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ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 14-18

Impact of irritable bowel syndrome and body mass index on mental health - A prospective cross sectional study


Department of Medicine, Dr D Y Patil Medical College, Hospital and Research Centre, Dr. D Y Patil Vidyapeeth, Pimpri, Maharashtra, India

Date of Submission04-May-2020
Date of Decision24-May-2020
Date of Acceptance27-May-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Arvind Bamanikar
Department of Medicine, Dr. D Y Patil Medical College, Hospital and Research Centre, Pimpri - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIHS.JIHS_10_20

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  Abstract 


Introduction: Irritable bowel syndrome (IBS) is one of the most common causes of chronic diarrhea. Chronic diarrhea has substantial effect on the physical and mental health (MH) of the patient. Aims: The aim of this study was to evaluate the association between IBS with chronic diarrhea and body mass index (BMI) and effect of severity of symptoms, body weight on MH of patients with IBS. Study Design: A prospective cross-sectional study was performed on patients having diarrhea predominant IBS during September 2017–August 2019. Methods: Ninety-seven patients suffering from IBS-D as diagnosed on the basis of Rome criteria IV had were studied. The severity of symptoms in IBS-D where evaluated according to the IBS-score of symptom-severity. MH was assessed by Patient Health Questionnaire-9 questionnaire. Statistical Analysis: SPSS statistical software was used to analyze the data. ANOVA was used to analyze demographic data. Pearson correlation coefficients were used to analyze linear correlation between demographics, BMI, and MH. Multiple regression test was used in MH analysis with respect to predictive role of BMI. Impact of confounding factors was tested with respect to the gender, age, family status, educational status, severity of the symptoms, and BMI. Results considered statistically significant if P < 0.05. Results: The mean BMI was 23.9 + 5.2 kg/m2. The BMI distribution showed that 59.2% of the IBS patients were of normal weight; 29.8% had BMI more than 25 kg/m2 and 11% had BMI subnormal (P < 0.01). MH was negatively associated with both overweight and severe symptoms of IBS-D; after adjusting for age, gender, marital status, and education. Conclusion: IBS-D patients were significantly overweight or obese which was associated with severe symptoms and impaired MH.

Keywords: Body mass index, chronic diarrhea, irritable bowel syndrome, mental health


How to cite this article:
Bamanikar A, Sharma S, Vaishnav B. Impact of irritable bowel syndrome and body mass index on mental health - A prospective cross sectional study. J Integr Health Sci 2020;8:14-8

How to cite this URL:
Bamanikar A, Sharma S, Vaishnav B. Impact of irritable bowel syndrome and body mass index on mental health - A prospective cross sectional study. J Integr Health Sci [serial online] 2020 [cited 2020 Sep 30];8:14-8. Available from: http://www.jihs.in/text.asp?2020/8/1/14/288679




  Introduction Top


By definition irritable bowel syndrome (IBS) does not have any structural changes in the intestines and usually has diarrhea or constipation in addition to pain or bloating. Unfortunately, the diagnosis of IBS cannot be made by a single test and usually exclusion of other causes and Rome criteria based on clinical features is used. Rome IV is the latest criteria are used for the diagnosis after they were revised from Rome III criteria 2016. Globally, IBS is estimated to be 10%–20% in adult population and more common in females.[1] IBS can be one of the important causes of chronic diarrhea debilitating the patient due to adverse effect on health, both mental and physical. In the developed world, the IBS is believed to be <15%.[2] The overall prevalence of IBS worldwide is estimated to be 45% of the general population;[3] thus making IBS a common disorder of gut. The prevalence of IBS is estimated to be 4%–22% in general population in Asia.[4],[5] Studies from India on IBS as have shown similar prevalence to the range of 30%–50%,[6] psychological factors have been implicated in the mechanism and persistence of irritable bowel. The prevalence of IBS-D in Northern India was 1.5% according to a community-based study by Makharia et al.,[5] and authors suggested that psychological factors were implicated as a causative and persistence of symptoms of IBS-D.

Lee et al.,[7] in their meta-analysis (2017) reported that anxiety, depression in IBS-D was high as compared to healthy controls. Pickett-Blakely,[8] in their study (2014) on association of IBS with obesity, concluded that it is not clear if obesity is more prevalent in those patients affected by IBS-D or IBS-D is more prevalent in obese patients. In their study, authors concluded that it is not clear if obesity is more prevalent in those patients affected by IBS-D or IBS-D is more prevalent in obese patients.

Population-based studies have shown that association exists between increased body mass index (BMI) and gastro esophageal reflux [9] but the same has not been established in obesity with IBS. According to multicenter cross-sectional study by Rizzi et al.,[10] body mass was related to 63%–80% of patients from gastrointestinal illnesses.

Talley N et al.[11] and van Oijen MG et al.[12] reported that both underweight and obese are associated with multiple abdominal symptoms and had poor quality of health (QOL). However, On the contrary, Choung et al.[13] reported from a population-based study that there is no association between IBS and BMI.

Therefore, the aim of this study was to find out if IBS-D and BMI are associated and to study if any association exists between IBS-D, BMI with the severity of symptoms and mental health (MH).


  Methods Top


Patients with chronic diarrhea were investigated in a tertiary care hospital. Moreover, only diagnosed to be having IBS-D by Rome IV criteria where included in this cross-sectionalP study. After, approval from the ethics committee of the institute the patients were enrolled in this prospective study during September 2017–August 2019.

Anthropometric and demographic details of all the patients were entered into excel sheet. All questionnaires were completed under supervision of an intern not related to this study. All the patients about the age of 18 years were enrolled if they had chronic diarrhea (>4 weeks) and diagnosed to be IBS. There were no additional exclusion criteria IBS-score of symptom-severity (SSS) and Patient Health Questionnaire (PHQ)-9 questionnaires were used to assess the severity of the symptoms of IBS and MH status.

The IBS-SSS is score of symptoms weighted and total is was derived, maximum score being 500. The scores are derived from five parameters as follows: (1) frequency of pain abdomen, (2) intensity of pain severity, (3) abdominal distension, (4) unhappy with defecation habits, and (5) interference of IBS with day-to-day activities. Three Severity groups consist of mild with score range of 75–175, moderate when score was in the range of 275–300, severe if score is >300 score. Similarly, MH was assessed by PHQ-9 questionnaire, having maximum score of 27. The score range of 5–9 suggests minimal depression, 10–14 shows minor depression, 15–19 indicative of major depression, score of >20 reflects severe depression. The guidelines on the duration of symptoms and other factors were specifically elaborated in the interpretation of PHQ9 score.

The analysis of the observations did not conclude that results were confirmative, but did have an explorative value.

BMI was calculated and categorized according to the Indian standards of the recent recommendation. The revised guidelines for determining the obesity on the basis of BMI in Indian population are as below. According to the revised criteria, BMI between 18.6–24.8/m2 is classified as normal weight, BMI < 18.5/m2 as underweight and BMI of 23.0–24.9 m2 as overweight and BMI more than 25 as obesity.[14]

Statistical analysis

SPSS statistical software (Version 24.0, developer IBM, USA) was used to analyze the data. Means and standard deviations reflected the descriptive statistics for noncategorical variables and absolute numbers and percentages for categorical variables reflect the continuous variables. ANOVA test was applied to analyze demographic data. Authors used Pearson correlation coefficient test to analyze linear correlation between demographics of BMI and MH. Test of multiple regression analysis was used in MH to analyze the predictive role of BMI; if so. Impact of the confounding factors namely age, sex, marital status, educational status, severity of the symptoms, and BMI (categories 1–3) were tested. In statistical analysis, significant result was accepted if P < 0.05.


  Results Top


A total of 97 patients fulfilling Rome IV criteria (males 42, 43.3% females 55, 56.7%) of IBS-D were enrolled in this study. BMI distribution consisted of normal weight patients 57 (58.8%), obese patients 29 (29.9%), and underweight 11 (11.3%). Three (3.1%) of the men and 8 (8.25%) of women were underweight; obesity was detected in 18 (18.6%) of men and 11 (11.3%) of women. Most patients reported moderate-to-severe IBS symptoms with the score of 128–494.

MH was affected in 78 (80.4%) of patients. Obese patients who suffered moderate depression were 86.6%. Statistical analysis by Pearson test reveal that high BMI and severity of IBS symptoms correlated with impaired MH. BMI had negative association with MH (r = −0.173, P < 0.01). There was negative correlation between symptom severity and MH (r = −0.391, P < 0.01).

Symptom severity and age also reflected negative correlation (r = 0.125, P < 0.01), similarly age and MH showed positive correlation (r = 0.161, P < 0.01).

[Table 1] shows the symptoms variety and MH demographics in IBS-D study subjects. Young adults of age 18–54 years had higher BMI level as compared to older patients of above 55 years (P < 0.01). However, younger patients showed less severity of the symptoms (P < 0.05) and better MH (P < 0.05) than the older patients. Patients living together either as couples or married had higher BMI than the single participants (P < 0.01). Less educated patients had adverse effect of IBS-D on their MH (P < 0.01). [Table 2] shows comparison of clinical parameters age, BMI, symptom severity and mental health.
Table 1: Comparison between body mass index, severity of irritable bowel syndrome-D and mental health

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Table 2: Comparison of clinical parameters in irritable bowel syndrome-D

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The association between BMI and MH was analyzed by multiple regression test [Table 3].
Table 3: Results of multiple regression tests related to mental health, age, sex, marital status, symptom severity, and body mass index

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Category 1 had significant (F = 2.289, P < 0.05) adverse effect of BMI on MH with a variance of 4.9% and educational status had significantly positive effect on MH (b = 0.171, P < 0.01).

In Category 2, additional parameter of severity of symptoms was analyzed, which showed severity of symptoms significantly associated with high BMI (P < 0.01) in model 3, BMI and MH were analyzed and showed significantly adverse effect (P < 0.05).


  Discussion Top


The study was aimed at the association between BMI and IBS-D since both the conditions are a common phenomenon. The study also examined the association between BMI and the severity of the symptoms of IBS-D as well as MH. The diagnosis of IBS-D was done according to Rome IV criteria and the evaluation of MH was done by standardized questionnaire PHQ-9.

We found that overweight or obesity was common detected in patients with IBS-D. Similar findings have been reported in earlier studies.[15] This study was carried out in France. According to this study, 30% the obese patients had IBS-D. The study had more than 40% patients with IBS-D either above or below the normal range, and similar trend was reported in other study.[16]

Lee et al.[17] studied the increased visceral fat and the risk of IBS-D and concluded that visceral adipose tissue is associated with the risk of IBS-D. Similarly, a study from Korea reported that the increased intestinal permeability was found with patients with IBS-D patients. It is postulated that the increase in permeability and increase in visceral fat are linked.[18] The visceral fat is responsible for increasing the osmolality of the intestinal secretions. This phenomenon in turn is responsible for chronic diarrhea in IBS.[19] It is noted that these studies were performed on Korean patients and their validity in other ethnic population is not documented. There are a few studies showing significant impact on the QOL [20],[21],[22],[23] due to IBS-D and high BMI. The study showed a negative association between severity of symptoms of IBS-D and MH. This was found to be significantly associated with moderate-to-severe symptoms of IBS-D; but not with milder symptoms.

Amouretti et al.[24] reported that the patients with IBS-D had suboptimal QOL due to severity of symptoms as compared to those with mild or moderate symptoms. However, this study did not provide category-wise analysis of physical and MH separately. In addition, the effects of BMI as a confounding factor were not considered in their study.

In statistical analysis, multiple regression tests were performed to test the relationship between MH and severity of symptoms, BMI. Increase in BMI was associated with gastrointestinal symptoms, bloating, or pain. This observation is in accordance with previous studies [12] showing obesity as a physiological stressor on the various organs.

Richard et al.[25] reported that obese have more severe pain which interfered with daily activities in contrast to normal weight patients. In our study, high BMI was associated with poor MH. Mykletun et al.[26] reported that BMI had a significant negative effect on the MH, specified as variation in mood and anxiety; however, their study was limited to women. One of the nonmodifiable factors in BMI as well as IBS is genetic predisposition. This was studied as effect of genes on the susceptibility to MH in the form of anxiety and depression.[27]

We, therefore, hypothesize that the association between BMI and IBS-D could be genetic in origin and possibly related deregulation of hypothalamic pituitary adrenal axis leading to mental stress, anxiety, and depression. Whether anxiety-depression is the cause or complication of IBS-D and high BMI is still not fully understood and can be a subject of future research.

Limitations

First, this is a cross-sectional study and conclusions cannot give causative association between BMI and IBS-D. Second, PHQ9 score may have missed the answers on milder form of anxiety or depression which would eventually affect the numbers counted towards MH impairment. Our study conclusions are based on the sample size, which is modest and need to be supported by very large number of patients.

The strengths of our study are both the high BMI and IBS-D are common health issues and preventive measures would have beneficial effects on the MH. We used commonly used simple questionnaire and information obtained from them was supervised to prevent inaccurate and nonspecific responses. Anthropometric data were recorded under supervision, thus eliminating the errors. Finally, IBS-D was according to most recent criteria (Rome IV) and BMI was amended to the Indian standards since all patients belong one of the Indian states.


  Conclusion Top


Overweight and obese patients have IBS-D significantly higher than general population. Both of them have negative influence on the MH. High BMI and severe IBS symptoms are risk factors for depression and anxiety which gets worse with uncontrolled IBS and increase in BMI. Patients with overweight as well as IBS-D should be screened for MH.

Acknowledgment

We would like to acknowledge the Department of Community Medicine, Dr. D Y Patil Medical College, Pimpri 4110018.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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