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Nutritional status and constipation scoring of inguinal hernia patients: a case–control study

Abstract

Purpose There are many risk factors for inguinal hernia that have been determined in the literature, but the relationship between nutritional status and inguinal hernia has not yet been examined. In this study, we evaluated the constipation scale and food consumption of patients with inguinal hernia. Methods This prospective case–control study was performed between March 2018 and March 2019. The patients who were admitted for inguinal hernia operation were the case group, and those patients who had been admitted to the same hospital without inguinal hernia were the control group. The age, body mass index, alcohol and smoking habits, daily activity, and the Wexner constipation scoring were examined using a questionnaire and 3-day food consumption records were noted. Results A total of 203 volunteers were included in the study. Of these, 88 patients were in the control group, and 115 patients were in the case group. The age and gender distribution of the groups was similar. Cigarette and alcohol usages are statistically high in the case group. The Wexner constipation scale of the groups was statistically high in the case group. In the univariate analysis, smoking, alcohol consumption, total constipation score, red meat consumption, chicken consumption, bread consumption, low fiber consumption, low egg consumption, low carbohydrate, and low energy intake were effective in hernia formation, and in the multivariate analysis, total constipation score, red meat consumption, chicken consumption, excess bread consumption, low energy intake, and low fiber consumption were significant as independent variables. Conclusion Our study is the first to evaluate whether there is a relationship between inguinal hernia and nutrition, according to the literature. Lifestyle modifications and a healthy diet with the consumption of less meat and more vegetables may have an impact on the reduction of hernia occurrence.
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https://doi.org/10.1007/s10029-019-02075-8
ORIGINAL ARTICLE
Nutritional status andconstipation scoring ofinguinal hernia patients:
acase–control study
C.Idiz1 · C.Cakir2
Received: 5 May 2019 / Accepted: 19 October 2019
© Springer-Verlag France SAS, part of Springer Nature 2019
Abstract
Purpose There are many risk factors for inguinal hernia that have been determined in the literature, but the relationship
between nutritional status and inguinal hernia has not yet been examined. In this study, we evaluated the constipation scale
and food consumption of patients with inguinal hernia.
Methods This prospective case–control study was performed between March 2018 and March 2019. The patients who were
admitted for inguinal hernia operation were the case group, and those patients who had been admitted to the same hospital
without inguinal hernia were the control group. The age, body mass index, alcohol and smoking habits, daily activity, and
the Wexner constipation scoring were examined using a questionnaire and 3-day food consumption records were noted.
Results A total of 203 volunteers were included in the study. Of these, 88 patients were in the control group, and 115 patients
were in the case group. The age and gender distribution of the groups was similar. Cigarette and alcohol usages are statisti-
cally high in the case group. The Wexner constipation scale of the groups was statistically high in the case group. In the
univariate analysis, smoking, alcohol consumption, total constipation score, red meat consumption, chicken consumption,
bread consumption, low fiber consumption, low egg consumption, low carbohydrate, and low energy intake were effective
in hernia formation, and in the multivariate analysis, total constipation score, red meat consumption, chicken consumption,
excess bread consumption, low energy intake, and low fiber consumption were significant as independent variables.
Conclusion Our study is the first to evaluate whether there is a relationship between inguinal hernia and nutrition, according
to the literature. Lifestyle modifications and a healthy diet with the consumption of less meat and more vegetables may have
an impact on the reduction of hernia occurrence.
Keywords Inguinal hernia· Nutrition· Constipation· Exercise
Introduction
Inguinal hernia is the most common type of abdominal
wall hernias, and its prevalence is estimated at 5–10% in
the USA [1]. Although many risk factors have been defined
for inguinal hernia, a family history of inguinal hernia has
been reported to be one of the most important factors [2].
In addition to this, advanced age, male gender, smoking,
chronic cough causing intra-abdominal pressure increase,
and chronic constipation defined as risk factors [36]. How-
ever, smoking is especially related to hernia recurrence and
the level of evidence of chronic constipation and chronic
cough is low as a risk factor. The hernias may recur accord-
ing to their original causes in the early or late period after
treatment.
Although the prevalence of chronic constipation is
reported to be 14%, some publications have also reported
that it can reach 40% [7, 8]. Several scales are used to deter-
mine constipation. The scale that was defined by Agachan
etal. is one of the generally accepted scales to evaluate con-
stipation prevalence and severity [9, 10]. The fact that intra-
abdominal pressure increase, such as chronic constipation, is
a risk factor for the development of inguinal hernia has been
emphasized since the beginning of the 1800s [11].
* C. Idiz
cemileidiz@gmail.com
C. Cakir
c_cakir@hotmail.com
1 Department ofInternal Medicine, Istanbul University,
Istanbul, Turkey
2 Department ofGeneral Surgery, Istanbul Training
andResearch Hospital, Istanbul, Turkey
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We did not find any published study examining the rela-
tionship between abdominal wall hernias and nutrition in
our literature search, though it is recommended that patients
should drink plenty of water and eat fiber-rich foods follow-
ing hernia surgery [12]. There are also reports that obesity
is a risk factor in abdominal wall hernias, especially in the
development and recurrence of incisional hernia [1315].
However, there are also reports that suggested that there is
no risk or reduced risk for inguinal hernia development in
obese and overweight individuals [1618].
In this study, the constipation and nutritional status of
inguinal hernia patients were evaluated, and it was aimed
at examining the relationship between inguinal hernia and
nutrition, which has not been previously evaluated in the
literature.
Materials andmethods
This prospective case–control study was between March
2018 and March 2019 following approval by the local human
ethical committee. The patients who were admitted to the
general surgery for operation with inguinal hernia were the
case group of this study. Also, the patients who were admit-
ted to the same hospital with complaints such as eye, ear/
nose/throat, dermatologic diseases, or elective surgeries
and did not have an inguinal hernia, constipation, or other
chronic diseases that could increase the intra-abdominal
pressure, were selected as the control group.
The inclusion criteria for the case group were 18–80-year-
old patients who had inguinal hernia. Those patients who
were pregnant or had cancer, chronic liver diseases, previous
abdominal surgery history, femoral hernia, or bilateral her-
nia, and the patients who had experienced weight loss above
20% of their body weight in the last 6months were excluded
from the study. Written informed consent was obtained from
each participant. The numbers of cases and controls were
matched, based on gender and age in each group.
The age, gender, body mass index, alcohol and smok-
ing habits, daily activity, frequency of food consumption,
and constipation scoring according to Agachan etal. were
examined using a questionnaire; 3-day food consumption
records were noted and evaluated in the BeBis 8 Full ver-
sion program. The demographic data, nutritional status, and
the constipation scores were compared among individuals
to identify differences between these two groups. Also, the
hernia group was divided into two subgroups as having indi-
rect and direct hernias. The whole analysis was performed
for all of the subgroups.
Statistical analysis
The software package SPSS 22.0 (IBM, Armonk, NY,
USA) was used for statistical analysis. Descriptive sta-
tistics included the mean, standard deviation, median,
minimum–maximum, and rate for numerical variables.
Kolmogorov–Smirnov tests were used to confirm a nor-
mal distribution, and the Mann–Whitney U test and Chi-
square test were used for independent variables. Univariate
and multivariate logistic regression tests were used for the
evaluation of the level of impact. The statistical signifi-
cance level was set at p < 0.05.
Results
A total of 203 volunteers were included in the study.
Of these, 88 patients who did not have inguinal hernia
were named as group 1 (Control), and 115 patients who
had inguinal hernia were named as group 2 (Case). The
mean age of the case group was 52.2 ± 13.9years, and the
female/male ratio was 10/105, and the mean age of the
Control group was 52.0 ± 11.6years, and the female/male
ratio was 9/79. The indirect/direct hernia ratio was 67/48.
The age, BMI, physical activity, cigarette, and alcohol
data of the groups were compared. Cigarette and alco-
hol usages are statistically high in the Case group. The
Wexner constipation scale of the groups was statistically
high in the case group (Table1). Food consumption and
dietary habits of the groups were evaluated. Daily red
meat, chicken, and bread consumption was statistically
high in the case group, and daily egg, nuts, energy intake,
carbohydrate, and fiber consumption was statistically low
in this group (Table2).
In the univariate model, smoking, alcohol consumption,
total constipation score, red meat consumption, chicken
consumption, bread consumption, carbohydrate intake and
energy intake, egg consumption, and low fiber consump-
tion were effective in increasing the risk of hernia forma-
tion (Table3).
In the multivariate reduced model, total constipation
score, red meat consumption, chicken consumption, excess
bread consumption, energy intake, and low fiber consump-
tion were significant as independent variables (Table3).
According to the indirect and direct hernia subgroup
analyses, the constipation score (p 0.000), daily bread (p
0.011), and red meat (p 0.000) consumption were statisti-
cally high, and energy intake (p 0.021) carbohydrate intake
(p 0.01) and fiber intake (p 0.004) were statistically low in
the indirect hernia group compared to the control group.
The multivariate logistic regression analysis also showed
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that red meat and bread consumption, high total constipa-
tion score, and low carbohydrate intake were independent
risk factors for indirect hernia development (Table4). It
was observed that patients with direct hernias consumed
more red meat (0.028) and chicken (p 0.007), fewer eggs
(p 0.033), and carbohydrate (p 0.001) than the control
group. Also, multivariate logistic regression analysis
showed that daily excess chicken consumption and less
egg and carbohydrate consumption were independent risk
factors for direct hernia formation (Table4).
The analysis between direct and indirect hernia groups
showed that there were no significant differences at all of the
parameters expect daily giblets consumption. The daily gib-
let consumption is significantly high in direct hernia patients
(p 0.019).
Discussion
Inguinal hernias are the third most common complaint in
patients admitted to the outpatient clinic with gastrointes-
tinal complaints, and they are eight times more common
in males than in females [16, 19, 20]. In the literature, risk
factors that were defined for the development of ingui-
nal hernia included: a previous history of hernia history,
advanced age, male sex, white race, chronic cough, chronic
constipation, abdomen wall damage, and family hernia his-
tory [6, 16, 1921].
The incidence of inguinal hernia increases with age and
especially the risk of developing inguinal hernia increases
more after 50years of age. The most probable cause is a
progressive weakening in the strength of collagen tissue with
increasing age [22]. In our study, volunteers with similar age
and sex were preferred in the case and control group because
of that there are no differences at the age and gender vari-
ables between the two groups.
There are contradictory reports in the literature on the
effect of smoking on inguinal hernia formation. It has been
reported that smoking is a risk factor for inguinal hernia
formation by affecting connective tissue metabolism [23]
and also may cause hernia recurrence [6]. The role of smok-
ing in the development of primary inguinal hernia is still
unclear, although the mechanisms of development of hernia
recurrence in smokers are often explained by transient tis-
sue hypoxia or excessive proteolysis that disrupts wound
healing [24]. On the contrary, in many studies, it is reported
that smoking is not related to the first diagnosis of inguinal
hernias [16, 18, 25]. Similarly, no relationship was found
between alcohol use and inguinal hernia development [16,
25]. In our study, however, it was observed that patients who
had inguinal hernia consumed more cigarettes and alcohol
than the control group.
Although it is thought that obesity may be a risk factor for
hernia development in general terms, many reports support
the view that obesity is a risk factor for the development
of incisional hernia [1315]. Also, it is reported in many
articles that the risk of inguinal hernia development is low
in overweight and obese individuals, but the cause is not
determined, [1618, 26]. In our study, no significant dif-
ference was found in terms of BMI in individuals with and
without a hernia.
It has been reported in various studies that intra-abdomi-
nal pressure is a risk in the development of inguinal hernia.
Many questionnaires and methods have been defined for the
evaluation of constipation, which is one of the factors caus-
ing intra-abdominal pressure increase [9, 10, 27]. A 30-point
and 8-question questionnaire scoring system known as the
Wexner constipation scale, which is defined by Agachan
etal., has been used for a long time. According to the scale,
score of 15 points and over is considered to be constipated
[9]. There are many studies about constipation and nutri-
tional habits. In the study of Huang etal., a meat-based
diet was found to be a cause of chronic constipation [28].
A low-fiber diet could also cause chronic constipation, and
constipation is considered a risk factor for inguinal hernia,
albeit at low level of evidence [36]. In a study conducted in
Table 1 The demographic data and the meal information of the
patients according to hernia existence (BMI: body mass index,
COLD: chronic obstructive lung diseases)
Group 1 (con-
trol) (n:88)
Group 2
(case) (n:115)
p value
Gender
Female 9 10 0.710
Male 79 105
Age (year ± SD) 52.0 ± 11.6 52.2 ± 13.9 0.924
BMI 27.1 ± 3.2 26.7 ± 3.9 0.270
Cigarette (n)
No 49 41 0.008
Quit 19 27
Yes 20 47
Alcohol (n)
Yes 10 29 0.013
No 78 86
Regular physical activity (at least 30min/week) (n)
Yes 17 31 0.204
No 71 84
Regular breakfast (n)
Yes 83 109 0.884
No 5 6
Skipping mean meal in a day (n)
Yes 33 42 0.886
No 55 73
Wexner Constipation
Scoring
5.7 ± 2.5 7.7 ± 3.9 0.001
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Table 2 Daily food habits
according to hernia existence
(g: gram, mg: milligram)
Group 1 Group 2 P value
Daily milk—yoghurt (ml) 129.6 ± 85.3 126.5 ± 94.8 0.447
Daily cheese (g) 55.9 ± 26.0 59.4 ± 35.6 0.538
Daily red meat (g) 15.2 ± 11.9 20.8 ± 11.4 0.000
Daily chicken (g) 29.2 ± 17.4 43.2 ± 37.4 0.028
Daily fish (g) 18.7 ± 21.1 18.4 ± 16.2 0.271
Daily salami—sausage (g) 7.7 ± 10.2 6.0 ± 7.1 0.638
Daily giblets (Liver, kidney etc.)(g) 4.3 ± 8.0 3.7 ± 8.5 0.401
Daily egg (g) 29.4 ± 21.7 22.6 ± 17.4 0.022
Daily nuts (g) 7.1 ± 7.5 6.1 ± 9.7 0.023
Daily legumes (g) 13.2 ± 9.7 13.0 ± 9.4 0.932
Daily bread (g) 149.5 ± 62.1 166.0 ± 62.1 0.034
Daily rice—pasta (g) 63.5 ± 34.7 66.7 ± 35.7 0.373
Daily vegetable (g) 130.6 ± 62.7 123.1 ± 67.7 0.179
Daily fruit (g) 118.0 ± 83.3 99.7 ± 93.5 0.084
Daily fast food (g) 19.5 ± 21.3 18.9 ± 13.8 0.241
Daily energy intake (kcal) 1832 ± 331.8 1726.2 ± 342.1 0.021
Daily carbohydrate (g) 222.3 ± 45.4 197.4 ± 44.8 0.000
Daily protein (g) 65.0 ± 13.9 65.4 ± 16.2 0.853
Daily fat (g) 74.2 ± 15.1 73.7 ± 20.3 0.500
Daily fiber (g) 18.2 ± 5.5 16.0 ± 4.9 0.003
Daily cholesterol (mg) 270.1 ± 107.9 255.0 ± 104.2 0.158
Daily calcium (mg) 621.7 ± 174.0 613.6 ± 184.9 0.719
Table 3 Univariate and
multivariate regression analysis
of variables
Univariate analysis Multivariate analysis
OR 95% CI pOR 95% CI p
Cigarette 1.68 1.20–2.34 0.002
Alcohol 2.63 1.20–5.75 0.015
Total Wexner score 1.22 1.10–1.36 0.000 1.29 1.13–1.46 0.000
Daily red meat 1.05 1.02–1.08 0.001 1.06 1.02–1.09 0.001
Daily chicken 1.02 1.01–1.03 0.003 1.02 1.01–1.04 0.001
Daily egg 0.98 0.97–1.00 0.015
Daily bread 1.00 1.00–1.01 0.044 1.01 1.01–1.02 0.000
Daily energy intake 1.00 1.00–1.00 0.032 1.00 1.00–1.00 0.001
Daily carbohydrate 0.99 0.98–0.99 0.000
Daily fiber 0.92 0.87–0.97 0.004 0.90 0.83–0.97 0.006
Table 4 Multivariate regression
analysis of variables according
to indirect and direct hernia
subgroups
Indirect hernia Direct hernia
Multivariate analysis Multivariate analysis
OR 95% CI pOR 95% CI p
Total Wexner score 0.78 0.67–0.89 0.001
Daily red meat 0.94 0.90–0.98 0.003
Daily chicken 0.97 0.95–0.99 0.005
Daily egg 1.02 1.00–1.04 0.024
Daily bread 0.98 0.97–0.99 0.000
Daily carbohydrate 1.01 1.00–1.03 0.049 1.01 1.00–1.02 0.008
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Japan, low consumption of bread according to the Japanese
traditional nutrition pattern was associated with a low preva-
lence of functional constipation [29]. In another study, con-
sumption of both wholemeal and white bread was associated
with constipation [30]. In our study, we used the Wexner
scale to evaluate the constipation status of the volunteers,
and although the mean scores in both groups were below
the constipation limit, there were statistically significantly
higher constipation scores in the hernia group. Also a lack
of fiber, high red meat, and bread consumption, which were
associated with constipation, was found to be an independ-
ent risk factor for inguinal hernia development in our study,
especially for the indirect type.
In our literature review, we could not find any study that
had investigated the effect of nutrition on inguinal her-
nia development. The American College of Surgeons and
National Institutes of Health suggest eating fresh vegetables,
fruits, and whole grain and high-fiber foods to reducing the
symptoms of inguinal hernia by preventing constipation [12,
31].
Low energy and carbohydrate intake were independent
risk factors according to our study. Biolo etal. stated that
calorie restriction could cause protein catabolism in the post-
absorptive period with an impaired postprandial anabolic
use of free amino acids [32]. In one study, it was reported
that there is a positive relationship between total limb lean
mass and appendicular skeletal muscle and carbohydrate
intake in men and women [33]. This protein catabolism
could enhance the muscle weakness so that low energy and
carbohydrate intake, which we found as an independent risk
factor, could cause hernia in that way.
The egg is an independent risk factor for direct hernia
patients according to our study. Eggs are inexpensive, eas-
ily accessible, and contain a moderate amount of leucine,
which plays an important role in muscle synthesis [34]. In a
study, it was found that the whole egg eaten after resistance
exercise resulted in more stimulation of myofibrillary protein
synthesis than did the white parts of the egg alone [35]. We
think that lower egg consumption can affect muscle mass
through unknown mechanisms in direct hernia.
The small number of patients and the lack of randomiza-
tion in the control group could be defined as the limitations
of our study. Even so, the number of patients and the subdi-
visions of hernias according to the nyhus classification and
the randomization of the patients in the control group will
help to increase the wider knowledge on this subject and to
clarify the literature.
In conclusion, our study helps to fill the gap in the lit-
erature as the first study evaluating whether there is a rela-
tionship between inguinal hernia development and nutri-
tion. Our study shows that the total constipation score, red
meat, chicken, excess bread consumption and low energy
intake, and lack of fiber consumption are independent risk
factors for hernia development. Also, constipation and the
factors that cause constipation play an important role in the
occurrence of indirect hernia. However, in direct hernia
development, changes related to protein metabolism could
play a role, rather than constipation. Considering that the
hernias may recur according to their original causes, the
lifestyle and nutrition recommendations—such as eating
less meat and more vegetables—given to individuals who
are at risks of hernia development may be an effective
method to prevent the occurrence of hernias in persons
who have not developed inguinal hernia and to prevent
recurrences in those who have had inguinal hernia repair.
Acknowledgments This research did not receive any specific grant
from funding agencies in the public, commercial, or not-for-profit
sectors.
Funding This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval Ethical approval was agreed by the ethical committee
of the institution.
Research involving human participants All procedures performed in
studies involving human participants were by the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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Background: Protein in the diet is commonly ingested from whole foods that contain various macro- and micronutrients. However, the effect of consuming protein within its natural whole-food matrix on postprandial protein metabolism remains understudied in humans.Objective: We aimed to compare the whole-body and muscle protein metabolic responses after the consumption of whole eggs with egg whites during exercise recovery in young men.Design: In crossover trials, 10 resistance-trained men [aged 21 ± 1 y; 88 ± 3 kg; body fat: 16% ± 1% (means ± SEMs)] received primed continuous l-[ring-(2)H5]phenylalanine and l-[1-(13)C]leucine infusions and performed a single bout of resistance exercise. After exercise, participants consumed intrinsically l-[5,5,5-(2)H3]leucine-labeled whole eggs (18 g protein, 17 g fat) or egg whites (18 g protein, 0 g fat). Repeated blood and muscle biopsy samples were collected to assess whole-body leucine kinetics, intramuscular signaling, and myofibrillar protein synthesis.Results: Plasma appearance rates of protein-derived leucine were more rapid after the consumption of egg whites than after whole eggs (P = 0.01). Total plasma availability of leucine over the 300-min postprandial period was similar (P= 0.75) between the ingestion of whole eggs (68% ± 1%) and egg whites (66% ± 2%), with no difference in whole-body net leucine balance (P = 0.27). Both whole-egg and egg white conditions increased the phosphorylation of mammalian target of rapamycin complex 1, ribosomal protein S6 kinase 1, and eukaryotic translation initiation factor 4E-binding protein 1 during postexercise recovery (all P < 0.05). However, whole-egg ingestion increased the postexercise myofibrillar protein synthetic response to a greater extent than did the ingestion of egg whites (P= 0.04).Conclusions: We show that the ingestion of whole eggs immediately after resistance exercise resulted in greater stimulation of myofibrillar protein synthesis than did the ingestion of egg whites, despite being matched for protein content in young men. Our data indicate that the ingestion of nutrient- and protein-dense foods differentially stimulates muscle anabolism compared with protein-dense foods. This trial was registered at clinicaltrials.gov as NCT03117127.
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Objectives: The pathophysiology behind functional gastrointestinal disease (FGID) has not been defined, but an intestinal accumulation of fermentable short-chain carbohydrates (FODMAPs) is thought to be involved. A restricted coffee intake is recommended. The aim was to investigate if symptoms of FGID were associated with intake of certain foods (including FODMAPs), as well as beverages (including coffee and tea). Method and materials: Data were used from participants, age range 45-75 years, who had answered the EpiHealth questionnaire about their background factors, health status and intake of food and beverages. After exclusion of organic bowel diseases, 16,840 participants remained. The impact of food and beverages on functional abdominal pain, functional bloating, functional constipation and functional diarrhea were examined by adjusted binary logistic regression. Results: Wholemeal bread (Swedish cracker) (OR: 1.361; 95% CI: 1.001-1.851) and white bread (low fiber content) (OR: 1.527; 95% CI: 1.075-2.169) were associated with constipation, whereas soft wholemeal bread (high fiber content) was associated with diarrhea (OR: 1.601; 95% CI: 1.040-2.463). Cheese was associated with bloating (OR: 1.460; 95% CI: 1.004-2.123). A high tea intake was associated with abdominal pain (p for trend =.003), bloating (p for trend = .039) and diarrhea (p for trend <.001), whereas coffee intake was associated with a decreased risk of abdominal pain (p for trend = .002) and bloating (p for trend = .007). High soda intake associated with abdominal pain and bloating and juice with diarrhea. Conclusion: There are weak associations between intake of grain and dairy products and FGID symptoms. Tea is associated with increased risks, whereas coffee is associated with lower risks, of FGID symptoms.