Prevalence of Irritable Bowel Syndrome: A Community Based ...

The prevalence of IBS in the general population varies from 9% to 22% in the United States and European countries. The rapid socioeconomic development in ... 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JNeurogastroenterolMotil2011;17(1):82-87  https://doi.org/10.5056/jnm.2011.17.1.82PrevalenceofIrritableBowelSyndrome:ACommunityBasedStudyFromNorthernIndiaGovindKMakharia*,AnilKVerma,RitvikAmarchand,AnilGoswami,PrashantSingh,AbhishekAgnihotri,FaizulSuhailandAnandKrishnanDepartmentofGastroenterologyandHumanNutritionandCentreforCommunityMedicine,AllIndiaInstituteofMedicalSciences,NewDelhi,India.Correspondenceto:Correspondence:GovindKMakharia,MD,DM,DNB,MNAMS.AssociateProfessor,DepartmentofGastroenterologyandHumanNutrition,AllIndiaInstituteofMedicalSciences,Ansarinagar,NewDelhi-110029,India.Tel:+91-11-26588091,Fax:+91-11-26588091,[email protected]:October8,2010;Revised:November18,2010;Accepted:November25,2010;Publishedonline:January26,2011©TheKoreanSocietyofNeurogastroenterologyandMotility.Allrightsreserved.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNon-CommercialLicense(http://creativecommons.org/licenses/by-nc/3.0)whichpermitsunrestrictednon-commercialuse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.OtherSectionsAbstractIntroductionMaterialsandMethodsResultsDiscussionFigureTableReferencesAbstractBackground/AimsTheprevalenceofirritablebowelsyndrome(IBS)variesfrom4%to20%indifferentAsiannations.PrevalenceofIBSinnativeNorthIndiancommunityisnotknown.MethodsBetweenNovember2008toDecember2009,weestimatedtheprevalenceofIBSinaruralcommunityofBallabgarhblock,locatedinHaryanastate.AstructuredquestionnairebasedonRomeIIImodulewasusedtocollectsymptomsrelatedtoIBSfromalltheparticipantsinadoortodoorsurvey.ARomeIIIcriterionwasusedfordiagnosisofIBS.IBSwasfurtherclassifiedbasedonpredominanceofsymptomsasconstipationpredominant,diarrheapredominant,mixedandunspecifiedbasedonRomeIIImodule.ResultsTherewere4,767participants(meanage34.6±10.8,males50%).Overall,555(11.6%;95%CI,10.7-12.5)hadconstipation,542(11.4%;95%CI,10.5-12.3)diarrheaand823(17.3%;95%CI,16.2-18.4)abdominalpain.TheoverallprevalenceofIBSwas4%(95%CI,3.5-4.6).TheprevalenceofconstipationpredominantIBSwas0.3%(95%CI,0.16-0.49),diarrheapredominantIBS1.5%(95%CI,1.18-1.90),mixedIBS1.7%(95%CI,1.35-2.11)andunsubtypedIBS0.5%(95%CI,0.32-0.75).TheprevalenceofIBSwassignificantlyhigherinfemalescomparedwithmales(4.8%vs3.2%,=0.008).However,therewasnosignificantdifferencebetweenmalesandfemalesintheprevalenceofdifferentsubtypesofIBS.Theprevalenceincreasedwithage.ConclusionsTheprevalenceofIBSinaNorthIndiancommunityis4%.IBSposesasignificantburdenontheruraladults.Keywords:Asia,Constipation,Diarrhea,Epidemiology,IrritablebowelsyndromeOtherSectionsAbstractIntroductionMaterialsandMethodsResultsDiscussionFigureTableReferencesIntroductionThemagnitudeofpatientswithfunctionalgastrointestinaldisordersvisitingoutpatientclinicsishighandaccountsforuptoonethirdofoutpatientconsultations.1Irritablebowelsyndrome(IBS)isafunctionalgastrointestinaldisordercharacterizedbyabdominalpain,discomfortandalterationofbowelhabitsintheabsenceofanyorganicdisorder.TheprevalenceofIBSinthegeneralpopulationvariesfrom9%to22%intheUnitedStatesandEuropeancountries.2-6Therapidsocioeconomicdevelopmentinthelast20yearshasalsocreatedatransitioninthehealthandenvironmentalsituationinAsia.TheprevalenceofIBSamongAsiancommunitiesappearstobeontherise.7,8UsingRomeIIcriteria,theprevalenceofIBSinSingapore(8.6%)andJapan(9.8%)arecomparabletothatinAustralia(6.9%)andEurope(9.6%),althoughnotashighasinCanadaandtheUK(12%).9-13TheprevalenceofIBSbothinthecommunityandevenintheoutpatientclinicsvariesanddependsonthecriteriausedsuchasManningcriteriaorRomecriteria.5,14Recently,theIndianSocietyofGastroenterologyconductedastudyinvolvingcloseto3,000IBSpatientsand4,500communitysubjectsdrawnfrom18centers.15ThisstudywasuniqueinthattheauthorshadadoptedanentirelysymptomsbaseddiagnosisofIBSratherthanusinganyoftheRomecriteriaorManningcriteria.TheestimatedprevalenceofIBSinthisstudywas4.2%.Inanotherstudyincluding2,549subjectsfromanurbancommunityfromWesternpartofIndia(Mumbai),Shahetal16reportedtheprevalenceofIBStobearound7.5%byManningcriteria.Bothoftheabovestudieswerenotreallyacommunitybasedstudy.Whilethefirststudyincludedamixofpatientsrelatives,hospitalstaff,studentsandgeneralpopulation;thesecondstudyincludedrelativesofpatientsvisitinghospitals,studentsandstaffmembersofthehospital.15,16ThereisalackofdataontherealandnativecommunitystudyfromIndia.WethereforeplannedtoestimatetheprevalenceofIBSusingRomeIIIcriteriainaruralNorthIndiancommunity.OtherSectionsAbstractIntroductionMaterialsandMethodsResultsDiscussionFigureTableReferencesMaterialsandMethodsStudySettingThestudywasconductedintheruralfieldpracticeareasoftheCentreforCommunityMedicine,AllIndiaInstituteofMedicalSciencesbetweenOctober2008andDecember2009.Theruralpracticeareaconsistedof87,002populationspreadover28villagesinBallabgarhblockofFaridabaddistrictandisservedby2primaryhealthcentersandasub-districtlevelhospitalatBallabgarh.Thiscommunityisanativestablecommunityandmigrationrateinthiscommunityisminimalnegligible.SampleSizeCalculationThestudywasconductedasanadd-ononapreviousstudycarriedouttoelicittheprevalenceofceliacdisease.Atotalof4,767adultswereincludedinthestudyandallofthemweresubjectedtoquestionsonIBS.CommunitystudiesinIndiahaveshowntheprevalenceofIBStobeapproximately5%andassumingthistobetheexpectedprevalence,thissamplesizewasexpectedtogivearelativeprecisionof33%ie,from3.4%-6.6%at5%alphaerror.Onusingaproportionatetopopulationsizesamplinglist,12villageswereselectedforsurvey.TheseincludedMacchgarh,Sotai,ShahpurKalan,Jawa,PanehraKalan,Fatehpur,Chandawali,Chhainsa,Dayalpur,Mauzpur,Atali,DayalpurandKhera.SelectionofHouseholdsandIndividualsInthechosenvillages,alternatehouseholdswereselectedforinclusioninthestudy.Itwasdecidedapriorithatfromeachselectedhousehold,1adultofeithergender(definedasindividualaged18to64years)wouldbeincludedinthestudy.Toaidselectionofthegenderofadulttobeinterviewedfromahousehold,eachteamwasprovidedwithapre-randomizedlist.Toselect1adultofthegenderoutofalladultsofthesamegenderinahousehold,thenamesofalladultmembersoftheselectedgenderinthehouseholdwerelisted.Then1memberwasselectedbyrollofadice.Theselectedindividual'sconsentwastakenandanIDnumberwasassigned.QuestionnaireBasedonRomeIIICriteriaAsimple10pointobjectivequestionnairebasedonRomeIIIIBSmodulewasusedinthisstudy.TheEnglishversionofthequestionnairewastranslatedintothenativelanguageHindi.DataCollectionThefieldinvestigatorsweretrainedtoadministerthepre-designedquestionnaire.Thefieldinvestigatorswereprovidedwithstructuredsurveysheetswhichtheyusedonlistedandenrolledhouseholdsastheywentalongwiththesurvey.Anyrefusalsor,lockedhouseholdswerealsorecordedinthesheet.Afterself-introductionandinformingthepurposeoftheirvisit,thefieldinvestigatorssoughtconsentfromtherespondentsforparticipatinginthestudy.QualityControlDuringthestudy,supervisoryvisitsandrandomchecksweredoneregardingthescreeningofthesubjects.Every4-6weeks,reviewmeetingswereconductedbystudypersonnelanddatawerereviewed.CriteriafortheDiagnosisofIrritableBowelSystemIBSwasdiagnosedonthebasisofRomeIIIcriteria,accordingtowhich,recurrentabdominalpainordiscomfortatleast3dayspermonthinthelast3monthswithonsetofsymptomsatleast6monthsbackwasessentialforsuspectingIBS.Inaddition,todiagnoseapersonasIBS,thepainneededtobeassociatedwithatleast2outof3featureswhichincludedimprovementofpainordiscomfortwithdefecationandonsetofpainordiscomfortassociatedwithachangeinfrequencyorform(appearance)ofstool.ThepatientswhowerediagnosedashavingIBSwerefurthersubclassifiedintodiarrheapredominantIBS(IBS-D)iftheyhadloose,mushyorwaterstoolsinthelast3monthswithnohardorlumpystools;constipationpredominantIBS(IBS-C)iftheyhadhardorlumpystoolswithnoloose,waterymushyorwaterystoolsinthepast3months;mixedIBS(IBS-M)iftheyhadbothlooseandhardstoolsinthepast3months;andunsubtypedIBS(IBS-U)iftheydidnotreporteitherlooseorhardstoolsinthepast3months.StatisticalMethodsAllthefilledquestionnairesheetswereenteredincomputerusingEpiinfoVersion3.4.1(CDC'sdatabaseandstatisticssoftwareforpublichealthprofessionals,Atlanta,GA,USA).Doubledataentrywasdoneforqualitycontrol.Entereddatawereanalyzedtoassessthecharacteristicsofthestudypopulationincludingageandgenderdistribution.STATA9.1statisticalsoftwarewasusedfordataanalysis.Proportionsand95%CIwerecalculatedusingChi-squaretest.AP-valuelessthan0.05wasconsideredsignificant.OtherSectionsAbstractIntroductionMaterialsandMethodsResultsDiscussionFigureTableReferencesResultsInthisprospectivestudytofindouttheprevalenceofIBSinaruralcommunity,4,767subjectswereinterviewed.Themeanageoftheparticipantswas34.6±10.8yearsand2,383(50%)weremale.TheagedistributionisshowninTable1.SubjectsHavingSymptomsofDiarrhea,ConstipationorAbdominalPainOf4,767subjectsinterviewed,555(11.6%;95%CI,10.7-12.5)hadconstipation,542(11.4%;95%CI,10.5-12.3)haddiarrheaand823(17.3%;95%CI,16.2-18.4)hadabdominalpain.PrevalenceofIrritableBowelSyndromeOnehundredandninety-onesubjectsfulfilledtheRomeIIIcriteriafordiagnosisofIBS.Therefore,theoverallprevalenceofIBSwas4%(95%CI,3.5-4.6).PrevalenceofSubtypesofIrritableBowelSyndromeThese191patientswerefurthersubclassifiedintoIBS-D,IBS-C,IBS-MandIBS-UaccordingtotheRomeIII.TherelativeproportionofIBS-Mwas42.4%,IBS-D37.7%,IBS-U13.6%andIBS-C6.3%.TheprevalenceofIBS-Cwas0.3%(95%CI,0.16-0.49),IBS-D1.5%(95%CI,1.18-1.90),IBS-M1.7%(95%CI,1.35-2.11)andIBS-U0.5%(95%CI,0.32-0.75).AgeandGenderStratifiedPrevalenceofIrritableBowelSyndromeandItsSubtypesTheprevalenceofIBSincreasedastheageadvancedandwasmaximum(5.8%)intheagegroup51-60(Table1andFig.1).TheprevalenceofIBSwassignificantlyhigherinfemalescomparedwithmales(4.8%vs3.2%,P=0.008)(Table2).However,therewasnosignificantdifferencebetweenmalesandfemalesintheprevalenceofdifferentsubtypesofIBS(Fig.2).TheprevalenceofIBS-C,IBS-D,IBS-MandIBS-UindifferentagegroupsisshowninFigure1.TheprevalenceofIBS-Uintheagegroup51-60washighestamongotheragegroups(P=0.01).OtherSectionsAbstractIntroductionMaterialsandMethodsResultsDiscussionFigureTableReferencesDiscussionTheprevalenceofIBSwasfoundtobe4%inthepresentNorthernIndianruralcommunitywiththeRomeIIIcriteria.TwootherstudiesontheprevalenceofIBSinIndiawerereported.WhileShahetal16reportedaprevalenceof7.6%fromMumbaiusingManningcriteria;Ghoshaletal15reportedaprevalenceof4.2%intheirprospectivemulti-centerstudyusingclinicalcriteria.Unlikepreviousstudies,thepresentstudywasdoneinanativeIndianruralcommunitywhichrepresents72.2%ofIndianpopulation.Thisstudywasdoneasdoortodoorsurveyusingrandomsampling.TheprevalenceofIBSinboththeabovecommunitybasedstudywasnotonlymuchlowerthanthatreportedfromtheWesterncountries;butalsomuchlowerthancommunitybasedstudiesfromotherAsiancountrieslikeTaiwan(22.1%byRomeIIcriteria),17China(11.5%byManningcriteria),18Singapore(8.6%byRomeIIcriteria),9Malaysia(15.6%byRomeIIcriteria),19Bangladesh(8.5%byRomeIIcriteria),20Pakistan(14%byRomeIIcriteria),21Turkey(10.2%byRomeIIcriteria),22Korea(6.6%byRomeIIcriteria)23andJapan(9.8%byRomeIIcriteria).10ItisdifficulttoestimatethetrueprevalenceofIBSasitisknowntochangedependingonthecriteriausedfordiagnosis.11,14,24RevisionsofthediagnosticcriteriaforIBShaveledtovaryingprevalenceestimatesinthesamepopulation.TheRomeIIIcriteriaislessrestrictiveandrequiresalowersymptomfrequencythanRomeIIcriteriaforIBS.Similarly,theprevalenceofIBShasbeenreportedtobehigherwithManningcriteriaandRomeIcriteriacomparedwithRomeIIcriteria.14Inastudyincluding2,000individualsfromSpain,Mearinetal14reportedamuchlowerprevalencerateusingtheRomeIIcriteria(3.3%)thanthatobtainedusingtheManning(10.3%)andtheRomeIcriteria(12.1%).Inanotherstudy,wherearepresentativesampleof1,000adultswereassessedforprevalenceofIBSusingRomeIIandRomeIIIintegrativequestionnaire;theprevalenceforIBSwasfoundtobe2.9%withRomeIIcriteriaand11.4%withRomeIIIcriteria.25Xiongetal18fromSouthernpartofChinareportedaprevalenceofIBSas11.5%withManningcriteriaand5.6%withRomeIIcriteriainapopulationbasedstudyincluding4,178subjects.Morerecently,agoodagreementintheprevalenceofIBSwasreportedbyParketal24fromKoreausingRomeII(8%)andRomeIIIcriteria(9%).ThereisacriticismthatRomeIIandRomeIIIcriteriaarenotsuitableforAsiannationsbecausebothofthemunderestimatetheprevalenceofIBSasaptlyshowninthestudyfromTehran.26,27Inastudyincluding18,180participantsfromTehranProvince,Iran,whiletheprevalenceoffunctionalboweldiseasewas10.1%,theprevalenceofIBSwasonly1.1%usingRomeIIIcriteriaagainsttheexpectedhigherprevalenceratesforIBS.27Ourestimationofprevalenceof4%maybeanunderestimationofprevalenceofIBS.Inthisprospectiveruralcommunitybasedstudy,IBS-MwithalternatingfeaturesofdiarrheaandconstipationwasthemostcommonformofIBSinIndiawithprevalenceof1.7%closelyfollowedbyIBS-Dwithprevalenceof1.5%.PredominanceofIBS-MamongIBSpatientshasalsobeenreportedfromtheUnitedState.3Inthepresentstudy,theprevalenceofconstipationpredominantIBSwas0.3%andthismaybeduetoahigherfiberintakeandfasterguttransittimeamongIndians.28TheprevalenceofIBSinthepresentstudywashigherinfemalescomparedtomales.WhileIBSismorecommoninwomenthanmeninmanyWesterncountries;noconsistentdifferenceshoweverhasbeenobservedfromAsia.2,3,12WhilestudiesfrommanyAsiannationssuchasHongKong,TaiwanandSingaporehavenotrevealedagenderdifferenceintheprevalenceofIBS,afemalepredominancehasbeenreportedfromBangladesh,Vietnam,MalaysiaandJapan.17,19,20,29-34Inthe2previoushospitalbasedstudiesfromIndia,IBSwasreportedtobemorecommoninmales.15,16Ontheotherhand,theprevalenceofIBSbetweenfemaleandmalewasalmostsameinthosewhohadsymptomsofIBSinthecommunitystudyfromIndiawithnonhealthseekers.15SinceIndiaisamaledominantsociety,healthseekingbehaviourofmalesisprobablythebestexplanationfordifferenceintheprevalenceofIBSinthestudiesconductedinhospitalsettingandthosedoneinthecommunity.13,35-38Femalesexhormonesaffectinggastrointestinalmotilityanddifferencesintheserotoninsynthesisinbrainareproposedmechanismsforhigheroccurrenceofmotilitydisordersinwomen.39,40ConsideringthecurrentprevalenceofIBSinourcommunity,IBSstillremainsanunder-diagnosedgastrointestinaldisorder.Thiscouldbeeitherduetolowhealthseekingbehaviorofthecommunityor,duetopoorabilityofmedicalfraternityinprimaryhealthcaretodiagnosethecondition.Thereisnostudyavailablewhichcorrelatestheseverityofillnesswithhealthcareseekingpatternofthesepatients.FurtherstudiesarethereforeneededtostudythehealthcareseekingpatternofIBSpatientsinourpopulationandtoassesstheseverityofIBS.Also,thereisnopopulationbasedinvestigationontheimpactofIBSonthehealth-relatedqualityoflife(HRQOL)inIndia.AssessmentofHRQOLinthesepatientswillnotonlygiveaninsightonseverityofdiseasebutalsohelpinoptimizingthetreatmentofIBS.Thestrengthofthisstudyisthatitisacommunitybasedstudywithlargesamplesize.Thisstudyislimitedtonativeruralpopulationandhasnotincludedurbanpopulation.TheremaybeadifferenceintheprevalenceofIBSamongstruralandurbanpopulation.Inconclusion,theprevalenceofIBSinaNorthernIndiancommunityis4%.ThepredominantsubtypeofIBSinthiscommunityisIBS-M.OtherSectionsAbstractIntroductionMaterialsandMethodsResultsDiscussionFigureTableReferencesFigures Fig.1.Prevalenceofirritablebowelsyndromesubtypesindifferentagegroup.IBS,irritablebowelsyndrome;IBS-C,constipationpredominantIBS;IBS-D,diarrheapredominantIBS;IBS-M,mixedIBS;IBS-U,unsubtypedIBS. Fig.2.Prevalenceofirritablebowelsyndromesubtypesinmenandwomen.AbbreviationsasFigure1. OtherSectionsAbstractIntroductionMaterialsandMethodsResultsDiscussionFigureTableReferencesTables Table.1.DemographicDetailsofIrritableBowelSyndromePatients IBS,irritablebowelsyndrome.aChi-squarefortrend. Table.2.GenderDistributionandPrevalenceofSubtypesofIrritableBowelSyndrome IBS,irritablebowelsyndrome.aChi-squarefortrend. OtherSectionsAbstractIntroductionMaterialsandMethodsResultsDiscussionFigureTableReferencesReferences OkumuraT,TannoS,OhhiraM,TannoS.PrevalenceoffunctionaldyspepsiainanoutpatientclinicwithprimarycarephysiciansinJapan.JGastroenterol.2010;45;187-194. JonesR,LydeardS.Irritablebowelsyndromeinthegeneralpopulation.BMJ.1992;304;87-90. HunginAP,ChangL,LockeGR,DennisEH,BarghoutV.IrritablebowelsyndromeintheUnitedStates:prevalence,symptompatternsandimpact.AlimentPharmacolTher.2005;21;1365-1375. 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ThisArticle PDF(Download:581) PubMed PubMedCentral GoogleScholarSearch CitedByArticles CrossRef(59) Services ExportCitationforthisArticle E-mailLinktothisArticle SocialNetworkService Searchfor AdvancedSearch Archives Copyright©TheKoreanSocietyofNeurogastroenterologyandMotility.AllRightsReserved.Room305,LotteGoldRoseVillII,31Seolleung-ro86-gil,Gangnam-gu,Seoul06193,KoreaTel)82-2-538-0634 Fax)82-2-538-0672 e-mail)[email protected].,Ltd