Abstract
Background: This study examined the associations of socioeconomic characteristics and dietary factors with chronic diarrhea in older adults. In addition, we explored socioeconomic differences in nutrient intake among those with chronic diarrhea. Methods: This cross-sectional study included 3498 adults aged 65 years or older from NHANES 2005–2010, of whom 328 had a usual Bristol Stool Form Scale type >5, characterizing the presence of diarrhea. Logistic and linear regression models were adjusted for age and sex. The Benjamini–Hochberg false discovery rate (FDR) procedure was applied post hoc within groups of related comparisons. Results: Lower family poverty–income ratio and educational attainment were associated with chronic diarrhea and remained significant after FDR correction. Emergency food assistance and periods without health insurance were nominally associated but did not remain significant after correction. Among participants with chronic diarrhea, higher poverty–income ratio remained associated with greater intake of energy, total fat, and saturated fat after FDR correction. Other nominal nutrient intake associations and the small difference in folate intake did not remain significant after correction. Conclusions: Socioeconomic disadvantage was associated with chronic diarrhea and differences in reported nutrient intake among older adults. These unweighted, exploratory findings require confirmation in further studies.
1. Introduction
Chronic diarrhea is a frequent gastrointestinal complaint characterized by the recurrent passage of loose or watery stools, although diagnostic criteria differ according to the definition applied [1,2]. Its causes are heterogeneous and include inflammatory and malabsorptive disorders, bile acid diarrhea, pancreatic disease, endocrine conditions, chronic infections, medication-related effects, and functional gastrointestinal disorders [1,3].
Nevertheless, less attention has been given to the broader social and nutritional context in which chronic diarrhea occurs, particularly among older adults. Socioeconomic disadvantage may influence both the occurrence and management of chronic diarrhea through reduced access to healthcare, delayed diagnosis and treatment, food insecurity, and poorer diet quality [4,5,6]. These factors may also contribute to inadequate nutrient intake, which is especially relevant in later life given the increased vulnerability of older adults to malnutrition and its clinical consequences [5,6]. Previous NHANES research has focused on food insecurity and bowel health [4]. Less is known about other socioeconomic characteristics and reported nutrient intake among older adults with loose or watery stools. Examining these factors may help identify social and nutritional needs during clinical assessment.
Based on these premises, the present study examined the associations of socioeconomic characteristics and dietary factors with chronic diarrhea in community-dwelling older adults and further explored whether socioeconomic vulnerability was related to nutrient intake among those with chronic diarrhea.
2. Materials and Methods
2.1. Study Design and Population
This cross-sectional study used data from the National Health and Nutrition Examination Survey (NHANES) conducted during the 2005–2006, 2007–2008, and 2009–2010 cycles. These NHANES cycles were selected to facilitate comparisons between our findings and those reported in previous studies, as investigations on this topic have used data from the same period [4]. NHANES is a continuous survey designed to assess the health and nutritional characteristics of the noninstitutionalized population of the United States through interviews, physical examinations, and laboratory and dietary assessments.
For the present study, data from the three survey cycles were combined using the unique participant identifier. Individuals aged ≥65 years were considered eligible. Among 4268 older adults identified in the pooled dataset, 3498 had available information on usual stool consistency and constituted the analytical sample. Of these, 328 were classified as having chronic diarrhea and 3170 as not having chronic diarrhea. Analyses involving specific socioeconomic, dietary, or nutritional variables were conducted using available cases because the availability of individual NHANES variables differed across survey components and cycles. Differences between included and excluded participants are shown in Table S1. Excluded participants were older, more frequently women, and had lower poverty–income ratios, educational attainment, and BMI than those included in the analyses. Significant differences were also observed in race/ethnicity. The final analytical cohort is depicted in Figure S1.
NHANES protocols were approved by the National Center for Health Statistics Research Ethics Review Board, and written informed consent was obtained from all participants. The study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (Table S2) [7].
2.2. Definition of Chronic Diarrhea
Chronic diarrhea was identified from the bowel-health questionnaire according to the participant’s self-reported usual or most common stool consistency in the 30 days before data collection. Stool consistency was assessed using the Bristol Stool Form Scale. Participants reporting a usual stool type >5 were classified as having chronic diarrhea, whereas those reporting stool types ≤5 were considered not to have chronic diarrhea [1].
2.3. Socioeconomic Characteristics
Socioeconomic information was obtained from NHANES demographic, food security, and health insurance questionnaires. Variables included household size, family size, family poverty–income ratio, educational attainment, marital status, household food security, adult food security, emergency food assistance received during the previous 12 months, food stamp/SNAP authorization during the previous 12 months, receipt of community or government-delivered meals, meals eaten at a community or senior center, current health insurance coverage, any period without health insurance during the previous year, and type of home.
Family poverty–income ratio was analyzed as a continuous variable, with lower values indicating greater socioeconomic disadvantage. Educational attainment was categorized as less than 9th grade, 9th–11th grade, high school graduate/GED, some college or associate degree, and college graduate or above. Household and adult food security were classified as full, marginal, low, or very low food security. Emergency food assistance, food stamp/SNAP authorization, community/government-delivered meals, meals at a community or senior center, health insurance coverage, and a period without insurance during the previous year were analyzed as categorical variables according to the NHANES response categories. Type of home was classified as mobile home or trailer, detached single-family house, attached single-family house, apartment, or dormitory.
2.4. Dietary Behaviors
Dietary behaviors were assessed using NHANES questionnaire items addressing the use of information displayed on food labels. Participants reported how frequently they used the Nutrition Facts panel, ingredient lists, and serving-size information, as well as how frequently they checked information concerning calories, total fat, sodium, fiber, and sugars. Response categories included: always, most of the time, sometimes, rarely, and never, with an additional “never seen” category where applicable.
2.5. Dietary and Nutrient Intake
Dietary intake was obtained from the first 24 h dietary recall conducted as part of NHANES. Nutrients examined included total energy, protein, carbohydrates, total sugars, dietary fiber, total fat, saturated fatty acids, cholesterol, vitamin C, vitamin B12, folate, calcium, magnesium, iron, zinc, sodium, potassium, caffeine, and alcohol. Nutrient intake was expressed in the units provided by NHANES. Relative protein intake was additionally calculated in g/kg/day using body weight obtained during the NHANES examination.
2.6. Statistical Analysis
Continuous variables are presented as mean ± standard deviation and categorical variables as number and percentage. Differences between participants with and without chronic diarrhea were examined using independent-samples t tests for continuous variables and Pearson chi-square tests for categorical variables. Expected cell frequencies were examined to assess the assumptions of Pearson’s chi-square test. Because of small cell counts, food-label response categories were also combined into three groups and the chi-square analyses repeated. Marital status and housing characteristic regressions were repeated using reference categories with larger numbers of participants. These additional results are presented in the Supplementary Materials. Associations between socioeconomic characteristics and chronic diarrhea were examined using binary logistic regression, with chronic diarrhea as the dependent variable. Unadjusted models were fitted, followed by models adjusted for age and sex. Results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Among participants with chronic diarrhea, associations between socioeconomic characteristics and continuous nutrient intake variables were examined using linear regression. Results are reported as unstandardized regression coefficients (B) with 95% CIs. Nutrient intake was not adjusted for total energy intake. Missing data were handled using an available-case approach. Participants with missing values for variables required for an analysis were excluded from that analysis; no imputation was performed. The number of observations varied by model, and complete-case counts and missing observations are reported in Supplementary Table S3. Participants included in and excluded from the analytical cohort were compared using independent-samples t tests and Pearson chi-square tests. Given the number of comparisons, the Benjamini–Hochberg false discovery rate (FDR) correction was applied post hoc within each group of related tests: participant characteristics (16 tests), original and regrouped food-label analyses (8 tests each), nutrient comparisons (19 tests), age- and sex-adjusted socioeconomic models (14 overall predictor tests), and unadjusted and adjusted nutrient regressions (30 tests each). For categorical socioeconomic predictors with several levels, overall model p values were used. The adjusted p values were calculated from the rounded p values reported in the tables and are presented in Supplementary Table S10. The main tables retain nominal p values. Analyses were unweighted and did not account for NHANES sampling strata or clustering. Analyses were conducted using SPSS, version 23 (IBM Corp., Armonk, NY, USA). All tests were two-sided, and nominal or FDR-adjusted p values < 0.05 were considered significant within their respective analyses. The results are exploratory.
3. Results
3.1. Participants’ Characteristics
The main characteristics of study participants are shown in Table 1. Participants with chronic diarrhea were more frequently women, had lower family poverty–income ratios and educational attainment, and more frequently reported emergency food assistance and a period without health insurance in the previous year. After FDR correction, the differences in sex, poverty–income ratio, educational attainment, and emergency food assistance remained significant, whereas the difference in periods without insurance did not (Supplementary Table S10).
Table 1.
Socioeconomic characteristics according to chronic diarrhea status (n = 3498).
3.2. Dietary Behaviors According to Chronic Diarrhea Status
Table 2 shows dietary behaviors according to chronic diarrhea status. Checking the sugar content of food labels differed between groups in the original analysis (p = 0.044), but not after FDR correction (adjusted p = 0.278). Because some original categories contained few participants, responses were also regrouped and the analyses repeated (Supplementary Table S7). No associations were significant after regrouping (checking sugars, p = 0.164).
Table 2.
Dietary behaviors according to chronic diarrhea status.
3.3. Nutrient Intake According to Chronic Diarrhea Status
Table 3 shows nutrient intake according to chronic diarrhea status. Folate intake was nominally lower among participants with chronic diarrhea (p = 0.044), but the difference was not significant after FDR correction (adjusted p = 0.399; Supplementary Table S10).
Table 3.
Nutrient intake according to chronic diarrhea status.
3.4. Socioeconomic Characteristics and Chronic Diarrhea
The unadjusted and adjusted associations between socioeconomic characteristics and chronic diarrhea are shown in Supplementary Table S4 and Table 4. In age- and sex-adjusted analyses, poverty–income ratio and educational attainment remained associated with chronic diarrhea after FDR correction (both adjusted p < 0.007). Emergency food assistance and a period without health insurance were nominally significant but not after correction (adjusted p = 0.070 and 0.098, respectively; Supplementary Table S10). Because some categories of marital status and housing characteristics contained few participants, the regressions were also repeated with larger reference categories (Supplementary Table S8). Their overall associations remained non-significant.
Table 4.
Age- and sex-adjusted associations between socioeconomic characteristics and chronic diarrhea.
3.5. Socioeconomic Characteristics and Dietary Intake
We examined the associations between socioeconomic characteristics and nutrient intake among participants with chronic diarrhea. Unadjusted and age- and sex-adjusted results are presented in Supplementary Table S9 and Table 5, respectively. After FDR correction, higher family poverty–income ratio remained associated with greater intake of energy, total fat, and saturated fat (adjusted p = 0.040 for each). Its nominal associations with carbohydrates, total sugars, and dietary fiber, and the association between emergency food assistance and relative protein intake, were no longer significant after correction (Supplementary Table S10). No significant associations were observed for periods without health insurance.
Table 5.
Age- and sex-adjusted associations between socioeconomic vulnerability and nutrient intake among participants with chronic diarrhea (n = 328).
4. Discussion
The main findings of the present study suggest a relationship between socioeconomic characteristics, chronic diarrhea, and nutrient intake. Older adults with chronic diarrhea had lower family poverty–income ratios and educational attainment, and these associations remained significant after FDR correction. Emergency food assistance and periods without health insurance were associated with chronic diarrhea in the original analyses but not after correction. Among participants with chronic diarrhea, higher poverty–income ratio remained associated with greater intake of energy, total fat, and saturated fat after FDR correction. Other nominal nutrient intake associations did not remain significant.
Findings of the present study are consistent with previous investigations reporting a significant association between socioeconomic status and chronic diarrhea among older adults [8,9]. Multiple mechanisms may underlie this relationship, as diarrhea is a symptom of numerous conditions (e.g., inflammatory bowel disease [IBD], microscopic colitis, celiac disease, and colorectal cancer), which may involve impaired intestinal absorption of water and electrolytes or excessive secretion of fluid into the bowel, resulting in the passage of inadequately formed stools [1,3]. For instance, many of the extensively described socioeconomic determinants of diarrhea among children might also affect older adults, including living standards, wealth, distribution of healthcare and sanitation resources, access to public health interventions and medical care, and neighborhood and familial density [8,10,11].
The nominal associations with having received emergency food assistance and having experienced a period without health insurance are particularly concerning because both indicators may reflect socioeconomic vulnerability. Numerous studies have suggested that limited or uncertain access to safe and nutritionally adequate food due to economic and/or social difficulties may affect dietary patterns and consequently influence bowel symptoms [4,5,6]. However, it is important to distinguish emergency food assistance from food insecurity, as these variables do not necessarily represent the same condition. Indeed, while emergency food assistance was nominally associated with chronic diarrhea, this association did not remain significant after FDR correction, and no significant associations were observed for household or adult food security. These differences may reflect the distinct characteristics of these indicators, since receiving emergency food assistance during the previous 12 months does not necessarily indicate current food insecurity.
Individuals experiencing food insecurity commonly consume lower-quality diets and are less likely to meet dietary recommendations [5,6]. They tend to demonstrate greater adherence to unhealthy dietary patterns (e.g., Western diet), characterized by lower intakes of health-promoting food groups, such as fruits and vegetables, together with higher consumption of ultra-processed foods, sugar-sweetened beverages, and red meat, as well as inadequate intakes of dietary fiber and protein [5,6]. These dietary characteristics have been associated with gastrointestinal symptoms: fatty foods, take-away meals, fried foods, creamy sauces, and high-fat dairy products are commonly reported as triggers of diarrhea, while reductions in dietary fat have been associated with improvements in diarrheal symptoms [12]. Likewise, studies in individuals with irritable bowel syndrome have shown that lowering dietary starch and sucrose intake can alleviate gastrointestinal symptoms, including those with diarrhea-predominant disease [13]. Nevertheless, whether these dietary characteristics explain the socioeconomic associations observed in the present study remains uncertain.
Our findings add to the current knowledge by suggesting that, among older adults with chronic diarrhea, greater socioeconomic resources were associated with higher total energy intake and higher absolute intakes of several macronutrients, including carbohydrates, total sugars, dietary fiber, and both total and saturated fat, whereas individuals with a lower family poverty–income ratio tended to consume less. However, after FDR correction, only the associations with energy, total fat, and saturated fat remained significant. However, these associations may partly reflect differences in total energy intake rather than differences in dietary quality, as the analyses were not adjusted for energy intake. Furthermore, higher or lower nutrient intake does not necessarily indicate better dietary quality or nutritional inadequacy, respectively. An important question is whether these differences are clinically meaningful and whether the observed nutrient intakes meet individual nutritional requirements, particularly among older adults with chronic gastrointestinal symptoms.
Although studies specifically designed to examine socioeconomic inequalities in diet among older adults with chronic diarrhea are needed, three additional observations may help interpret our findings. First, receipt of emergency food assistance during the previous 12 months was nominally associated with higher relative protein intake, but this association did not remain significant after FDR correction. However, this association should be interpreted cautiously, since receiving food assistance does not necessarily indicate current food insecurity, and NHANES does not establish the timing of food assistance in relation to dietary intake. Therefore, whether food assistance influenced protein consumption cannot be determined. Second, socioeconomic characteristics were not significantly associated with the frequency of gastrointestinal symptoms among participants with chronic diarrhea (Table S5). Although this finding suggests that socioeconomic differences in dietary intake were not accompanied by statistically significant differences in bowel-symptom frequency, the possibility of differences in gastrointestinal symptom burden cannot be excluded. Finally, adherence to recommended macronutrient intake levels did not differ significantly according to poverty–income ratio (Table S6). Although some numerical differences were observed, these findings do not provide sufficient evidence of differences in nutritional adequacy according to socioeconomic status. Taken together, our findings suggest that socioeconomic characteristics may be associated with differences in reported dietary intake among older adults with chronic diarrhea. However, whether these differences translate into clinically relevant nutritional consequences remains to be established.
An additional observation of the present study was that lower educational attainment was associated with chronic diarrhea. This finding may underscore the potential importance of education and disease-related knowledge in the management of chronic diarrhea. Educational attainment may influence several preventive and self-management behaviors, including food hygiene, food preparation practices, recognition of dietary triggers, and the ability to understand and apply nutritional recommendations [8,14].
Regarding food-label use, no significant differences were observed between participants with and without chronic diarrhea after regrouping the response categories. Although food-label use may reflect nutritional knowledge and awareness of diet-related conditions, our findings do not support a significant association between these behaviors and chronic diarrhea. Nevertheless, educational strategies aimed at improving nutritional knowledge, identifying dietary triggers, and maintaining adequate nutritional status may be relevant for older adults with chronic diarrhea, particularly those with lower educational attainment.
A final observation of the present study was that individuals with chronic diarrhea had a slightly lower folate intake compared with those without chronic diarrhea. Folate is an essential water-soluble B vitamin found in several foods, including fruits, legumes, green leafy vegetables, and grains. It plays an important role in DNA and RNA synthesis, and its deficiency may lead to conditions such as megaloblastic anemia. The difference between groups was relatively small (approximately 35 µg DFE/day) and was not significant after FDR correction (adjusted p = 0.399); mean folate intake among individuals with chronic diarrhea was approximately 449 µg DFE/day. These findings suggest that the clinical relevance of this difference remains uncertain. Furthermore, as dietary intake was assessed using a single 24 h recall, we cannot determine whether the observed differences reflect habitual folate intake or are associated with nutritional inadequacy.
Several limitations should be considered when interpreting these findings. Chronic diarrhea was defined on the basis of usual stool consistency, following the approach proposed by the British Society of Gastroenterology [1]. However, NHANES did not provide sufficient information on symptom duration and frequency to establish a clinical diagnosis of chronic diarrhea, and other diagnostic approaches, including the Rome IV criteria [15], could not be applied. Consequently, some participants may have been misclassified. The etiology of diarrhea was also unavailable. Given the heterogeneous causes of chronic diarrhea and its frequent coexistence with gastrointestinal and systemic disorders [1], some of the observed associations may reflect underlying diseases rather than diarrhea per se. Most variables were self-reported and are therefore susceptible to recall and reporting bias. Furthermore, the available assessment methods were not specifically designed to comprehensively evaluate several of the conditions examined in the present study, and some variables were therefore based on adapted or proxy definitions.
Regarding dietary assessment, information on food-label use does not necessarily reflect habitual dietary behaviors or overall diet quality. Dietary intake was assessed using a single 24 h recall, which may not adequately represent habitual intake because of day-to-day variability. In addition, reported nutrient intake does not necessarily reflect actual nutrient absorption, particularly among individuals with gastrointestinal disorders, and differences in nutrient intake cannot be interpreted as evidence of nutritional deficiency or malnutrition. Likewise, higher absolute intakes of macronutrients may partly reflect greater total energy intake rather than differences in dietary quality, since the associations were not adjusted for total energy intake.
Some methodological and statistical limitations should also be acknowledged. Although the regression analyses were adjusted for age and sex, residual confounding cannot be excluded. Other potentially relevant factors, including body mass index, smoking, alcohol consumption, comorbidities, and medication use, may have influenced the observed associations. Furthermore, the use of available-case analyses may have introduced selection bias. Indeed, excluded participants were older, more frequently women, and had lower poverty–income ratios, educational attainment, and BMI than those included in the analyses. Significant differences were also observed in race/ethnicity. These findings suggest that the exclusion of participants with missing stool-consistency information may have influenced the observed associations. In addition, the number of observations varied across the analyses because of missing data. Some associations were also based on relatively small subgroups, particularly participants reporting emergency food assistance or periods without health insurance, which may have reduced the precision and stability of the regression estimates. Moreover, the large number of statistical comparisons increases the likelihood of chance findings. A post hoc FDR correction was therefore applied, and several nominal associations were no longer significant. The results should be considered exploratory. The distinction between household food insecurity and receipt of emergency food assistance should also be considered, as these variables represent related but different dimensions of socioeconomic vulnerability and are not necessarily interchangeable. Finally, the analyses did not account for the complex NHANES sampling design, including sampling weights, stratification, and clustering, which may have affected the estimates and their precision and limits the generalizability of the findings to the US population.
The cross-sectional design represents another important limitation, as the temporal direction of the associations cannot be established and no causal inference can be made. Socioeconomic disadvantage may influence gastrointestinal health, but persistent gastrointestinal symptoms may also affect healthcare expenditures, economic circumstances, and access to resources. Moreover, the NHANES data were collected between 2005 and 2010, and changes in socioeconomic conditions, dietary patterns, and healthcare access over time may limit the applicability of these findings to contemporary populations. Longitudinal studies using validated clinical assessments, more comprehensive dietary evaluations, and appropriate adjustment for potential confounders are needed to confirm these observations.
5. Conclusions
In this exploratory study, lower family poverty–income ratio and educational attainment remained associated with chronic diarrhea after FDR correction. Among those with chronic diarrhea, higher poverty–income ratio remained associated with greater energy, total fat, and saturated fat intake. Other nominal associations were not retained after correction. Given the cross-sectional design and the limitations of the unweighted analyses, these results require confirmation in further studies.
Supplementary Materials
The following supporting information can be downloaded at https://www.mdpi.com/article/10.3390/diseases14110412/s1: Figure S1, Flowchart of participants selection; Table S1, Characteristics of participants included in and excluded from the analytical sample according to the availability of stool-consistency data (n = 4268); Table S2, STROBE checklist for cross-sectional studies; Table S3, Complete-case sample sizes and missing observations for the regression models; Table S4, Unadjusted associations between socioeconomic characteristics and chronic diarrhea; Table S5, Associations between socioeconomic characteristics and bowel symptoms among participants with chronic diarrhea (n = 328); Table S6, Energy and macronutrient intake according to family poverty-income ratio among participants with chronic diarrhea; Table S7, Regrouped food-label-use analyses; Table S8, Regression analyses with revised reference categories; Table S9, Unadjusted nutrient-intake regressions; Table S10, Post hoc Benjamini–Hochberg correction.
Author Contributions
E.M. and H.J.C.-J. contributed to the following parts of this study: conceptualization, methodology, formal analysis, investigation, data curation, writing—original draft preparation, and writing—review and editing. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki, and approved by the National Center for Health Statistics (NCHS) Research Ethics Review Board (Protocol #2005-06).
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement
The data analyzed in this study are publicly available from the National Health and Nutrition Examination Survey (NHANES), conducted by the U.S. Centers for Disease Control and Prevention (CDC). The datasets can be accessed at https://www.cdc.gov/nchs/nhanes/ (accessed on 4 November 2026).
Acknowledgments
The APC was funded by the Italian Ministry of Health (Ricerca Corrente 2026).
Conflicts of Interest
The authors declare no conflicts of interest.
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