31.4.6 Risk Factors Associated with Gastro-Esophageal Reflux Disease

Original Article

 

Gastro-Esophageal Reflux Disease

Risk Factors Associated with Gastro-Esophageal Reflux Disease

Shahid Karim, Syeda Nosheen Zehra, Hamid Ali Kalwar, Afsheen Faryal and Muhammad Tanweer Khalid

ABSTRACT

Objective: To study the risk factors associated with Gastroesophageal reflux disease (GERD), in a tertiary care Hospital of Karachi.

Study Design: Prospective, cross sectional study

Place and Duration of Study: This study was conducted at the Department Internal Medicine and Gastroenterology, Liaquat National Hospital, Karachi from February 2009 to March 2010.

Materials and Methods: Attendants of patients sitting in the waiting area with no comorbid, and who were non-smoker and non-alcoholic were recruited after taking informed consent. Data was entered in given performa. Logistic regression was applied with 95% confidence interval.

Results: Total 2191 participants were included in our study. 1130 patients (51.6%) were males and 1061 (48.4%) were females, with mean age of 33.92+12.36 years. GERD symptoms were present in 760 patients (34.7%). GERD symptoms were common in patients taking spicy meals ( 37.2%) and in urdu speaking ethnic group  (52.5%). In  those who had a high  waist hip ratio, 0.9 +-0.15 waist height ratio 0.52+-0.07 and waist circumference ratio  84.57+-10.92.

Conclusion: Gastroesophageal reflux disease is common in our population and there is significant inverse association of GERD with Waist hip ratio and waist height ratio.

Key Words: Gastroesophageal reflux disease, body mass index

Citation of article: Karim S, Zehra SN, Kalwar HA, Faryal A, Khalid MT. Risk Factors Associated with Gastro-Esophageal Reflux Disease. Med Forum 2020;31(4):23-27.

 

 

INTRODUCTION

Gastroesophageal reflux disease (GERD) is one of the commonly known disorders in upper gastrointestinal tract1. GERD has been observed in  an increasing extent in Europe as well as United States of America2,3.The symptoms of GERD are  considered as the most common symptoms among the gastrointestinal symptoms in the regions as mentioned earlier with the occurrence of  10-25% as indicated by the different population based studies4.

The occurrence of Gastro esophageal reflux disease <5% is reported for Asia5. Literature from Iran indicates same rate of prevalence of GERD which have been reported for the western countries6. GERD can be categorized on the basis of typical, atypical and esophageal symptoms. Typical symptoms include
heart  burn,  regurgitation  and  dysphagia  the   atypical

 

 

Department of Internal Medicine and Gastroenterology, Liaquat National Hospital, Karachi.

 

 

Correspondence: Dr. Syeda Nosheen Zehra, Liaquat National Hospital & Medical College, Karachi.

Contact No: 03222231028, 03322262564

Email: enzee84@gmail.com

 

 

Received:  November, 2019

Accepted:  January, 2019

Printed:      April, 2020

 

 

symptoms include cough and wheezing, hoarseness, sore throat, otitis media, non cardiac chest pain, enamel erosion or dental manifestations. The treatment is based on lifestyle modifications and control of gastric acid secretion through medical therapy with proton pump inhibitors and antacids or through corrective antireflux surgery7.

Contributing factors of GERD have been examined in the population generally as reported by various studies but some of potential contributing factors have indicated different results8,9. The data from the developing and under developed countries have been obtained in limited amount and only few population based studies have been conducted which present the determinants of GERD10. This study is aimed to investigate the contributing factors of Gastro esophageal reflux disease (GERD). A potential unit of around 2290 volunteers was recruited in a tertiary care hospital of Karachi, Pakistan. Data was analyzed on the basis of frequency, perceived severity of symptoms and the time of first occurrence of GERD symptoms.

MATERIALS AND METHODS

Single center Prospective, cross sectional study was conducted from the duration of of February 2018 to March 2019. Patients were recruited after taking informed consent and were   above 18 years of age present in outpatient clinic of the various section of hospital having no history of comorbids  such as; diabetes, ischaemic heart disease, hypertension, stroke, and renal diseases and were  non smokers and non  addicts with no   history  of taking beta-blocker, aspirin or NSAIDS  within the duration of last 6 months. This study was conducted by the team of trained doctors and medical students who explained everything to the respondents in the case of any confusion. Patients were inquired about GERD and screening questions were asked from them i.e. presence of retrosternal burning, burning of throat`s back, sour / bitter taste, symptoms of GERD after meal, simultaneously, they were asked about the symptoms of GERD two or more than two times in week. Two or more "Yes" for asked questions was interpreted as the presence of symptoms of GERD. On the basis of presence or absence of gastroesophageal reflux symptoms (GERD) the respondents were divided into two groups. The variables i.e.  age, gender, geographical background, education, eating habits, frequency of meals, GERD symptoms, BMI, hip waist circumference, hip waist ratio, height waist ratio were recorded by the researcher on already designed Performa/questionnaire . The questionnaire was already validated and as well as translated in local language for the study which was conducted at the department of gastroenterology (medicine) in 2005 at Agha Khan University Hospital11. Exclusion criteria were strictly followed so that the confounding variables could be avoided.

Statistical analysis: The obtained data was analyzed by using the commonly used software i.e. statistical package for social sciences (SPSS) version 22. At the very first the descriptive statistics was used for the analysis. Frequency distribution i.e. counts and percentages were reported. The whole data was presented by using the mean + standard deviation. The level of statistical significance of comparison of means was investigated by using chi square and t-test and Fisher`s exact formula. 5% statistical significance i.e. p—value = 0.05 was considered.

RESULTS

Total 2191 participants were included in our study. 1130 patients (51.6%) were male and 1061 (48.4%) were females, with mean age of 33.92+12.36 years.

In our study GERD symptoms were present in 760 patients (34.7%), as shown in Table-1

Table No.1: Frequency distribution of total number of study participants and gender

Total number of study participants

Frequency (n)

Percentage (%)

Gerd present

760

34.7%

Gerd not present

1431

65.3%

Gender

 

 

Male

1130

51.6%

Female

1061

48.4%

Table No. 2: Frequency distribution of age, bmi, waist hip ratio, waist height ratio and waist circumference

Variables

Min.

Max.

Mean+sd

Age years

18

87

33.92+12.36

Bmi

18

41.88

24.09+3.98

Waist hip ratio

0.67

3.95

0.90+0.15

Waist height ratio

0.36

0.92

0.52+0.07

Waist circumference ratio

66

140

84.57+10.92

Table No. 3: Frequency distribution of ethnicity, education level and occupation

Ethnicity

Frequency (n)

Percentage(%)

Punjab

351

16%

Sindh

332

15.2%

Kpk

256

11.7%

Urdu speaking

1150

52.5%

Balochistan

111

4.8%

Education level

Graduate

1068

48.7%

Inter pass

320

14.6%

Middle pass + matriculation

415

18.9%

Illitrate

388

17.7%

Table No.4: Frequency distribution of frequency of GERD symptoms

Uncomfortable feeling behind the sternum

Frequency (n)

Percentage (%)

Yes

944

43.1%

No

1247

56.9%

Burnining back of throat

Yes

528

24.1%

No

1663

75.9%

Bitter taste of mouth

Yes

577

26.3%

No

1614

73.3%

Symptoms after meal

Yes

856

39.1%

No

1335

60.9%

Two or more times gerd symptoms/week

Yes

460

21%

No

1731

79%

Temporary relief with proton pump inhabitor and h2 receptor blocker

Yes

507

23.1%

No

1684

76.9%

       

The majority of subjects 1150 (52.5%) included in our study were Urdu speaking people, 351 (16%) were Punjabi, 332 (15.2%) were Sindhi, 256 (11.7%) were pathan and 111 (4.8%) were Balochi as in table I.

Regarding education status in our study, majority of patient were 1068 (48.7%) were graduate, 388 (17.7%) were illiterate, 320 (14.6%) were intermediate pass and 415 (18.9%) were middle pass / matriculation pass.

 The mean BMI was 24.09+3.98 kg/m2, the mean Waist hip ratio was 0.90+0.15 cm, the mean Waist height ratio was 0.52+0.07cm and the mean waist circumference ration was 84.57+10.92 cm as shown in table 2.

History of fixed meal was observed in 706 patients (32.2%), spicy meal 816 (37.2%), cold drink in 158 (7.2%) and history of chocolate was seen in 80 patients (3.7%), as shown in Table-5.

GERD symptoms e.g. uncomfortable feeling behind breast bone moving upward were observed in 944 (43.1%) patients, burning back of throat in 528 (24.1%), bitter taste in mouth in 577 (26.3%), symptoms after meal in 856 (39.1%), as shown in Table-4

Two or more time GERD symptoms per week were observed in 460 patients (21%), temporary relief with medicine was observed in 507 (23.1%), as shown in Table-4.

GERD symptoms were more common in graduates and in Urdu speakers and patients taking spicy meals. GERD is significantly associated with  increased Waist hip ratio and waist height ratio.

Table No. 5: Frequency distribution of aggregating factors

Aggregating factors

Fixed meal

Frequency (n)

Percentage (%)

Yes

706

32.2%

No

1485

67.8%

Spicy meal

Yes

816

37.2%

No

1375

62.8%

Cold drink

Yes

158

7.2%

No

2033

98.8%

Chocolate

Yes

80

3.7%

No

2111

96.3

       

 Table No. 6: Frequency distribution of GERD

 

 

Univariate analysis

Multivariate analysis

BMI

Confidence Interval (Ci)

P-value

Confidence interval(ci)

P-value

18-23

1

 

1

 

23-25

1.25(0.99-1.56)

0.051

1.11(0.88-1.4)

0.39

>25

1.70(1.38-2.09)

0.001

1.15(0.88-1.51)

0.32

Waist circumference

 

 

 

 

<90 cm

1

 

1

 

91-100 cm

1.24(0.97-1.60)

0.09

0.74(0.55-1.01)

0.06

> 101

1.90(1.41-2.54)

0.001

0.91(0.58-1.42)

0.66

Waist hip ratio

 

 

 

 

<0.90

1

 

1

 

0.91-1.00

1.47(1.22-1.77)

0.001

1.38(1.14-1.68)

0.001

>1.01

2.35(1.71-3.80)

0.001

2.15(1.42-3.25)

0.001

Waist height ratio

 

 

 

 

<0.50

1

 

1

 

0.51-0.6

1.67(1.38-2.02)

0.001

1.59(1.24-2.02)

0.001

>0.61

2.16(1.63-2.87)

0.001

2.06(1.30-3.27)

0.002

 

 

DISCUSSION

GERD is an unremitting disease of multi-factorial etiology in which genetic and environmental factors play a pivotal; role. It was shown in global studies that different anthropometric measurements were studied for GERD, that included Hip circumference grips, BMI, Waist circumference grips along with other factors like Age, Education level, Socioeconomic status. In most but not in all studies11,12. positive relation between GERD and age have been kept under consideration. The relationship between GERD symptoms and gender are mixed in present evidences. But in most of the studies this association has not been shown13. In our study GERD symptoms were present in 34.7% patients actively employed in a job as compare to 18.1% prevalence of GERD symptoms in another study. No association was found with socioeconomic conditions in our study as compared to a previously conducted study which indicated association between GERD symptoms and the socioeconomic status14.

 In our study GERD symptoms were common in graduates which is similar to one pervious study showing the prevalence of the GERD symptoms greater in the respondents having higher educational level; it was 34.1% in the graduate respondents. The association of both was highlighted as the inverse association; especially for those respondents with lower educational level15.This association can be explained by the fact that the greater the educational level of an individual more will be the level of perception of stress by these individuals, secondarily these people are more likely to be employed in sedentary desk jobs

In our study GERD symptoms were seen more in males (20.5%) as compared to females (15.2%), the previous literature did not highlight any difference regarding the relationship of GERD and obesity in terms of gender [23].  In relation to age   (17.6%) observed in age group of 31-50 years. This is the most active age group where an individual is exposed to more stress as well as the body starts losing the lithe form and tends to accumulate abdominal fat 

Higher prevalence of GERD symptoms i.e. 23% were documented in the respondents with body mass index (BMI) i.e. 23-27.4 kg/m2. Those Respondents having overweight and normal BMI, GERD was commonly found as compared to patients with BMI above 28, high lighting the fact that overall obesity is not as important a risk factor than central obesity  this is in accordance with another study  which showed that central obesity seemed a more  important factor than overall obesity18. However many previously conducted studies have indicated the relationship between GERD symptoms and higher level of BMI16,17. Increased inner abdominal pressure probably is the explanation of relationship of GERD with body mass index (BMI) and especially central obesity19,21. Although, other mechanisms also seemed to be there which contribute in this relationship i.e. lower pressure of esophageal sphincter in fat individuals20,21. Exposure of esophageal acid has been positively correlated with body mass index (BMI)20 as well as waist circumference22. The clear relationship of GERD and obesity has been indicated in the western countries23. But in this study the relationship between generalized obesity and GERD was not found. Inconsistent results have been concluded from the population based studies of China on the relationship between GERD and BMI24.The association of GERD and abdominal fat  was assessed in the study conducted by Chen et al; but no significant relationship between central obesity and reflux symptoms was found25. However our study is showing only association of central obesity with GERD rather than generalized obesity This study found the significant inverse association between GERD symptoms with waist hip ratio and waist height ratio. More longitudinal studies on this issue are required to be conducted.

CONCLUSION

In conclusion GERD is common in our population and there is significant inverse association of GERD with Waist hip ratio and Waist height ratio. Thus abdominal obesity rather than generalized obesity was more prominent risk factor in our population.

 

Author’s Contribution:

Concept & Design of Study:

Shahid Karim

Drafting:

Syeda Nosheen Zehra, Hamid Ali Kalwar

Data Analysis:

Afsheen Faryal, Muhammad Tanweer Khalid

Revisiting Critically:

Shahid Karim

Final Approval of version:

Shahid Karim

Conflict of Interest: The study has no conflict of interest to declare by any author.

REFERENCES

1.     DeVault KR, Castell DO. American College of Gastroenterology. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol 2005;100:190-200.

2.     Friedenberg FK, Hanlon A, Vanar V, Nehemia D, Mekapati J, et al. Trends in gastroesophageal reflux disease as measured by the National Ambulatory Medical Care Survey. Dig Dis Sci 2010;55:1911–1917.

3.     Ness-Jensen E, Lindam A, Lagergren J, Hveem K. Changes in prevalence, incidence and spontaneous loss of gastro-oesophageal reflux symptoms: a prospective population-based cohort study, the HUNT study. Gut 2012;61:1390–1397.

4.     Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterol 2012;143: 1179–1187

5.     Goh KL, Chang CS, Fock KM, Ke M, Park HJ, Lam SK. Gastro-oesophageal reflux disease in Asia. J Gastroenterol Hepatol 2000;15:230-8.

6.     Fazel M, Keshteli AH, Jahangiri P, Daneshpajouhnejad P, Adibi P. Gastroesophageal Reflux Disease in Iran: SEPAHAN Systematic Review No. 2. Int J Prev Med 2012;3:S10–S17.

7.     Fass R, Sifrim D. Management of heartburn not responding to proton pump inhibitors. Gut 2009; 58(2):295-309. 

8.     Pandeya N, Green AC, Whiteman DC. Prevalence and determinants of frequent gastroesophageal reflux symptoms in the Australian community. Dis Esophagus 2012;25:573–583.

9.     Matsuki N, Fujita T, Watanabe N, Sugahara A, Watanabe A, et al. Lifestyle factors associated with gastroesophageal reflux disease in the Japanese population. J Gastroenterol 2013;48:340–349.

10.            Somi MH, Farhang S, Nasseri-Moghadam S, Jazayeri ES, Mirinezhad SK, et al. Prevalence and risk factors of gastroesophageal reflux disease in Tabriz, Iran. Iran J Public Health 2008;37: 85–90

11.            Moayyedi P, Talley NJ. Gastro-oesophageal reflux disease. Lancet 2006;367: 2086–2100

12.            Locke GR III, Talley NJ, Fett SL, Zinsmeister AR, Melton LJ III. Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterol 1997;112: 1448–1456.

13.            Nusrat S, Nusrat S, Bielefeldt K. Reflux and sex: what drives testing, what drives treatment? Eur J Gastroenterol Hepatol 2012;24:233–247.

14.            Jansson C, Nordenstedt H, Johansson S, Wallander MA, Johnsen R, et al. Relation between gastroesophageal reflux symptoms and socioeconomic factors: a population-based study (the HUNT Study). Clin Gastroenterol Hepatol 2007;5: 1029–1034

15.            Nocon M, Keil T, Willich SN. Prevalence and sociodemographics of reflux symptoms in Germany–results from a national survey. Aliment Pharmacol Ther 2006;23:1601–1605.

16.            El Serag H. The association between obesity and GERD: a review of the epidemiological evidence. Dig Dis Sci 2008;53: 2307–2312.

17.            Eslick GD. Gastrointestinal symptoms and obesity: a meta-analysis. Obes Rev 2012l13: 469–479.

18.            Singh S, Sharma AN, Murad MH, Buttar NS, El Serag HB, et al. Central Adiposity is Associated with Increased Risk of Esophageal Inflammation, Metaplasia, and Adenocarcinoma: a Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2013;11: 1399–1412.

19.            Ayazi S, Demeester SR, Hsieh CC, Zehetner J, Sharma G, et al. Thoraco-abdominal pressure gradients during the phases of respiration contribute to gastroesophageal reflux disease. Dig Dis Sci 2011;56: 1718–1722.

20.            Derakhshan MH, Robertson EV, Fletcher J, Jones GR, Lee YY, et al. Mechanism of association between BMI and dysfunction of the gastro-oesophageal barrier in patients with normal endoscopy. Gut 2012;61: 337–343

21.            Anggiansah R, Sweis R, Anggiansah A, Wong T, Cooper D, et al. The effects of obesity on oesophageal function, acid exposure and the symptoms of gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2013;37: 555–563

22.            Robertson EV, Derakhshan MH, Wirz AA, Lee YY, Seenan JP, et al. Central obesity in asymptomatic volunteers is associated with increased intrasphincteric acid reflux and lengthening of the cardiac mucosa. Gastroenterol 2013;145: 730–739.

23.            Corley DA, Kubo A, Zhao W: Abdominal obesity, ethnicity and gastro-oesophageal reflux symptoms. Gut 2007;56:756-762.

24.            He J, Ma X, Zhao Y, Wang R, Yan X, Yan H, , et al: A population-based survey of the epidemiology of symptom-defined gastroesophageal reflux disease: the systematic investigation of gastrointestinal diseases in China. BMC Gastroenterol 2010;10: 94-10.

25.            Chen T, Lu M, Wang X, Yang Y, Zhang J, Jin L, Ye W. Prevalence and risk factors of gastroesophageal reflux symptoms in a Chinese retiree cohort. BMC Gastroenterol 2012;12(1):161.