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OESO©2015
 
Volume: The Esophageal Mucosa
Chapter: Epidemiology
 

What is the frequency of gastroesophageal reflux in young subjects?

JM. Debonne, P. Berthezene, F. Klotz, J.C. Grimaud, J.P. Durbec (Marseilles)

Gastroesophageal reflux disease (GERD) represents a major health problem in the industrialized countries due to its frequency and economic cost. Even though modern digestive functional exploration methods have brought improvements in the understanding of its physiopathology and symptomatology, there are still some technical

difficulties in the study of its epidemiology, such as the choice of diagnostic criteria, of the methods of data collection and of the samples to be studied [1]. Moreover, the complexity and multifactorial nature of its pathogenesis also limits the possibilities of using epidemiological studies to look for extrinsic and intrinsic factors. For all these reasons, we felt it would be interesting to study the main features of heartburn in the young adult using simple standardized criteria on a perfectly defined large homogeneous sample. The aims of the study were to study the prevalence of heartburn in a changing population of young men embarking on military service, to describe its main characteristics and to look for determinant factors through descriptive and analytic statistical analysis.

Population and Methods

Population

During the Army medical examinations in February, April and June 1990, 6,397 young French men conscripted for military service were questioned about any functional digestive symptoms they may have. The interview was performed on an individual basis by a team of physicians and nurses and included around 100 multiple choice and closed questions. The main question used to identify and quantify heartburn was: "Have you ever felt burning going up into the chest from the stomach sometimes with an acid taste in the mouth?". A further question specifying the daily, weekly or monthly frequency was asked for any positive replies to the first question. Those with occasional heartburn (less than once a month) were considered negative. All those taking part in the study had to reply to all the questions relating to their socioeconomic (geographic origin, social status, profession and family details) and physiological details (age and body mass index (BMI) = weight in kg/height in m2), the state of their physical and mental health, family and personal history, any digestive or nondigestive symptoms they may have, their alcohol and tobacco consumption, a rough outline of their usual diet and the number of times they had sought medical advice.

Analysis of the results

The relationship between heartburn and the various items studied was analyzed using frequency tables and the distributions compared by the Chi2 test together with calculation of the coefficient Phi (VChi™/VN, varying ± 1). Phi enabled a comparison to be made of the extent to which heartburn was related to the variables being studied. Here we only describe the analysis of the results of this bivariate analysis. The results of the multivariate study with an analysis of any associations between the various factors and stepwise conditional logistic regression, which is described in detail in the reference article [2], are not presented here. This noninvasive study was performed with the consent of the participants and of the Army Health Department.

Table 1. .Frequency of the features of heartburn

H1a

H2b

H3C

Total

x2

N

75 (100)

217 (100)

447(100)

739 (100)

Continuous

45 (61.6)

139 (64.4)

148 (45.2)

382 (52.6)

s

Occurring at night

22 (29.3)

66 (30.4)

94 (21)

182(24.6)

NS

Bending down

27 (36)

62 (28.6)

130(29)

219 (29.6)

NS

Effort

40 (53.3)

99 (45.6)

178 (39.8)

317 (42.9)

NS

Meals

55 (73.3)

124 (59.4)

275 (61.5)

459(62.1)

NS

Numbers in parentheses represent percentage; aH1: daily heartburn; bH2: weekly heartburn; CH3: monthly heartburn.

Results

A total of 6,385 completed questionnaires were suitable for analysis. The mean age of the participants was 19.6 ± 2.9 years, and they were from all over France, especially from the Southeast region.

The number of participants who admitted having heartburn was 11.57% (739/6,385). In 75 of them (P1 = 1.17%) heartburn occurred daily, in 217 (P2 = 3.4%) weekly and in 447 (P3 = 7%) monthly. In addition, 1,148 (18%) said that they had occasionally experienced heartburn, whereas 4498 (70.45%) had never had it. Of 6,385 participants, 1,133 (17.74%) stated that they had acid regurgitation, but 810 (12.68%) did not have heartburn. Therefore 24.24% of the people questioned had symptoms suggestive of GERD (heartburn and/or acid regurgitation). Fifty-three percent of these suffered the symptoms continually throughout the year (Table 1), especially in more severe cases. The rest only had heartburn from time to time. The symptoms occurred at night (25%) or after meals (62%), were brought on by certain postures (30%) or by effort (43%) irrespective of the frequency of the symptom. Twenty-nine percent had also consulted for this condition, of whom 41% had already been investigated, 28% had followed a diet and 69% had been prescribed medical treatment. Another 26% had already treated themselves with medicines (Table 2). Overall 4.8% of all those interviewed stated that they were troubled by this symptom

Table 2. .Heartburn and treatment

aHI

bH2

CH3

Total

N

75 (100)

217 (100)

447 (100)

739(100)

Consultation

36 (49)

67(31)

111 (25)

216 (29)

Investigations

25 (33)

23(11)

41 (9)

89(12)

Diet

17 (23)

24(11)

20 (4.5)

61 (8)

Medication

32 (43)

45 (21)

72 (16)

149 (20)

Self medication

17 (23)

66 (30)

111 (25)

194 (26)

Significant discomfort

50 (66.7)

105 (48.4)

152 (34)

307(41.5)

Numbers in parentheses represent percentage; aHI: daily heartburn; bH2 weekly heartburn; CH3 monthly heartburn.

and 3.4% had already sought treatment.

Bivariate analysis did not show any link between heartburn and socioeconomic factors, age or body mass index. There was, however, a significant association between heartburn and respiratory and otorhinolaryngological disorders, thoracic pain and digestive symptoms. Also, those who complained of having heartburn had the highest frequency of other psychological problems and had the greatest tendency to mention various other problems that they had (Fig. 1). With respect to diet, bivariate analysis revealed a weak but significant association between heartburn and the consumption of alcohol, fizzy and/or sweet drinks, coffee, fat and spices. There was a slightly stronger association for tobacco or a sedentary lifestyle (Fig. 2).

Discussion

The results of studies looking into the epidemiology of GERD [3-9] should be interpreted in the light of the population studied and the methods employed. This makes any direct comparison of results difficult. We studied young men embarking on military service. This created an important bias because anyone who was exempted form military service was not included in the study. Because of this, a similar questionnaire was performed at the Army Selection Center to which almost the entire young male French population is called up, to see if they are fit for military service. Amongst the 500 people questioned, the prevalence of heartburn was 11%, not very different from that which was obtained with the questionnaire at the time of incorporation. Our results can therefore be taken as representative of the 18 to 22 year-old age group, rarely studied in the literature.

0011F1.JPG

Figure I. .Frequency of associated disorders in the presence or absence of heartburn.

0011F2.JPG

Figure 2. .Frequency of dietary factors in the absence and presence of heartburn.

The considerable homogeneity and large size of this group are two features which make this study a useful and original contribution to research into heartburn. The percentage of the sample who reported having heartburn at least monthly was 11.6% which is lower than the rates described in the literature (Table 3). Apart from the sampling methods, these differences could be explained by the diversity of symptoms studied and the way the data was collected. Our main criterion was heartburn, a symptom which is simple to describe, specific to GERD and very often causes people to seek medical help. Using the same criteria, Nebel [6] obtained a larger prevalence of heartburn (36%) in his controls who had not consulted for this symptom. Nebel [6], Smart [8], Welch [9], Ruth [7] and Thompson [10] also quantified heartburn according to its frequency. The first three of these authors found 7, 7 and 8.5%,

Table 3. .Prevalence of heartburn in the literature

Year

Author

N

aRep

bDS

cMethod

Rate

Ref

1976

Nebel

335

NR

H

Q

36%

(6)

1981

Kjellen

2095

NR

H/A

SQ

16%

(5)

1986

Bommelaer

1200

NR

H

SQ

38.5%

(3)

1986

Smart

150

NR

H/A

Q

26%

(8)

1988

Bruley

1798

R

A

Q

27.1%

(4)

1990

Welch

285

NR

H/A

Q

20%

(9)

1991

Ruth

337

NR

H/A

SQ

26%

(7)

a REP : NR = non representative, R = representative; b DS: digestive symptoms, H = heartburn, A acid regurgitation;c Method: Q= direct questionnaire, SQ= self questionnaire.

respectively, of their patients to be suffering from heartburn daily compared with 3% for Ruth, 4% for Thompson and 1.2% in this study. If acid regurgitation is included in heartburn, the prevalence of symptoms suggestive of GERD reaches 25%, this being similar to data found in the literature. Heartburn is a frequent reason, even amongst young men, to seek medical advice. This is confirmed by the literature where GERD is considered as one of the main reasons for gastrointestinal endoscopy [2], for a gastroenterological opinion [11-13] or for self-medication [14]. In our sample, as a result of the consultation, four out of 10 cases needed further investigation and seven out of 10 began medical treatment. The economic consequences are even more important because it is a chronic illness often treated by self-medication.

We did not find a clear association between heartburn and the socioeconomic factors studied. The strong link between heartburn and gastrointestinal and nongastrointestinal, respiratory and otorhinolaryngological symptoms does not have any bearing on the pathophysiology of this condition because as our study showed, these patients have a tendency to somatize and to complain of a large number of symptoms. We did not find that excess weight had an influence, although the body weights in our sample were very evenly distributed around the normal value for age and sex (BMI = 22). Heartburn does, however, tend to be more frequent towards the extreme limits (BMI >23 or < 21). We noted a strong link between heartburn and certain psychological disorders, mostly severe anxiety, adaptation difficulties and immaturity. These people also had a marked tendency to somatize their symptoms as for example in irritable bowel syndrome. The relationship between GERD and psychological disorders has been emphasized recently by other authors [15,16].

The relationship between heartburn and dietary factors was studied using a preliminary bivariate analysis. This type of analysis, which has already been employed in the literature, often shows multiple significant associations, although these are usually of limited clinical interest [4,6,7,12,13,17-23]. The influence of alcohol and tobacco consumption remains unclear, whereas dietary factors, which have not been studied much, would appear to have an influence, for example fats as well as sugar, coffee, spices and tea, although these have not yet been sufficiently documented in the literature. Our results confirm most of these findings although they emphasize that the associations are weak, except for tobacco consumption and a sedentary lifestyle which are more strongly linked. The extent to which these factors are linked to heartburn is specified by descriptive and analytical multivariate analysis [2].

In conclusion, gastroesophageal reflux disease is, in its usual symptomatic form, a frequent finding in young men. The prevalence that we found was lower than in previous studies of the general population, but this may well be due to the different methods used and to the age of those studied. Even in this age group, many seek medical help for heartburn, which is often associated with dietary factors and a certain psychological pattern, something that would doubtless be worth clarifying by further studies.

References

1. Howard PJ, Heading RC. Epidemiology of gastroesophageal reflux disease. World J Surg 1992; 16:288-293.

2. Debonne JM. Le pyrosis et l'homme jeune. Etude ‰pid‰miologique et analyse statistique multivari‰e de 6385 sujets. M‰moire de DEA, Marseille, 1991.

3. Bommelaer G, Rouch M, Dapoigny M et al. Epid‰miologie des troubles fonctionnels intestinaux dans une population apparemment saine. Gastroenterol Clin Biol 1986;10:7-12.

4. Bruley des Varannes S, Galmiche JP, Bernades P, Bader JP. Douleurs ‰pigastriques et regurgitations: ‰pid‰miologie descriptive dans un ‰chantillon repr‰sentatif de la population fran‡aise adulte. Gastroenterol Clin Biol 1988;12:721-728.

5. Kjellen G, Tibbling L. Manometric oesophageal function, acid perfusion test and symptomatology in a 55 year old general population. Clin Physiol 1981;l:405-415.

6. Nebel OT, Fornes MF, Castell DO. Symptomatic gastroesophageal reflux: incidence and precipitating factors. Am J Dig Dis 1976;ll:953-956.

7. Ruth M, Mansson I, Sandberg M. The prevalence of symptoms suggestive of esophageal disorders. Scand J Gastroenterol 1991:26:73-81.

8. Smart HL, Nicholson DA, Atkinson M. Gastro-oesophageal reflux in the irritable syndrome. Gut 1986:27:1127-1131.

9. Welch WG, Pomare EW. Functional gastrointestinal symptoms in a Wellington community sample. N Zealand J Med 1990; 418-420.

10. Thompson WG, Heaton KW Heartburn and globus in apparently healthy people. J Can Med Assoc 1982;126:46-48.

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14. Graham DY, Smith JL, Patterson DJ. Why do apparently healthy people use antacid tablets? Am J Gastroenterol 1983; 78:257-260.

15. Johnston BT, Lewis SA, Love AHG. Patients with heartburn have a specific personality profile. Gut 1992;33:S36.

16. Scarinci IC, Schan CA, Halle JM. Psychological distress and health care seeking behavior among persons with symptoms of gastroesophageal reflux disease. Gastroenterology 1992;102:A509.

17. Carteret E, Pasqual JC, Renard P, Zeitoun P. Fr‰quence et facteurs prognostiques de I'oesophagite par reflux. Gastroenterol Clin Biol 1988;l2(suppl 2B):A44.

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19. Micaleff A, Richard-Berthe C, Huyghe JL. Oesophagite de reflux: r‰sultats d'une enquŠte ‰pid‰miologique et endoscopique chez 679 patients, r‰alis‰e par 146 gastroent‰rologues de ville. Med Chir Dig 1985;(special issue):8-14.

20. Stene-Larsen G, Weberg R, Froyshov Larsen I et al. Relationship of overweight to hiatus hernia and reflux oesophagitis. Scand J Gastroenterol 1988;23:427-432.

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Publication date: May 1994 OESO©2015