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Association of the body roundness index with chronic diarrhea and chronic constipation: findings based on the National Health and Nutrition Examination Survey 2005–2010 data

Lipids in Health and Disease volume 24, Article number: 33 (2025) Cite this article

Abstract

Aim

The study aimed to explore potential links between long-term digestive issues (specifically diarrhea and constipation) and body roundness index (BRI) in a representative U.S. population sample.

Methods

This study adopted a design that is cross sectional, drawing on data from the NHANES, gathered from 2005 to 2010 with health information from a total of 11,235 individuals. Persistent bowel movement patterns were categorized based on the BSFS—Bristol Stool Form Scale, while stool types 1 and 2 were designated as indicators of long-term constipation and types 6 and 7 were identified as markers of persistent diarrhea. To assess the relationship between digestive health and the BRI, this study employed weighted logistic regression analysis. To capture and visualize the nuanced interplay between BRI and gastrointestinal patterns, we utilized advanced nonlinear regression methods, specifically restricted cubic spline (RCS) analyses. Additionally, the research compared the efficacy of various physical measurements—including BRI, WC, BMI (body roundness index, waist circumference, and body mass index, respectively)—to determine their respective diagnostic power for chronic diarrhea and constipation through comparative analysis of receiver operating characteristic (ROC) curves.

Results

After comprehensive adjustment in the final statistical model (Model 3), the BRI demonstrated the statistically significant associations with diarrhea and persistent constipation. RCS analysis further uncovered statistically significant nonlinear positive associations of BRI and with diarrhea (P = 0.005) and constipation (P = 0.037). Further stratified analyses revealed that the relationship between BRI and persistent diarrhea was particularly evident among individuals with diabetes. In contrast, the association between BRI and constipation was stronger in individuals under 60 years of age. ROC analysis indicated that BRI outperformed conventional anthropometric measures (AUC, area under the curve: 0.601). Specifically, BMI resulted in an AUC of 0.569, while WC produced an AUC of 0.572. However, the AUC value of BRI (0.537) was less effective than BMI (0.551) and WC (0.570) in diagnosing constipation.

Conclusions

BRI is strongly associated with changes in the individual’s bowel habits, particularly in diagnosing chronic diarrhea. This study highlighted the potential significance of maintaining moderate BRI levels to improve bowel health and prevent diarrhea.

Introduction

Persistent bowel disorders, particularly chronic diarrhea and persistent constipation, represent widespread digestive health challenges. These conditions exert a significant impact on global health, affecting a considerable segment of the world’s population [1,2,3]. Current epidemiological data indicate that chronic diarrhea impacts approximately 17% and chronic constipation afflicts 14–20% of individuals worldwide [1,2,3]. Such long-term digestive disturbances significantly diminish the overall quality of life for those experiencing these conditions [1,2,3]. Numerous factors can lead to these conditions, with obesity often playing a direct or indirect role in many digestive system diseases [4], such as nonalcoholic fatty liver disease [5] and reflux esophagitis [6]. Notably, diarrhea is a prevalent symptom among obese individuals [7, 8]. However, studies show conflicting results regarding the association between obesity and constipation [9,10,11,12]. While body mass index (BMI) remains the predominant measure for obesity assessment, it lacks precision in determining adipose tissue distribution. Cutting-edge radiological techniques, notably computed tomography (CT) and magnetic resonance imaging (MRI), enable a highly accurate assessment of internal fat distribution. However, these methods are impractical for routine use due to their time-intensive protocols and substantial financial burden [13].

Thomas and colleagues proposed the BRI in 2013 as an innovative approach to evaluate body composition and visceral adiposity [14]. This easily accessible, economical, and non-invasive technique yields a more accurate evaluation of overall and intra-abdominal adiposity compared with BMI, potentially improving its prognostic capabilities [14]. The BRI has shown promise as an effective instrument for community-wide health assessment and early identification of metabolic risks [15]. Studies have shown that BRI is significantly correlated with numerous health issues, including cardiovascular disease [16,17,18], metabolic syndrome [19, 20], and diabetes [21, 22]. Meanwhile, BRI, chronic diarrhea and chronic constipation are all correlated with obesity, which is robustly linked with lipid metabolism [7, 10, 23]. Nevertheless, as a convenient new measurement index capable of assessing intra-abdominal fat and reflecting the degree of central obesity, the relationship between BRI and persistent gastrointestinal disorders, specifically chronic diarrhea and chronic constipation, remains understudied. To bridge this lack of know-how, the research strived to examine the possible relationship of BRI with these chronic bowel conditions. This research seeks to provide new perspectives and contribute to the development of approaches for preventing and managing these chronic gastrointestinal disorders, as well as detecting population at high risk of chronic diarrhea and chronic constipation.

Materials and methods

Study population

The investigation analyzed information acquired through NHANES—National Health and Nutrition Examination Survey, an all-inclusive human healthiness evaluation initiative. This extensive program is conducted and managed by the CDC—Centers for Disease Control and Prevention. The NHANES’ program implements biennial health evaluations on a national scale, assessing the physiological status and dietary profiles of Americans across all age groups. It is worth noting that data pertaining to bowel habits have been incorporated into only three of these survey cycles: 2005–2006, 2007–2008, and 2009–2010. Across these cycles, 17,132 participants aged 20 years and older were enrolled. During this period, a total of 17,132 individuals, all of whom were 20 years of age or older, were recruited as participants. However, the study excluded participants who provided incomplete responses to the bowel health questionnaire (n = 1920), incomplete BRI data (n = 379), or incomplete data for any covariables (n = 3005). Consequently, the major analyzed cohort consisted of 11,235 subjects (Fig. 1). Considering the potential influence of factors, the sensitivity analysis excluded participants with proton pump inhibitors (n = 1102), gastrointestinal medications (n = 388), hypoglycemic medications (n = 857), and depression (n = 10) (Fig. 1). The ethical framework and research methodology of the NHANES initiative underwent rigorous scrutiny and received formal approval from the Ethics Review Committee of the National Center for Health Statistics. All subjects consented to take part in the study. The complete dataset is publicly accessible and may be retrieved from https://www.cdc.gov/nchs/nhanes/index.htm.

Fig. 1
figure 1

Flow diagram of study cohort selection

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Bowel health questionnaire

The gastrointestinal health component of ‘NHANES from 2005 to 2010’ served as a means to scrutinize bowel habits among participants who willingly shared details about their bowel movements. The researcher used the BSFS card, which features color illustrations of seven distinct stool types, for evaluation purposes. Participants who recognized their typical bowel movements as corresponding to BSFS type 1 (defined as distinct, firm pellets akin to nuts) or BSFS type 2 (described as a cohesive mass with a lumpy surface) were classified as experiencing persistent constipation. Individuals whose typical stool type fell into the categories of BSFS type 6 (described as fluffy, irregular-edged pieces with a mushy consistency) or BSFS type 7 (consisting of water-like samples with no solid feces) were considered to have chronic diarrhea. The remaining participants were deemed to have normal bowel function [24, 25].

Anthropometric measures

The measurement of WC was conducted using a measuring tape, with readings taken in centimeters at the uppermost edge of the iliac crest. The calculation of BMI and BRI utilized established formulas from the previous literature: the study calculated BMI by dividing the participants’ weight (kg) by the square of their height (m), while we derived BRI using a specific Eq. 364.2–365.5 × (1-[WC(m)/2π]2/[0.5 × height (m)]2)½ [14]. For subsequent univariable analysis and multivariable logistic regression models, BRI was categorized into 3 groups (< 4.26, 4.26–6.02, > 6.02) according to tertiles and the lowest tertile was set as the reference group.

Covariables

In this investigation, numerous potential confounding factors affecting BRI and the likelihood of persistent diarrhea and constipation were taken into account. These variables encompassed several categories. (1) Demographic factors: the study accounted for age, male/female, race/ethnicity, single/married status, and education level. (2) Lifestyle factors: The analysis incorporated smoking patterns and alcohol consumption behaviors. (3) Economic status: Socioeconomic status was assessed using the family PIR (Poverty-to-income ratio). (4) Health comorbidities: the models included hypertension, cardiovascular disease, and diabetes mellitus (DM). (5) Dietary aspects: the study considered total daily caloric intake and scores on the healthy eating index-2015 (HEI-2015) in accordance to previous studies [26]. Detailed information could be achieved in the supplementary material (Supplementary Table 1) [27].

Statistical analysis

In accordance with NHANES protocols, this investigation utilized recommended sample weights to improve data accuracy and mitigate the effects of intricate multistage sampling designs on NHANES research. In the statistical analysis, the study presented the results for categorical variables as weighted percentages, reflecting the complex survey design of NHANES. For continuous variables, the study reported weighted medians along with the first and third quartiles to account for sampling variability. Weighted analyses of variances and chi square tests were conducted to compare the differences of characteristics among BRI groups. To investigate the potential links between BRI and chronic gastrointestinal symptoms, the study employed weighted multivariable logistic regression analyses. These analyses accounted for various confounding factors, with adjustments made for both continuous and quantile outcomes. The analysis employed three distinct models. The initial model (Model 1) was uncontrolled for any variables. The second model (Model 2) incorporated adjustments for key demographic variables. Specifically, this model accounted for race/ethnicity, age, gender, level of education, and single/married status. The most comprehensive model (Model 3) expanded upon Model 2 by additionally controlling for BMI, socioeconomic status (as measured by PIR), lifestyle habits (such as smoking habits, alcohol use patterns), comorbidities (such as DM, high blood pressure, and cardiovascular disease), and dietary factors (specifically total caloric intake and HEI). Additionally, the study utilized weighted RCS curves within Model 3 to further examine potential nonlinear relationships between BRI and chronic bowel symptoms, with 4 knots located at the 5th, 35th, 65th, and 95th percentiles based on Akaike information criterion. The research also conducted stratified analyses based on a range of demographic factors and variables related to health, including age categories, male/female, educational level, single/married status, smoking habits, and the presence of common chronic diseases. To assess and contrast the diagnostic capabilities of WC, BMI, and BRI for long-term diarrhea and constipation, the study analyzed ROC curves and calculated the AUC area. To determine the most effective threshold ‘values for WC, BRI, and BMI’ in diagnosing chronic diarrhea and constipation, the study utilized the Youden index. The entirety of the statistical computations was performed using R software, (v. 4.2.2; http://www.Rproject.org), with a threshold for statistical significance established at P < 0.05.

Results

The study sample characteristics, grouped by BRI tertiles, are summarized in Table 1. The analysis included a total of 11,235 subjects, and the median age of participants was 46 years. The gender distribution of the cohort was nearly balanced, with males comprising 48.25% of the sample. The BRI ranges defined as < 4.26 for the first tertile (T1), 4.26–6.02 for the second tertile (T2), and > 6.02 for the third tertile (T3). The study found that diarrhea affected 6.75% of the overall population, with its prevalence varying across BRI tertiles: (1) lowest BRI tertile: 4.80% prevalence; (2) middle BRI tertile: 6.00% prevalence; and (3) highest BRI tertile: 10.21% prevalence. Constipation was observed in 7.07% of the total sample, showing a different distribution across BRI tertiles: 8.08% in the first tertile, 7.15% in the second tertile, and 5.63% in the third tertile. The statistical analysis uncovered significant differences (P < 0.05) across BRI tertiles for several factors: demographic characteristics (age, ethnicity, male/female, educational attainment, and single/married status), socioeconomic indicators (PIR), lifestyle habits (smoking habits and alcohol consumption), physical and mental well-being (high blood pressure, diabetes, heart disease), anthropometric measures (BMI, WC), and dietary factors (total caloric intake and HEI).

Table 1 Weighted characteristics of the study population according to the tertiles of BRI a
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Association of BRI with chronic diarrhea and chronic constipation

In this study, logistic modeling examining the relationship between chronic intestinal disorders and BRI yielded the following key findings, as presented in Table 2. BRI was set as a categorical variable in the logistic regression models (tertiles). For chronic diarrhea, participants in the highest BRI tertile showed significantly increased risk compared to the lowest tertile after full adjustment (T3 vs. T1: OR: 1.65, 95% CI 1.09–2.50, P = 0.020). As for Chronic constipation, no statistically significant relationship was observed between BRI tertiles and constipation risk (T3 vs. T1: OR: 0.84, 95% CI: 0.53–1.34, P = 0.458).

Table 2 Association between BRI with diarrhea and constipation a
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Nonlinear association

To explore possible nonlinear associations between BRI and the prevalence of chronic gastrointestinal disorders, the study conducted a weighted multivariable–adjusted RCS analysis. The results of this analysis are presented graphically in Fig. 2 and uncovered a complex, nonlinear positive relationship between BRI and both intestinal conditions: diarrhea (P = 0.005) and constipation (P for nonlinearity = 0.037). Chronic diarrhea risk increased significantly at BRI values above 3.4. In contrast, the risk of constipation gradually increased with initial increases in BRI. However, when BRI reached 5.10, the risk of constipation plateaued, and it did not rise again until BRI exceeded 5.78.

Fig. 2
figure 2

Association between BRI with diarrhea (A) and constipation (B). Adjustment factors included age, sex, race, education attainment, marital status, BMI, PIR, smoking status, drinking status, hypertension, DM, CVD, total energy intake, and HEI

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Subgroup analyses

In the present study, subgroup analyses showed significant variations in the association between BRI and bowel habits across different subgroups (Fig. 3). the analysis revealed significant interactive effects between specific DM subgroups and BRI with respect to diarrhea, as well as between age subgroups and BRI with respect to constipation (P < 0.05). Specifically, BRI exhibited a strong and statistically significant positive association with diarrhea in the diabetes subgroup. Furthermore, individuals under 60 years of age had 20% elevated risk (OR: 1.20, 95% CI: 1.00–1.44) of constipation with each incremental unit of the body shape indicator. Conversely, among participants 60 years of age and above, the study did not detect this positive association.

Fig. 3
figure 3

Subgroup analyses between BRI with diarrhea (A) and constipation (B). Each subgroup analysis adjusted for age, sex, race, education attainment, marital status, BMI, PIR, smoking status, drinking status, hypertension, DM, CVD, total energy intake, and HEI

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Sensitivity analysis

To evaluate the stability of the findings, we conducted sensitivity analyses (Supplementary Tables 2, 3). Considering the potential influence of factors such as medication, depression, and diet, we excluded participants using gastrointestinal medications, proton pump inhibitors, and hypoglycemic medications, and further adjusted for covariables, including depression, dietary caffeine intake, and dietary fiber intake. Our results consistently indicated a positive association between the BRI and diarrhea.

Comparing WC, BMI, and BRI as indicators of chronic bowel issues

ROC analysis results (Table 3; Fig. 4) showed BRI had a higher performance (AUC: 0.601) for diarrhea diagnosis than BMI (0.569) or WC (0.572). Delong’s test confirmed BRI’s significantly higher diagnostic ability for diarrhea compared with both BMI and WC (P < 0.001 for both comparisons). Conversely, in diagnosing constipation, BRI showed a lower AUC value (0.537) than both BMI (0.551) and WC (0.570). Delong’s test revealed significant differences in diagnostic performance: BRI underperformed BMI (P = 0.002) and WC (P < 0.001). These results indicate that BRI was less effective than BMI and WC in the diagnosis of constipation.

Table 3 Diagnostic efficacy of ROC analysis of obesity-related indices for diarrhea and constipation
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Fig. 4
figure 4

Receiver operating characteristic (ROC) curve analysis for predicting diarrhea (A) and constipation (B)

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Discussion

This investigation broke new ground by exploring the relationship between BRI and the occurrence of intestinal disorders, specifically diarrhea and constipation using a cross-sectional analytical approach. Employing weighted multivariable logistic regression techniques, the research demonstrated that BRI maintained its status as an independent potential diagnostic factor of diarrhea, despite controlling for various potential confounders. In contrast, the study found no statistically significant relationship between BRI and chronic constipation. RCS showed nonlinear relationships between BRI levels and the likelihood of experiencing diarrhea and constipation. Subgroup analyses revealed significant interactions between various diabetic statuses, age groups, and BRI levels, influencing the likelihood of both diarrhea and constipation. In a comparative analysis with other anthropometric indices like BMI and WC, BRI demonstrated a better diagnostic performance for diarrhea, but not for constipation. These results underscore BRI’s particular efficacy as an indicator of diarrhea occurrence, suggesting that addressing obesity may aid in its prevention.

Historically, the BMI has been criticized for its inability to accurately reflect the association between obesity and bowel habits, frequently leading to inconsistent research outcomes [10, 12, 28,29,30]. BRI represents an innovative obesity metric derived using height and WC measurements to assess body composition and fat distribution more comprehensively than conventional metrics like BMI [14]. A comprehensive meta-analysis has demonstrated BRI’s superior predictive capacity for metabolic syndrome when compared to other indices like ‘waist-to-hip ratio, BMI, body adiposity index, and body shape index [31]. Moreover, research has linked BRI to a range of health conditions, including overactive bladder [32], cholelithiasis [33], cardiovascular diseases [16,17,18], and DM [21, 22]. However, prior to this investigation, the relationship between BRI and intestinal function had not been explored in the scientific literature. This study analyzed this association for the first time using a large dataset from NHANES. the study identified a significant positive association between BRI and diarrhea, enabling effective indicators of diarrhea risk.

In the nonlinear association analysis between BRI and bowel habits, we observed that the probability of experiencing chronic diarrhea began to increase only when BRI values surpassed 3.40. Additionally, the analysis revealed that the likelihood of chronic constipation demonstrated a progressive increase once BRI values surpassed 5.78. Notably, both values were below the highest tertile of the BRI. This suggested that an elevated BRI may be closely associated with persistent gastrointestinal disturbances, specifically chronic diarrhea and constipation, among those with substantial adiposity. Hence, in severely obese individuals, significant emphasis should be placed on regulating BRI levels to improve bowel habits.

Persistent alterations in bowel habits, particularly long-term diarrhea and constipation, rank among the most prevalent digestive issues linked to excess body weight. These conditions significantly diminish the well-being and overall health status of those affected [7, 34,35,36,37,38]. However, despite their prominence in the medical literature, few studies have explored diarrhea and constipation as aspects of obesity, resulting in a lack of sufficient clinical attention. Numerous studies have investigated the mechanisms linking obesity to bowel habits. However, the specific mechanisms by which obesity leads to diarrhea and constipation remain unclear. Regarding diarrhea, researches have revealed that the expedited movement of contents through the small intestine and distal colon, coupled with an excess of body weight, are potential contributors to the underlying mechanisms of idiopathic bile acid malabsorption [39,40,41,42]. Delgado-Aros showed that obesity, causing dysfunction such as accelerated colonic transport, may lead to diarrhea [43]. Studies focusing on constipation have uncovered that individuals with obesity tend to display reduced concentrations of growth hormone–releasing peptides while simultaneously showing increased levels of leptin. These hormonal imbalances may restrict gastric emptying and slow gastric motility, potentially triggering constipation [44, 45]. Furthermore, obesity may increase the amount of fat entering the intestines, which interferes with hormone release and causes the relaxation of smooth muscles in the colon, thereby obstructing the propulsion of intestinal contents and contributing to constipation [46, 47]. Moreover, several alterations in the gut microbiome can contribute to obesity by influencing metabolic pathways and modulating the host’s eating behaviors through the gut-brain axis [48]. Reversely, the gut microbiota is able to modulate various behaviors including eating, and obesity-related behaviors, by influencing the neuroendocrine system of the brain, particularly the hypothalamus-pituitary-adrenal axis [49]. Hence, the association between obesity and gastrointestinal disturbances is bidirectional and robust, warranting further exploration in future studies.

Study strengths and limitations

This study had several strengths. First, it represents the inaugural investigation utilizing an extensive cross-sectional approach with NHANES data to reveal a nonlinear positive relationship between BRI and diarrhea. Second, the methodology was rigorous, incorporating sampling weights, adjusting for numerous potential confounders, and employing sophisticated statistical techniques such as multivariable logistic regression, RCS analysis, and stratified subgroup analysis. These methodological choices significantly bolster the precision and robustness of the results. Finally, the study compared the diagnostic efficacy of BRI with BMI and WC in diagnosing diarrhea, revealing that BRI demonstrates a superior diagnostic performance. Limitations of this study: (1) The cross-sectional approach and retrospective bowel health investigations of this research does not allow for determining causality between BRI and chronic bowel symptoms such as diarrhea and constipation. (2) The findings may not apply to populations outside the U.S. due to the study’s limited geographic scope. (3) Information about bowel disorders was collected through self-reported questionnaires, a method potentially subject to recall bias. Participants’ recollections of their gastrointestinal symptoms might not always accurately reflect their true health status. Finally, the investigators could not ascertain any additional confounding variables that may have been overlooked in this investigation.

Conclusions

The analysis revealed a complex, nonlinear positive relationship between BRI values and the likelihood of experiencing long-term diarrhea and constipation. The relationship was especially evident in subjects with severe adiposity. Regulating BRI levels could help improve bowel habits, particularly in cases of severe obesity. Furthermore, BRI demonstrates superior diagnostic performance for chronic diarrhea when compared with traditional ‘anthropometric indicators like BMI and WC.’ These results highlight the possible advantages of sustaining reasonable BRI values in fostering optimal intestinal function and reducing the risk of long-term gastrointestinal issues.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

AUC:

Area under the curve

BMI:

Body mass index

BRI:

Body roundness index

BSFS:

Bristol Stool Form Scale

CI:

Confidence interval

CT:

Computed tomography

CVD:

Cardiovascular disease

DM:

Diabetes mellitus

MRI:

Magnetic resonance imaging

NHANES:

National Health and Nutrition Examination Survey

OR:

Odds ratio

PIR:

Poverty income ratio

RCS:

Restricted cubic spline

ROC:

Receiver operating characteristic

WC:

Waist circumference

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Acknowledgements

The study acknowledges the NHANES program for’ providing the comprehensive database and resources that made this research possible. the study also thanks all the contributors for sharing their datasets and all the individuals who volunteered their time and information as subjects in this study, without whom this investigation would not have been feasible.

Funding

No funding was received for this study.

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Authors and Affiliations

  1. Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Jiaxing University, 1518 North Huancheng Road, Jiaxing, Zhejiang, 314000, P.R. China

    Yinda Wang & Binzhong Zhang

  2. Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Jiaxing University, 1518 North Huancheng Road, Jiaxing, Zhejiang, 314000, P.R. China

    Fei Chen & Zhengwei Song

Authors
  1. Yinda Wang
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  2. Fei Chen
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  3. Binzhong Zhang
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  4. Zhengwei Song
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Contributions

The research project was conceptualized and structured by Y.W. and F. C. These two researchers were also responsible for data collection and analysis. Together, they produced the first version of the manuscript. B.Z. and Z.S. revised the manuscript. Y.W. provided the final review for the entire text. Each researcher involved provided substantial input to the paper. The final version of this document was reviewed and approved by each of the contributing authors prior to submission.

Corresponding author

Correspondence to Fei Chen.

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Ethics approval and consent to participate

The present study employed anonymized data obtained from ‘the publicly accessible NHANES database. The study received ethical approval from ‘the National Center for Health Statistics’ Ethics Review Committee’ and followed relevant guidelines, including those set forth in ‘the Declaration of Helsinki. Importantly, all NHANES participants gave documented consent before their involvement. This consent process occurred prior to any data collection, ensuring that subjects were fully aware of and agreed to their participation in the survey.

Consent for publication

The “Consent for publication” section is not needed for this type of study using anonymized ‘public data’.

Competing interests

The authors declare no competing interests.

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Wang, Y., Chen, F., Zhang, B. et al. Association of the body roundness index with chronic diarrhea and chronic constipation: findings based on the National Health and Nutrition Examination Survey 2005–2010 data. Lipids Health Dis 24, 33 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12944-025-02451-7

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12944-025-02451-7

Keywords

Lipids in Health and Disease

ISSN: 1476-511X