1. Prevalence of chronic constipation in general population Dr. Vicente Garrigues Gastroenterology Unit Hospital Universitario LA FE Valencia - Spain

2. Gastroenterologist since 1985. Working in a 1.500-bed University Hospital. Interested in Digestive Functional Disorders and in Epidemiology & Statistics. At present, Head of Education of the Hospital

3. Learning objectives 1.To know current definitions of chronic constipation. 2. To find out the prevalence of constipation. 3. To know which variables are associated to constipation.

4. Performance objectives 1.To select a sample for a prevalence study. 2. To perform statistics in a prevalence study. 3. To understand the meaning of likelihood ratios.

5.  Evaluate the prevalence of chronic constipation in the general population.  Assess agreement among several diagnostic criteria of constipation Aims

6.  Evaluate the diagnostic accuracy of self-reported definition of constipation; and of symptoms included in Rome II criteria.  Identify factors associated to chronic constipation Aims

7. Definition of constipation Self-reported by subject Rome criteria Rome II criteria

8. Study subjects. Selection of population Target population: General population from the town of Aldaya: 23.425 inhabitants Elegible population: subjects aged between 18 and 65 years: 15.696 subjects

9. Study subjects. Selection of sample. For an expected prevalence of 20 + 4% (95% C.I.): 375 subjects were needed. Sampling procedure. Systematic, age-stratified sampling was performed, selecting 506 subjects.

10. Questionnaire A validated questionnaire with 21 items was mailed – up to 6 times- to sampled subjects. Items allowed diagnosis of constipation and evaluated associated variables.

11. Response WomenMen 18- 30 yr 31- 50 yr 51- 65yr Total Population 7743 (49) 7953 (51) 5308 (34) 6854 (44) 3534 (22) 15696 Sample 250 (49) 256 (51) 171 (34) 221 (43) 114 (23) 506 Responders 182 (52) 167 (48) 120 (34) 154 (44) 75 (22) 349 (71.5) 349 subjects (71.5%) replied.

12. Prevalence of constipation WomenMenTotal Self- reported 40.1 33.0- 47.2 18.0 12.1- 23.8 29.5 24.7- 34.3 Rome 28.6 22.0- 35.1 9.0 4.6- 13.3 19.2 15.1- 23.3 Rome II 22.0 16.0- 28.0 5.5 2.5- 10.0 14.0 10.4- 17.7

13. 18-30 yr 31-50 yr 51-65 yr Self- reported 29.2 21.0- 37.3 29.2 22.0-36.4 30.7 20.5- 42.4 Rome 21.7 14.3- 29.0 18.2 12.1- 24.3 17.3 9.6- 27.8 Rome II 13.3 7.3- 19.4 14.3 8.7- 19.8 14.7 6.6- 22.7 Prevalence of constipation

14. Rome II criteria including diarrhea Global 21.2 (16.9-22.5) Women 32.4 (25.6- 39.2) Men 9.0 (5.1- 11.4) 18-30 yr 23.3 (15.8- 30.9) 31-50 yr 20.8 (14.4- 27.2) 51-65 yr 18.7 (10.6- 29.3) Prevalence of constipation

15. Agreement among criteria Rome +-Total+-Total 6439103 3243246 67282349 Kappa: 0.68 95%-IC: 0.59- 0.77 Self-reported

16. Agreement among criteria Rome II +-Total+-Total 4855103 1245246 49300349 Kappa: 0.55 95%-IC: 0.44- 0.65 Self-reported

17. Agreement among criteria Rome II +-Total+-Total 442367 5277282 49300349 Kappa: 0.71 95%-IC: 0.61- 0.81 Rome

18. Diagnostic accuracy of Rome II qualifying symptoms SeSpLR+1/LR- Straining 5699562.3 Hard stools 6496162.7 Incomplete evac. 3098151.4 Anal blockage 48100∞1.9 Maneuvers 23977.71.3 <3 defecations/w 2298111.3 Gold-standard: self-reported

19. SeSpLR+1/LR- Self-reported 98825.441 Straining 8494145.9 Hard stools 92909.211.3 Incomplete evac. 43958.61.7 Anal blockage 719514.23.3 Maneuvers 29944.81.3 <3 defecations/w 31967.81.4 Accuracy of self-reported and Rome II symptoms Gold-standard: Rome II

20. Variables associated with constipation OR95%-CI2p Self- reported Female2.901.68-4.980.0001 ROME II Female4.581.98-10.60.0004 Fiber0.380.14-0.960.04 Occasional exercise 0.430.20-0.890.02 Habitual exercise 0.310.11-0.870.03

21. Conclusions Constipation is highly prevalent, especially in women. Different prevalence rates are observed using different criteria,although agreement is acceptable. Anal blockage, straining and hard stools show the greatest diagnostic accuracy.