Int Urogynecol J DOI 10.1007/s00192-015-2730-9
ORIGINAL ARTICLE
Factors associated with fecal incontinence in a nationally representative sample of diabetic women Maria De La Luz Nieto 1 & Jennifer M. Wu 1,2 & Catherine Matthews 1 & William E. Whitehead 3 & Alayne D. Markland 4,5
Received: 4 February 2015 / Accepted: 22 April 2015 # The International Urogynecological Association 2015
Abstract Introduction and hypothesis Fecal incontinence (FI) is a debilitating condition that significantly affects quality of life, and has been associated with multiple risk factors. Our goal was to assess the prevalence of FI among diabetic women and evaluate factors associated with FI in this population. Methods The National Health and Nutrition Examination Survey (NHANES) from 2005 to 2010 was used to evaluate women with diabetes mellitus and FI. FI was defined as involuntary loss of mucus, liquid, or solid stool at least monthly. Severity was evaluated using the Fecal Incontinence Severity Index. Potential risk factors associated with FI were explored with weighted chi-squared statistics. Variables associated with FI in multivariable logistic regression analysis are reported with odds ratios (OR) and 95 % confidence intervals (95 % CI). Results Among 7,039 women, 13.6 % were diabetic, and 18.1 % of diabetic women reported FI compared to 8.4 % in the overall NHANES population (p < .001). In diabetic
* Maria De La Luz Nieto [email protected] 1
Division of Urogynecology, Department of Ob/Gyn, University of North Carolina at Chapel Hill, CB#7570, 3032 Old Clinics Building, Chapel Hill, NC 27599-7570, USA
2
Center for Women’s Health Research, Center for Aging and Health, University of North Carolina, Chapel Hill, NC, USA
3
Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
4
Birmingham VAMC GRECC, Birmingham, AL, USA
5
Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, The University of Alabama at Birmingham, Birmingham, AL, USA
women, FI was associated with advancing age (OR 1.3, 95 % CI 1.1 – 1.5), depression (OR 2.0 95 % CI 0.9 – 4.5), poorer health status (OR 1.9, 95 % CI 1.2 – 3.1), urinary incontinence (OR 3.5, 95 % CI 2.1 – 5.9) and bowel movement frequency of ≥21/week (OR 4.9, 95 % CI 2.3 – 10.6) in a multivariable logistic regression model adjusted for race, education level, BMI, comorbidities, prior hysterectomy, and stool consistency. Conclusions FI affects one in five diabetic women and is strongly associated with high bowel movement frequency, a possible important modifiable factor that should be investigated further in prospective studies. Keywords Diabetes . Fecal incontinence . Urinary incontinence . Health status
Introduction Fecal incontinence (FI) is a debilitating condition that significantly affects quality of life [1, 2]. The prevalence of FI in women ranges from 2.2 % to 12 % in ambulatory populations and up to 50 % of nursing home patients [3, 4]. The societal burden of FI is significant as it is associated with social isolation, depression, anxiety, and loss of employment [1, 3]. Given the rising prevalence of FI as the population ages, it is critical to identify high-risk populations for this condition and explore associated factors that may be reversible or preventable. Diabetic women have been identified as a potentially higher risk group for FI in several studies [5, 6]. While plausible explanations for an increased prevalence in this population exist, such as alterations in bowel movement frequency and stool consistency, previous studies did not focused exclusively on diabetic women and therefore were not designed to investigate the unique factors associated with FI in
Int Urogynecol J
this group. In addition, the prevalence of FI among women with diabetes has not been previously investigated in a large population-based sample. Currently, one in ten adults has diabetes [7], and models project that one in three adults will be afflicted by type II diabetes by the year 2050 given the obesity epidemic [8, 9]. Because of the significant burden of both FI and diabetes mellitus on individuals and families, it is imperative to better understand and identify modifiable associated factors in this high-risk patient population. The aim of this study, therefore, was to estimate the prevalence of FI and identify associated factors among diabetic women using the US National Health and Nutritional Examination Survey (NHANES) database from 2005 to 2010.
Materials and methods A cross-sectional analysis was performed using the NHANES 2005 – 2006, 2007 – 2008, and 2009 – 2010 cycles, which were combined to provide overall characterization of the study population. These data consist of cross-sectional, national health surveys conducted by the National Center for Health Statistics (NCHS), Center for Disease Control Prevention and participants who provide data in a particular cycle and are not resampled in subsequent years. The surveys collect demographic data, socioeconomic, and health data at mobile examination centers located throughout the US, and they provide estimates of the health status of the US population by selecting a representative sample of the noninstitutionalized population using complex, stratified, multistage, cluster design. The NCHS Ethics Review Board approved the protocol, and all participants provided written informed consent. Our data combine three NHANES cross-sectional cycles for 8,368 nonpregnant women aged 20 years and older who completed in-home interviews and/or were evaluated at a mobile examination center [10]. Subjects were considered diabetic if they answered ‘yes’ to either of the questions: BHas a doctor or other health professional told you that you had diabetes?^ or BAre you currently taking insulin, diabetic pills or both?^. We defined FI as the involuntary loss of mucus, liquid or solid stool which occurs at least monthly from the Fecal Incontinence Severity Index (FISI) [11]. Within NHANES, the bowel health questionnaire includes an assessment of bowel movement frequency, stool consistency and severity of FI. Bowel movement frequency is categorized into three ranges: 21/ week. The Bristol Stool Form Scale (BSFS) was used to determine stool consistency [12]. Survey participants were asked the following question: BWhat is your usual or most common stool type?^ Responses were categorized into hard (BSFS 1/2), normal (BSFS 3 – 5), and loose/diarrhea (BSFS 6/7). Severity was evaluated using the FISI scores utilizing
patient-derived weights to calculate the overall severity index [11]. The four symptoms composing the FISI score are based on a frequency matrix to obtain a subject’s perception of stool leakage. The four symptoms composing the index are incontinence of gas, mucus, liquid stool, and solid stool. The FISI responses are weighted on a 1 – 20 point severity scale and a total FISI score can be calculated. We did not include gas in our definition of FI but did include gas to calculate the total FISI scores. We evaluated additional demographic and patient characteristics as follows: race and ethnicity were self-reported and were categorized as non-Hispanic white, non-Hispanic black, Hispanic (including Mexican American), and other or mixed race ethnicity; age was categorized in 10-year increments from 20 to 79 years, with women aged 80 years and older in the same category; education was categorized as less than a 12th grade education, high school graduation or equivalent, or more than high school. The poverty income ratio, an indicator of socioeconomic status that uses the ratio of income to the family’s poverty threshold set by the US Census Bureau, was categorized as less than 1 (below the poverty threshold), 1 (at the poverty threshold), and 2 or more (greater than two times the poverty threshold). Body mass index (BMI) was categorized as less than 25.0 kg/m2 (underweight or normal weight), 25.0 to 29.9 kg/m2 (overweight), and 30.0 kg/m2 or more (obese). The reproductive health questionnaire reported on parity, type of delivery, and hysterectomy status. Women responded to the following question on parity: BHow many deliveries have you had that resulted in a live birth?^ and the parity variable was dichotomized as none and at least one or more. The question BHave you had a hysterectomy, including a partial hysterectomy, i.e., surgery to remove your uterus or womb?^ defined hysterectomy status and response options were ‘yes’ or ‘no’. Urinary incontinence was evaluated in NHANES using the Incontinence Severity Index that combines responses into a score based on frequency and volume lost from incontinence [13]. Urinary incontinence was defined as moderate to severe with a combined score of 3 or greater. Participants with chronic disease were ascertained by selfreport and categorized as osteoarthritis, chronic lung disease (emphysema, chronic bronchitis, asthma), chronic heart disease (congestive heart failure, coronary heart disease, angina, heart attack), stroke, any liver condition, or cancer [14]. The numbers of chronic diseases were categorized from individual diseases to create a comorbidity index of 1, 2 or ≥3. Depression was assessed during a private interview in the mobile examination centers using the validated Patient Health Questionnaire–9 (PHQ-9). The PHQ-9 yields scores from 0 to 27 and scores ≥10 are used to define major depression [15]. Selfreported general health status was categorized as Bexcellent^/ Bvery good^/Bgood^ vs. Bfair^/Bpoor^.
Int Urogynecol J
For the statistical analysis, all estimates were derived using the sampling weights provided by the NCHS (STATA 12.2, Stata Corporation, College Station, TX). Weighted bivariate analysis for continuous and categorical variables that reached statistical significance at a limit of
ORIGINAL ARTICLE
Factors associated with fecal incontinence in a nationally representative sample of diabetic women Maria De La Luz Nieto 1 & Jennifer M. Wu 1,2 & Catherine Matthews 1 & William E. Whitehead 3 & Alayne D. Markland 4,5
Received: 4 February 2015 / Accepted: 22 April 2015 # The International Urogynecological Association 2015
Abstract Introduction and hypothesis Fecal incontinence (FI) is a debilitating condition that significantly affects quality of life, and has been associated with multiple risk factors. Our goal was to assess the prevalence of FI among diabetic women and evaluate factors associated with FI in this population. Methods The National Health and Nutrition Examination Survey (NHANES) from 2005 to 2010 was used to evaluate women with diabetes mellitus and FI. FI was defined as involuntary loss of mucus, liquid, or solid stool at least monthly. Severity was evaluated using the Fecal Incontinence Severity Index. Potential risk factors associated with FI were explored with weighted chi-squared statistics. Variables associated with FI in multivariable logistic regression analysis are reported with odds ratios (OR) and 95 % confidence intervals (95 % CI). Results Among 7,039 women, 13.6 % were diabetic, and 18.1 % of diabetic women reported FI compared to 8.4 % in the overall NHANES population (p < .001). In diabetic
* Maria De La Luz Nieto [email protected] 1
Division of Urogynecology, Department of Ob/Gyn, University of North Carolina at Chapel Hill, CB#7570, 3032 Old Clinics Building, Chapel Hill, NC 27599-7570, USA
2
Center for Women’s Health Research, Center for Aging and Health, University of North Carolina, Chapel Hill, NC, USA
3
Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
4
Birmingham VAMC GRECC, Birmingham, AL, USA
5
Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, The University of Alabama at Birmingham, Birmingham, AL, USA
women, FI was associated with advancing age (OR 1.3, 95 % CI 1.1 – 1.5), depression (OR 2.0 95 % CI 0.9 – 4.5), poorer health status (OR 1.9, 95 % CI 1.2 – 3.1), urinary incontinence (OR 3.5, 95 % CI 2.1 – 5.9) and bowel movement frequency of ≥21/week (OR 4.9, 95 % CI 2.3 – 10.6) in a multivariable logistic regression model adjusted for race, education level, BMI, comorbidities, prior hysterectomy, and stool consistency. Conclusions FI affects one in five diabetic women and is strongly associated with high bowel movement frequency, a possible important modifiable factor that should be investigated further in prospective studies. Keywords Diabetes . Fecal incontinence . Urinary incontinence . Health status
Introduction Fecal incontinence (FI) is a debilitating condition that significantly affects quality of life [1, 2]. The prevalence of FI in women ranges from 2.2 % to 12 % in ambulatory populations and up to 50 % of nursing home patients [3, 4]. The societal burden of FI is significant as it is associated with social isolation, depression, anxiety, and loss of employment [1, 3]. Given the rising prevalence of FI as the population ages, it is critical to identify high-risk populations for this condition and explore associated factors that may be reversible or preventable. Diabetic women have been identified as a potentially higher risk group for FI in several studies [5, 6]. While plausible explanations for an increased prevalence in this population exist, such as alterations in bowel movement frequency and stool consistency, previous studies did not focused exclusively on diabetic women and therefore were not designed to investigate the unique factors associated with FI in
Int Urogynecol J
this group. In addition, the prevalence of FI among women with diabetes has not been previously investigated in a large population-based sample. Currently, one in ten adults has diabetes [7], and models project that one in three adults will be afflicted by type II diabetes by the year 2050 given the obesity epidemic [8, 9]. Because of the significant burden of both FI and diabetes mellitus on individuals and families, it is imperative to better understand and identify modifiable associated factors in this high-risk patient population. The aim of this study, therefore, was to estimate the prevalence of FI and identify associated factors among diabetic women using the US National Health and Nutritional Examination Survey (NHANES) database from 2005 to 2010.
Materials and methods A cross-sectional analysis was performed using the NHANES 2005 – 2006, 2007 – 2008, and 2009 – 2010 cycles, which were combined to provide overall characterization of the study population. These data consist of cross-sectional, national health surveys conducted by the National Center for Health Statistics (NCHS), Center for Disease Control Prevention and participants who provide data in a particular cycle and are not resampled in subsequent years. The surveys collect demographic data, socioeconomic, and health data at mobile examination centers located throughout the US, and they provide estimates of the health status of the US population by selecting a representative sample of the noninstitutionalized population using complex, stratified, multistage, cluster design. The NCHS Ethics Review Board approved the protocol, and all participants provided written informed consent. Our data combine three NHANES cross-sectional cycles for 8,368 nonpregnant women aged 20 years and older who completed in-home interviews and/or were evaluated at a mobile examination center [10]. Subjects were considered diabetic if they answered ‘yes’ to either of the questions: BHas a doctor or other health professional told you that you had diabetes?^ or BAre you currently taking insulin, diabetic pills or both?^. We defined FI as the involuntary loss of mucus, liquid or solid stool which occurs at least monthly from the Fecal Incontinence Severity Index (FISI) [11]. Within NHANES, the bowel health questionnaire includes an assessment of bowel movement frequency, stool consistency and severity of FI. Bowel movement frequency is categorized into three ranges: 21/ week. The Bristol Stool Form Scale (BSFS) was used to determine stool consistency [12]. Survey participants were asked the following question: BWhat is your usual or most common stool type?^ Responses were categorized into hard (BSFS 1/2), normal (BSFS 3 – 5), and loose/diarrhea (BSFS 6/7). Severity was evaluated using the FISI scores utilizing
patient-derived weights to calculate the overall severity index [11]. The four symptoms composing the FISI score are based on a frequency matrix to obtain a subject’s perception of stool leakage. The four symptoms composing the index are incontinence of gas, mucus, liquid stool, and solid stool. The FISI responses are weighted on a 1 – 20 point severity scale and a total FISI score can be calculated. We did not include gas in our definition of FI but did include gas to calculate the total FISI scores. We evaluated additional demographic and patient characteristics as follows: race and ethnicity were self-reported and were categorized as non-Hispanic white, non-Hispanic black, Hispanic (including Mexican American), and other or mixed race ethnicity; age was categorized in 10-year increments from 20 to 79 years, with women aged 80 years and older in the same category; education was categorized as less than a 12th grade education, high school graduation or equivalent, or more than high school. The poverty income ratio, an indicator of socioeconomic status that uses the ratio of income to the family’s poverty threshold set by the US Census Bureau, was categorized as less than 1 (below the poverty threshold), 1 (at the poverty threshold), and 2 or more (greater than two times the poverty threshold). Body mass index (BMI) was categorized as less than 25.0 kg/m2 (underweight or normal weight), 25.0 to 29.9 kg/m2 (overweight), and 30.0 kg/m2 or more (obese). The reproductive health questionnaire reported on parity, type of delivery, and hysterectomy status. Women responded to the following question on parity: BHow many deliveries have you had that resulted in a live birth?^ and the parity variable was dichotomized as none and at least one or more. The question BHave you had a hysterectomy, including a partial hysterectomy, i.e., surgery to remove your uterus or womb?^ defined hysterectomy status and response options were ‘yes’ or ‘no’. Urinary incontinence was evaluated in NHANES using the Incontinence Severity Index that combines responses into a score based on frequency and volume lost from incontinence [13]. Urinary incontinence was defined as moderate to severe with a combined score of 3 or greater. Participants with chronic disease were ascertained by selfreport and categorized as osteoarthritis, chronic lung disease (emphysema, chronic bronchitis, asthma), chronic heart disease (congestive heart failure, coronary heart disease, angina, heart attack), stroke, any liver condition, or cancer [14]. The numbers of chronic diseases were categorized from individual diseases to create a comorbidity index of 1, 2 or ≥3. Depression was assessed during a private interview in the mobile examination centers using the validated Patient Health Questionnaire–9 (PHQ-9). The PHQ-9 yields scores from 0 to 27 and scores ≥10 are used to define major depression [15]. Selfreported general health status was categorized as Bexcellent^/ Bvery good^/Bgood^ vs. Bfair^/Bpoor^.
Int Urogynecol J
For the statistical analysis, all estimates were derived using the sampling weights provided by the NCHS (STATA 12.2, Stata Corporation, College Station, TX). Weighted bivariate analysis for continuous and categorical variables that reached statistical significance at a limit of
