Gastroesophageal reflux disease symptoms: Prevalence, sociodemographics and treatment patterns in the adult Israeli population

Abstract

AIM: To evaluate the prevalence and sociodemographics of gastroesophageal reflux disease (GERD) symptoms and to identify treatment patterns among GERD patients.

METHODS: A telephone survey of a representative sample of the adult Israeli population was conducted. The questionnaire included detailed sociodemographics, history of GERD symptoms and the various treatments used.

RESULTS: The survey included 2027 subjects. Twice weekly, once weekly and monthly GERD symptoms were reported by 8.4%, 12.5% and 21.5% of subjects, respectively. There was no difference in prevalence between men and woman; however, GERD symptoms were significantly more prevalent within the older age group and lower socioeconomic status. Among those reporting weekly symptoms, a quarter did not use any kind of therapy and another quarter used various traditional remedies (e.g. soda, milk, almonds, etc.). Antacids were used by 35.1%, H₂ blockers by 13.2% and PPIs by 17.5%.

CONCLUSION: We found that 12.5% of the adult Israeli population experience weekly GERD symptoms. GERD prevalence and sociodemographics are similar to those described in other Western countries, and treatment is still suboptimal.

Key Words: Gastroesophageal reflux disease, Prevalence, Sociodemographics

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a highly prevalent gastrointestinal (GI) disorder and is one of the most common GI illnesses encountered in clinical practice[1,2]. Heartburn and acid regurgitation are the most common symptoms reported by patients with GERD[3,4]. The prevalence of GERD has been studied in many parts of the world and has been shown to be high in the Western population[5]. In the United States, 44% of the adult population have reported experiencing heartburn at least once a month, 14% have reported experiencing it weekly, and 7% have reported experiencing it daily[6]. Previous studies have shown an association between GERD and several demographic and behavioral factors such as gender, age, educational level and socioeconomic status[1,7]. However, inconsistent results have been reported for both GERD prevalence rates and possible associated risk factors in different countries. These inconsistencies may be the result of geographical variation, different lifestyle habits and methodological differences concerning the definition and evaluation of GERD symptoms[8].

The aim of the present study was to define the prevalence of GERD in Israel, to assess the effect of sociodemographic factors on the occurrence of GERD and to evaluate treatment patterns and use of medications among GERD patients.

MATERIALS AND METHODS

Subjects

The study was conducted in late 2006. A total of 2033 individuals aged 18 years or more were included in the study.

Questionnaire

A telephone questionnaire designed for use in large, population-based studies to assess the prevalence of GERD was administered. The interview was performed by non-health related professional reviewers (Geocartography Group Information Strategy & Solutions, Israel). The interviewers were totally familiar with the questionnaire and were instructed to better explain any eventual question that might not have been fully understood by the interviewed individuals.

After disclosing their age and giving voluntary consent to participate in the study, the participants were asked if they had ever experienced heartburn or gastric content regurgitation. Heartburn was defined as burning feeling starting in the stomach and radiating towards the throat. The questionnaire included questions related to the following information: presence and characteristics of heartburn or regurgitation, frequency of symptoms and type of treatments that were used. The questionnaire also included demographic variables such as: age, gender, ethnic origin, education, monthly income and living conditions.

Statistical analysis

Categorical variables were summarized with number and percentage of patients. The χ² and Fisher exact tests were used to compare categorical variables whereas Kruskal-Wallis one-way analysis of variance was used to analyze the demographic data. A P < 0.05 was considered statistically significant. Data were analyzed using SPSS version 15.0 (SPSS Inc. Chicago, IL).

RESULTS

The study population consisted of 2027 subjects. There were 1060 (52.3%) females and 967 (47.7%) males. The mean age was 44 ± 14 years. 572 individuals (29.6%) reported GERD symptoms at any frequency over the previous year, and 252 individuals (12.5%) reported reflux symptoms occurring at least once a week (Table 1).

Table 1 Frequency of gastroesophageal reflux disease symptoms among the studied population.

Frequency of heartburn events	No. of patients (%)
Daily	81 (4)
4-6 times/wk	32 (1.6)
2-3 times/wk	57 (2.8)
Once weekly	82 (4.1)
Once/2 wk	65 (3.2)
Once/mo	117 (5.8)
< Once/mo	145 (7.2)
Never	1448 (71.3)
Total	2027 (100)

Table 2 shows the frequency and severity of GERD symptoms in relation to sociodemographic parameters. There was no difference between males and females regarding GERD symptoms, but GERD symptoms were more frequent among older subjects (P = 0.0002). GERD symptoms were significantly more common among subjects with lower education level (P = 0.03) and in those with lower income (P = 0.008). GERD symptoms were also more frequent among subjects of Oriental ethnic origin, and lower among Israeli-born subjects (P = 0.003). All the differences were significant only among the subjects who had significant GERD symptoms defined as having symptoms at least once a week.

Table 2 Frequency of gastroesophageal reflux disease symptoms according to various demographic parameters.

Parameter	No.	> 1/wk (%)	< 1/wk (%)	None (%)	P value
Gender
Male	967	12.4	16.1	71.5	0.1
Female	1060	12.5	16.4	71.1
Age (yr)
18-34	744	8.71	17.6	73.7	0.0002
35-54	677	12.2	16	71.8
> 55	606	17.21	15.2	67.6
Education
Basic	774	15.41	16.8	67.8	0.03
High school	417	12.2	18.9	68.9
Academic	836	9.51	16.7	73.8
Income (IS)
< 7000	855	17.81	19.4	62.9	0.008
7000-10 000	571	7.51	20	72.5
> 10 000	601	9.91	12.9	77.1
Ethnic origin
Oriental	585	16.81	15.2	68	0.003
Western	539	10	15.1	74.8
Israeli born	516	9.61	17.2	73.2
New immigrant	387	12.8	18.5	68.8
Number of family Members
1-2	702	14	16.7	69.3	0.56
3-4	730	12.1	16.5	71.4
≥ 5	595	11	18.4	70.6

¹Statistically significant.

Table 3 shows the pattern of anti-reflux medications that were used by the study population. Twenty-five percent of subjects with significant GERD (at least once a week GERD episode), and 38.5% of those with less frequent GERD, did not take any treatment. Natural and traditional remedies were used by 22%-25% of subjects and only 20% of subjects with significant GERD used proton pump inhibitors (PPI).

Table 3 Type of treatment according to heartburn severity (More than one type may be used).

Type of treatment	High heartburn frequency > 1/wk	Low heartburn frequency < 1/wk	P value
	n = 253 (%)	n = 330 (%)
Proton pump inhibitors	50 (19.8)	22 (6.7)	< 0.001
H2 Blockers	33 (13)	24 (7.2)	0.02
Commercial antacids	89 (35.2)	71 (21.5)	< 0.001
Natural and traditional remedies (milk, almonds, ice cubes, etc.)	57 (22.5)	83 (25.2)	0.46
Analgesics	1 (0.4)	10 (3)	0.04
Prescription drugs (does not remember the name)	8 (3.2)	2 (0.6)	0.04
OTC (does not remember the name)	2 (0.8)	10 (3)	0.11
Other	27 (10.7)	31 (9.4)	0.6
Does not remember	14 (5.5)	13 (3.9)	0.36
Does not take any treatment	65 (25.7)	127 (38.5)	0.001

DISCUSSION

The results of the present study show that the prevalence of typical GERD defined by heartburn and/or acid regurgitation in the general adult population in Israel is close to 30%, and 12.5% of this population has suffered from at least one of these symptoms once weekly over the past year. These rates are similar to those reported in prior studies among Western populations, and recently in Israel[1,3-6,9].

In our study, GERD symptom prevalence was strongly associated with increasing age (17.2% in the > 55 years age group and 12.2% in the 18-34 years age group). However, higher prevalence was observed only in the high frequency patient group (≥ once/wk) but not in the lower frequency group. The effect of increasing age on the prevalence of GERD symptoms has been reported by two European studies[3,10], but was not seen in a study from Minnesota, USA[6]. In the UK GP database study, the trend of increased GERD incidence with age was reversed at the age of 69 years[11], while in the Georgia Medicaid study, the trend reversed earlier, at 55 years[12]. In all of these studies, GERD was defined on a symptomatic basis which lacks the ability to evaluate whether objective aspects of GERD, such as reflux esophagitis, are more prevalent or severe in older individuals.

A recent study from Israel reported that GERD symptoms are more common and severe among men[9]. However, our study, similar to several previous cross-sectional and longitudinal studies, did not find a significant association between gender and GERD[3,6,7,10,12].

An interesting observation of the current study is the effect of low socioeconomic status on the prevalence of GERD symptoms. Increased prevalence of GERD symptoms was reported in our study by subjects with lower income, lower level of education and by those of Oriental ethnic origin. Previous studies have found an increased GERD prevalence among subjects with lower educational level[13-14]. Recently, Nocon et al^[15] from Germany reported similar results. A reasonable explanation for this observation is that people from a lower social class are more likely to have lifestyle-related risk factors, such as smoking or overweight. However, Nokon et al[15] have found that even after adjusting for smoking and BMI, being in middle or lower social class nearly doubled the risk of severe GERD symptoms. The association of GERD and Helicobacter pylori (H. pylori) is controversial. While some argue for a preventive role of H. pylori in the pathogenesis of GERD by its ability to alter the nature of gastric refluxate, others find no link between the infection and GERD[16]. The prevalence of H. pylori in Israel has been found to be similar to that of other Western countries.

Another important finding of the current study is that a third of the subjects suffering from GERD symptoms do not use any of the accepted medical treatments, such as antacids or antisecretory drugs. Self-medication is still very common, even in those who have reported frequent symptoms, and popular and traditional remedies (as well as antacids) are still widely used.

There are several limitations to this study, and interpretation of the results should be cautious. The questionnaire included only the major and most common GERD symptoms: heartburn and acid regurgitation, but not other symptoms. Extra-esophageal manifestations of GERD were not included. Moreover, symptoms were assessed only by using patient questionnaires and not by a physician. Indeed, in the absence of a gold standard for diagnosing GERD, patient questionnaires remain the common outcome in clinical or epidemiological studies. Finally, we also were unable to obtain data on body mass index, diet, smoking status, and alcohol intake, which may have been confounding factors. However, despite these limitations, our findings are in accordance with population-based studies from other Western countries and with a recent report from Israel.

In conclusion, we found that the prevalence of typical GERD symptoms in the general adult population in Israel is close to 30%, and 12.5% of this population has suffered from at least one of these symptoms once weekly over the past year. These figures are similar to those found in other Western populations. There is an association between the frequency and severity of GERD symptoms and increased age, low income and low educational level. Antacids and traditional remedies are still widely used, and PPI treatment has not reached its full potential.

COMMENTS

Background

Gastroesophageal reflux disease, commonly referred to as Gastroesophageal reflux disease (GERD), is defined as chronic symptoms or mucosal damage induced by abnormal regurgitation of fluids from the stomach into the esophagus. The most typical symptoms are heartburn and regurgitation. In most cases, this is a result of inappropriate lower esophageal sphincter (LES) function. Gastro-esophageal refluxate contains a variety of noxious agents, mainly acid but also pepsin, bile salts and pancreatic enzymes, and the exposure of the esophageal mucosa to these agents may result in significant injuries to the esophageal mucosa. These injuries include: reflux esophagitis, esophageal stricture, Barrett’s esophagus and esophageal adenocarcinoma. Over the past three decades, the incidence of GERD as well as esophageal adenocarcinoma has risen rapidly, especially in Western countries. Lifestyle modifications combined with proton pump inhibitors (PPI) are currently the first-line treatment for subjects with GERD. It is important, therefore, to identify populations at risk for GERD and to recognize those who are inappropriately or inadequately treated. The aim of the current study was to assess the prevalence and risk factors of GERD, presenting as heartburn or regurgitation, among the Israeli adult population and to identify treatment patterns exhibited by this population.

Research frontiers

In the current study the authors placed our emphasis on the importance of sociodemographic factors as risk factors for GERD. In addition, the authors examined to what extent subjects who suffer from GERD are treated appropriately according to current recommendations in the literature.

Innovations and breakthroughs

The authors have found an increased prevalence of GERD symptoms among subjects from lower socioeconomic status, defined as those with lower income, lower level of education and those of Oriental ethnic origin. The authors have also found that a significant proportion of GERD patients are not treated adequately.

Applications

More efforts are needed to identify subjects who are at risk for GERD, to promote lifestyle improving programs and to encourage adequate treatment for GERD in order to prevent complications, especially esophageal adenocarcinoma.

Peer review

In this manuscript, the authors described the prevalence of GERD and its related factors in an adult Israeli population. The study was uniquely performed and interesting.