest a close relationship between obesity and constipation: evidence from NHANES. BMC Public Health. 2024;24(1):1273.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgasawara N, Kasugai K, Funaki Y, Ebi M, Izawa S, Tamura Y, Kato A, Yamaguchi Y, Adachi K, Sugiyama T, et al. Relationships between body mass index and constipation, gastroesophageal reflux disease, stool forms based on the Bristol Stool Form Scale, and education level: results from an internet survey in Japan. J Clin Biochem Nutr. 2023;73(1):84\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBouchoucha M, Fysekidis M, Rompteaux P, Airinei G, Sabate JM, Benamouzig R. Influence of Age and Body Mass Index on Total and Segmental Colonic Transit Times in Constipated Subjects. J Neurogastroenterol Motil. 2019;25(2):258\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoubert K, Laryea JA. Abdominal Approaches to Rectal Prolapse. Clin Colon Rectal Surg. 2017;30(1):57\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeong HY, Park DH, Lee JK. Levator plate descent angle in pelvic floor disorders. Tech Coloproctol. 2021;25(9):1011\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJung SE, Joo NS, Han KS, Kim KN. Obesity Is Inversely Related to Hydrogen-Producing Small Intestinal Bacterial Overgrowth in Non-Constipation Irritable Bowel Syndrome. J Korean Med Sci 2017, 32(6):948\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTarasiuk A, Mosińska P, Fichna J. The mechanisms linking obesity to colon cancer: An overview. Obes Res Clin Pract. 2018;12(3):251\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu JY, Liu MY, Sun C. Assessment of the triglyceride glucose index in adult patients with chronic diarrhea and constipation. World J Clin cases. 2024;12(6):1094\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCallan NGL, Mitchell ES, Heitkemper MM, Woods NF. Constipation and diarrhea during the menopause transition and early postmenopause: observations from the Seattle Midlife Women's Health Study. \u003cem\u003eMenopause (New York, NY)\u003c/em\u003e 2018, 25(6):615\u0026ndash;624.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadeghi E, Khodadadiyan A, Hosseini SA, Hosseini SM, Aminorroaya A, Amini M, Javadi S. Novel anthropometric indices for predicting type 2 diabetes mellitus. BMC Public Health. 2024;24(1):1033.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRico-Mart\u0026iacute;n S, Calder\u0026oacute;n-Garc\u0026iacute;a JF, S\u0026aacute;nchez-Rey P, Franco-Antonio C, Mart\u0026iacute;nez Alvarez M, S\u0026aacute;nchez Mu\u0026ntilde;oz-Torrero JF. Effectiveness of body roundness index in predicting metabolic syndrome: A systematic review and meta-analysis. Obes reviews: official J Int Association Study Obes. 2020;21(7):e13023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Song J, Li B, Wu Y, Jia S, Shu H, Liu F, Yang X. Association between body roundness index and overactive bladder: results from the NHANES 2005\u0026ndash;2018. Lipids Health Dis. 2024;23(1):184.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Body roundness index, Visceral fat, Constipation, NHANES, Obesity","lastPublishedDoi":"10.21203/rs.3.rs-5082782/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5082782/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eObesity, particularly visceral fat, is linked to constipation. And Body Roundness Index (BRI) offers a precise evaluation of visceral fat levels. Nevertheless, the risk of developing constipation is not yet known to be connected with BRI.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFrom the National Health and Nutrition Examination Survey (NHANES), 8,388 individuals aged 20 years or older were recruited for the study. The primary strategy employed to examine the relationship between BRI and the possibility of constipation was logistical regression, which encompassed multivariable regression analysis, smoothing curve fitting, and subgroup analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThese findings revealed a negative correlation between elevated BRI values and the likelihood of constipation. After adjusting for variables, persons in the uppermost quartile (Q4) of BRI showed a 0.574-fold reduced likelihood of constipation in contrast to people who were in the bottom quartile (Q1), as shown in Table\u0026nbsp;2. The 95% confidence interval (CI) for this risk was 0.464\u0026ndash;0.710, where P\u0026thinsp;\u0026lt;\u0026thinsp;0.001. These findings support the negative correlation between increased BRI and reduced likelihood of constipation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAn elevated BRI ratio was linked to a reduced likelihood of developing constipation. Our findings suggest that maintaining a certain level of visceral fat may have a preventive and alleviating effect on constipation. However, additional prospective investigations are necessary to validate this hypothesis.\u003c/p\u003e","manuscriptTitle":"The association between body roundness index and constipation: a cross‑sectional survey of NHANES 2005–2010","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-03 09:25:07","doi":"10.21203/rs.3.rs-5082782/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8266e190-0948-478f-abcd-e9349d1b2a29","owner":[],"postedDate":"December 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-15T14:23:46+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-03 09:25:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5082782","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5082782","identity":"rs-5082782","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}