DDW 2014 Note: How Common is Functional Dyspepsia in U.S. Adults? Findings From Our National Survey.

Functional dyspepsia (FD) is a common disorder characterized by symptoms that are often described as indigestion; unpleasant sensations in the middle of the abdomen, uncomfortable fullness after eating, and sometimes inability to eat normal-size meals. FD is a much-researched disorder, but surprisingly, no nationwide studies have been done in the U.S. to evaluate what proportion of adults actually meet formal criteria for FD as defined by the current Rome III diagnostic criteria. Moreover, little is known about how rates of dyspepsia differ among race or ethnic groups or between different age group in the American population.

Today (May 3, 2014) I presented in poster format at Digestive Disease Week 2014 in Chicago the results of statistical analyses that our research team carried out to estimate how common FD is in American adults. We used for this purpose data from the Rome Normative Gastrointestinal Symptom Survey that we conducted last year, and which was sponsored by the Rome Foundation. In this secure online survey, we obtained responses from a large group of adults across every state in the U.S. The survey included questions about the responders’ demographics, health history, and the whole Rome III Diagnostic Questionnaire that diagnoses all functional gastrointestinal disorders. To minimize bias due to the possibility that people with GI symptoms might be more interested than others in participating and therefore be over-represented in our sample, invitations to participate described the study as a physical symptoms survey but did not mention gastrointestinal symptoms. We also controlled how many participants in different demographic categories could participate, in order to ensure equal gender proportions and get enough minority participation for our sample to be similar to the U.S. population.
A total of 1,665 individuals ranging in age from 18-94 years completed our survey, but we then eliminated from our analysis dataset people who showed evidence of inconsistent survey answers (we included three repeat questions in the survey for quality-check purposes), leaving us with responses from 1,277 people suitable for analysis. We have used that sample to estimate how common different functional gastrointestinal disorders are in the U.S. population and whether they have different frequency in various subgroups of the population (like males vs. females or older individuals versus young). In today’s presentation we only reported such findings for FD, but we will also be presenting our results for IBS and fecal incontinence separately here at DDW on Tuesday. We found that 11.4% of the people who completed our survey met Rome III criteria for FD. However, to get a more accurate estimate of the national dyspepsia prevalence, we statistically adjusted (weighted) our calculations to make the sample match the national adult age, gender and race/ethnicity distribution in the 2010 U.S. Census. Doing this only altered our numbers slightly, resulting in an estimated overall national U.S. FD rate of 11.9%.

We also found that functional dyspepsia tended to be more common in women than men (13.0% versus 9.9%) but this actually did not quite reach statistical significance, so we cannot be confident about the sexes really being different in this regard. In both sexes, FD rates were lowest in the youngest and oldest age groups, and significantly higher at mid-life; see the Figure below. Dyspepsia prevalence was not significantly different in white (12.3%) hispanic (12.9%) and black (9.6%) respondents in our survey.

FDrate

There are presently two recognized subtypes of FD, separated by difference in the symptom pattern. A surprising finding in our survey was that only 3 individuals in our whole sample (a mere 0.2%) met criteria for one of those sub-types, which is called Epigastric Pain Syndrome (defined primarily by pain in the upper gut, above the stomach). In contrast, most of the people (87%) in our survey who qualified for FD diagnosis based on their responses fit into the other subgroup, called Postprandial Distress Syndrome (meaning that they mostly have uncomfortable fullness after eating).
In summary, our analyses of responses to the FD diagnostic questions in this large nationwide survey give a clear picture for the first time of the prevalence of this disorder overall in the U.S. and in population subgroups, as it is defined by current Rome symptom criteria. Our results indicate that about 12% of American adults have this disorder, which makes it one of the most common of all gastrointestinal problems in the U.S.

Presentation:

Sa1335. Olafur S. Palsson, Miranda A. Van Tilburg, Brennan M. Spiegel, Jan F. Tack, Robin C. Spiller, Lynn S. Walker, Yunsheng Yang, William E. Whitehead. Uninvestigated Dyspepsia in the U.S. General Population: Results From the ROME Normative Gastrointestinal Symptoms Survey (RNGSS). Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC; Digestive Diseases, VA/UCLA, Los Angeles, CA; TARGID, University Hospitals of Gasthuisberg, Leuven, Belgium; Nottingham Digestive Diseases Centre Biomedical Research Unit, University of Nottingham, Nottingham, United Kingdom; Adolescent Medicine, Vanderbilt Children’s Hospital, Nashville, TN; Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China.

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DDW 2013 Note: What Keeps Patients and Doctors from Addressing Fecal Incontinence?

Fecal incontinence (accidental loss of liquid or solid stool), which will be abbreviated FI here, is a sensitive and difficult health problem that is present in about 9% of the overall adult population1. It becomes more common with age, rising in prevalence from about 3% of people aged 20-30 to more than 15% in those 70 years and older1. When FI happens frequently (2.7% of U.S. adults have FI episodes once a week or more) it can have a major adverse impact on people’s lives if untreated, leading to substantial problems in areas such as mobility, work, social life, and self-esteem.

FI is a highly treatable problem.  Anorectal biofeedback2 and sacral nerve stimulation3,4 are both treatments that seem to help get rid of the problem entirely in half of cases and also significantly improve about half of the remaining cases where complete continence is not achieved. Furthermore, a much simpler treatment that consists of systematic use of pelvic floor exercises results in improvement in FI in roughly half of cases as well5. But even though these methods are highly effective, they actually benefit far fewer individuals than one might hope, because most cases of fecal incontinence never even come to the attention of healthcare providers and no treatment can therefore be offered. Surveys indicate that 70 to 90 percent of individuals who have FI have not talked to their doctor about it6. Although it is understandable that fecal incontinence can be hard to talk about, there are important and often severe adverse personal consequences that can be prevented only by addressing the problem it in healthcare encounters. Finding ways to systematically overcome the barriers that keep fecal incontinence a largely hidden and unaddressed health problem could improve the lives of millions of adults who now suffer the consequences without any help. The first step is to understand what keep patients and doctors from addressing the problem.

In a poster presentation at Digestive Disease Week 2013 in Orlando yesterday, Saturday May 18, investigators in our UNC Center for Functional GI & Motility Disorders reported the findings of a study of 124 adults who were identified as having FI by asking them about it when they came to clinic visits in a variety of clinics in the UNC Healthcare System (primary care, urogynecolory, gastroenterology and geriatrics). Eighty-eight of these individuals had consulted with  doctors about their FI problem  (those can be called FI consulters) but 36 had not done so (i.e., they were FI non-consulters). The patients were surveyed through written questionnaires to evaluate the severity and frequency of their FI and its impact on their lives, and they were also interviewed over the phone about their experiences and views on interacting with healthcare providers about it and outlook on treatment for the problem.

Some of the key findings were:

    • The  severity and frequency of fecal incontinence episodes was not different between FI consulters and  non-consulters (as measured on the validated Fecal Incontinence Severity Index)
    • Most (77.1%) FI  non-consulters stated that doctors need to ask directly about  incontinence. However, half of them also indicated a preference for being asked about it through a questionnaire.
    • The only aspects of quality of life impact of fecal incontinence (measured on a validated FI-QOL scale) that was different between consulters and non-consulters was depression/self-esteem impact, which was greater in consulters
    • Among FI non-consulters, 44.4% reported that they believed that there was no effective treatment available for fecal incontinence, versus only 15.6% of FI consulters.
    • The three most common reasons FI non-consulters gave for not discussing their FI problem with their doctor were not thinking it was serious enough (57.1%), thinking it was just a normal part of aging rather than a medical problem (45.7%), and embarrassment (37.1%).

The investigators also interviewed 11 physicians in the clinics where the patients were recruited, to get a sense of the reasons why doctors fail to screen routinely for fecal incontinence by asking their patients about it. Only 4 of the 11 doctors reported that they did not screen for fecal incontinence, and they mostly stated lack of time in patient visits as a reason not to do so. They were also more likely than doctors who screened to believe that fecal incontinence is a rare condition.

This study gives a fairly clear idea of what keeps so many patients and doctors from addressing FI in clinical encounters, and also provides some insights about what is needed to overcome those barriers. The results indicate that more than half of the patients who do not report FI to their doctors simply do not regard their FI as a significant problem. However, many other patients are held back from reporting FI to doctors by embarrassment or because they wrongly do not believe it is treatable. It would seem that the patients in the latter category need to be helped to overcome the hindrances to getting help for FI by making education about effective treatments for FI widely available and by screening for FI in a way that minimizes embarrassment and doctor time burden. It is noteworthy that individuals with FI who have not consulted doctors mostly do feel that doctors and clinics should ask them about it directly and many of them would prefer that this be done via a questionnaire. Routine use of a few simple questions (or even a single one) on paper to screen for this problem in all visits to major healthcare service settings like primary care and geriatric clinics would enable healthcare providers to reliably identify and offer care for fecal incontinence in most adults who make any use of healthcare.

Presentation:

Sa2036. “Fecal Incontinence: What Determines Which Patients Consult Physicians and Which Physicians Screen?” Lalitha Kunduru, Sung M. Kim, Steve Heymen, William E. Whitehead. Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC.

          References:

1. Whitehead WE, Borrud L, Goode PS, Meikle S, Mueller ER, Tuteja A, Weidner A, Weinstein M, Ye W. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterol 2009;137:512-517.

2. Heymen S, Scarlett Y, Jones K, Ringel Y, Drossman D, Whitehead WE. Randomized controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence. Dis Colon Rectum 2009;52:1730-1737.

3. Tjandra JJ, Chan MK, Yeh CH, Murray-Green C. Sacral Nerve Stimulation is more Effective than Optimal Medical Therapy for Severe Fecal Incontinence: A Randomized, Controlled Study. Dis Colon Rectum 2008;51:494-502.

4. Wexner SD, Coller JA, Devroede G, Hull T, McCallum R, Chan M, Ayscue JM, Shobeiri AS, Margolin D, England M, Kaufman H, Snape WJ, Mutlu E, Chua H, Pettit P, Nagle D, Madoff RD, Lerew DR, Mellgren A. Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study. Ann Surg 2010;251:441-449.

5. Norton C, Chelvanayagam S, Wilson-Barnett J, Redfern S, Kamm MA. Randomized controlled trial of biofeedback for fecal incontinence. Gastroenterology. 2003 Nov;125(5):1320-9.

6. Dunivan GC, Heymen S, Palsson OS, von Korff M, Turner MJ, Melville JL, Whitehead WE. Fecal incontinence in primary care: prevalence, diagnosis, and
health care utilization. Am J Obstet Gynecol. 2010 May;202(5):493.e1-6. doi: 10.1016/j.ajog.2010.01.018. PubMed PMID: 20223447.