ASSOCIATION OF GASTROESOPHAGEAL REFLUX SYMPTOMS (FREQUENCY AND SEVERITY) WITH BODY MASS INDEX IN FEMALES WITH GASTROESOPHAGEAL REFLUX DISEASE

BACKGROUND & OBJECTIVE: Overweight individuals have a greater tendency to develop gastroesophageal reflux disease (GERD). This study aims at comparing gastroesophageal reflux symptoms (frequency and severity) in females with different body mass index (BMI) categories. METHODOLOGY: This cross-sectional comparative research study was conducted over duration of 8 months. Both indoor and outdoor patients of medical unit – II Benazir Bhutto Hospital, Rawalpindi, fulfilling the inclusion criteria i.e. females 30-55 years of age with confirmed diagnosis of GERD and informed consent were included. Subjects with history of cigarette smoking, diabetes, use of postmenopausal hormone replacement therapy (HRT), anti-hypertensive or asthma medication were all excluded. Data were collected via proforma and analyzed on SPSS version 17.

Gastroesophageal reflux disease (GERD) with the characteristic features of acid regurgitation and heartburn is a prevalent disease involving up to 60% of population at some time during the course of a year and 20-30% of population at [1,2] least weekly . It is among the most common d i s e a s e o f g a s t r o i n t e s t i n a l t r a c t . A n incompetent barrier at the gastroesophageal junction leads to backflow of gastric acid and other gastric content into esophagus and that produces symptoms. GERD leads to different complications including reflux esophagitis, peptic stricture and intestinal metaplasia (Barrett's esophagus) which predisposes to adenocarcinoma. In patients with persistent symptoms or complications or those who show no response to therapy, diagnostic studies are [2,3] required . Mucosal damage is documented by using barium swallow, esophagoscopy and mucosal biopsy. Quantification of reflux can be done by ambulatory long term (24 hours) esophageal pH recording.
All gathered data was recorded on SPSS version This cross sectional comparative study was carried out on both indoor and outdoor patients of medical unit-II Benazir Bhutto Hospital fulfilling the inclusion criteria. The study was th conducted for a period of 8 months, from 17 April 2018 to 17th December 2018. The study has been approved by the ethical review committee of Benazir Bhutto Hospital, Rawalpindi. Sample size was calculated to be 2 2 360 with formula, n=Z pq/E keeping 5% error [13] and a prevalence of 57% . Women with age of 30 to 55 years, with symptomatology suggestive of GERD, encompassing all BMI ranges and giving consent were included in the study. Those females with diabetes and cigarette smoking and use of postmenopausal HRT, antihypertensive or asthma medicines were excluded. Females using less than 5 cups per day of coffee or tea were also excluded. After written informed consent and approval of hospital ethical committee prior to the commencement of study, all ethical issues were addressed at every step of data collection i.e. history taking, physical examination and check list for severity of symptoms. Patients fulfilling the inclusion criteria were selected by purposive sampling. BMI of selected subjects was calculated by measuring height and weight and subsequently subjects were segregated in underweight, normal, overweight, obese and morbidly obese groups according to BMI. Questionnaire was given to participants of the study to look for severity of symptoms of GERD and then compared for comparative cross sectional study.

INTRODUCTION:
The purpose is to determine association between BMI and severity and frequency of symptoms of GERD in Pakistan female population and to make recommendations for patients, health services provider and policy makers.

METHODOLOGY:
BMI is the most widely used tool to gauge obesity, which is equal to weight in kg/ height in 2 2 [4] m (kg/m ) . At a similar BMI, women have more body fat than men. BMI of 30 is most commonly used as a cut-off value for obesity in [5] both men and women . Some authorities use the term overweight to describe the individuals with BMI between 25 and 30. High BMI is associated with symptoms of GERD in both normal weight and overweight women. Even moderate weight gain among persons of normal weight previously may cause or exacerbate [6,7] symptoms of gastroesophageal reflux . [8] Obesity is a risk factor for symptoms of GERD . Essential part of treatment of gastroesophageal disease includes weight loss which results in marked improvement in symptoms of GERD. Several cross sectional studies and one metaanalysis conducted in west have depicted a positive association between elevated BMI and [8,9] symptoms of GERD . GERD is a lifelong disease that requires life style modification and [10] weight loss besides avoiding acidic foods and products that reduce lower esophageal sphincter tone or delay gastric emptying and reduction of meal size etc. is an important [11,12] advice to be given to the patients of GERD . An association between BMI and symptoms of GERD are demonstrated in this study.

RESULTS:
17 after manual cleaning. Descriptive statistics, frequencies and percentages were calculated for the background variables, severity and frequency of symptoms and BMI. Mean ± SD for numerical data like age. Frequency and percentage were applied for gender, social status and BMI. Chi square test was applied to see the difference in proportion of two groups.
Among these 360 women, 110 (30.6%) subjects had mild severity of GERD symptoms. While 141 (39.2%) presented with moderately severe GERD. 81 (22.5%) subjects had severe GERD while 28 (7.8%) belonged to very severe category of GERD (Table-II).Out of total subjects, 02 (0.6%) subjectshad no symptoms of both acid regurgitation and heart burns while 81 (22.5%) had both symptoms with less than a m o n t h f r e q u e n c y. H e a r t b u r n a n d a c i d regurgitation frequency was once a month in 45 (12.5%) subjects while 131 (36.4%) had frequency of once a week. 72 (20%) had both symptoms more than once a week and 29 (8.1%) subjects had more frequent symptoms of both heart burn and acid regurgitation ( Table-III; Graph-II).
In this study a total of 360 women were enrolled. Mean age and standard deviation of these subjects was 41.61 ± 7.69 years ranging from 30 years to 55 years (Graph-I). BMI of these 360 subjects was calculated by dividing their weight in kilograms with height in meters square. BMI of 8 (2.2%) subjects was below 18.5, belonging to underweight group. BMI of 109 (30.3%) subjects was normal (18.5-24.9), while 151 (41.9%) belonged to overweight group as their BMI ranged between 25 and 29.9. BMI of 88 subjects(24.4%) subjects ranged between 30 and 39.9 and they were classified as obese, while 04 (1.1%) subjects belonged to morbidly obese group as their BMI was >40 (Table-I).

Figure-I: Age of participants of study.
Graph-II: Frequency of symptoms.     Increase in BMI is associated with considerable rise in both mortality and morbidity. Frequency of many diseases increase with obesity. Most common and important of these include hypertension, hyperlipidemia, coronary heart disease and type 2 diabetes mellitus, psychosocial disability, respiratory problems, [16] degenerative joint diseases and depression . Obese patients have more surgical and obstetric complications. They have more chances of pulmonary function deterioration, endocrine abnormalities, proteinuria and [17] polycythemia . They have greater incidence of central nervous system disorders like stroke due to hyper viscosity, hyperlipidemia and [18] impaired glucose tolerance . In middle age and young population, mortality from cardiovascular disorders and mortality from all causes rise in proportion to the degree of [19] obesity . Successful treatment of obesity requires a multifaceted approach to behavior modification to change eating habits, to weight loss with hypocaloric diet, aerobic exercise and [20] social support .
BMI has strong associations with frequency and [24] severity of symptoms of GERD . Obesity significantly increases the risk of symptoms of GERD, Barrett's esophagus, erosive esophagitis a n d e s o p h a g e a l a d e n o c a r c i n o m a . T h e relationship of GERD with obesity has been c o n fi r m e d i n s t u d i e s o f s e v e r e gastroesophageal reflux symptoms and [25] esophagitis related hospitalization . In a study conducted by El-serag and colleagues showed increased association of obesity with severity of [26] GERD and the same fact is also highlighted in the results of our study. Our study showed that in underweight subjects, the severity was mild while symptoms were also mild. However, in normal and overweight subjects, more subjects had moderate to severe symptoms resulting in moderate to severe GERD in these categories. The severity of GERD and frequency of its symptoms became severe and more severe in obese and morbidly obese subjects In another study, overweight subjects greatly increases the chances of having heartburn and acid regurgitation and obese population is almost three times as likely to have symptoms [27] as those of ideal weight and our study results second this fact, as 16 out of 109 participants with normal BMI had severe and very severe symptoms, which makes around 14.6%; while 39 out of 88 participants who were obese had severe and very severe symptoms, which makes around 44.3%. Also 4 out of 4, i.e. 100% participants who were morbidly obese had severe and very severe symptoms of GERD. Another study showed marked association of BMI with symptoms of GERD in both normal and overweight women. It suggested that even among normal weight individuals, risk of symptomatic GERD rises progressively with increasing BMI. Notably weight loss was associated with a reduced chance of symptoms [28] . However, this fact could not be compared with our study results as ours was a crosssectional one and the participants enrolled were not followed prospectively for association of weight changes with symptomatology of GERD.
Obesity is one of the most prevalent disorders in clinical practice and also most frustrating and [14] challenging to treat . Obesity is more quantitatively evaluated by calculating BMI. It is estimated by dividing body weight in kilograms [15] by height in meters square . According to National Institute of Health, BMI is defined as normal when it ranges from 18.5 to 24.9, overweight when BMI is from 25 to 29.9. Class I obesity is 30-34.9, class II obesity when BMI is 35-39.9 and class III or morbid obesity when BMI is >40.

DISCUSSION:
GERD influences 20% of adult population, who reports at least once a week episode of heartburn and up to 10% complain of daily [21] symptoms . Mechanism of GERD includes incompetent lower esophageal sphincter resulting in regurgitation of stomach contents [22] into esophagus during swallowing . Hiatal hernias are more common in victims of GERD. Reduced peristaltic clearance was found to be present in one third of those suffering from [ 2 3 ] severe GERD . Partial gastric outlet obstruction or impaired gastric emptying due to gastric paresis also contributes to and potentiates GERD.
We conclude that there is strong association between symptoms of gastroesophageal reflux disease and BMI in women. Reflux symptoms