Overweight status, abdominal circumference, physical activity, and functional constipation in children

SUMMARY

OBJECTIVE:

The aim of this study was to assess the prevalence of functional constipation and its relationship with the food intake, overweight status, and physical activity of children.

METHODS:

This cross-sectional study included students from two public schools in the municipality of Osasco, which is located in the metropolitan area of São Paulo. Functional constipation was diagnosed if the clinical manifestations of the Rome IV criteria were present for more than 2 months. A 24-h recall survey was used to determine the daily food intake. Weight, height, abdominal circumference, and bioelectrical impedance were used to evaluate the weight status. Active commuting to school and physical activity scores were assessed using a questionnaire that has been validated in Brazil.

RESULTS:

A total of 452 children, aged 6–12 years, were evaluated. Functional constipation was observed in 22.3% of participants. A greater abdominal circumference was associated with functional constipation in girls (p=0.036) in the bivariate analysis but not in the logistic regression model. Boys with functional constipation consumed higher quantities of fats (p=0.041). There was no statistically significant relationship between functional constipation and overweight status (44.6 and 34.5% of children with and without constipation, respectively; p=0.083) and active commuting to school (48.5 and 56.7% of children with and without constipation, respectively; p=0.179).

CONCLUSION:

Functional constipation was associated with a greater abdominal circumference in girls in the bivariate analysis, however, without association in the logistic regression model. Boys with functional constipation consumed higher quantities of fat. No association was found between functional constipation, overweight status, and physical activity.

KEYWORDS:
Child; Constipation; Eating; Pediatric obesity; Exercise; Sagittal abdominal diameter

INTRODUCTION

Functional constipation is a functional gastrointestinal disorder that is a highly prevalent health issue in children¹−³. Functional constipation is caused by the interaction of biopsychosocial factors such as genetic features, intestinal motility disturbance, low dietary fiber intake, low fluid intake, physical inactivity, and a vicious cycle of painful evacuation leading to fecal retention due to the inhibition of bowel movements¹−⁶.

In adolescents and adults, constipation is more frequent in females; however, in children, there is no consensus on the distribution of constipation between the sexes¹,⁴.

Increasing the intake of dietary fiber and water is recommended to treat and prevent functional constipation⁶−⁸. However, the effects of energy intake and different types of dietary nutrients as factors associated with functional constipation have not been completely explored⁹,¹⁰.

Although few studies have indicated that overweight status is a risk factor for functional constipation²−¹¹, the scientific evidence is controversial²,¹¹. An association between visceral body fat and irritable bowel syndrome in adult women was recently reported¹². However, the relationship between abdominal circumference and functional constipation has not been evaluated in the pediatric age range. Furthermore, the effects of physical activity and its intensity on functional constipation in children and adolescents have not been widely investigated¹³−¹⁵. This study was conducted to assess the prevalence of functional constipation and its relationship with food intake, overweight status, and physical activity of children.

METHODS

Study design

This cross-sectional study included students from two public schools in the municipality of Osasco, which is located in the metropolitan area of São Paulo. Functional constipation was diagnosed based on the clinical manifestations of the Rome IV criteria for more than 2 months. Food intake was evaluated using the 24-h dietary recall. Overweight status was evaluated using anthropometric and electrical bioimpedance measurements. Physical activity was evaluated based on the active commuting of the students to school and physical activity scores were obtained using a questionnaire validated in Brazil. The study was approved by the Research Ethics Committee of the Federal University of São Paulo (CEP 2.250.658).

Participants

Data were collected between November 2014 and 2015. The Department of Education selected the schools where greater collaboration and adherence of employees was expected to carry out the study. The only inclusion criterion was the enrollment in the schools included in the study by the Secretary of Education of the Municipality of Osasco. Therefore, all students were invited to participate in the study, regardless of their sex, nutritional status, race, or economic status. Patients with severe genetic, neurologic, cardiopulmonary, inflammatory, endocrine, or chronic kidney diseases were excluded from the data analysis.

A total of 1,770 students between 6 and 12 years of age attended the two designated schools. A presentation on the topic of the study was made to all parents and/or guardians. Authorization to participate in the study was requested from all parents or guardians. The parents of 480 (27.1%) children signed an informed consent form, while one student refused to participate in this study. The parents of 25 students could not be interviewed to provide information for the study. Two students were excluded because of severe disease (one with myelomeningocele and one with cerebral palsy). Finally, a total of 452 participants were included in this study.

Method

Functional constipation diagnosis

Functional constipation was diagnosed when the children had two or more of the following six clinical manifestations of the Rome IV criteria³ for a minimum of 2 months⁵: two or fewer defecations per week in the toilet for a child of developmental age (at least 4 years of age); at least one episode of fecal incontinence per week; history of retentive posturing or excessive volitional stool retention; history of painful or hard bowel movements; and history of large-diameter stools that can obstruct the toilet³,⁵.

Parents answered questions about the Rome IV criteria during the face-to-face interviews. The questions used in the interview were in Portuguese, and they had been tested for comprehension and were successfully used to identify functional constipation¹⁶ in accordance with the Rome criteria³,⁵.

Food intake analysis

The 24-h dietary recall survey, answered by parents/guardians, was used to obtain data for the quantitative analysis¹⁷. The nutrient calculations were performed using the Nut Win version 2.5 software developed by the Health Information Technology Department of the Federal University of São Paulo (São Paulo, Brazil).

Weight, height, and abdominal circumference measurements

Weight and height were measured as recommended¹⁸. Abdominal circumference was measured with an inelastic tape from the midpoint between the last rib and the upper border of the iliac crest (hip bone)¹⁸. The height-for-age z-scores and the relationship between the body mass index and age were calculated by the Anthro plus software version 1.0.4 (World Health Organization, Geneva, Switzerland).

Electrical bioimpedance analysis

The electrical bioimpedance test was performed using electrode placement (101 Quantum; RJL Systems, Miami, FL, USA) and BC software version 1.038 (RJL Systems, Miami, FL, USA) to estimate the body fat mass and lean mass.

Physical activity analysis

To evaluate physical activity, the children received illustrated questionnaires with drawings related to the activities they might have performed the previous day. The previous day's version improves measurements and reduces the child's need for recall by preventing craving behavior responses¹⁹. During the first part, they identified the means of transportation used to go to school (on foot, or by bicycle, public bus, car, or school bus). Then, the answer was rated as active or inactive commuting to school¹⁹,²⁰.

During the second part of the test, the participants were asked to choose the intensity level of each type of activity (low, medium, or high). The survey illustrated 11 possible types of activities (dancing, walking/running, biking, performing chores, going up the stairs, playing soccer, jumping rope, swimming, gymnastics, skating, and playing with a dog). The score for each activity was determined by assigning 1 point for low intensity, 3 points for medium intensity, and 9 points for high intensity; the maximum score for all activities was 99¹⁹,²⁰.

Statistical analysis

Parametric and nonparametric statistical tests were performed according to the variable distribution to analyze the results along with the Sigma Plot version 11.2 software (Systat Software, San Jose, CA, USA). For all the tests, the significance level was set at 5% or 0.05.

RESULTS

The prevalence of functional constipation was 22.3% (101/452) for the total population, with a rate of 23.9% (65/273) for girls and 20.1% (36/179) for boys (p=0.419). The mean age was similar in children with (9.4 years±1.3) and without (9.2 years±1.5) constipation (p=0.257). Logistic regression showed a statistically significant effect (p=0.011) on the interaction between sex and age. Up to 9 years of age, the proportion of constipation was similar in both sexes; however, from 10 years onward, it was more frequent (p<0.05) in females.

Food intake was similar between children with and without functional constipation; however, fat intake was higher for boys with functional constipation (Table 1). The body mass index, height-for-age z-scores, lean mass, and fat mass did not differ between children with and without functional constipation (Table 2). The abdominal circumference was larger for girls with functional constipation than for boys.

Table 1
Food intake of children according to sex and the presence of functional constipation.

		Functional constipation		p-valuea
		Yes	No
Energy (kcal)
	Girls	1960.7±906.7	1980.1±750.4	0.615
	Boys	2199.2±631.5	2049.6±771.5	0.071
	Total	2045.7±823.9	2008.4±758.7	0.571
Protein (g)
	Girls	89.2±45.0	93.7±44.7	0.258
	Boys	101.8±37.2	101.4±57.0	0.416
	Total	93.7±42.7	96.8±50.2	0.689
Lipid (g)
	Girls	54.0±40.2	56.3±29.8	0.255
	Boys	62.8±24.2	55.6±26.7	0.041
	Total	57.2±35.5	55.9±28.5	0.770
Carbohydrate (g)
	Girls	280.7±126.8	275.7±110.9	0.909
	Boys	307.3±105.2	285.6±102.5	0.240
	Total	290.2±119.7	279.7±107.5	0.474
Water (mL)
	Girls	1212.3±506.9	1216.6±453.8	0.579
	Boys	1348.7±445.7	1286.2±488.9	0.618
	Total	1260.9±488.2	1244.9±468.9	0.926
Dietary fiber (g)
	Girls	25.9±15.2	28.3±17.5	0.466
	Boys	33.1±19.3	29.8±18.2	0.444
	Total	28.5±17.1	28.9±17.8	0.828
Calcium (mg)
	Girls	597.7±323.2	611.7±337.7	0.612
	Boys	639.4±300.7	673.8±395.0	0.825
	Total	612.6±314.5	637.0±362.9	0.607
Iron (mg)
	Girls	9.7±5.3	9.9±4.5	0.362
	Boys	11.5±4.3	10.8±5.1	0.176
	Total	10.3±5.0	10.3±4.8	1.000
Vitamin A (IU)
	Girls	622.2±1140.0	509.9±480.2	0.832
	Boys	550.7 ± 397.4	834.2±3057.4	0.993
	Total	596.7 ± 942.5	641.9±1988.5	0.883
Vitamin C (mg)
	Girls	69.5±91.9	81.5±119.1	0.333
	Boys	76.1±88.2	62.0±76.7	0.443
	Total	71.9±90.2	73.6±104.2	0.738
Cholesterol (mg)
	Girls	217.1±112.5	265.3±185.3	0.141
	Boys	263.2±125.0	262.6±206.1	0.272
	Total	233.5±118.6	264.2±193.7	0.605

• Number of children with constipation: 65 girls and 36 boys. Number of children without constipation: 208 girls and 143 boys. Mean±standard deviation.
• ^a
  Student's t-test was performed for independent samples. Bold indicates statistically significant p-values.

Table 2
Body mass index, height-for-age z-score, abdominal circumference, abdominal circumference for height, and body composition of children according to sex and the presence of functional constipation.

		Functional constipation		p-valuea
		Yes	No
Body mass index (kg/m2)
	Girls	19.0±3.5	18.2±3.4	0.074
	Boys	18.2±3.7	17.9±3.3	0.616
	Total	18.7±3.6	18.1±3.4	0.079
Height for age (z-score)
	Girls	0.3±1.1	0.4±0.9	0.590
	Boys	0.3±0.9	0.3±1.1	0.806
	Total	0.3±1.0	0.3±1.0	0.578
Abdominal circumference (cm)
	Girls	64.5±9.2	61.9±8.8	0.036
	Boys	62.9±9.4	62.5±8.9	0.693
	Total	63.9±9.3	60.2±8.9	0.054
Abdominal circumferencea / height (cm)
	Girls	0.47±0.1	0.46±0.1	0.274
	Boys	0.47±0.1	0.46±0.0	0.524
	Total	0.47±0.1	0.46±0.1	0.202
Lean mass (%)
	Girls	74.2±7.8	74.9±7.3	0.541
	Boys	76.3±7.3	77.0±0.6	0.705
	Total	74.9±7.7	75.7±7.1	0.283
Fat mass (%)
	Girls	25.8±7.8	25.0±7.1	0.470
	Boys	23.7±7.3	22.9±6.7	0.701
	Total	25.0±7.7	24.2±6.9	0.268

• Number of children with constipation: 65 girls and 36 boys. Number of children without constipation: 208 girls and 143 boys. Mean±standard deviation.
• ^a
  Student's t-test was performed for independent samples. Bold indicates statistically significant p-values.

Overweight status was more frequent in boys and girls with functional constipation (44.6%; 45/101) than in those without constipation (34.5%; 121/351). However, the difference was not statistically significant (p=0.083); a total of 46.2% (30/65) and 37.0% (77/208) of girls with and without functional constipation, respectively, were overweight (p=0.242). Furthermore, 41.7% (15/36) and 30.8% (44/143) of boys with and without functional constipation, respectively, were overweight (p=0.296). There was no difference in the frequency of active commuting to school or in the physical activity scores of the groups with and without functional constipation (Table 3).

Table 3
Physical activity of children according to sex and the presence of functional constipation.

		Functional constipation		p-value
		Yes	No
Physical activity score
	Girls	15.4±8.1	16.4±10.4	0.901a
	Boys	20.7±16.3	18.7±10.1	0.792a
	Total	17.3±11.9	17.3±10.3	0.601a
Active commuting to school
	Girls	44.6% (29/65)	52.9% (110/208)	0.307b
	Boys	55.6% (20/36)	62.2% (89/143)	0.587b
	Total	48.5% (49/101)	56.7% (199/351)	0.179b

• Number of children with constipation: 65 girls and 36 boys, n=36. Number of children without constipation: 208 girls and 143 boys. Mean±standard deviation.
• ^a
  Student's t-test was performed for independent samples
• ^b
  Pearson's chi-square test.

The logistic regression model including sex, age, overweight, and functional constipation did not confirm the association between abdominal circumference and functional constipation (p=0.705) in female students as found in the bivariate analysis.

DISCUSSION

The prevalence of functional constipation in the present study was similar to that reported by other studies in Brazil¹ and other countries⁴.

For boys, a higher fat intake was observed, which was in concordance with a study on Japanese children⁹. This finding suggests that there might be an abnormal gastrocolic reflex response with prolonged retrograde phasic contraction after eating a fat-rich meal⁹. This mechanism may be related to dysmotility in functional constipation. No additional differences were observed in the intake of other nutrients, including dietary fiber, between the groups with and without functional constipation. However, studies showed that children with functional constipation had a lower intake of total dietary fiber, insoluble dietary fiber, vegetables, fruits, and fluids¹⁵,²¹. The absence of relationships between functional constipation and other nutrients observed during this study may be related to the fact that the participants had mild functional constipation.

Our results are also in agreement with those of studies performed in Brazil²² and Colombia¹¹ that did not demonstrate any association between functional constipation and overweight status; however, this result differed from those of studies performed in developed countries. Moreover, this discrepancy can be explained by hormonal, emotional, and genetic factors, as well as by eating habits, lifestyle, and financial status in different countries¹¹, in addition to the severity of functional constipation.

This study is the first to show the relationship between increased abdominal circumference and functional constipation in children, specifically in girls. This result agrees with the amount of visceral fat observed using abdominal tomography in adult women with irritable bowel syndrome¹². The fact that fecal incontinence was not observed in patients with functional constipation suggests that there was insufficient fecal retention in the colon that could increase the abdominal circumference. Notably, the relationship between functional constipation and abdominal circumference observed during our study agrees with the results of another study in Brazil that demonstrated a higher correlation between metabolic syndrome and abdominal circumference in relation to the ratio of the abdominal circumference to height²³.

The relationship between increased abdominal circumference and functional constipation dysmotility may be related to increased intra-abdominal pressure caused by excess visceral fat. Another possible mechanism is related to the amount of adipokines and cytokines secreted by the visceral adipose tissue, which cause low-grade tissue inflammation in the gut. Inflammation may result in abnormal epithelial secretion, visceral hypersensitivity, smooth muscle dysfunction syndrome, dysmotility, and pain perceived by the enteric nervous system¹¹,²². However, further studies are required to explore and support this hypothesis.

In contrast to the literature¹⁵,²⁴,²⁵, no connection between less physical activity and functional constipation was observed. Research involving children and teenagers in Iceland has shown a connection between these two factors for children older than 10 years²⁴. However, the children and teenagers studied in Iceland were older than the children evaluated during our study.

A limitation of this study is its cross-sectional design that does not allow for establishing a cause–effect relationship. The study was performed in only one city and thus does not represent the entire Brazilian population. The results of the present study justify the development of future projects in not only public but also private schools. In addition, there is a need for further studies on the intensity of physical activity and constipation in children to elucidate whether there is a relationship.

CONCLUSION

The prevalence of functional constipation was similar to that observed in other epidemiological studies. Functional constipation was associated with a greater abdominal circumference in girls in the bivariate analysis; however, there was no association in the logistic regression model. Boys with functional constipation consumed higher quantities of fat. No association was found among functional constipation, overweight status, and physical activity.

• Funding: Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) e Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).

ACKNOWLEDGMENTS

We thank the Secretary of Education and Secretary of Health of the Municipality of Osasco, the Educational Supervisor Marilisa Vidal Gellis Gasparini, and the directors and staff of Oscar Pennacino Elementary School and Luiz Bortolosso Elementary School.

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Publication Dates

• Publication in this collection
  20 Feb 2023
• Date of issue
  2023

History

• Received
  01 Dec 2022
• Accepted
  14 Dec 2022