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    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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Functional Gastrointestinal Disorders in Young Military Men

Chang Seok Bang*, Yeon Soo Kim*, Jin Hyung Han, Yong Sub Lee*, Gwang Ho Baik*, Jin Bong Kim*, Ki Tae Suk*, Jai Hoon Yoon*, and Dong Joon Kim*

*Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea

Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea

Correspondence to: Gwang Ho Baik, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 77 Sakju-ro, Chuncheon 200-704, Korea, Tel: +82-33-240-5821, Fax: +82-33-241-8064, E-mail: baikgh@hallym.or.kr

Received: March 26, 2014; Revised: May 1, 2014; Accepted: May 4, 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2015;9(4):509-515. https://doi.org/10.5009/gnl14109

Published online December 5, 2014, Published date July 31, 2015

Copyright © Gut and Liver.

Background/Aims

To estimate the prevalence and evaluate the associated psychological factors of functional gastrointestinal disorders (FGIDs) in males in their twenties who are currently enrolled in military service.

Methods

A total of 1,073 men in the Korean army were asked to complete questionnaires based on the Rome III criteria and Symptom Checklist-90-revised (SCL-90R). The prevalence of FGIDs was estimated, and the associated psychological factors were evaluated.

Results

A total of 967 men participated. The total prevalence of FGIDs was 18.5% (age-adjusted prevalence, 18.1%; 95% confidence interval [CI], 15.3% to 20.8%). The total SCL-90R scores were higher in men with FGIDs than men without FGIDs (24 [interquartile range, 13 to 44] vs 13 [5 to 28], p<0.001) and higher in men with overlapping syndromes than in those with single FGIDs (31 [18 to 57] vs 14 [5.75 to 29], p<0.001). Somatization (odds ratio [OR], 1.141; 95% CI, 1.09 to 1.20; p<0.001), obsessive-compulsive behaviors (OR, 1.084; 95% CI, 1.03 to 1.14; p=0.002) and depression (OR, 0.943; 95% CI, 0.90 to 0.99; p=0.020) were identified as independent predictive factors for FGIDs.

Conclusions

FGIDs are common among men in their twenties who are fulfilling their military duty. Somatization and obsessive-compulsive features from the tense atmosphere are associated with the development or progression of FGIDs. Patients who exhibit overlapping syndromes require greater attention given their more severe psychopathology.

Keywords: Gastrointestinal diseases, Military, Psychologic factors

Functional gastrointestinal disorders (FGIDs) are commonly observed in clinical practice.1 Patients complain a variety of symptoms, as these disorders result in a great burden in terms of quality of life and health care expenditures.2 The Rome criteria, which are based on symptom clusters, are currently used to diagnose FGIDs.3 This metric was updated in 2006, as the Rome III version, and 28 disorders are included in these criteria.4 There have been studies estimating the prevalence of FGIDs using Rome III criteria in Korea;5,6 however, the exact prevalence and pathophysiology of FGIDs remain unclear.

Young soldiers, who are highly trained and submitted to strictly imposed discipline, tend to face more serious stress than the general population. All Korean males in their twenties who do not have a serious disability have an obligation to fulfill a term of military service. However, studies on FGIDs investigating this population are lacking.

The aim of this study was to estimate the prevalence and evaluate the associated psychological factors of FGIDs among males in their twenties currently completing military service.

1. Ethics statement

This study was conducted according to the principles expressed in the Declaration of Helsinki. Voluntary participation was requested, and written informed consent was obtained from each participant. This study was approved by the Institutional Review Board of the Armed Forces Medical Command of Korea before initiation of this study (AFMC-13-IRB-010).

2. Patients and methods

Between January and May 2013, a total of 1,073 participants from eight different regiments of three different divisions of Republic of Korea Army were asked to complete questionnaires based on the Rome III criteria and Symptom Checklist-90-revised (SCL-90R). The three divisions were located in the Gangwon, Gyeonggi, and Chungcheongnam provinces of Korea, respectively. The study population included male soldiers in their twenties who participated voluntarily. The survey was performed face-to-face in the military at doctors’ offices by three military doctors (C.S.B., J.H.H., and Y.S.L.). The prevalence of FGIDs was estimated, and all associated psychological factors were evaluated using the Rome III criteria and a SCL-90R based questionnaire. Participants who were positive for alarm symptoms during the screening for organic diseases or who presented an incomplete questionnaire were excluded from this study.

3. Questionnaires

This study was conducted using a self-reported questionnaire. The Korean version of a Rome III criteria-based questionnaire was produced according to the following steps: (1) independent translations of the original version of the Rome III criteria by two native speakers of Korean who are fluent in English; (2) comparison of the two versions of the questionnaire with the two translators making adjustments for better understanding to create a reconciled version; (3) evaluation of the questionnaire by three internal medicine doctors, followed by revision until interobserver agreement was achieved and its use was approved in soldiers; and (4) administration of a pretest to 300 soldiers in three different regiments to detect unrecognized errors, which were corrected in the final version. The questionnaire consisted of 86 queries, including 75 Rome criteria-based questions, seven alarming symptom questions, and four demographic information questions. Alarm symptoms included unintentional weight loss, blood in the stool, a history of organic bowel disease or intestinal surgery, unexplained anemia or fever, and awakening due to abdominal pain during the night time.

The SCL-90 is a questionnaire that was developed in 1973 to assess psychological distress for clinical practice and research purposes.7 The Korean version of the SCL-90R was created and validated in 1984.8 This 5-point Likert-scale questionnaire consists of 90 queries, and each question represents a single psychological symptom. Using this questionnaire, the psychological symptoms can be classified into nine categories (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism), and the global severity can be assessed. The scores of global severity and of each category are expressed as t scores.8,9

4. Sample size

Based on a study of Chinese college and university students,10 representing the same age groups that are in our study, a sample size was calculated. According to that study, the prevalence of FGIDs among males was estimated at 20.4%. The authors assumed that the total prevalence of FGIDs in the military would be 25%; thus, the sample size was calculated with 80% power at a two-sided p-value of 0.05 and a drop rate of 10%. A minimum sample size of 700 was required.

5. Statistical analysis

Continuous data are expressed as the medians and the inter-quartile ranges, and categorical data are given as the frequencies (percentages). The Mann-Whitney test and Fisher exact test were used to evaluate the baseline characteristics and to compare the SCL-90R scores (soldiers with FGIDs vs without FGIDs/soldiers with overlap syndrome vs single FGIDs), because of the nonnormal distribution of the data. Age-adjusted prevalence of FGIDs was calculated with the population in 2010 Korean Census as the standard population (classified and weighted by 5-year age interval). A multivariate logistic regression test was used to detect the independent psychological risk factors associated with FGIDs. A p-value <0.05 was considered statistically significant for all tests. The analysis was performed using the SPSS software version 18.0 (SPSS Inc., Chicago, IL, USA).

1. The characteristic of enrolled population

Of the 1,073 soldiers who took the questionnaire, 106 men submitted incomplete questionnaires and were excluded from this study. A total of 967 men participated, for a response rate of 90.1%. The median age was 21 years (interquartile range, 20 to 21 years), and the proportions of smokers and alcohol drinkers were 49.4% and 72.2%, respectively. The median body mass index (BMI) was 22.2 (interquartile range, 20.8 to 24). The characteristics of the total enrolled soldiers are listed in Table 1.

2. The prevalence and spectrum of FGIDs

The total prevalence of FGIDs was 18.5% (n=179). The age-adjusted prevalence of FGIDs was 18.05% (95% confidence interval [CI], 15.3% to 20.8%) (Table 2). The proportions of each FGID were as follows: functional dyspepsia (FD) (8.2%), functional chest pain (FCP) (5.1%), functional heartburn (FH) (2.8%), irritable bowel syndrome (IBS) (2.6%), and functional dysphagia (2.6%). The prevalence of each FGID in soldiers is shown in Table 3.

Among soldiers with functional dyspepsia, a subtype of postprandial distress syndrome (PDS) was more prevalent than epigastric pain syndrome (EPS) (n=78 vs 1). In the subtype of IBS, diarrhea-type IBS was most prevalent (n=10), followed by mixed (n=9), constipation type (n=3), and unsubtyped IBS (n=3) (Table 4).

3. Overlap syndrome

Among the 179 soldiers with FGIDs, 53 soldiers (29.6%) had combined FGIDs, that is, meeting the criteria for more than one disease category (5.5% of total population). The most prevalent combination was FD with FH and FCP (n=7, 3.9% of all FGIDs), followed by FD+FCP (n=6, 3.3% of all FGIDs) and FD+IBS (n=5, 2.8% of all FGIDs). FD, FH, FCP, and IBS were the prevalent components of such combinations (Table 5).

4. Psychological factors

The total SCL-90R score, which indicates a global severity, was 24 (13 to 44) in soldiers with FGIDs, which was significantly higher than 13 (5 to 28) found in soldiers without FGIDs (interquartile range). All nine categories of psychopathologic variables showed a higher score in soldiers with FGIDs than without FGIDs (Table 6).

In the analysis of overlapping syndromes, the total SCL-90R score showed a significantly higher score in soldiers with overlapping syndromes than in soldiers with single FGIDs (31 [18 to 57] vs 14 [5.75 to 29], p<0.001). The scores of all of the psychopathologic variables were also higher in soldiers with overlapping syndromes than in those with single FGIDs (Table 7).

Multivariate logistic regression analysis was performed to assess the associated psychological factors of FGIDs. The factors of somatization (odds ratio [OR], 1.141; 95% CI, 1.09 to 1.20; p<0.001), obsessive compulsive behaviors (OR, 1.084; 95% CI, 1.03 to 1.14; p=0.002), and depression (OR, 0.943; 95% CI, 0.90 to 0.99; p=0.020) were found to be independent predictive factors for FGIDs (model chi-square test, p<0.001; Hosmer-Lemeshow’s goodness-of-fit test, p=0.09) (age, smoking, alcohol, BMI, and psychopathologic variables of SCL-90R adjusted) (Table 8).

FGIDs are prevalent in the general population.1 According to epidemiologic studies of IBS, which is the most widely investigated FGID, the prevalence of IBS is estimated to range from 3% to 27%, considering differences in race and study methodology.1119 A recent study in Korea found a prevalence of FGIDs in patients who visited primary clinics and tertiary care hospitals estimated at 49.7%.5 However, studies aiming at young populations are limited. Moreover, there are no data concerning FGIDs in the military.

This population consumes a similar diet and performs regular exercise with controlled life activities. The prevalence of total FGIDs in this population was estimated to be 18.5% in this study (age-adjusted prevalence, 18.1%). This result is lower than that from a study of Chinese air force population (23.5%).20 However, among the 4,170 soldiers, 1,070 officers with higher education and longer years of service were included in that study. Moreover, about 37% of soldiers were aged over 25 (13.1% were in age >35).20 According to the another study of Chinese college and university students of the young age group, the prevalence of total FGIDs was 23%.10 However, considering the fact that FGIDs are more prevalent in females, the results of our study may agree with those of the Chinese study. In a subgroup analysis of the Chinese study, the prevalence of FIGDs in males was 20.4%, whereas that in females was 25.5%.10 Regarding the influence of the military, the strong military discipline instituted daily could cause serious stress, triggering FGIDs more easily than in the general population.21 However, regular diet and exercise, restricting alcohol and eating between meals could act as a positive impact on the development or progression of FGIDs. From a study on the impact of diet on FD, the regular diet group (three meals per day) showed a lower incidence of FD.22 There have been contradictory results about the relationship between obesity and FGIDs.2325 In this study, few obese soldiers were enrolled, and the authors could not find differences in the BMI between soldiers with FGIDs and without FGIDs (Table 1). Overall, FGIDs are prevalent in the military; however, they are not more prevalent than in the general population of the similar age group,10 most likely due to the absence of factors contributing to the development of FGIDs.

In the subtype analysis of FGIDs, FD was the most prevalent disorder (8.2%), followed by FCP (5.1%), FH (2.8%), IBS (2.6%), and functional dysphagia (2.6%) (Table 3). According to a Chinese study on the similar age group, FD showed the highest prevalence at 9.3%, followed by IBS at 8.3% and functional constipation at 5.5%.10 However, this study estimated the prevalence of only three FGIDs, including FD, IBS, and functional constipation. The results of a hospital-based study in Korea were consistent with those of the Chinese study (FD, 46%; IBS, 40.2%), although the overall prevalence was much higher.5 In the present study and the Chinese study, no endoscopic investigation was performed to rule out organic diseases. Only alarm symptoms based the questionnaires were used. Thus, gastroesophageal reflux disease (GERD), which is not included in the Rome III criteria categories, could not be assessed. Regarding GERD patients in Korea, who commonly express symptoms similar to a burning sensation, a substantial portion of FCP and FH patients in this study might overlap with GERD. Cautious interpretations should be made regarding this aspect. The prevalence of IBS in this study was much lower than in the Chinese or Korean studies (2.6%).5,10 The positive impact from dietary and daily activity factors could explain the lower prevalence. However, more studies are needed to identify the factors responsible for this result.

As shown in previous studies, a subtype of PDS was more prevalent than EPS among soldiers with FD (n=78 vs 1).5,10 It has been speculated that the diagnostic criteria for EPS in the Rome III standard were too strict and that patients had difficulty understanding the meaning of the questionnaire with respect to differentiating between epigastric burning and heartburn.5 This problem is expected to be solved in the subsequent revised version of the Rome criteria. Of the subtypes of IBS, diarrhea type IBS was most prevalent (n=10), followed by mixed (n=9), constipation type (n=3), and unsubtyped IBS (n=3); however, the number of patients detected was too small to establish significant differences (Table 3).

In terms of overlapping syndromes, the prevalence was estimated at 5.5% of the total population and 29.6% of the FGID patients from this study. In previous studies, the prevalence has been reported to range from 1% to 17%, not much different from our study.2630 In a recent Korean study, the most common combination was FD+IBS, and the systematic review showed that the pooled OR of IBS in patients with FD was 8 (OR, 8; 95% CI, 5.7 to 11.2).5,31 However, our study showed that FD+FH+FCP (n=7, 3.9% of all FGIDs) was most prevalent, followed by FD+FCP (n=6, 3.3% of all FGIDs) and FD+IBS (n=5, 2.8% of all FGIDs) (Table 5). According to the study of healthy military males from United States, the most common combination of overlap syndrome was IBS+functional constipation.32 Functional constipation was also the most prevalent FGID in that study.32 The reason of the different combinations from studies are unclear. Another consideration is about GERD. FGIDs and GERD presumably share the same pathophysiology.19 However, the exact mechanism and prevalence of each combination is unclear. Regarding the pitfalls stated above in this study regarding GERD, some clinical aspects of GERD might be hidden by the results of this study (soldiers with FH or FCP might be included in GERD), although many other epidemiologic studies have also excluded GERD in the analysis of overlapping syndrome and FGIDs. According to one study on the overlap of GERD and FD, a prevalence of 4% was found in the general population.33 Overall, overlapping syndromes are commonly observed, not only in the general population but also in soldiers.

In agreement with the results of previous studies, psychological distress was associated with FGIDs and overlapping syndromes.5,10,22,28 All components of the SCL-90R showed a higher score in soldiers with FGIDs (than without FGIDs) and overlapping syndromes (than without overlapping syndromes) (Tables 6 and 7). In the multivariate logistic regression analysis to assess the associated psychological factors of FGIDs, the factors of somatization (OR, 1.141) and obsessive compulsive feature (OR, 1.084) proved to be independent risk factors for FGIDs. However, depression (OR, 0.943) revealed a negative relation to FGIDs (Table 8). In a Chinese study of the same age and race group, depression also showed an OR of 0.55, although the 95% CI included 1.0 (95% CI, 0.15 to 1.05; p=0.045).20 According to a study of the brain-gut pathway, which is presumed to be one pathophysiology of the FGIDs, depression was not an independent predictor for developing FGIDs, whereas anxiety was a risk factor.34 The exact reason or mechanism is unclear regarding this issue. More studies are needed to elucidate the association between each of the psychological factors and FGIDs.

There are limitations to this study. First, this study used only self-administered questionnaires without endoscopic investigations. Secondly, the questionnaire used in this study was not validated. At the time of this study, the Korean version of the Rome III questionnaire, which was validated recently, was not available; however, it is currently applicable in clinical practice.35

However, this study is the first epidemiologic study of FGIDs in the Korean military, and subsequent studies which have endoscopic investigation for all participants and survey with validated questionnaire can be planned and executed to better assess this population based on the results of this study.

In conclusion, FGIDs are common among men in their twenties completing military duty. Somatization and obsessive compulsive disorders deriving from the tense atmosphere are associated with the development or progression of FGIDs. Patients who have overlapping syndromes require greater attention due to their more severe psychopathology.

Clinical Characteristics of Total Enrolled Population

CharacteristicTotal (n=967)Soldiers with FGIDs (n=179, 18.5%)Soldiers without FGIDs (n=788, 81.5%)p-value
Age, yr21 (20–21)21 (20–22)21 (20–21)0.01
BMI22.2 (20.8–24.0)22.4 (20.8–24.6)22.2 (20.8–23.9)0.43
Smoking478 (49.4)94 (52.5)384 (48.7)0.36
 Cigarette per day0 (0–10)3 (0–10)0 (0–10)0.24
Alcohol698 (72.2)135 (75.4)563 (71.4)0.31
SCL-90R15 (6–30)24 (13–44)13 (5–28)<0.001

Age-Adjusted Prevalence of Functional Gastrointestinal Disorders

Age class, yrTotal cases of each age classCases with FGIDsPrevalence of FGIDs, %Standard population of Korean Census
15–1910017171,826,179
20–2485015618.41,625,371
25–2916637.51,802,805
30–351001,866,397
Total96717918.5-
Age-adjusted prevalence of FIGDs: 18.1% (95% CI, 15.3%–20.8%)

Proportion of Functional Gastrointestinal Disorders

FGIDsNo. (% of all population)% of FGIDs
Functional dyspepsia79 (8.2)44.1
Functional chest pain49 (5.1)27.4
Functional heartburn27 (2.8)15.1
Irritable bowel syndrome25 (2.6)14.0
Functional dysphagia25 (2.6)14.0
Functional diarrhea20 (2.1)11.2
Functional constipation13 (1.3)7.3
Globus12 (1.2)6.7
Functional bloating10 (1.0)5.6
Proctalgia fugax5 (0.5)2.8
Chronic idiopathic nausea4 (0.4)2.2
Aerophagia3 (0.3)1.7
Cyclic vomiting syndrome3 (0.3)1.7
Rumination syndrome2 (0.2)1.1

Subtypes of Functional Dyspepsia and Irritable Bowel Syndrome

FGIDsNo. (% of all population)% of FGIDs
Functional dyspepsia79 (8.2)44.1
 Postprandial distress syndrome78 (8.1)43.6
 Epigastric pain syndrome1 (0.1)0.6
IBS25 (2.6)14.0
 IBS-C3 (0.3)1.7
 IBS-D10 (1.0)5.6
 IBS-M9 (0.9)5.0
 IBS-U3 (0.3)1.7

Types of Overlapping Syndromes

Overlap syndromeNo. (% of all population)% of FGIDs
Total53 (5.5)29.6
FD+FH+FCP7 (0.7)3.9
FD+FCP6 (0.6)3.3
FD+IBS5 (0.5)2.8
IBS+FCP4 (0.4)2.2
FH+FCP4 (0.4)2.2
FD+IBS+FCP4 (0.4)2.2
FD+FH2 (0.2)1.1
IBS+FH2 (0.2)1.1

SCL-90R Scores: Soldiers with Functional Gastrointestinal Disorders versus without Functional Gastrointestinal Disorders

Psychopathologic variableSoldiers with FGIDs (n=179, 18.5%)Soldiers without FGIDs (n=788, 81.5%)p-value
Somatization4 (2–8)2 (1–4)<0.001
Obsessive compulsive5 (2–9)3 (1–7)<0.001
Interpersonal sensitivity3 (1–6)2 (0–4)<0.001
Depression3 (1–8)2 (0–5)<0.001
Anxiety2 (1–3)1 (0–2)<0.001
Hostility1 (1–3)0 (0–1.75)<0.001
Phobic anxiety0 (0–1)0 (0–0)<0.001
Paranoid ideation1 (0–2)0 (0–1)<0.001
Psychoticism0 (0–2)0 (0–1)<0.001
SCL-90R24 (13–44)13 (5–28)<0.001

SCL-90R Scores: Soldiers with Overlap Syndrome versus Single Functional Gastrointestinal Disorders

Psychopathologic variableCombined FGIDs (n=53, 5.5%)Single FGIDs (n=126, 13%)p-value
Somatization6 (3–9)2 (1–5)<0.001
Obsessive compulsive7 (3–10.5)3 (1–7)<0.001
Interpersonal sensitivity4 (2–8)2 (0–5)<0.001
Depression4 (1.5–9)2 (0–6)0.001
Anxiety2 (1–4)1 (0–2)<0.001
Hostility1 (0–3)0 (0–2)<0.001
Phobic anxiety0 (0–1)0 (0–0)0.006
Paranoid ideation2 (0–5)0 (0–1)<0.001
Psychoticism1 (0–3)0 (0–1)0.001
SCL-90R31 (18–57)14 (5.75–29)<0.001

Multivariate Logistic Regression Analysis to Assess Psychological Factors Associated with Functional Gastrointestinal Disorders

VariableβStandard errorWaldOR (95% CI)p-value
Somatization0.1320.02626.5181.141 (1.09–1.20)<0.001
Obsessive compulsive0.0810.0269.3161.084 (1.03–1.14)0.002
Depression−0.0590.0255.5740.943 (0.90–0.99)0.020

  1. Halder, SL, Locke, GR, Schleck, CD, Zinsmeister, AR, Melton, LJ, Talley, NJ. Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study. Gastroenterology, 2007;133;799-807.
    Pubmed CrossRef
  2. Agarwal, N, Spiegel, BM. The effect of irritable bowel syndrome on health-related quality of life and health care expenditures. Gastroenterol Clin North Am, 2011;40;11-19.
    Pubmed CrossRef
  3. Jung, HK. Rome III criteria for functional gastrointestinal disorders: is there a need for a better definition?. J Neurogastroenterol Motil, 2011;17;211-212.
    Pubmed KoreaMed CrossRef
  4. Drossman, DA, Dumitrascu, DL. Rome III: new standard for functional gastrointestinal disorders. J Gastrointestin Liver Dis, 2006;15;237-241.
    Pubmed
  5. Park, JM, Choi, MG, Cho, YK, et al. Functional gastrointestinal disorders diagnosed by Rome III questionnaire in Korea. J Neurogastroenterol Motil, 2011;17;279-286.
    Pubmed KoreaMed CrossRef
  6. Kim, ES, Lee, BJ, Kim, YS, Lee, SI, Park, H. Validation of Rome III criteria in the diagnosis of functional gastrointestinal disorders in Korean patients. Korean J Neurogastroenterol Motil, 2008;14;39-44.
  7. Derogatis, LR, Lipman, RS, Covi, L. SCL-90: an outpatient psychiatric rating scale--preliminary report. Psychopharmacol Bull, 1973;9;13-28.
    Pubmed
  8. Kim, JH, Kim, KI. The standardization study of Symptom Checklist-90-revision in Korea III. Ment Health Res, 1984;2;278-311.
  9. Derogatis LR. SCL-90-R: Symptom Checklist-90-R: administration, scoring, and procedures manual. Minneapolis: NCS Pearson.
  10. Dong, YY, Chen, FX, Yu, YB, et al. A school-based study with Rome III criteria on the prevalence of functional gastrointestinal disorders in Chinese college and university students. PLoS One, 2013;8;e54183.
    Pubmed KoreaMed CrossRef
  11. Talley, NJ, Zinsmeister, AR, Van Dyke, C, Melton, LJ. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology, 1991;101;927-934.
    Pubmed
  12. Sandler, RS. Epidemiology of irritable bowel syndrome in the United States. Gastroenterology, 1990;99;409-415.
    Pubmed
  13. Drossman, DA, Li, Z, Andruzzi, E, et al. U.S. householder survey of functional gastrointestinal disorders: prevalence, sociodemography, and health impact. Dig Dis Sci, 1993;38;1569-1580.
    Pubmed CrossRef
  14. Choung, RS, Locke, GR, Zinsmeister, AR, Schleck, CD, Talley, NJ. Psychosocial distress and somatic symptoms in community subjects with irritable bowel syndrome: a psychological component is the rule. Am J Gastroenterol, 2009;104;1772-1779.
    Pubmed KoreaMed CrossRef
  15. Brandt, LJ, Chey, WD, et al, American College of Gastroenterology Task Force on Irritable Bowel Syndrome. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol, 2009;104;S1-S35.
    Pubmed CrossRef
  16. Hahn, BA, Saunders, WB, Maier, WC. Differences between individuals with self-reported irritable bowel syndrome (IBS) and IBS-like symptoms. Dig Dis Sci, 1997;42;2585-2590.
    Pubmed CrossRef
  17. Saito, YA, Locke, GR, Talley, NJ, Zinsmeister, AR, Fett, SL, Melton, LJ. A comparison of the Rome and Manning criteria for case identification in epidemiological investigations of irritable bowel syndrome. Am J Gastroenterol, 2000;95;2816-2824.
    Pubmed CrossRef
  18. Thompson, WG, Irvine, EJ, Pare, P, Ferrazzi, S, Rance, L. Functional gastrointestinal disorders in Canada: first population-based survey using Rome II criteria with suggestions for improving the questionnaire. Dig Dis Sci, 2002;47;225-235.
    Pubmed CrossRef
  19. Choung, RS. Natural history and overlap of functional gastrointestinal disorders. Korean J Gastroenterol, 2012;60;345-348.
    Pubmed CrossRef
  20. Wu, W, Guo, X, Yang, Y, et al. The prevalence of functional gastrointestinal disorders in the chinese air force population. Gastroenterol Res Pract, 2013;2013;497585.
    Pubmed KoreaMed CrossRef
  21. Bennett, EJ, Tennant, CC, Piesse, C, Badcock, CA, Kellow, JE. Level of chronic life stress predicts clinical outcome in irritable bowel syndrome. Gut, 1998;43;256-261.
    Pubmed CrossRef
  22. Mullan, A, Kavanagh, P, O’Mahony, P, Joy, T, Gleeson, F, Gibney, MJ. Food and nutrient intakes and eating patterns in functional and organic dyspepsia. Eur J Clin Nutr, 1994;48;97-105.
    Pubmed
  23. van Oijen, MG, Josemanders, DF, Laheij, RJ, van Rossum, LG, Tan, AC, Jansen, JB. Gastrointestinal disorders and symptoms: does body mass index matter?. Neth J Med, 2006;64;45-49.
    Pubmed
  24. Delgado-Aros, S, Locke, GR, Camilleri, M, et al. Obesity is associated with increased risk of gastrointestinal symptoms: a population-based study. Am J Gastroenterol, 2004;99;1801-1806.
    Pubmed CrossRef
  25. Cremonini, F, Locke, GR, Schleck, CD, Zinsmeister, AR, Talley, NJ. Relationship between upper gastrointestinal symptoms and changes in body weight in a population-based cohort. Neurogastroenterol Motil, 2006;18;987-994.
    Pubmed CrossRef
  26. Locke, GR, Zinsmeister, AR, Fett, SL, Melton, LJ, Talley, NJ. Overlap of gastrointestinal symptom complexes in a US community. Neurogastroenterol Motil, 2005;17;29-34.
    Pubmed CrossRef
  27. Lee, SY, Lee, KJ, Kim, SJ, Cho, SW. Prevalence and risk factors for overlaps between gastroesophageal reflux disease, dyspepsia, and irritable bowel syndrome: a population-based study. Digestion, 2009;79;196-201.
    Pubmed CrossRef
  28. Kaji, M, Fujiwara, Y, Shiba, M, et al. Prevalence of overlaps between GERD, FD and IBS and impact on health-related quality of life. J Gastroenterol Hepatol, 2010;25;1151-1156.
    Pubmed CrossRef
  29. Lee, HJ, Lee, SY, Kim, JH, et al. Depressive mood and quality of life in functional gastrointestinal disorders: differences between functional dyspepsia, irritable bowel syndrome and overlap syndrome. Gen Hosp Psychiatry, 2010;32;499-502.
    Pubmed CrossRef
  30. Wang, A, Liao, X, Xiong, L, et al. The clinical overlap between functional dyspepsia and irritable bowel syndrome based on Rome III criteria. BMC Gastroenterol, 2008;8;43.
    Pubmed KoreaMed CrossRef
  31. Ford, AC, Marwaha, A, Lim, A, Moayyedi, P. Systematic review and meta-analysis of the prevalence of irritable bowel syndrome in individuals with dyspepsia. Clin Gastroenterol Hepatol, 2010;8;401-409.
    Pubmed CrossRef
  32. Porter, CK, Gormley, R, Tribble, DR, Cash, BD, Riddle, MS. The incidence and gastrointestinal infectious risk of functional gastrointestinal disorders in a healthy US adult population. Am J Gastroenterol, 2011;106;130-138.
    Pubmed CrossRef
  33. Choung, RS, Locke, GR, Schleck, CD, Zinsmeister, AR, Talley, NJ. Overlap of dyspepsia and gastroesophageal reflux in the general population: one disease or distinct entities?. Neurogastroenterol Motil, 2012;24;229-234.
    Pubmed CrossRef
  34. Koloski, NA, Jones, M, Kalantar, J, Weltman, M, Zaguirre, J, Talley, NJ. The brain: gut pathway in functional gastrointestinal disorders is bidirectional: a 12-year prospective population-based study. Gut, 2012;61;1284-1290.
    Pubmed CrossRef
  35. Song, KH, Jung, HK, Min, BH, et al. Development and validation of the Korean Rome III questionnaire for diagnosis of functional gastrointestinal disorders. J Neurogastroenterol Motil, 2013;19;509-515.
    Pubmed KoreaMed CrossRef

Article

Original Article

Gut Liver 2015; 9(4): 509-515

Published online July 31, 2015 https://doi.org/10.5009/gnl14109

Copyright © Gut and Liver.

Functional Gastrointestinal Disorders in Young Military Men

Chang Seok Bang*, Yeon Soo Kim*, Jin Hyung Han, Yong Sub Lee*, Gwang Ho Baik*, Jin Bong Kim*, Ki Tae Suk*, Jai Hoon Yoon*, and Dong Joon Kim*

*Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea

Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea

Correspondence to: Gwang Ho Baik, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 77 Sakju-ro, Chuncheon 200-704, Korea, Tel: +82-33-240-5821, Fax: +82-33-241-8064, E-mail: baikgh@hallym.or.kr

Received: March 26, 2014; Revised: May 1, 2014; Accepted: May 4, 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

To estimate the prevalence and evaluate the associated psychological factors of functional gastrointestinal disorders (FGIDs) in males in their twenties who are currently enrolled in military service.

Methods

A total of 1,073 men in the Korean army were asked to complete questionnaires based on the Rome III criteria and Symptom Checklist-90-revised (SCL-90R). The prevalence of FGIDs was estimated, and the associated psychological factors were evaluated.

Results

A total of 967 men participated. The total prevalence of FGIDs was 18.5% (age-adjusted prevalence, 18.1%; 95% confidence interval [CI], 15.3% to 20.8%). The total SCL-90R scores were higher in men with FGIDs than men without FGIDs (24 [interquartile range, 13 to 44] vs 13 [5 to 28], p<0.001) and higher in men with overlapping syndromes than in those with single FGIDs (31 [18 to 57] vs 14 [5.75 to 29], p<0.001). Somatization (odds ratio [OR], 1.141; 95% CI, 1.09 to 1.20; p<0.001), obsessive-compulsive behaviors (OR, 1.084; 95% CI, 1.03 to 1.14; p=0.002) and depression (OR, 0.943; 95% CI, 0.90 to 0.99; p=0.020) were identified as independent predictive factors for FGIDs.

Conclusions

FGIDs are common among men in their twenties who are fulfilling their military duty. Somatization and obsessive-compulsive features from the tense atmosphere are associated with the development or progression of FGIDs. Patients who exhibit overlapping syndromes require greater attention given their more severe psychopathology.

Keywords: Gastrointestinal diseases, Military, Psychologic factors

INTRODUCTION

Functional gastrointestinal disorders (FGIDs) are commonly observed in clinical practice.1 Patients complain a variety of symptoms, as these disorders result in a great burden in terms of quality of life and health care expenditures.2 The Rome criteria, which are based on symptom clusters, are currently used to diagnose FGIDs.3 This metric was updated in 2006, as the Rome III version, and 28 disorders are included in these criteria.4 There have been studies estimating the prevalence of FGIDs using Rome III criteria in Korea;5,6 however, the exact prevalence and pathophysiology of FGIDs remain unclear.

Young soldiers, who are highly trained and submitted to strictly imposed discipline, tend to face more serious stress than the general population. All Korean males in their twenties who do not have a serious disability have an obligation to fulfill a term of military service. However, studies on FGIDs investigating this population are lacking.

The aim of this study was to estimate the prevalence and evaluate the associated psychological factors of FGIDs among males in their twenties currently completing military service.

MATERIALS AND METHODS

1. Ethics statement

This study was conducted according to the principles expressed in the Declaration of Helsinki. Voluntary participation was requested, and written informed consent was obtained from each participant. This study was approved by the Institutional Review Board of the Armed Forces Medical Command of Korea before initiation of this study (AFMC-13-IRB-010).

2. Patients and methods

Between January and May 2013, a total of 1,073 participants from eight different regiments of three different divisions of Republic of Korea Army were asked to complete questionnaires based on the Rome III criteria and Symptom Checklist-90-revised (SCL-90R). The three divisions were located in the Gangwon, Gyeonggi, and Chungcheongnam provinces of Korea, respectively. The study population included male soldiers in their twenties who participated voluntarily. The survey was performed face-to-face in the military at doctors’ offices by three military doctors (C.S.B., J.H.H., and Y.S.L.). The prevalence of FGIDs was estimated, and all associated psychological factors were evaluated using the Rome III criteria and a SCL-90R based questionnaire. Participants who were positive for alarm symptoms during the screening for organic diseases or who presented an incomplete questionnaire were excluded from this study.

3. Questionnaires

This study was conducted using a self-reported questionnaire. The Korean version of a Rome III criteria-based questionnaire was produced according to the following steps: (1) independent translations of the original version of the Rome III criteria by two native speakers of Korean who are fluent in English; (2) comparison of the two versions of the questionnaire with the two translators making adjustments for better understanding to create a reconciled version; (3) evaluation of the questionnaire by three internal medicine doctors, followed by revision until interobserver agreement was achieved and its use was approved in soldiers; and (4) administration of a pretest to 300 soldiers in three different regiments to detect unrecognized errors, which were corrected in the final version. The questionnaire consisted of 86 queries, including 75 Rome criteria-based questions, seven alarming symptom questions, and four demographic information questions. Alarm symptoms included unintentional weight loss, blood in the stool, a history of organic bowel disease or intestinal surgery, unexplained anemia or fever, and awakening due to abdominal pain during the night time.

The SCL-90 is a questionnaire that was developed in 1973 to assess psychological distress for clinical practice and research purposes.7 The Korean version of the SCL-90R was created and validated in 1984.8 This 5-point Likert-scale questionnaire consists of 90 queries, and each question represents a single psychological symptom. Using this questionnaire, the psychological symptoms can be classified into nine categories (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism), and the global severity can be assessed. The scores of global severity and of each category are expressed as t scores.8,9

4. Sample size

Based on a study of Chinese college and university students,10 representing the same age groups that are in our study, a sample size was calculated. According to that study, the prevalence of FGIDs among males was estimated at 20.4%. The authors assumed that the total prevalence of FGIDs in the military would be 25%; thus, the sample size was calculated with 80% power at a two-sided p-value of 0.05 and a drop rate of 10%. A minimum sample size of 700 was required.

5. Statistical analysis

Continuous data are expressed as the medians and the inter-quartile ranges, and categorical data are given as the frequencies (percentages). The Mann-Whitney test and Fisher exact test were used to evaluate the baseline characteristics and to compare the SCL-90R scores (soldiers with FGIDs vs without FGIDs/soldiers with overlap syndrome vs single FGIDs), because of the nonnormal distribution of the data. Age-adjusted prevalence of FGIDs was calculated with the population in 2010 Korean Census as the standard population (classified and weighted by 5-year age interval). A multivariate logistic regression test was used to detect the independent psychological risk factors associated with FGIDs. A p-value <0.05 was considered statistically significant for all tests. The analysis was performed using the SPSS software version 18.0 (SPSS Inc., Chicago, IL, USA).

RESULTS

1. The characteristic of enrolled population

Of the 1,073 soldiers who took the questionnaire, 106 men submitted incomplete questionnaires and were excluded from this study. A total of 967 men participated, for a response rate of 90.1%. The median age was 21 years (interquartile range, 20 to 21 years), and the proportions of smokers and alcohol drinkers were 49.4% and 72.2%, respectively. The median body mass index (BMI) was 22.2 (interquartile range, 20.8 to 24). The characteristics of the total enrolled soldiers are listed in Table 1.

2. The prevalence and spectrum of FGIDs

The total prevalence of FGIDs was 18.5% (n=179). The age-adjusted prevalence of FGIDs was 18.05% (95% confidence interval [CI], 15.3% to 20.8%) (Table 2). The proportions of each FGID were as follows: functional dyspepsia (FD) (8.2%), functional chest pain (FCP) (5.1%), functional heartburn (FH) (2.8%), irritable bowel syndrome (IBS) (2.6%), and functional dysphagia (2.6%). The prevalence of each FGID in soldiers is shown in Table 3.

Among soldiers with functional dyspepsia, a subtype of postprandial distress syndrome (PDS) was more prevalent than epigastric pain syndrome (EPS) (n=78 vs 1). In the subtype of IBS, diarrhea-type IBS was most prevalent (n=10), followed by mixed (n=9), constipation type (n=3), and unsubtyped IBS (n=3) (Table 4).

3. Overlap syndrome

Among the 179 soldiers with FGIDs, 53 soldiers (29.6%) had combined FGIDs, that is, meeting the criteria for more than one disease category (5.5% of total population). The most prevalent combination was FD with FH and FCP (n=7, 3.9% of all FGIDs), followed by FD+FCP (n=6, 3.3% of all FGIDs) and FD+IBS (n=5, 2.8% of all FGIDs). FD, FH, FCP, and IBS were the prevalent components of such combinations (Table 5).

4. Psychological factors

The total SCL-90R score, which indicates a global severity, was 24 (13 to 44) in soldiers with FGIDs, which was significantly higher than 13 (5 to 28) found in soldiers without FGIDs (interquartile range). All nine categories of psychopathologic variables showed a higher score in soldiers with FGIDs than without FGIDs (Table 6).

In the analysis of overlapping syndromes, the total SCL-90R score showed a significantly higher score in soldiers with overlapping syndromes than in soldiers with single FGIDs (31 [18 to 57] vs 14 [5.75 to 29], p<0.001). The scores of all of the psychopathologic variables were also higher in soldiers with overlapping syndromes than in those with single FGIDs (Table 7).

Multivariate logistic regression analysis was performed to assess the associated psychological factors of FGIDs. The factors of somatization (odds ratio [OR], 1.141; 95% CI, 1.09 to 1.20; p<0.001), obsessive compulsive behaviors (OR, 1.084; 95% CI, 1.03 to 1.14; p=0.002), and depression (OR, 0.943; 95% CI, 0.90 to 0.99; p=0.020) were found to be independent predictive factors for FGIDs (model chi-square test, p<0.001; Hosmer-Lemeshow’s goodness-of-fit test, p=0.09) (age, smoking, alcohol, BMI, and psychopathologic variables of SCL-90R adjusted) (Table 8).

DISCUSSION

FGIDs are prevalent in the general population.1 According to epidemiologic studies of IBS, which is the most widely investigated FGID, the prevalence of IBS is estimated to range from 3% to 27%, considering differences in race and study methodology.1119 A recent study in Korea found a prevalence of FGIDs in patients who visited primary clinics and tertiary care hospitals estimated at 49.7%.5 However, studies aiming at young populations are limited. Moreover, there are no data concerning FGIDs in the military.

This population consumes a similar diet and performs regular exercise with controlled life activities. The prevalence of total FGIDs in this population was estimated to be 18.5% in this study (age-adjusted prevalence, 18.1%). This result is lower than that from a study of Chinese air force population (23.5%).20 However, among the 4,170 soldiers, 1,070 officers with higher education and longer years of service were included in that study. Moreover, about 37% of soldiers were aged over 25 (13.1% were in age >35).20 According to the another study of Chinese college and university students of the young age group, the prevalence of total FGIDs was 23%.10 However, considering the fact that FGIDs are more prevalent in females, the results of our study may agree with those of the Chinese study. In a subgroup analysis of the Chinese study, the prevalence of FIGDs in males was 20.4%, whereas that in females was 25.5%.10 Regarding the influence of the military, the strong military discipline instituted daily could cause serious stress, triggering FGIDs more easily than in the general population.21 However, regular diet and exercise, restricting alcohol and eating between meals could act as a positive impact on the development or progression of FGIDs. From a study on the impact of diet on FD, the regular diet group (three meals per day) showed a lower incidence of FD.22 There have been contradictory results about the relationship between obesity and FGIDs.2325 In this study, few obese soldiers were enrolled, and the authors could not find differences in the BMI between soldiers with FGIDs and without FGIDs (Table 1). Overall, FGIDs are prevalent in the military; however, they are not more prevalent than in the general population of the similar age group,10 most likely due to the absence of factors contributing to the development of FGIDs.

In the subtype analysis of FGIDs, FD was the most prevalent disorder (8.2%), followed by FCP (5.1%), FH (2.8%), IBS (2.6%), and functional dysphagia (2.6%) (Table 3). According to a Chinese study on the similar age group, FD showed the highest prevalence at 9.3%, followed by IBS at 8.3% and functional constipation at 5.5%.10 However, this study estimated the prevalence of only three FGIDs, including FD, IBS, and functional constipation. The results of a hospital-based study in Korea were consistent with those of the Chinese study (FD, 46%; IBS, 40.2%), although the overall prevalence was much higher.5 In the present study and the Chinese study, no endoscopic investigation was performed to rule out organic diseases. Only alarm symptoms based the questionnaires were used. Thus, gastroesophageal reflux disease (GERD), which is not included in the Rome III criteria categories, could not be assessed. Regarding GERD patients in Korea, who commonly express symptoms similar to a burning sensation, a substantial portion of FCP and FH patients in this study might overlap with GERD. Cautious interpretations should be made regarding this aspect. The prevalence of IBS in this study was much lower than in the Chinese or Korean studies (2.6%).5,10 The positive impact from dietary and daily activity factors could explain the lower prevalence. However, more studies are needed to identify the factors responsible for this result.

As shown in previous studies, a subtype of PDS was more prevalent than EPS among soldiers with FD (n=78 vs 1).5,10 It has been speculated that the diagnostic criteria for EPS in the Rome III standard were too strict and that patients had difficulty understanding the meaning of the questionnaire with respect to differentiating between epigastric burning and heartburn.5 This problem is expected to be solved in the subsequent revised version of the Rome criteria. Of the subtypes of IBS, diarrhea type IBS was most prevalent (n=10), followed by mixed (n=9), constipation type (n=3), and unsubtyped IBS (n=3); however, the number of patients detected was too small to establish significant differences (Table 3).

In terms of overlapping syndromes, the prevalence was estimated at 5.5% of the total population and 29.6% of the FGID patients from this study. In previous studies, the prevalence has been reported to range from 1% to 17%, not much different from our study.2630 In a recent Korean study, the most common combination was FD+IBS, and the systematic review showed that the pooled OR of IBS in patients with FD was 8 (OR, 8; 95% CI, 5.7 to 11.2).5,31 However, our study showed that FD+FH+FCP (n=7, 3.9% of all FGIDs) was most prevalent, followed by FD+FCP (n=6, 3.3% of all FGIDs) and FD+IBS (n=5, 2.8% of all FGIDs) (Table 5). According to the study of healthy military males from United States, the most common combination of overlap syndrome was IBS+functional constipation.32 Functional constipation was also the most prevalent FGID in that study.32 The reason of the different combinations from studies are unclear. Another consideration is about GERD. FGIDs and GERD presumably share the same pathophysiology.19 However, the exact mechanism and prevalence of each combination is unclear. Regarding the pitfalls stated above in this study regarding GERD, some clinical aspects of GERD might be hidden by the results of this study (soldiers with FH or FCP might be included in GERD), although many other epidemiologic studies have also excluded GERD in the analysis of overlapping syndrome and FGIDs. According to one study on the overlap of GERD and FD, a prevalence of 4% was found in the general population.33 Overall, overlapping syndromes are commonly observed, not only in the general population but also in soldiers.

In agreement with the results of previous studies, psychological distress was associated with FGIDs and overlapping syndromes.5,10,22,28 All components of the SCL-90R showed a higher score in soldiers with FGIDs (than without FGIDs) and overlapping syndromes (than without overlapping syndromes) (Tables 6 and 7). In the multivariate logistic regression analysis to assess the associated psychological factors of FGIDs, the factors of somatization (OR, 1.141) and obsessive compulsive feature (OR, 1.084) proved to be independent risk factors for FGIDs. However, depression (OR, 0.943) revealed a negative relation to FGIDs (Table 8). In a Chinese study of the same age and race group, depression also showed an OR of 0.55, although the 95% CI included 1.0 (95% CI, 0.15 to 1.05; p=0.045).20 According to a study of the brain-gut pathway, which is presumed to be one pathophysiology of the FGIDs, depression was not an independent predictor for developing FGIDs, whereas anxiety was a risk factor.34 The exact reason or mechanism is unclear regarding this issue. More studies are needed to elucidate the association between each of the psychological factors and FGIDs.

There are limitations to this study. First, this study used only self-administered questionnaires without endoscopic investigations. Secondly, the questionnaire used in this study was not validated. At the time of this study, the Korean version of the Rome III questionnaire, which was validated recently, was not available; however, it is currently applicable in clinical practice.35

However, this study is the first epidemiologic study of FGIDs in the Korean military, and subsequent studies which have endoscopic investigation for all participants and survey with validated questionnaire can be planned and executed to better assess this population based on the results of this study.

In conclusion, FGIDs are common among men in their twenties completing military duty. Somatization and obsessive compulsive disorders deriving from the tense atmosphere are associated with the development or progression of FGIDs. Patients who have overlapping syndromes require greater attention due to their more severe psychopathology.

Table 1 Clinical Characteristics of Total Enrolled Population

CharacteristicTotal (n=967)Soldiers with FGIDs (n=179, 18.5%)Soldiers without FGIDs (n=788, 81.5%)p-value
Age, yr21 (20–21)21 (20–22)21 (20–21)0.01
BMI22.2 (20.8–24.0)22.4 (20.8–24.6)22.2 (20.8–23.9)0.43
Smoking478 (49.4)94 (52.5)384 (48.7)0.36
 Cigarette per day0 (0–10)3 (0–10)0 (0–10)0.24
Alcohol698 (72.2)135 (75.4)563 (71.4)0.31
SCL-90R15 (6–30)24 (13–44)13 (5–28)<0.001

Data are presented as median (interquartile range) or number (%).

FGIDs, functional gastrointestinal disorders; BMI, body mass index; SCL-90R, Symptom Checklist-90-revised.


Table 2 Age-Adjusted Prevalence of Functional Gastrointestinal Disorders

Age class, yrTotal cases of each age classCases with FGIDsPrevalence of FGIDs, %Standard population of Korean Census
15–1910017171,826,179
20–2485015618.41,625,371
25–2916637.51,802,805
30–351001,866,397
Total96717918.5-
Age-adjusted prevalence of FIGDs: 18.1% (95% CI, 15.3%–20.8%)

FGIDs, functional gastrointestinal disorders; CI, confidence interval.


Table 3 Proportion of Functional Gastrointestinal Disorders

FGIDsNo. (% of all population)% of FGIDs
Functional dyspepsia79 (8.2)44.1
Functional chest pain49 (5.1)27.4
Functional heartburn27 (2.8)15.1
Irritable bowel syndrome25 (2.6)14.0
Functional dysphagia25 (2.6)14.0
Functional diarrhea20 (2.1)11.2
Functional constipation13 (1.3)7.3
Globus12 (1.2)6.7
Functional bloating10 (1.0)5.6
Proctalgia fugax5 (0.5)2.8
Chronic idiopathic nausea4 (0.4)2.2
Aerophagia3 (0.3)1.7
Cyclic vomiting syndrome3 (0.3)1.7
Rumination syndrome2 (0.2)1.1

FGIDs, functional gastrointestinal disorders.


Table 4 Subtypes of Functional Dyspepsia and Irritable Bowel Syndrome

FGIDsNo. (% of all population)% of FGIDs
Functional dyspepsia79 (8.2)44.1
 Postprandial distress syndrome78 (8.1)43.6
 Epigastric pain syndrome1 (0.1)0.6
IBS25 (2.6)14.0
 IBS-C3 (0.3)1.7
 IBS-D10 (1.0)5.6
 IBS-M9 (0.9)5.0
 IBS-U3 (0.3)1.7

FGIDs, functional gastrointestinal disorders; IBS, irritable bowel syndrome; IBS-C, constipation type IBS; IBS-D, diarrhea type IBS; IBS-M, mixed type IBS; IBS-U, unsubtyped IBS.


Table 5 Types of Overlapping Syndromes

Overlap syndromeNo. (% of all population)% of FGIDs
Total53 (5.5)29.6
FD+FH+FCP7 (0.7)3.9
FD+FCP6 (0.6)3.3
FD+IBS5 (0.5)2.8
IBS+FCP4 (0.4)2.2
FH+FCP4 (0.4)2.2
FD+IBS+FCP4 (0.4)2.2
FD+FH2 (0.2)1.1
IBS+FH2 (0.2)1.1

Nineteen single combinations of overlapping syndrome were omitted in this table.

FGIDs, functional gastrointestinal disorders; FD, functional dyspepsia; FH, functional heartburn; FCP, functional chest pain; IBS, irritable bowel syndrome.


Table 6 SCL-90R Scores: Soldiers with Functional Gastrointestinal Disorders versus without Functional Gastrointestinal Disorders

Psychopathologic variableSoldiers with FGIDs (n=179, 18.5%)Soldiers without FGIDs (n=788, 81.5%)p-value
Somatization4 (2–8)2 (1–4)<0.001
Obsessive compulsive5 (2–9)3 (1–7)<0.001
Interpersonal sensitivity3 (1–6)2 (0–4)<0.001
Depression3 (1–8)2 (0–5)<0.001
Anxiety2 (1–3)1 (0–2)<0.001
Hostility1 (1–3)0 (0–1.75)<0.001
Phobic anxiety0 (0–1)0 (0–0)<0.001
Paranoid ideation1 (0–2)0 (0–1)<0.001
Psychoticism0 (0–2)0 (0–1)<0.001
SCL-90R24 (13–44)13 (5–28)<0.001

Data are presented as median (interquartile range).

SCL-90R, Symptom Checklist-90-revised; FGIDs, functional gastrointestinal disorders.


Table 7 SCL-90R Scores: Soldiers with Overlap Syndrome versus Single Functional Gastrointestinal Disorders

Psychopathologic variableCombined FGIDs (n=53, 5.5%)Single FGIDs (n=126, 13%)p-value
Somatization6 (3–9)2 (1–5)<0.001
Obsessive compulsive7 (3–10.5)3 (1–7)<0.001
Interpersonal sensitivity4 (2–8)2 (0–5)<0.001
Depression4 (1.5–9)2 (0–6)0.001
Anxiety2 (1–4)1 (0–2)<0.001
Hostility1 (0–3)0 (0–2)<0.001
Phobic anxiety0 (0–1)0 (0–0)0.006
Paranoid ideation2 (0–5)0 (0–1)<0.001
Psychoticism1 (0–3)0 (0–1)0.001
SCL-90R31 (18–57)14 (5.75–29)<0.001

Data are presented as median (interquartile range).

SCL-90R, Symptom Checklist-90-revised; FGIDs, functional gastrointestinal disorders.


Table 8 Multivariate Logistic Regression Analysis to Assess Psychological Factors Associated with Functional Gastrointestinal Disorders

VariableβStandard errorWaldOR (95% CI)p-value
Somatization0.1320.02626.5181.141 (1.09–1.20)<0.001
Obsessive compulsive0.0810.0269.3161.084 (1.03–1.14)0.002
Depression−0.0590.0255.5740.943 (0.90–0.99)0.020

OR, odds ratio; CI, confidence interval.


References

  1. Halder, SL, Locke, GR, Schleck, CD, Zinsmeister, AR, Melton, LJ, Talley, NJ. Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study. Gastroenterology, 2007;133;799-807.
    Pubmed CrossRef
  2. Agarwal, N, Spiegel, BM. The effect of irritable bowel syndrome on health-related quality of life and health care expenditures. Gastroenterol Clin North Am, 2011;40;11-19.
    Pubmed CrossRef
  3. Jung, HK. Rome III criteria for functional gastrointestinal disorders: is there a need for a better definition?. J Neurogastroenterol Motil, 2011;17;211-212.
    Pubmed KoreaMed CrossRef
  4. Drossman, DA, Dumitrascu, DL. Rome III: new standard for functional gastrointestinal disorders. J Gastrointestin Liver Dis, 2006;15;237-241.
    Pubmed
  5. Park, JM, Choi, MG, Cho, YK, et al. Functional gastrointestinal disorders diagnosed by Rome III questionnaire in Korea. J Neurogastroenterol Motil, 2011;17;279-286.
    Pubmed KoreaMed CrossRef
  6. Kim, ES, Lee, BJ, Kim, YS, Lee, SI, Park, H. Validation of Rome III criteria in the diagnosis of functional gastrointestinal disorders in Korean patients. Korean J Neurogastroenterol Motil, 2008;14;39-44.
  7. Derogatis, LR, Lipman, RS, Covi, L. SCL-90: an outpatient psychiatric rating scale--preliminary report. Psychopharmacol Bull, 1973;9;13-28.
    Pubmed
  8. Kim, JH, Kim, KI. The standardization study of Symptom Checklist-90-revision in Korea III. Ment Health Res, 1984;2;278-311.
  9. Derogatis LR. SCL-90-R: Symptom Checklist-90-R: administration, scoring, and procedures manual. Minneapolis: NCS Pearson.
  10. Dong, YY, Chen, FX, Yu, YB, et al. A school-based study with Rome III criteria on the prevalence of functional gastrointestinal disorders in Chinese college and university students. PLoS One, 2013;8;e54183.
    Pubmed KoreaMed CrossRef
  11. Talley, NJ, Zinsmeister, AR, Van Dyke, C, Melton, LJ. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology, 1991;101;927-934.
    Pubmed
  12. Sandler, RS. Epidemiology of irritable bowel syndrome in the United States. Gastroenterology, 1990;99;409-415.
    Pubmed
  13. Drossman, DA, Li, Z, Andruzzi, E, et al. U.S. householder survey of functional gastrointestinal disorders: prevalence, sociodemography, and health impact. Dig Dis Sci, 1993;38;1569-1580.
    Pubmed CrossRef
  14. Choung, RS, Locke, GR, Zinsmeister, AR, Schleck, CD, Talley, NJ. Psychosocial distress and somatic symptoms in community subjects with irritable bowel syndrome: a psychological component is the rule. Am J Gastroenterol, 2009;104;1772-1779.
    Pubmed KoreaMed CrossRef
  15. Brandt, LJ, Chey, WD, et al, American College of Gastroenterology Task Force on Irritable Bowel Syndrome. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol, 2009;104;S1-S35.
    Pubmed CrossRef
  16. Hahn, BA, Saunders, WB, Maier, WC. Differences between individuals with self-reported irritable bowel syndrome (IBS) and IBS-like symptoms. Dig Dis Sci, 1997;42;2585-2590.
    Pubmed CrossRef
  17. Saito, YA, Locke, GR, Talley, NJ, Zinsmeister, AR, Fett, SL, Melton, LJ. A comparison of the Rome and Manning criteria for case identification in epidemiological investigations of irritable bowel syndrome. Am J Gastroenterol, 2000;95;2816-2824.
    Pubmed CrossRef
  18. Thompson, WG, Irvine, EJ, Pare, P, Ferrazzi, S, Rance, L. Functional gastrointestinal disorders in Canada: first population-based survey using Rome II criteria with suggestions for improving the questionnaire. Dig Dis Sci, 2002;47;225-235.
    Pubmed CrossRef
  19. Choung, RS. Natural history and overlap of functional gastrointestinal disorders. Korean J Gastroenterol, 2012;60;345-348.
    Pubmed CrossRef
  20. Wu, W, Guo, X, Yang, Y, et al. The prevalence of functional gastrointestinal disorders in the chinese air force population. Gastroenterol Res Pract, 2013;2013;497585.
    Pubmed KoreaMed CrossRef
  21. Bennett, EJ, Tennant, CC, Piesse, C, Badcock, CA, Kellow, JE. Level of chronic life stress predicts clinical outcome in irritable bowel syndrome. Gut, 1998;43;256-261.
    Pubmed CrossRef
  22. Mullan, A, Kavanagh, P, O’Mahony, P, Joy, T, Gleeson, F, Gibney, MJ. Food and nutrient intakes and eating patterns in functional and organic dyspepsia. Eur J Clin Nutr, 1994;48;97-105.
    Pubmed
  23. van Oijen, MG, Josemanders, DF, Laheij, RJ, van Rossum, LG, Tan, AC, Jansen, JB. Gastrointestinal disorders and symptoms: does body mass index matter?. Neth J Med, 2006;64;45-49.
    Pubmed
  24. Delgado-Aros, S, Locke, GR, Camilleri, M, et al. Obesity is associated with increased risk of gastrointestinal symptoms: a population-based study. Am J Gastroenterol, 2004;99;1801-1806.
    Pubmed CrossRef
  25. Cremonini, F, Locke, GR, Schleck, CD, Zinsmeister, AR, Talley, NJ. Relationship between upper gastrointestinal symptoms and changes in body weight in a population-based cohort. Neurogastroenterol Motil, 2006;18;987-994.
    Pubmed CrossRef
  26. Locke, GR, Zinsmeister, AR, Fett, SL, Melton, LJ, Talley, NJ. Overlap of gastrointestinal symptom complexes in a US community. Neurogastroenterol Motil, 2005;17;29-34.
    Pubmed CrossRef
  27. Lee, SY, Lee, KJ, Kim, SJ, Cho, SW. Prevalence and risk factors for overlaps between gastroesophageal reflux disease, dyspepsia, and irritable bowel syndrome: a population-based study. Digestion, 2009;79;196-201.
    Pubmed CrossRef
  28. Kaji, M, Fujiwara, Y, Shiba, M, et al. Prevalence of overlaps between GERD, FD and IBS and impact on health-related quality of life. J Gastroenterol Hepatol, 2010;25;1151-1156.
    Pubmed CrossRef
  29. Lee, HJ, Lee, SY, Kim, JH, et al. Depressive mood and quality of life in functional gastrointestinal disorders: differences between functional dyspepsia, irritable bowel syndrome and overlap syndrome. Gen Hosp Psychiatry, 2010;32;499-502.
    Pubmed CrossRef
  30. Wang, A, Liao, X, Xiong, L, et al. The clinical overlap between functional dyspepsia and irritable bowel syndrome based on Rome III criteria. BMC Gastroenterol, 2008;8;43.
    Pubmed KoreaMed CrossRef
  31. Ford, AC, Marwaha, A, Lim, A, Moayyedi, P. Systematic review and meta-analysis of the prevalence of irritable bowel syndrome in individuals with dyspepsia. Clin Gastroenterol Hepatol, 2010;8;401-409.
    Pubmed CrossRef
  32. Porter, CK, Gormley, R, Tribble, DR, Cash, BD, Riddle, MS. The incidence and gastrointestinal infectious risk of functional gastrointestinal disorders in a healthy US adult population. Am J Gastroenterol, 2011;106;130-138.
    Pubmed CrossRef
  33. Choung, RS, Locke, GR, Schleck, CD, Zinsmeister, AR, Talley, NJ. Overlap of dyspepsia and gastroesophageal reflux in the general population: one disease or distinct entities?. Neurogastroenterol Motil, 2012;24;229-234.
    Pubmed CrossRef
  34. Koloski, NA, Jones, M, Kalantar, J, Weltman, M, Zaguirre, J, Talley, NJ. The brain: gut pathway in functional gastrointestinal disorders is bidirectional: a 12-year prospective population-based study. Gut, 2012;61;1284-1290.
    Pubmed CrossRef
  35. Song, KH, Jung, HK, Min, BH, et al. Development and validation of the Korean Rome III questionnaire for diagnosis of functional gastrointestinal disorders. J Neurogastroenterol Motil, 2013;19;509-515.
    Pubmed KoreaMed CrossRef
Gut and Liver

Vol.18 No.4
July, 2024

pISSN 1976-2283
eISSN 2005-1212

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