Diseases of the Esophagus (2015) ••, ••–•• DOI: 10.1111/dote.12310
Original article
Prevalence of gastroesophageal reflux disease in Moscow S. Bor,1 L. B Lazebnik,2 G. Kitapcioglu,3 I. Manannikof,2 Y. Vasiliev4 Section of Gastroenterology & Ege Reflux Study Group and 3Department of Biostatistics & Ege Reflux Study Group, Ege University, Izmir, Turkey; and 2Central Research Institute of Gastroenterology, and 4Department of Pathology of Upper Digestive Tract, Moscow Clinical and Research Center, Moscow, Russia 1
SUMMARY. Limited data exist to determine the prevalence and clinical spectrum of gastroesophageal reflux disease (GERD) in the Russian population, which might be different from those in Western countries. This study was performed in Moscow on randomized 1065 adults aged ≥15 years. A validated reflux questionnaire comprising 72 questions and an additional 29 sub-questions were used. The questions assessed (heartburn and regurgitation) and related (dyspepsia, dysphagia, odynophagia and chest pain) symptoms, the triggering factors of these symptoms, family history and data on demographic and socioeconomic features. GERD was defined as heartburn and/or regurgitation once a week or common. Of the 1065 participants, 42.1% were male and 57.9% were female. The prevalences of frequent and occasional symptoms were 17.6 and 22.1% for heartburn and 17.5 and 21.8% for regurgitation, respectively, over the last 12 months. The prevalence of GERD was found to be 23.6%. The rate of GERD was significantly higher in females than in males (15.4 vs. 29.5%, P < 0.001) and significantly increased as the age of the participants increased (P = 0.011). GERD was present in 20.4% of smokers, 24.2% of coffee drinkers, 21.5% of alcohol consumers and 45.9% of stressed participants. Although the rate of alcohol consumers was lower in those with GERD compared with those without GERD, the rate of coffee drinkers and stressed participants was higher among those with GERD. The rate of additional symptoms was higher even in participants complaining of regurgitation/heartburn rarely, compared with those without complaints. Using the same questionnaire, which makes it possible to compare the present results with those from different countries, we found the prevalence of GERD in Moscow to be 23.6%, one of highest in the Western populations. The rates of heartburn and regurgitation were found to be similar, which constitutes a different result than has been found in similar studies. Additional symptoms should be assessed, in all GERD patients even in the presence of rare complaints of regurgitation/heartburn. KEY WORDS: epidemiology, gastroesophageal reflux, heartburn, Moscow, regurgitation, Russia.
INTRODUCTION Gastroesophageal reflux disease (GERD) is one of the most common diseases in modern populations. An increased prevalence is associated with numerous factors, including lifestyle changes, such as nutritional habits, and obesity.1 Although the number of Address correspondence to: Professor Serhat Bor, MD, Section of Gastroenterology & Ege Reflux Study Group, Ege University, Izmir 35100, Turkey. Email: [email protected] Specific author contributions: Serhat Bor: study concept and design; analysis and interpretation of data; drafting and finalizing the manuscript. Leonid B. Lazebnik: administrative, study supervision, critical revision of the manuscript for important intellectual content. Gul Kitapcioglu: statistical analysis, study design, critical revision of the manuscript for important intellectual content. Igor Manannikof: acquisition of data, study design, technical or material support. Yuriy Vasiliev: technical support, acquisition of data. © 2015 International Society for Diseases of the Esophagus
investigations about debatable association between Helicobacter pylori infection and GERD has continued to rise, large epidemiological studies have reported an inverse association.2 Other conditions that have been linked to GERD include dietary indiscretion, coffee, smoking and alcohol use. The role of certain medications, such as nonsteroidal antiinflammatory agents, in GERD still requires critical evaluation.1 GERD appears to be significantly more common in Western countries. The prevalence of GERD has been shown to increase in the last decade; if GERD is defined as reflux occurring twice weekly over several months, it has been estimated to affect 10–20% of the Western populations and 5% of the Asian population.1 Recent studies have reported that the prevalence of GERD has also been increasing in Asian 1
2
Diseases of the Esophagus
countries.3 Genetic, demographic and behavioral factors influence the incidence and course of the disease. Gastrointestinal, pulmonary, laryngeal, metabolic, neurological and psychiatric conditions have been linked to GERD.4 Despite the absence of standard criteria for diagnosis, several symptombased diagnostic questionnaires and criteria have been defined.2,3,5,6 It is difficult to compare the results of studies and to evaluate the differences between countries due to differences between questionnaires. Detailed population-based data regarding the prevalence and symptom profile of GERD in Russia are limited. To the best of our knowledge, there is no related study published in English literature. The aim of the present study was to determine the prevalence and clinical spectrum of GERD in the Russian population in Moscow, which is one of the biggest cities in the world, as it is very possible that these data would differ from those in Western countries.
MATERIALS AND METHODS The study was performed in Moscow between February 2003 and April 2004. Assuming a maximum GERD prevalence of 20% in this population, a sample size consisted of 1065 adults (99% confidence interval, with a worst acceptable of ±3%) and their addresses were randomly selected from the white pages. Subjects aged ≥15 years were included, and those who had died or moved away from the city before the interview, possessed any mental or psychiatric disease, were unable to communicate due to dementia or refused to complete the survey were excluded. The population of Moscow grew rapidly between 1918 and 1990. However, because then, the population has declined due to a decreasing birth rate and increased migration away from the city, particularly in the early 1990s. Despite this decrease, according to the results of the national census in 2002, Moscow has remained the largest city in the Russian Federation, with a population of 10.4 million or approximately 7.2% of the Federation’s total population of 143.5 million. We used a reflux questionnaire derived from et al.6 It was previously validated in an English-speaking Western culture and then translated into the Russian language; after which, it was linguistically validated and adapted to the cultural profile of Moscow. As a summary, the process of translation included independent translation, back translation, a pilot test using 25 subjects, and review and approval from the original questionnaire developers. Feasibility was assessed in terms of the percentage of nonresponse and missing values, difficulty ratings (interviewer and interviewee) and administration time. Test–retest reliability was analyzed for each respondent using the Cohen’s kappa coefficients in a sub-sample who repeated the inter-
view 2–3 weeks after the first administration. The test–retest reliability of the Russian version of the questionnaire was good, and the Cronbach’s alpha values were all higher than 70% for all major symptoms within the 12-month period of prevalence. Frequent symptoms were defined as an episode of one of the major symptoms occurring at least once a week. Occasional symptoms were defined as an episode of one of the major symptoms occurring less than once a week within the past 12 months. Subjects were determined to have GERD if they had heartburn and/or regurgitation once a week or common. The questionnaire was administered through face-to face interviews at the Central Research Institute of Gastroenterology after an invitation via telephone. The total questionnaire contained 72 questions plus an additional of 29 sub-questions. The questions included major (heartburn and regurgitation) and related (dyspepsia, dysphagia, odynophagia and chest pain) symptoms, triggering factors of these symptoms, such as related medical conditions and past medical history, family history, and demographic and socioeconomic data, including the number of households and children, total monthly income, age, weight, height, employment, level of education and marital status. Past medical history included upper (nausea, vomiting and belching) and lower gastrointestinal symptoms (abdominal pain or discomfort); respiratory, throat and cardiac problems; the number of physician visits and diagnostic procedures related to upper gastrointestinal symptoms, medication usage (nonsteroidal antiinflammatory drug, acetylsalicylic acid and all drugs that have been related to upper gastrointestinal complaints or other health problems); pregnancy; present or previous smoking; and consumption of alcohol, regular coffee or tea. Data were analyzed using the Statistical package for the Social Sciences (SPSS Inc., Chicago, IL, USA) version 15.0. Categorical variables were expressed as frequency tables. Categorical comparisons between the groups were performed using cross-table statistics, and the significance level was analyzed by the chi-squared test. The statistical significance level was considered P < 0.05.
RESULTS Out of 1065 participants, 42.1% were male and 57.9% were female. The general characteristics of the participants are summarized in Table 1. The prevalences of frequent and occasional symptoms were 17.6 and 22.1% for heartburn and 17.5 and 21.8% for regurgitation, respectively, within the last 12 months. The prevalence of GERD (presence of heartburn and/or regurgitation at least once in a week) was 23.6% (Fig. 1). © 2015 International Society for Diseases of the Esophagus
Prevalence of GERD in Moscow Table 1 General characteristics of the participants Characteristic Gender Age (years)
Marital status Education level Income (monthly)
Body mass index (BMI) Lifestyle/habits
n (%) Male Female 15–24 25–34 35–44 45–54 55–64 65–74 75+ Married Single Divorced/widow University High school Primary school (8 years) 99$ 75-year-old age group (28.4%). The increases in the rate of GERD became significant as age increased (P = 0.011). The rate of GERD was 20.6% among married participants, 24.7% among singles and 31.6% among divorced/ widowed participants and showed significant differences across these marital status groups (P = 0.005). However, no significant difference was found across the education level groups in the rate of GERD
(P = 0.318). The rate of GERD in monthly income groups was significantly higher among with a monthly income lower than $50 (31.0%) compared with the other groups (P = 0.039). The rate of GERD showed no significant difference between the groups with body mass index (BMI)
Original article
Prevalence of gastroesophageal reflux disease in Moscow S. Bor,1 L. B Lazebnik,2 G. Kitapcioglu,3 I. Manannikof,2 Y. Vasiliev4 Section of Gastroenterology & Ege Reflux Study Group and 3Department of Biostatistics & Ege Reflux Study Group, Ege University, Izmir, Turkey; and 2Central Research Institute of Gastroenterology, and 4Department of Pathology of Upper Digestive Tract, Moscow Clinical and Research Center, Moscow, Russia 1
SUMMARY. Limited data exist to determine the prevalence and clinical spectrum of gastroesophageal reflux disease (GERD) in the Russian population, which might be different from those in Western countries. This study was performed in Moscow on randomized 1065 adults aged ≥15 years. A validated reflux questionnaire comprising 72 questions and an additional 29 sub-questions were used. The questions assessed (heartburn and regurgitation) and related (dyspepsia, dysphagia, odynophagia and chest pain) symptoms, the triggering factors of these symptoms, family history and data on demographic and socioeconomic features. GERD was defined as heartburn and/or regurgitation once a week or common. Of the 1065 participants, 42.1% were male and 57.9% were female. The prevalences of frequent and occasional symptoms were 17.6 and 22.1% for heartburn and 17.5 and 21.8% for regurgitation, respectively, over the last 12 months. The prevalence of GERD was found to be 23.6%. The rate of GERD was significantly higher in females than in males (15.4 vs. 29.5%, P < 0.001) and significantly increased as the age of the participants increased (P = 0.011). GERD was present in 20.4% of smokers, 24.2% of coffee drinkers, 21.5% of alcohol consumers and 45.9% of stressed participants. Although the rate of alcohol consumers was lower in those with GERD compared with those without GERD, the rate of coffee drinkers and stressed participants was higher among those with GERD. The rate of additional symptoms was higher even in participants complaining of regurgitation/heartburn rarely, compared with those without complaints. Using the same questionnaire, which makes it possible to compare the present results with those from different countries, we found the prevalence of GERD in Moscow to be 23.6%, one of highest in the Western populations. The rates of heartburn and regurgitation were found to be similar, which constitutes a different result than has been found in similar studies. Additional symptoms should be assessed, in all GERD patients even in the presence of rare complaints of regurgitation/heartburn. KEY WORDS: epidemiology, gastroesophageal reflux, heartburn, Moscow, regurgitation, Russia.
INTRODUCTION Gastroesophageal reflux disease (GERD) is one of the most common diseases in modern populations. An increased prevalence is associated with numerous factors, including lifestyle changes, such as nutritional habits, and obesity.1 Although the number of Address correspondence to: Professor Serhat Bor, MD, Section of Gastroenterology & Ege Reflux Study Group, Ege University, Izmir 35100, Turkey. Email: [email protected] Specific author contributions: Serhat Bor: study concept and design; analysis and interpretation of data; drafting and finalizing the manuscript. Leonid B. Lazebnik: administrative, study supervision, critical revision of the manuscript for important intellectual content. Gul Kitapcioglu: statistical analysis, study design, critical revision of the manuscript for important intellectual content. Igor Manannikof: acquisition of data, study design, technical or material support. Yuriy Vasiliev: technical support, acquisition of data. © 2015 International Society for Diseases of the Esophagus
investigations about debatable association between Helicobacter pylori infection and GERD has continued to rise, large epidemiological studies have reported an inverse association.2 Other conditions that have been linked to GERD include dietary indiscretion, coffee, smoking and alcohol use. The role of certain medications, such as nonsteroidal antiinflammatory agents, in GERD still requires critical evaluation.1 GERD appears to be significantly more common in Western countries. The prevalence of GERD has been shown to increase in the last decade; if GERD is defined as reflux occurring twice weekly over several months, it has been estimated to affect 10–20% of the Western populations and 5% of the Asian population.1 Recent studies have reported that the prevalence of GERD has also been increasing in Asian 1
2
Diseases of the Esophagus
countries.3 Genetic, demographic and behavioral factors influence the incidence and course of the disease. Gastrointestinal, pulmonary, laryngeal, metabolic, neurological and psychiatric conditions have been linked to GERD.4 Despite the absence of standard criteria for diagnosis, several symptombased diagnostic questionnaires and criteria have been defined.2,3,5,6 It is difficult to compare the results of studies and to evaluate the differences between countries due to differences between questionnaires. Detailed population-based data regarding the prevalence and symptom profile of GERD in Russia are limited. To the best of our knowledge, there is no related study published in English literature. The aim of the present study was to determine the prevalence and clinical spectrum of GERD in the Russian population in Moscow, which is one of the biggest cities in the world, as it is very possible that these data would differ from those in Western countries.
MATERIALS AND METHODS The study was performed in Moscow between February 2003 and April 2004. Assuming a maximum GERD prevalence of 20% in this population, a sample size consisted of 1065 adults (99% confidence interval, with a worst acceptable of ±3%) and their addresses were randomly selected from the white pages. Subjects aged ≥15 years were included, and those who had died or moved away from the city before the interview, possessed any mental or psychiatric disease, were unable to communicate due to dementia or refused to complete the survey were excluded. The population of Moscow grew rapidly between 1918 and 1990. However, because then, the population has declined due to a decreasing birth rate and increased migration away from the city, particularly in the early 1990s. Despite this decrease, according to the results of the national census in 2002, Moscow has remained the largest city in the Russian Federation, with a population of 10.4 million or approximately 7.2% of the Federation’s total population of 143.5 million. We used a reflux questionnaire derived from et al.6 It was previously validated in an English-speaking Western culture and then translated into the Russian language; after which, it was linguistically validated and adapted to the cultural profile of Moscow. As a summary, the process of translation included independent translation, back translation, a pilot test using 25 subjects, and review and approval from the original questionnaire developers. Feasibility was assessed in terms of the percentage of nonresponse and missing values, difficulty ratings (interviewer and interviewee) and administration time. Test–retest reliability was analyzed for each respondent using the Cohen’s kappa coefficients in a sub-sample who repeated the inter-
view 2–3 weeks after the first administration. The test–retest reliability of the Russian version of the questionnaire was good, and the Cronbach’s alpha values were all higher than 70% for all major symptoms within the 12-month period of prevalence. Frequent symptoms were defined as an episode of one of the major symptoms occurring at least once a week. Occasional symptoms were defined as an episode of one of the major symptoms occurring less than once a week within the past 12 months. Subjects were determined to have GERD if they had heartburn and/or regurgitation once a week or common. The questionnaire was administered through face-to face interviews at the Central Research Institute of Gastroenterology after an invitation via telephone. The total questionnaire contained 72 questions plus an additional of 29 sub-questions. The questions included major (heartburn and regurgitation) and related (dyspepsia, dysphagia, odynophagia and chest pain) symptoms, triggering factors of these symptoms, such as related medical conditions and past medical history, family history, and demographic and socioeconomic data, including the number of households and children, total monthly income, age, weight, height, employment, level of education and marital status. Past medical history included upper (nausea, vomiting and belching) and lower gastrointestinal symptoms (abdominal pain or discomfort); respiratory, throat and cardiac problems; the number of physician visits and diagnostic procedures related to upper gastrointestinal symptoms, medication usage (nonsteroidal antiinflammatory drug, acetylsalicylic acid and all drugs that have been related to upper gastrointestinal complaints or other health problems); pregnancy; present or previous smoking; and consumption of alcohol, regular coffee or tea. Data were analyzed using the Statistical package for the Social Sciences (SPSS Inc., Chicago, IL, USA) version 15.0. Categorical variables were expressed as frequency tables. Categorical comparisons between the groups were performed using cross-table statistics, and the significance level was analyzed by the chi-squared test. The statistical significance level was considered P < 0.05.
RESULTS Out of 1065 participants, 42.1% were male and 57.9% were female. The general characteristics of the participants are summarized in Table 1. The prevalences of frequent and occasional symptoms were 17.6 and 22.1% for heartburn and 17.5 and 21.8% for regurgitation, respectively, within the last 12 months. The prevalence of GERD (presence of heartburn and/or regurgitation at least once in a week) was 23.6% (Fig. 1). © 2015 International Society for Diseases of the Esophagus
Prevalence of GERD in Moscow Table 1 General characteristics of the participants Characteristic Gender Age (years)
Marital status Education level Income (monthly)
Body mass index (BMI) Lifestyle/habits
n (%) Male Female 15–24 25–34 35–44 45–54 55–64 65–74 75+ Married Single Divorced/widow University High school Primary school (8 years) 99$ 75-year-old age group (28.4%). The increases in the rate of GERD became significant as age increased (P = 0.011). The rate of GERD was 20.6% among married participants, 24.7% among singles and 31.6% among divorced/ widowed participants and showed significant differences across these marital status groups (P = 0.005). However, no significant difference was found across the education level groups in the rate of GERD
(P = 0.318). The rate of GERD in monthly income groups was significantly higher among with a monthly income lower than $50 (31.0%) compared with the other groups (P = 0.039). The rate of GERD showed no significant difference between the groups with body mass index (BMI)
