Abstract
Objective:
To investigate the potential association between Dietary Inflammatory Index (DII) scores and constipation among a sample of adults in the United States.
Methods:
This cross-sectional study used data from adult participants in the 2005 to 2010 National Health and Nutrition Examination Survey (ie, “NHANES”). Self-reported information was used to identify cases of constipation. The DII was used to assess inflammatory potential of the diet. Odds ratios (ORs) and corresponding 95% CIs for the association between the DII and constipation were determined using multivariate logistic regression modeling. Stratified analyses explored whether there was effect modification to influence the relationship between DII and constipation.
Results:
Of 8272 subjects, 759 reported constipation, and 7513 did not, corresponding to a prevalence of 9.2%. After adjusting for age, gender, race/ethnicity, marital status, education level, smoking status, alcohol consumption, physical activity, body mass index (BMI), cardiovascular diseases (CVD), hypertension, stroke, diabetes, energy intake, carbohydrate intake, and selective serotonin reuptake inhibitor (SSRI) use. Compared with lower DII scores group T1 (−5.28 to ≤0.72), the adjusted OR values for DII scores and constipation in T2 (>0.72 to ≤2.50) and T3 (>2.50 to 5.24) were 1.27 (95% CI: 1.02–1.58, P=0.029) and 1.43(95% CI: 1.14–1.8, P=0.002). Subgroup analyses showed that there were effect modification of gender and physical activity factors on DII scores and constipation.
Conclusions:
Results of this cross-sectional study suggest that a higher dietary inflammatory index score was associated with increased risk of constipation after adjustment for confounding in a multivariable analysis. gender and physical activity were found to be an effect modifier of this relationship.
Key Words: constipation, DII, NHANES
Constipation is an intestinal disorder characterized by decreased bowel movement(s) and difficulty with defecation. The prevalence of constipation in the normal population is 3% to 27%.1 In the United States, approximately1 million individuals with constipation require treatment from gastroenterologists annually, which imposes significant economic and social health care burdens.2 It also seriously affects the quality of life in the normal population.3
The Dietary Inflammatory Index (DII) is a scoring system used to assess dietary inflammatory potential.4 Previous studies have shown that dietary inflammatory potential values reflect the function of gut flora in patients with constipation, with greater DII values significantly associated with constipation and elevated risk for major chronic diseases and death.5,6 In the treatment of constipation, patients are often asked to alter their diet. However, changes in dietary structure cause alterations in the occurrence of dietary inflammatory potential, and it is unknown whether alterations in dietary inflammatory potential affect the prevalence and treatment of constipation.
Approximately 10% to 15% of the US population experiences constipation in normal life.7 However, the relationship between dietary inflammatory potential and constipation has been less well studied in the US population. Therefore, exploring the correlation between dietary inflammatory potential and constipation could help further our understanding of the relationship between dietary factors and constipation. We evaluated the relationship between the inflammatory potential of diet and constipation in the US population using representative data from the National Health and Nutrition Examination Survey (NHANES). We hypothesized an association between constipation and DII scores, with those affected by constipation having higher DII scores than those who were nonconstipated.
MATERIALS AND METHODS
Data Sources
NHANES is a nationally representative survey conducted by the National Center for Health Statistics (NCHS) using stratified, multistage probability cluster sampling to assess the health and nutritional status of the noninstitutionalized US population.8 Data regarding constipation were available only for NHANES cycles 2005-2010. The NHANES study protocol was approved by the NCHS research ethics review board, and participants provided written informed consent on enrollment. The study conducted at Shangluo Central Hospital (Shangluo, China) was deemed exempt by the institutional review board due to the use of publicly available, anonymized data, and informed consent was waived.9 This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.
Study Design and Population
The present analysis was based on data collected during three, 2-year, NHANES cycles (2005-2006, 2007-2008, and 2009-2010). To limit the analysis to patients with constipation, the following exclusion criteria were applied: <20 years of age, pregnancy, colorectal cancer, and missing/unavailable data regarding DII, constipation, and covariates. A flow diagram illustrating subject enrollment is presented in Figure 1.
FIGURE 1.
The study’s flow diagram.
Ascertainment of Constipation and DII Scores
The US NHANES uses bowel frequency and stool traits to measure constipation in participants administered the Bowel Health Questionnaire. According to NHANES, decreased bowel frequency and type of stool trait are often used to define constipation.10 Stool traits were measured using the Bristol Stool Trait Scale, which consists of various colored cards and seven stool types (type 1: sausage-like but with a cracked surface; type 2: sausage-like but with clumps; type 3: sausage-like, but with a cracked surface. Type 4: sausage or snake-like, smooth and soft; type 5: soft lumps with clear edges; type 6: hairy, uneven edges, soft stools; type 7: watery, no solid debris). participants were asked, “Please look at this card and tell me the number that corresponds to your usual or most common type of stool?” constipation was defined as type 1 or type 2, and types 3 to 7 were defined as nonconstipated.11 Participants were asked, “How many times per week do you usually have a bowel movement?”, with constipation defined as <3 bowel movements per week and more than 3 or more bowel movements per week are defined as nonconstipation.12,13
The DII is a scoring system developed by Shivappa et al14 to assess the potential inflammatory levels of dietary components. Food parameters are scored based on their effect on 6 indicators of inflammation, including interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP), IL-4, and IL-10. Foods that cause a significant increase in IL-1b, IL-6, TNF-alpha or CRP, or a decrease in IL-4 or IL-10, are considered to be proinflammatory (score +1). Conversely, foods with the opposite effect were considered to be anti-inflammatory (score 1). Foods that did not produce any change in the above parameters were scored 0. The DII scores were calculated based on the individual components of the diet consumed during the first 24 hours and included scores for both proinflammatory and anti-inflammatory diets. Greater DII scores were indicative of diets that contained proinflammatory substances, whereas lower DII scores were indicative of diets that contained anti-inflammatory substances.15–17 Subjects were categorized into 3 groups according to DII scores.
Covariates
On the basis of previous studies, the potential covariates considered in the analysis included age, sex, marital status (categorized as married/living with a partner or living alone, including never married, separated, divorced, and widowed), race/ethnicity (categorized as non-Hispanic White, non-Hispanic Black, Mexican American, or other), years of education (<9, 9 to 12, or >12 y), hypertension (defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, diagnosed by a physician, or use of antihypertensive medication), stroke (diagnosed by a doctor), and cardiovascular diseases (diagnosed by a physician). Family income was classified into 3 levels based on the poverty income ratio (PIR): low (PIR ≤1.3); medium (PIR, 1.3–3.5); and high (PIR >3.5).18 On the basis of previous studies, the diagnostic criteria for diabetes included a diagnosis from a physician, glycosylated hemoglobin (HbA1c) level >6.5%, fasting glucose levels ≥7.0 mmol/L, random/2 h oral glucose tolerance test, blood glucose levels ≥11.1 mmol/L, or use of diabetes medication/insulin.19 Lifestyle characteristics included alcohol consumption and smoking. Alcohol use was defined as alcohol consumption at least 12 times per year. Those who smoked ≥100 cigarettes in their lifetime were defined as smokers.11 BMI was calculated as body weight (kg)/height (m)2. Weight and height were measured at the Mobile Examination Center.20 Physical activity was defined as “organized or unorganized sports, fitness or recreational activities (eg, gym workouts, cycling, running, and all team sports), active modes of travel such as walking or cycling, and any other physical activity at work, in or around the home, or while volunteering.” Physical inactivity is defined as <150 minutes of moderate-intensity physical activity per week.21 Carbohydrate and energy intake were obtained by asking respondents to recall all beverages consumed and all foods eaten in the 24 hours before the interview. The US Department of Agriculture Nutrient Database was used to calculate the dietary nutrient intake data.22 SSRI use was classified as “yes” or “no” based on participant reports.12
Statistical Analysis
Participant characteristics are expressed as means and corresponding 95% CIs for continuous variables and percentages and 95% CIs for categorical variables. One-way analysis of variance (ANOVA) was used for normally distributed data, and the Kruskal-Walli’s test was used for data with a skewed distribution. Categorical variables are expressed as proportion (%), and continuous variables are expressed as mean (SD) or median [interquartile range (IQR)], as appropriate. Differences between groups were assessed using one-way ANOVA (for normally distributed data), the Kruskal-Walli’s test for data with a skewed distribution, and χ2 tests for categorical variables. Multivariable logistic regression models were used to determine the odds ratio (OR) and corresponding 95% CI for the association between DII scores and constipation. Model 1 was adjusted for sociodemographic characteristics (sex, marital status, race/ethnicity, education, household income), and NHANES cycle. Model 2 was adjusted for factors in model 1 and smoking status, drinking status, physical activity, BMI, CVD, stroke, hypertension, and diabetes. Model 3 was adjusted for factors in model 2 and energy intake, carbohydrate intake, SSRI use. In addition, to assess the stability of the association between DII scores and constipation in different populations, interaction subgroup analyses were performed according to sex, age (20 to 65 vs. ≥65 y), physical activity (<150 min/week, ≥150 min/wk), BMI (<30, ≥30 kg/m2), and presence of diabetes. Heterogeneity and interaction between subgroups were assessed using logistic regression models and likelihood ratio tests, respectively. Statistical power was not calculated a priori because the sample size was based exclusively on available data. R version 4.2.1 (R Foundation for Statistical Computing, Vienna, Austria <http://www.Rproject.org>) and Free Statistical Software version 1.9 (Beijing Free Clinical Medical Technology Co., Ltd.) were used for the analyses. In all analyses, differences with a 2-sided P<0.05 were considered to be statistically significant. The data were analyzed from November to December 2023.
RESULTS
Study Population
Of the 17,132 participants of NHANES 2005 to 2010 who were ≥20 years of age, the following were excluded for the following reasons: colorectal cancer (n=130), pregnancy (n=387), missing data from the Bowel Health Questionnaire (n=2349), missing data from the DII (n=252), and covariates (n=5742). As a result, 8272 subjects were included in the final analyses (Fig. 1).
Baseline Characteristics
A total of 759 subjects (9.2%) had constipation, and 7513 subjects (90.8%) did not have constipation. Table 1 summarizes the baseline characteristics of the 8272 study subjects stratified according to the DII scores. The mean age (±SD) of the study subjects was 48.0±17.1 years, of which 3951 (47.8%) were female. In the high DII subgroup (>2.50 to 5.24), women had higher DII scores than men [n=1691 (61.3%) vs. n=1067 (38.7%)]. In addition, among the high DII subgroups (>2.50 to 5.24), dietary inflammation scores were generally higher among non-Hispanic whites, married, middle-income, highly educated, alcohol drinkers, and those who exercised ≥150 minutes per week. DII scores also differed somewhat from other groups among those with cardiovascular disease, hypertension, diabetes, stroke, constipation, and the use of selective serotonin reuptake inhibitors.
TABLE 1.
General Characteristics of the Participants From the National Health and Nutrition Examination Survey 2005 to 2010 Cycles
| DII | |||||
|---|---|---|---|---|---|
| Characteristics | Total | T1 (−5.28 to ≤0.72) | T2 (>0.72 to ≤2.50) | T3 (>2.50 to 5.24) | P |
| No. | 8272 | 2757 | 2757 | 2758 | — |
| Age (y), Mean (SD) | 48.0 (17.1) | 48.8 (16.7) | 48.0 (17.2) | 47.4 (17.5) | 0.009 |
| Gender, n (%) | — | — | — | — | <0.001 |
| Male | 4321 (52.2) | 1762 (63.9) | 1492 (54.1) | 1067 (38.7) | — |
| Female | 3951 (47.8) | 995 (36.1) | 1265 (45.9) | 1691 (61.3) | — |
| Race/ethnicity, n (%) | — | — | — | — | <0.001 |
| Non-Hispanic White | 4521 (54.7) | 1593 (57.8) | 1504 (54.6) | 1424 (51.6) | — |
| Non-Hispanic Black | 1473 (17.8) | 389 (14.1) | 481 (17.4) | 603 (21.9) | — |
| Mexican American | 1319 (15.9) | 471 (17.1) | 450 (16.3) | 398 (14.4) | — |
| Others | 959 (11.6) | 304 (11) | 322 (11.7) | 333 (12.1) | — |
| Marital status, n (%) | — | — | — | — | <0.001 |
| Married | 4583 (55.4) | 1660 (60.2) | 1569 (56.9) | 1354 (49.1) | — |
| Never married | 1422 (17.2) | 412 (14.9) | 474 (17.2) | 536 (19.4) | — |
| Living with partner | 657 (7.9) | 219 (7.9) | 211 (7.7) | 227 (8.2) | — |
| Others | 1610 (19.5) | 466 (16.9) | 503 (18.2) | 641 (23.2) | — |
| Family income, n (%) | — | — | — | — | <0.001 |
| ≤1.30 | 2192 (26.5) | 609 (22.1) | 658 (23.9) | 925 (33.5) | — |
| 1.31-3.50 | 3108 (37.6) | 934 (33.9) | 1083 (39.3) | 1091 (39.6) | — |
| >3.50 | 2972 (35.9) | 1214 (44) | 1016 (36.9) | 742 (26.9) | — |
| Educational level (y), n (%) | — | — | — | — | <0.001 |
| <9 | 1839 (22.2) | 519 (18.8) | 591 (21.4) | 729 (26.4) | — |
| 9-12 | 1936 (23.4) | 552 (20) | 636 (23.1) | 748 (27.1) | — |
| >12 | 4497 (54.4) | 1686 (61.2) | 1530 (55.5) | 1281 (46.4) | — |
| Smoking, n (%) | — | — | — | — | 0.065 |
| No | 4357 (52.7) | 1494 (54.2) | 1455 (52.8) | 1408 (51.1) | — |
| Yes | 3915 (47.3) | 1263 (45.8) | 1302 (47.2) | 1350 (48.9) | — |
| Drinking, n (%) | — | — | — | — | <0.001 |
| No | 914 (11.0) | 246 (8.9) | 276 (10) | 392 (14.2) | — |
| Yes | 7358 (89.0) | 2511 (91.1) | 2481 (90) | 2366 (85.8) | — |
| Physical activity, n (%) | — | — | — | — | <0.001 |
| <150 min/wk | 2463 (29.8) | 712 (25.8) | 854 (31) | 897 (32.5) | — |
| ≥150 min/wk | 5809 (70.2) | 2045 (74.2) | 1903 (69) | 1861 (67.5) | — |
| BMI (kg/m2), n (%) | 28.7 (6.5) | 28.15 (5.9) | 28.8 (6.5) | 29.2 (6.8) | <0.001 |
| CVD, n (%) | 727 (8.8) | 207 (7.5) | 250 (9.1) | 270 (9.8) | 0.009 |
| Stroke, n (%) | 229 (2.8) | 57 (2.1) | 74 (2.7) | 98 (3.6) | 0.003 |
| Hypertension, n (%) | 3181 (38.5) | 1026 (37.2) | 1052 (38.2) | 1103 (40) | 0.098 |
| Diabetes, n (%) | 1174 (14.2) | 345 (12.5) | 405 (14.7) | 424 (15.4) | 0.006 |
| Energy intake (kcal/d), Mean (SD | 2176.8 (1017.0) | 2804.3 (1157.5) | 2129.5 (766.5) | 1596.9 (666.3) | <0.001 |
| Carbohydrate intake (g/d), Mean (SD) | 263.5 (129.1) | 339.4 (143.0) | 254.6 (103.6) | 196.4 (92.2) | <0.001 |
| SSRI use, n (%) | — | — | — | — | 0.114 |
| No | 7784 (94.1) | 2607 (94.6) | 2602 (94.4) | 2575 (93.4) | — |
| Yes | 486 (5.9) | 150 (5.4) | 153 (5.6) | 183 (6.6) | — |
| BM frequency, n (%) | — | — | — | — | <0.001 |
| No | 8013 (96.9) | 2714 (98.4) | 2681 (97.2) | 2618 (94.9) | — |
| Yes | 259 (3.1) | 43 (1.6) | 76 (2.8) | 140 (5.1) | — |
| Bristol stool, n (%) | — | — | — | — | <0.001 |
| No | 7719 (93.3) | 2616 (94.9) | 2570 (93.2) | 2533 (91.8) | |
| Yes | 553 (6.7) | 141 (5.1) | 187 (6.8) | 225 (8.2) | |
| BM frequency + Bristol stool, n (%) | — | — | — | — | <0.001 |
| No | 7513 (90.8) | 2584 (93.7) | 2510 (91) | 2419 (87.7) | — |
| Yes | 759 (9.2) | 173 (6.3) | 247 (9) | 339 (12.3) | — |
The continuous data were shown as mean (SD), and differences between groups were compared using a t test, one-way analyses of variance (normal distribution), and Kruskal-Wallis tests (skewed distribution). The categorical data were shown as numbers and percentages [n (%)], and differences between groups were compared using the χ2 test.
BM frequency indicates bowel movement frequency; BMI, body mass index; CVD, cardiovascular diseases; DII, Dietary inflammatory index; SSRI, selective serotonin reuptake inhibitor use.
Association Between DII Scores and Constipation
After adjusting for age, sex, marital status, race/ethnicity, education level, household income, smoking status, drinking status, physical activity, BMI, CVD, hypertension, stroke, diabetes, energy intake, carbohydrate intake, and selective serotonin reuptake inhibitor (SSRI) use. A stable association between DII and constipation was found in bowel movements frequency alone and in the composite definition of constipation, whereas it was not found in constipation defined by Bristol fecal pattern alone. In combined-defined constipation, compared with lower DII scores group T1 (−5.28 to ≤0.72), the adjusted OR values for DII scores and constipation in T2 (>0.72 to ≤2.50) and T3 (>2.50 to 5.24) were 1.27 (95% CI: 1.02–1.58, P=0.029), and 1.43 (95% CI: 1.14–1.8, P=0.002) (Table 2).
TABLE 2.
Relationship Between DII and Constipation in US Adult Participants in the NHANES 2005 to 2010 Cycles
| DII Score | ||||
|---|---|---|---|---|
| Variable | T1 (−5.28 to ≤0.72) | T2(>0.72 to ≤2.50) | T3 (>2.50 to 5.24) | P |
| No. | 2757 | 2757 | 2758 | |
| BM frequency | ||||
| Unadjusted | 1(Ref) | 1.79 (1.23~2.61) | 3.38 (2.39~4.77) | <0.001 |
| Model 1 | 1(Ref) | 1.46 (1.00~2.15) | 2.06 (1.44~2.95) | <0.001 |
| Model 2 | 1(Ref) | 1.46 (0.99~2.15) | 2.09 (1.46~2.99) | <0.001 |
| Model 3 | 1(Ref) | 1.49 (1.00~2.21) | 2.13 (1.41~3.20) | <0.001 |
| Bristol stool | ||||
| Unadjusted | 1(Ref) | 1.35 (1.08~1.69) | 1.65 (1.33~2.05) | <0.001 |
| Model 1 | 1(Ref) | 1.18 (0.94~1.48) | 1.18 (0.94~1.48) | 0.17 |
| Model 2 | 1(Ref) | 1.21 (0.96~1.52) | 1.22 (0.97~1.53) | 0.10 |
| Model 3 | 1(Ref) | 1.18 (0.93~1.50) | 1.16 (0.89~1.51) | 0.304 |
| BM frequency+ Bristol stool | ||||
| Unadjusted | 1(Ref) | 1.47 (1.20~1.80) | 2.09 (1.73~2.53) | <0.001 |
| Model 1 | 1(Ref) | 1.26 (1.03~1.55) | 1.44 (1.18~1.75) | <0.001 |
| Model 2 | 1(Ref) | 1.28 (1.04~1.58) | 1.48 (1.21~1.80) | <0.001 |
| Model 3 | 1(Ref) | 1.27 (1.02~1.58) | 1.43 (1.14~1.80) | <0.003 |
Model 1 adjusted for socioeconomic factors (gender, age, race/ethnicity, marital status, education level, and family income).
Model 2 was adjusted for model 1 + smoking status, drinking state, physical activity, BMI, CVD, stroke, hypertension, and diabetes.
Model 3 was adjusted for model 2 + energy intake, carbohydrate intake, and SSRI use.
BM frequency indicates Bowel movement frequency; BMI, body mass index; CVD, cardiovascular diseases; DII, dietary inflammatory, index; NHANES, National Health and Nutrition Examination Survey; OR (95% CI), Odds ratios (ORs) with their 95% CIs; Ref, reference; SSRI, selective serotonin reuptake inhibitor use; T, tertile.
Subgroup Analyses
To assess the potential impact of the relationship between DII scores and constipation, we used stratified analyses to assess whether there was an effect modifier for constipation by the individual variables. After stratification according to age, gender, physical activity, body mass index, and presence of diabetes, gender and physical activity were found to be effect modification in the effects of DII and constipation (Fig. 2).
FIGURE 2.
Association between constipation and DII in different subgroups. Adjusted for age, gender, race/ethnicity, marital status, education level, physical activity, body mass index, family poverty income ratio, smoking status, alcohol intake, heart disease, hypertension, stroke, diabetes, energy intake, carbohydrate intake, and SSRI use.
DISCUSSION
Data from the NHANES database were used to conduct this study. This study used data from the NHANES database. The results of the study showed a significant correlation between DII scores and the risk of constipation in different DII subgroups after adjusting for multifactorial modeling. the tertile analysis showed that the third tertile of DII consumption was associated with a 43% increase in the odds of constipation compared to the first tertile of DII consumption.
Previous studies have reported that the inflammatory potential of the diet is associated with constipation. One clinical study found an association between the prevalence of constipation and mortality from chronic diseases as DII scores increased.6 Another study found that the inflammatory potential of the diet was associated with the abundance of gut flora in patients with constipation.5 Unlike previous studies, the present study used data from NHANES focused on the relationship between the DII and constipation and adjusted for potential confounders using multivariate regression analysis. Results revealed that the risk for constipation increased with increasing DII scores and that the DII scores were positively associated with the development of constipation. The relationship remained stable in the subgroup analysis.
Treatment of constipation involves modification of diet, change(s) in lifestyle habits, and use of medications.2,23 Although altering dietary structure and composition is considered to be the first step in the treatment of constipation, food composition has an important influence on the distribution of intestinal flora, intestinal mucosal function, and intestinal motility function.24,25 DII is the primary indicator for assessing inflammatory components in food, and elevated scores have been associated with the occurrence of chronic constipation in the gut. Inflammatory components of food were positively correlated with the relative abundance of the flora of Bacteroides thetaiotaomicron and Bacteroides caccae, and negatively correlated with the relative abundance of Hungatella spp. and Bacteroides fragilis. 6,26 The altered microenvironment of intestinal flora may affect intestinal peristalsis and emptying function.27 Elevated inflammatory components of foods in the DII scores affect the intestinal microenvironment and enterocyte function, causing chronic inflammation in the intestinal tract, functional constipation, or the possibility of inducing intestinal tumors.28,29 In the present study, elevated DII score was found to be significantly associated with constipation findings, and inflammatory components in food may have increased the incidence of constipation.
The present study, however, also had some limitations, First, constipation was defined in terms of the reduced number of bowel movements and type of faecalis trait, which is inconsistent with the clinical symptoms of patients with constipation, and should also include other symptoms such as incomplete bowel movements and straining to pass stools, which could not be obtained due to the lack of relevant content in the Bowel Health Questionnaire. Second, the cross-sectional design of this study did not allow for the identification of temporal associations between DII and constipation in the population. Also, residual confounding effects could not be excluded. We constructed multivariate logistic regression models and performed subgroup analyses to control for the effect of potential confounders on the relationship between DII scores and constipation. Third, because data regarding diet and constipation in our study were obtained through a questionnaire, memory bias may have been introduced. Fourth, because our study was conducted using data from patients with adults in the United States, further research is needed to generalize the findings to other populations. Finally, our study could not assess the causal relationship between DII and constipation in patients. Therefore, further research is needed to investigate whether there is a causal relationship between the inflammatory potential of diet and constipation.
CONCLUSIONS
Results of this cross-sectional study suggest that a higher dietary inflammatory index score was associated with increased risk of constipation after adjustment for confounding in a multivariable analysis. Gender and physical activity were found to be an effect modifier of this relationship.
Acknowledgments
The authors thank Huanxian Liu of the Department of Neurology, First Medical Center of Chinese PLA General Hospital, Beijing, China. The authors thank Haoxian Tang of the Department of Vasculocardiology, Shantou University, Guangdong, China. The authors also thank Jie Liu of the Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, for contribution to statistical support, study design consultations, and comments regarding the manuscript.
Footnotes
W.F.L., L.L., and Y.H.Z. contributed equally to this work.
Data availability: These survey data are free and publicly available, and can be downloaded directly from the NHANES website (http://www.cdc.gov/nchs/nhanes.htm) by users and researchers worldwide.
W.L., L.L., and H.L.: analyzed and interpreted the data and results and drafted the manuscript. H.L., H.T., W.L., and Y.Z.: revised the manuscript. H.L. and J.L.: proposed the concept and design of the study and revised manuscript for critical intellectual content. H.L. revised manuscript for critical intellectual content.
The authors declare that they have nothing to disclose.
Contributor Information
Wang Feng Lu, Email: luwangfengsl@126.com.
Lei Liu, Email: 18709143001@139.com.
Yong Hong Zhang, Email: zhangyoohoo@163.com.
Huanxian Liu, Email: huanxian_liu@126.com.
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