|Year : 2013 | Volume
| Issue : 2 | Page : 57-61
Obesity and gastrointestinal quality of life: A hospital-based survey
Tonguc Utku Yilmaz
Department of General Surgery, Kocaeli University School of Medicine, Kocaeli, Turkey
|Date of Web Publication||12-Mar-2014|
Tonguc Utku Yilmaz
Department of General Surgery, Kocaeli University School of Medicine, 41380 Umuttepe, Kocaeli
Source of Support: None, Conflict of Interest: None
Objective: We tried to find whether obesity worsens gastrointestinal (GI) quality of life score among patients with GI symptoms. Materials and Methods: This descriptive study was performed in general surgery outpatient clinic in a slum part of a city. Body mass index (BMI) of the patients was measured. The patients with GI symptoms were included. The demographic data obtained. GI quality of life score questionnaires were performed. Results : The prevalence of being overweight and obesity were 32.4% and 40.1% respectively. There 442 patients with GI symptoms among 1250 outpatient admissions. The mean age, BMI and GI quality of life index scores of the patients were 46.3 (18-87), 31.1 (18.8-44.4) and 89.9 (63-121) respectively. The percentage of obese and overweight patients was significantly higher than the percentage of patients with normal weight. The quality of life decreased significantly in overweight and obese patients when compared with normal weight patients. Conclusion : The prevalence of obesity among females and older age was higher. Obesity is worsening the GI quality of life.
Keywords: Age, body mass index, gastrointestinal symptoms, obesity, quality of life
|How to cite this article:|
Yilmaz TU. Obesity and gastrointestinal quality of life: A hospital-based survey. Saudi J Obesity 2013;1:57-61
| Introduction|| |
With its increasing prevalence, obesity is becoming a significant public health concern world-wide, regardless of the level of population development. The prevalence of obesity in the adult population in the United States, Western Europe and Turkey is 30%, 50% and 36% respectively. , If precautions are not taken, the number of obese people in the world in 2030 is estimated to be 600 million. 
Obesity has been shown to be a risk factor for several chronic diseases such as diabetes mellitus type 2, cardiovascular disease, hypertension, dyslipidemia, gall bladder disease, gastroesophageal reflux disease (GERD), sleep apnea and respiratory problems. Excess body weight has also been associated with an increased risk of all-cause mortality.  If its prevalence continues to increase, obesity may overtake tobacco as the leading preventable cause of death.
Health-related quality of life has gained increasing interest as an outcome measure in clinical medicine and in public health settings. It is particularly useful in studies on chronic diseases where the realistic goal of care is to make life as comfortable as possible. Gastrointestinal (GI) quality of life is a unique way of estimating personal perception of GI symptoms and is a way of measuring the effects of symptoms on the personal lives of patients. 
As the GI tract is the dominant organ system associated with food intake, increased food intake might lead to enhanced physiological responses that induce GI symptoms, which is generally a unique personal perception. Dysregulation of the mechanisms that control food intake and energy expenditure is key to the development of obesity. High-calorie, high-fat diets and increased food intake might lead to several GI symptoms and diseases. The potential role of obesity in GI symptoms is unclear. Reports from several health surveys show inconsistent results. ,, The perception of some GI sensations - like satiation - may be reduced in individuals with an increased body mass index (BMI), resulting in a lower rate of certain GI symptoms in obesity. The quality of life associated with GI symptoms has emerged from on-going studies that consider the relationship between obesity and GI symptoms.
The aim of this study is to evaluate whether obesity worsens GI quality of life score among patients with GI symptoms.
| Materials and Methods|| |
This descriptive cross-sectional study was conducted in the slum part of Ankara, the capital city of Turkey. This region is characterized by a population with a low socio-economic status. The polyclinics found in this district provide outpatient services by different departments, including general surgery. Approximately 30 patients attend the general surgery outpatient clinic daily. The patients come to the general surgery outpatient clinic by self-referral or through inter-department consultation and referral. This study was performed among the patients that attended the general surgery out-patient clinic between December 2011 and April 2012.
Body weight was categorized using the BMI (BMI; kg/m 2 ) with underweight defined as BMI < 18.5 kg/m 2 , normal weight as 18.5 ≤ BMI < 25 kg/m 2 , overweight as 25 ≤BMI <30 kg/m 2 and obese as BMI ≥30 kg/m 2 .
Individual self-reported details, including sex, age were obtained. Weights and heights of the patients were also measured in the outpatient clinic. Only those patients with GI symptoms were included in the study. Patients with certain disease and/or medication history that might lead to weight loss or weight gain (malignancy, hypo/hyperthyroiditis, organ failure, adrenal gland disease, GI resections, antipsychotic drugs, antidepressant drugs and glucocorticoid drugs, etc.) were excluded from the study. Non-consenting patients and those who did not complete the questionnaire were also excluded.
The GI symptoms were categorized into nausea, heartburn, epigastric pain, anal pain and lower abdominal pain, as in previous studies.  The defined symptoms were described by patients as below:
- Nausea, a sensation of wanting to vomit, generally with postprandial fullness and bloating
- Heartburn, a burning pain or discomfort behind the breastbone rising toward the throat
- Epigastric pain, a burning pain or discomfort inferior to the xiphoid that spreads to the umbilicus or back;
- Anal pain, a dull or sharp pain during defecation generally associated with constipation
- And lower abdominal pain, a dull pain in the lower quadrants of the abdomen.
GI quality of life index (GIQLI) was selected as it may be used to assess the impact of GI disturbances, as well as generic influences on the patients' quality of life. The GIQLI questionnaire consists of 36 multiple-choice items, each comprised of five response categories scored from 0 to 4. Each question can be assigned to the following aspects of quality of the life; core symptoms, physical function, emotional condition, disease-specific and social function. The maximum total score is 144. 
Data are presented as mean ± standard deviation. The sex distribution is shown by the ratio of female to male patients. Statistical analyzes were performed by SPSS version 13.00 (SPSS Inc., Chicago, IL, USA). Differences between the observed GI symptoms in the varying BMI groups were determined by one-way analysis of variance followed by a post-hoc Tukey's test. Gender-specific outcomes and the distribution of BMI groups were analyzed using t-tests. A P < 0.05 was considered to be significant. The relationship between age, GIQLI score and BMI were analyzed by Pearson correlation tests.
| Results|| |
A total of 1250 patients came to the general surgery out-patient department during the study period. The mean BMI of the patients was 28.8 ± 5.8. More than half of the patients were either overweight (32.4%) or obese (40.1%). A total of 442 patients were included in the study. The mean age, BMI and GIQLI scores of the patients were 46.3 ± 15.2, 31.1 ± 5.5 and 89.9 ± 19.9, respectively. The percentages of overweight and obese patients with GI symptoms were 26.2% and 58.4% respectively. There were 342 female and 100 male patients. The mean age, GIQLI score and BMI of female patients were 45.9 ± 15.1, 83.2 ± 18.6 and 31.6 ± 5.1, respectively. The mean age, GIQLI score and BMI of male patients were 47.4 ± 13.8, 86.8 ± 17.9 and 29.1 ± 4.3, respectively. There were no significant differences between age, GIQLI score and BMI of female and male patients (P > 0.1).
The age, BMI, GIQLI scores and sex distribution of the patients according to GI symptoms are given in [Table 1]. Regarding age, no significant difference was found between the GI symptoms. Among the GI symptoms, the patients with lower abdominal pain had significantly lower BMI values than those in other groups. The BMI of the female patients with epigastric pain and heartburn were significantly higher than the male patients with the same symptoms. The quality of life was lowest in patients with epigastric pain and highest in patients with lower abdominal pain.
|Table 1: The mean age, the mean BMI, the mean GIQLI scores and sex distribution of patients with different gastrointestinal symptoms|
Click here to view
The ages, GIQLI scores and sex distribution of the patients according to BMI are given in [Table 2]. The number of obese and overweight patients was significantly higher than the number of patients with normal weight (P < 0.001). The mean age of patients with normal weight was significantly lower than the other groups (P ≤ 0.01). The ratio of female to male patients was significantly higher in the obese group when compared with other groups. There were significant differences between the quality of life of the patients in all three groups. Quality of life was decreased significantly in overweight and obese patients when compared with normal weight patients. The distribution of subgroups of GIQLI is given in [Figure 1]. In the quality of life subgroups, it was seen that core symptom, social and disease-specific item scores were not significantly different between normal weight and overweight patients (P ≥ 0.1). However, all items in obese patients showed significant decreases when compared with normal weight and overweight patients (P < 0.001).
|Figure 1: Subgroups of gastrointestinal quality of life index among body mass index groups|
Click here to view
|Table 2: The mean ages, mean GIQLI scores and sex distribution of patients among three BMI groups|
Click here to view
Decreasing quality of life with increasing BMI was observed in our study [Figure 2]. The negative correlation between BMI and GIQLI is significant (R2 = 0.53, P = 0.002).
|Figure 2: The correlation between body mass index and gastrointestinal quality of life index scores of the patients|
Click here to view
| Discussion|| |
In this descriptive study, we found that obesity worsened GI quality of life in patients with GI symptoms. Physical, psychological and social items of GI quality of life decreased with an increase in weight.
This study included patients that came to the general surgery outpatient department. The overall incidence of obesity is 40.1%, but is increased to 58.4% in patients with GI symptoms. Prevalence studies performed in Turkey between 1999 and 2009 reported that the prevalence of obesity increased from 22% to 31.7% respectively, , corresponding to an increase rate of 65% for men and 30% for women during this time.  The world-wide prevalence of obesity is still increasing. In studies performed in several out-patient clinics, the frequency of obesity was found to be similar to community based studies (28-34.5%). ,
Recently, the prevalence of obesity was found to be high in patients with GI symptoms. ,,, Although these studies are much more symptom-specific, it is obvious that GI symptoms are frequent among obese patients. However, the rate observed in this study is higher than rates given in the literature. ,,, The high obesity incidence observed in this study be due to increasing obesity in the population or to selection bias of patients with low socio-economic status.
As mentioned in previous studies, low socio-economic status and low education levels are risk factors for obesity. , We found that our data corresponded with several studies that mentioned older age and female gender as risk factors for obesity. , The mean age of patients with normal body weight was significantly lower than that of overweight and obese patients. Positive correlation between BMI and age of patients was observed in this study [Table 2].
GI symptoms have been shown to be associated with the BMI of the patients. Locke et al. have reported that obesity is a risk factor for esophagitis.  Similarly, van Oijen et al. in their study showed heartburn, regurgitation and GERD are frequent among obese patients.  A community-based, randomized, controlled trial by Murray et al. showed a positive correlation between BMI and prevalence of GI symptoms.  In the meta-analysis of Eslick upper abdominal pain, gastroesophageal reflux, chest pain/heartburn and retching are the main symptoms associated with obesity.  Talley et al. also showed that nausea, heartburn and bloating were observed more often in obese patients, independent of age, gender and smoking status,  results that are similar to our findings. The mean BMI of patients with nausea, epigastric pain and heartburn were in the range of obesity. However, BMI values of patients with lower abdominal pain were significantly lower than those of other symptom groups. A literature search revealed no significant association between lower abdominal pain and BMI.  Although these studies included diarrhea as a condition of lower abdominal pain, it was mentioned that diarrhea was expected to be more prevalent in obese patients due to high fat diets, increased bile acid secretion and increased gastric emptying.  However, diverticular disease and appendicitis are included as conditions of lower abdominal pain in our study. A meta-analysis found that constipation was not associated with obesity. 
Recent studies have mentioned decreased quality of life scores related with obesity. ,,, However, this study could be the first one to evaluate the association between GI quality of life and BMI. In the study of Jia and Lubetkin measures of quality of life - including short form physical and mental summary scores - was found to be negatively associated with obesity.  The effect of obesity was found to be greater on physical status than on mental health. In the Swedish study of Larsson et al., obesity in young patients had a negative affect on physical health, but not mental health.  In the study conducted by Dinç et al., obesity was shown to have an independent impact on quality of life.  In this study,  patients were evaluated with a World Health Organization quality of life questionnaire and physical, psychological and social relationships were shown to be negatively affected by increased weight. Dinç et al. demonstrated that obesity could have an independent impact on quality of life in a representative sample of the population with high obesity.  In the present study, obese and overweight subgroups had GIQLI scores that were significantly lower than those of the normal weight patients (P < 0.01). However, the difference between psychological items of obese and normal weight patients was less significant (P = 0.03).Previous studies showed lesser effects of obesity on mental health. , Similarly psychological effects were found less significant in our study.
When we analyzed the results according to the weight groups, the core symptoms, physical, psychological, social and disease-specific items of GIQLI were found to be significantly decreased in obese patients. All domains of GIQLI significantly decreased with increases in weight. There is a significant negative correlation between BMI and GIQLI scores of the patients. Obese patients suffer more often from GI symptoms and increased complaints than patients with normal body weight. An increased prevalence of different GI symptoms has been reported in obese patients seeking treatment in a tertiary care center when compared with community controls.  Many other studies suggest that the burden of obesity is primarily perceived as physical in nature; yet, some studies show a negative association between the degree of obesity and physical, psychological and social dimensions of quality of life.  Decreased quality of life with increased weight has been observed in several studies, ,,, but GIQLI score analysis is unique for the perception and effects of GI symptoms. Decreased GIQLI scores in obese patients showed increased personal perception of GI symptoms. Although some hypotheses suggest that the perception of GI symptoms decreases with less satiation, it was found increased perception of symptoms in obese patients.  In previous studies performed among healthy volunteers, mean GIQLI scores range between 118.4 and 125.8.  These results are similar to those observed in patients with normal weight; however, GIQLI significantly increases with obesity. On the other hand, as seen in the literature, GIQLI scores after bariatric surgeries are increasing.  Dinç et al. showed that weight loss had been associated with improvements in quality of life and that weight gain had been associated with deteriorations in quality of life. 
| Conclusion|| |
Body weight alone not only elevates the risk of morbidity and mortality, but also negatively affects the perceived health and quality of life of the patients. Obese patients suffer more often from GI symptoms and have a decreased quality of life related to GI symptoms. This may lead to increased expression of symptoms with many more complaints in obese patients.
| References|| |
|1.||Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002;288:1723-7. |
|2.||Hatemi H, Yumuk VD, Turan N, Arik N. Prevalence of overweight and obesity in Turkey. Metab Syndr Relat Disord 2003;1:285-90. |
|3.||Kelly T, Yang W, Chen CS, Reynolds K, He J. Global burden of obesity in 2005 and projections to 2030. Int J Obes (Lond) 2008;32:1431-7. |
|4.||Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual deaths attributable to obesity in the United States. JAMA 1999;282:1530-8. |
|5.||Eypasch E, Williams JI, Wood-Dauphinee S, Ure BM, Schmülling C, Neugebauer E, et al. Gastrointestinal quality of life index: Development, validation and application of a new instrument. Br J Surg 1995;82:216-22. |
|6.||Eslick GD. Gastrointestinal symptoms and obesity: A meta-analysis. Obes Rev 2012;13:469-79. |
|7.||Delgado-Aros S, Locke GR 3 rd , Camilleri M, Talley NJ, Fett S, Zinsmeister AR, et al. Obesity is associated with increased risk of gastrointestinal symptoms: A population-based study. Am J Gastroenterol 2004;99:1801-6. |
|8.||Talley NJ, Quan C, Jones MP, Horowitz M. Association of upper and lower gastrointestinal tract symptoms with body mass index in an Australian cohort. Neurogastroenterol Motil 2004;16:413-9. |
|9.||Onat A, Yıldırım B, Çetinkaya A, Aksu H, Keles I, Uslu N, et al. Predictors and relations of central obesity and obesity in adults: Obesity significantly increased in men between 1990 and 1998. Türk Kardiyol Dern Arº 1999;27:209-217. |
|10.||Iseri A, Arslan N. Obesity in adults in Turkey: Age and regional effects. Eur J Public Health 2009;19:91-4. |
|11.||Akman M, Budak S, Kendir M. Obesity and related health problems: an adult outpatient clinical setting. Marmara Med J 2004;17:113-20. |
|12.||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;64:45-9. |
|13.||McTigue KM, Harris R, Hemphill B, Lux L, Sutton S, Bunton AJ, et al. Screening and interventions for obesity in adults: Summary of the evidence for the U.S. Preventive services task force. Ann Intern Med 2003;139:933-49. |
|14.||Yalçın BM, Sahin EM, Yalçın E. Prevalence and epidemiologic risk factors of obesity in Turkey. Middle East J Fam Med 2004;6:1-5. |
|15.||Rennie KL, Jebb SA. Prevalence of obesity in Great Britain. Obes Rev 2005;6:11-2. |
|16.||Locke GR 3 rd , Talley NJ, Fett SL, Zinsmeister AR, Melton LJ 3 rd . Risk factors associated with symptoms of gastroesophageal reflux. Am J Med 1999;106:642-9. |
|17.||Murray L, Johnston B, Lane A, Harvey I, Donovan J, Nair P, et al. Relationship between body mass and gastro-oesophageal reflux symptoms: The Bristol Helicobacter Project. Int J Epidemiol 2003;32:645-50. |
|18.||Dinç G, Eser E, Saatli GL, Cihan UA, Oral A, Baydur H, et al. The relationship between obesity and health related quality of life of women in a Turkish city with a high prevalence of obesity. Asia Pac J Clin Nutr 2006;15:508-15. |
|19.||Huang IC, Frangakis C, Wu AW. The relationship of excess body weight and health-related quality of life: Evidence from a population study in Taiwan. Int J Obes (Lond) 2006;30:1250-9. |
|20.||Larsson U, Karlsson J, Sullivan M. Impact of overweight and obesity on health-related quality of life - A Swedish population study. Int J Obes Relat Metab Disord 2002;26:417-24. |
|21.||Jia H, Lubetkin EI. The impact of obesity on health-related quality-of-life in the general adult US population. J Public Health (Oxf) 2005;27:156-64. |
|22.||French SJ, Murray B, Rumsey RD, Sepple CP, Read NW. Preliminary studies on the gastrointestinal responses to fatty meals in obese people. Int J Obes Relat Metab Disord 1993;17:295-300. |
|23.||Overs SE, Freeman RA, Zarshenas N, Walton KL, Jorgensen JO. Food tolerance and gastrointestinal quality of life following three bariatric procedures: Adjustable gastric banding, Roux-en-Y gastric bypass, and sleeve gastrectomy. Obes Surg 2012;22:536-43. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]