Abstract
Background and aims.
Bloating is a common symptom in the general population and among disorders of gut-brain interaction (DGBI), although its prevalence has not been well characterized. The aim of this study is to report the prevalence of bloating as a symptom in the worldwide population and to identify factors associated with this symptom in the general population.
Methods.
Rome Foundation Global Epidemiology Study internet survey data were analyzed. After excluding respondents with potential organic causes of bowel symptoms, the current analysis included 51,425 individuals in 26 countries. Data included diet, medical history, quality of life and Rome IV diagnostic questions. Presence of bloating was defined as experiencing bloating at least once per week for the last 3 months. Descriptive statistics estimated prevalence by country, region, and DGBI diagnosis. Logistic regression evaluated predictors of bloating
Results.
Nearly 18% of the global study population reported bloating (ranging from 11% in East Asia to 20% in Latin America). Prevalence decreased with age and women were about twice as likely as men to report bloating. Over half of respondents who reported weekly epigastric pain (71.39%), nausea (59.7%), or abdominal pain (61.69%) also reported bloating at least once per week. In logistic regression, the strongest associations were with abdominal pain (OR=2.90) and epigastric pain (OR=2.07).
Conclusion.
Bloating is common throughout the world. Nearly 18% of the general population experience bloating at least once per week. Reported bloating prevalence is lower in older age groups, is most common in women, and is strongly associated with abdominal pain.
Keywords: functional bowel disorders, irritable bowel syndrome, distension, epidemiology
Background
Abdominal bloating is the subjective sensation of abdominal fullness with or without visible distension and is thought to be most common in women under the age of 65.1,2 Bloating is a common and multifactorial symptom that is present in the general population as well as among disorders of gut-brain interaction (DGBI). In the population, the prevalence of bloating as a symptom has been reported anywhere between 11% to 30%, although these studies have been conducted primarily in English speaking countries3–6. The prevalence of bloating among disorders of gut-brain interaction (DGBI) has only been evaluated in functional dyspepsia, functional constipation and irritable bowel syndrome, and has been reported to be as high as 96%6–9. Little is known about the global prevalence of bloating as a symptom, or about differences in bloating prevalence between countries, regions of the world, or among various DGBI diagnoses.
There are multiple possible mechanisms of bloating, which can vary between patients10. This indeterminate pathophysiology makes it difficult to treat bloating effectively. Research on physiological, psychological, or clinical predictors of bloating has suggested that female sex, constipation, dyspepsia, and somatization may be associated with bloating and/or distension.10,11 Another recent study using Rome IV criteria in a sample of tertiary care patients reported that severe bloating is more common in patients who are female, young, and have co-existing functional dyspepsia or functional constipation12. Moreover, several dietary factors also play a role in the pathophysiology of abdominal bloating. Patients with DGBI often report bloating post-prandially, and dietary interventions, such as a diet low in fermentable oligo- di- and monosaccharides (FODMAPs), improve bloating in patients with IBS. Further research, with larger sample sizes from general population, evaluating demographic, clinical and dietary factors associated with bloating may help to improve clinical understanding of bloating as a symptom.
The current study draws on global data from the Rome Foundation Global Epidemiology Study (RFGES) in order to: 1) characterize the prevalence of bloating as a symptom in the global population; 2) characterize the prevalence of bloating as a symptom among DGBI; and 3) identify demographic, clinical, and dietary factors associated with the presence of bloating.
Methods
This study uses internet survey data from the RFGES. Internet surveys were conducted in 26 countries (Argentina, Australia, Belgium, Brazil, Canada, China, Colombia, Egypt, France, Germany, Holland, Israel, Italy, Japan, South Korea, Turkey, Mexico, Poland, Romania, Russia, Singapore, South Africa, Spain, Sweden, USA, UK) and were completed by a total of 54,127 people. The pre-determined demographic quota, a minimum of 2000 participants in each country with 50% female, 40% ages 18 to 39 years, 40% ages 40 to 64 years, and 20% ages 65+ years, were met with slight deviations. Surveys included the Rome IV diagnostic questionnaire and 80 other questions related to diet, medical history, and quality of life. For more details on the study methods, see Sperber et al. 2021.13
From the data that were collected in the RFGES, the current study evaluated the following: demographic data including age, gender, size of community, country; Rome IV questionnaire data including DGBI diagnosis (y/n for each possible diagnosis), and one item evaluating frequency of bloating in the last three months (“how often did you feel bloated or notice that your belly looked unusually large”); dietary practices data included the question: “On average, how many days a week do you eat the following food types?,” where food types included: milk products, vegetables and legumes, fruit, bread, and pasta (response options ranged from 0 days per week to 7 days per week); clinical data included body mass index and scores from a single-item question evaluating concern with bowel functioning (“Not at all concerned”, “Somewhat concerned” and “Very concerned”); finally, psychological and quality of life data included scores on validated measures of depression and anxiety (PHQ-4)14, somatization (PHQ-12)15, and quality of life (PROMIS Global Health)16.
This study defined presence/absence of bloating based on whether or not a respondent reported experiencing bloating at least once per week for the last 3 months. The cutoff of once per week was chosen to approximate clinically meaningful symptoms, and was based on the Rome IV criteria cutoff for most DGBI symptoms. This cutoff is also consistent with prior studies that have evaluated prevalence of bloating6,7. Respondents were considered ineligible (n=2,702) if they reported a diagnosis of celiac disease, Crohn’s disease or ulcerative colitis, stomach cancer or bowel cancer, diverticulitis, or bowel resection.
Descriptive statistics were used to estimate prevalence of bloating as a symptom by country, by region (USA and Canada, Latin America, Europe, East Asia, Middle East, and other), by age group, by other gastrointestinal symptoms, and by DGBI diagnosis. For each region, the average number of days per week of consumption of different food categories are reported. Logistic regression was used to evaluate demographic, clinical, dietary, and psychological factors associated with bloating as a symptom. Finally, we studied the association between bloating and psychological and physical health by comparing subjects with versus without bloating in regard to depression and anxiety severity (PHQ-4 sum score), and global mental and physical health (PROMIS Global-10 component scores). We use pairwise contrasts between groups for these analyses.
Nota bene:
Some of the data in this paper have already been reported in previous Global Study papers. This is inevitable since the original paper13 included a broad range of descriptive statistics for all countries and all disorders. Other papers, including the present one, which use the same database, are reporting in-depth analyses for countries, disorders, and methods, and these include a brief overview of some specific data previously reported.
Results
Of 54,127 respondents across 26 countries, 51,425 were eligible to be included in the current analysis after survey participants with potential organic causes of their bowel symptoms by self-reported history were excluded (figure 1). The global prevalence of bloating at least once per week was 17.68%. A larger proportion of women, globally, reported bloating compared to men (23.4% of all women in the worldwide sample reported bloating vs. 12.2% of all men). Similarly, the majority of all people reporting bloating at least once per week were women (64.9%). Table 1 provides prevalence of bloating at least once per week, separately by age group. The youngest respondents (ages 18–34 years old) had the highest prevalence of bloating (20.29%), while the oldest respondents (ages 65+) had the lowest prevalence (10.44%). Supplement Table 1 provides gender, size of community, and numbers of individuals reporting bloating in each of the 26 countries.
Figure 1:
Flow chart of participant inclusion/exclusion
Table 1.
Prevalence of bloating at least once a week by age group
n | N | Prevalence (as %) | CI 95% | |
---|---|---|---|---|
| ||||
18–34 years | 3472 | 17109 | 20.29 | 19.7 – 20.9 |
35–49 years | 3066 | 15771 | 19.44 | 18.83 – 20.07 |
50–64 years | 1719 | 10545 | 16.3 | 15.61 – 17.02 |
65+ years | 835 | 8000 | 10.44 | 9.79 – 11.13 |
| ||||
Sum | 9092 | 51425 | 17.68 | 17.35 – 18.01 |
The prevalence of respondents meeting criteria for the diagnosis of functional abdominal bloating/distension (FABD) in this sample was 3.47%, and the prevalence of FABD among individuals reporting bloating at least once per week was 19.63%. Those that reported bloating at least once per week were five times more likely than not (OR=5.00, 95%CI 4.75–5.25) to report bloating as their most bothersome symptom than those that did not.
Figure 2 provides prevalence of bloating in each of the 26 countries and regions. East Asia had the lowest prevalence of bloating as a symptom, with the combined prevalence of 11%, while Latin America had the highest prevalence of bloating at 20%. Figure 3 and supplement table 2 report the average number of days/week that respondents reported consuming milk products, vegetables and legumes, fruit, bread, and pasta in the last week (possible responses: 0–7 days) in each country and each region. In East Asia, which had the lowest prevalence of bloating, participants reported eating pasta the least frequently (mean=1.06 days/week, SD=1.39), followed by milk (mean=3.62 days/week, SD=2.46), bread (mean=3.69 days/week, SD=2.25), fruit (mean=4.07 days/week, SD=2.32), and vegetables/legumes (mean=5.29 days/week, SD=1.92). For comparison, in Latin America, which had the highest prevalence of bloating, participants reported eating pasta an average of 2.63 days/week (SD=1.73) and ate milk, vegetables/legumes, fruits, and bread on average between 4–5 days per week.
Figure 2:
Prevalence of bloating at least 1x/week in different countries and global regions. N= total sample per country and region; n=total number reporting bloating in each country or region
Figure 3:
Average number of days per week reported consuming different food groups by global region
Table 2 shows the frequency of bloating in patients who report each of the following symptoms: epigastric pain at least once per week; early satiety at least once a week; nausea at least once per week; diarrhea at least 30% of all bowel movements; constipation at least 30% of all bowel movements; and abdominal pain at least once a week. Over half of respondents who reported epigastric pain (71.39%), nausea (59.7%), or abdominal pain (61.69%) at least 1x/week also reported bloating at least once per week. Lower rates of bloating were reported by those who had diarrhea (33.04%), constipation (32.62%), and early satiety (46.79%). Supplement table 3 reports the prevalence of bloating at least once per week among DGBI. Prevalence ranged from 21% (functional diarrhea) to 74% (epigastric pain syndrome). Data are not presented for the following DGBI due to n<50 sample size: cannabinoid hyperemesis syndrome, functional biliary pain, central abdominal pain syndrome (CAPS).
Table 2.
Frequency of bloating in individuals reporting other GI symptoms
Bloating frequency | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
never | < 1 day/month | 1–3 days/month | 1x/week | most days | every day | ||||||||
Total n |
n | % | n | % | n | % | n | % | n | % | n | % | |
Epigastric pain | |||||||||||||
No | 49409 | 20496 | 41.48 | 10540 | 21.33 | 10720 | 21.7 | 5166 | 10.46 | 1612 | 3.26 | 875 | 1.77 |
Yes | 2016 | 100 | 4.96 | 81 | 4.02 | 396 | 19.64 | 743 | 36.86 | 385 | 19.1 | 311 | 15.43 |
Bloating at least 1x/week=71.39% | |||||||||||||
| |||||||||||||
Early Satiety | |||||||||||||
No | 45899 | 19667 | 42.85 | 9936 | 21.65 | 9790 | 21.33 | 4423 | 9.64 | 1369 | 2.98 | 714 | 1.56 |
Yes | 5526 | 929 | 16.81 | 685 | 12.4 | 1326 | 24 | 1486 | 26.89 | 628 | 11.36 | 472 | 8.54 |
Bloating at least 1x/week=46.79% | |||||||||||||
| |||||||||||||
Nausea | |||||||||||||
No | 49400 | 20386 | 41.27 | 10457 | 21.17 | 10674 | 21.61 | 5283 | 10.69 | 1686 | 3.41 | 914 | 1.85 |
Yes | 2025 | 210 | 10.37 | 164 | 8.1 | 442 | 21.83 | 626 | 30.91 | 311 | 15.36 | 272 | 13.43 |
Bloating at least 1x/week=59.70% | |||||||||||||
| |||||||||||||
Diarrhea | |||||||||||||
No | 40017 | 17950 | 44.86 | 8812 | 22.02 | 7932 | 19.82 | 3541 | 8.85 | 1135 | 2.84 | 647 | 1.62 |
Yes | 11408 | 2646 | 23.19 | 1809 | 15.86 | 3184 | 27.91 | 2368 | 20.76 | 862 | 7.56 | 539 | 4.72 |
Bloating at least 1x/week=33.04% | |||||||||||||
| |||||||||||||
Constipation | |||||||||||||
No | 37713 | 17477 | 46.34 | 8379 | 22.22 | 7237 | 19.19 | 3124 | 8.28 | 932 | 2.47 | 564 | 1.5 |
Yes | 13712 | 3119 | 22.75 | 2242 | 16.35 | 3879 | 28.29 | 2785 | 20.31 | 1065 | 7.77 | 622 | 4.54 |
Bloating at least 1x/week=32.62% | |||||||||||||
| |||||||||||||
Abdominal pain | |||||||||||||
No | 47032 | 20189 | 42.93 | 10304 | 21.91 | 10157 | 21.6 | 4404 | 9.36 | 1304 | 2.77 | 674 | 1.43 |
Yes | 4393 | 407 | 9.26 | 317 | 7.22 | 959 | 21.83 | 1505 | 34.26 | 693 | 15.78 | 512 | 11.65 |
Bloating at least 1x/week=61.69% |
Symptom definitions: Epigastric pain at least once per week; Early satiety at least once a week; Nausea at least once per week; Diarrhea at least 30% of all bowel movements; Constipation at least 30% of all bowel movements; Abdominal pain at least once a week
Finally, Table 3 shows the results of a hierarchical logistic regression evaluating factors potentially associated with presence/absence of weekly bloating. In the final model, controlling for demographic, psychological, health, and dietary factors, the following factors were independently and significantly associated with bloating: female sex; age; somatic symptoms; depression and anxiety; reported concern about bowel functioning; worse global physical health; presence of abdominal pain, constipation, diarrhea, nausea, epigastric pain, early satiety; and more milk consumption. The strongest associations were with abdominal pain (OR=2.90) and epigastric pain (OR=2.07).
Table 3.
Logistic regression for presence of bloating at least once a week. Odds ratios include 95% confidence limits.
Model predictors: demographics | Model predictors: psychological burden | Model predictors: Health | Model predictors: Gastrointestinal symptoms | Model predictors: Dietary factors | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Predictors | Odds Ratios |
CI | p | Odds Ratios |
CI | p | Odds Ratios |
CI | p | Odds Ratios |
CI | p | Odds Ratios |
CI | p |
| |||||||||||||||
(Intercept) | 0.23 | 0.21 – 0.25 | <0.001 | 0.05 | 0.04 – 0.05 | <0.001 | 0.03 | 0.02 – 0.04 | <0.001 | 0.02 | 0.02 – 0.03 | <0.001 | 0.02 | 0.02 – 0.03 | <0.001 |
Female gender | 2.14 | 2.04 – 2.25 | <0.001 | 1.56 | 1.48 – 1.64 | <0.001 | 1.55 | 1.47 – 1.63 | <0.001 | 1.59 | 1.51 – 1.68 | <0.001 | 1.58 | 1.50 – 1.68 | <0.001 |
Age | 0.99 | 0.99 – 0.99 | <0.001 | 1.00 | 1.00 – 1.00 | 0.529 | 1.00 | 1.00 – 1.00 | 0.031 | 1.00 | 1.00 – 1.00 | 0.004 | 1.00 | 1.00 – 1.00 | 0.004 |
PHQ-12 sum score | 1.15 | 1.15 – 1.16 | <0.001 | 1.09 | 1.08 – 1.10 | <0.001 | 1.05 | 1.04 – 1.05 | <0.001 | 1.05 | 1.04 – 1.05 | <0.001 | |||
PHQ-4 sum score | 1.14 | 1.13 – 1.15 | <0.001 | 1.07 | 1.06 – 1.08 | <0.001 | 1.05 | 1.03 – 1.06 | <0.001 | 1.05 | 1.03 – 1.06 | <0.001 | |||
Concern about bowel functioning | 1.54 | 1.51 – 1.57 | <0.001 | 1.38 | 1.36 – 1.41 | <0.001 | 1.39 | 1.36 – 1.42 | <0.001 | ||||||
Global Physical Health | 0.89 | 0.87 – 0.90 | <0.001 | 0.93 | 0.92 – 0.95 | <0.001 | 0.93 | 0.92 – 0.95 | <0.001 | ||||||
Global Mental Health | 1.04 | 1.03 – 1.05 | <0.001 | 1.01 | 1.00 – 1.02 | 0.086 | 1.01 | 1.00 – 1.02 | 0.066 | ||||||
Abdominal pain at least once a week | 2.89 | 2.66 – 3.14 | <0.001 | 2.90 | 2.67 – 3.14 | <0.001 | |||||||||
Constipation of at least 30% of all bowel movements | 1.75 | 1.66 – 1.85 | <0.001 | 1.75 | 1.65 – 1.85 | <0.001 | |||||||||
Diarrhea of at least 30% of all bowel movements | 1.57 | 1.48 – 1.67 | <0.001 | 1.58 | 1.49 – 1.67 | <0.001 | |||||||||
Nausea at least once a week | 1.26 | 1.11 – 1.42 | <0.001 | 1.26 | 1.12 – 1.42 | <0.001 | |||||||||
Early satiety at least once a week | 1.87 | 1.74 – 2.02 | <0.001 | 1.87 | 1.74 – 2.02 | <0.001 | |||||||||
Epigastric pain at least once a week | 2.07 | 1.82 – 2.34 | <0.001 | 2.07 | 1.83 – 2.35 | <0.001 | |||||||||
Milk products | 1.02 | 1.00 – 1.03 | 0.005 | ||||||||||||
Vegetables and legumes | 1.00 | 0.98 – 1.01 | 0.538 | ||||||||||||
Fruit | 0.99 | 0.98 – 1.01 | 0.438 | ||||||||||||
Bread | 0.99 | 0.98 – 1.00 | 0.051 | ||||||||||||
Pasta | 0.99 | 0.98 – 1.01 | 0.512 | ||||||||||||
| |||||||||||||||
Observations | 51425 | 51425 | 51341 | 51341 | 51341 | ||||||||||
R2 Tjur | 0.026 | 0.125 | 0.179 | 0.251 | 0.251 | ||||||||||
log-Likelihood | −23306.489 | −21013.506 | −19682.772 | −18305.774 | −18299.751 |
Symptom definitions: Epigastric pain at least once per week; Early satiety at least once a week; Nausea at least once per week; Diarrhea at least 30% of all bowel movements; Constipation at least 30% of all bowel movements; Abdominal pain at least once a week
PHQ-12: a validated measure of somatization
PHQ-4: a validated measure of emotional distress (anxiety/depression)
Bloating frequency and bloating severity together with the presence of a DGBI, affect psychological and physical health as the analyses of pairwise contrasts show (Supplement table 4). We compared subjects who did not report digestive symptoms to the following groups: 1) subjects reporting bloating at least once a week, 2) bloating at least once a week with comorbid DGBI, 3) bloating at least once a week with bloating as the most bothersome symptoms, and 4) bloating at least once a week with bloating as the most bothersome symptom and comorbid DGBI. Subjects suffering from bloating show significantly higher levels of depression and anxiety severity, lower global mental health, and lower global physical health. Furthermore, the magnitudes of the contrast estimates show that the presence of a DGBI yielded estimates indicating higher burden in psychological and physical health.
Discussion
Bloating is a commonly reported symptom in the general population and is exceedingly common among individuals reporting chronic GI symptoms and among those meeting Rome IV criteria for DGBI. The current study found that 17% of the global study population reported experiencing bloating at least once per week (ranging from 11% in East Asia to 20% in Latin America). Over half of respondents reporting nausea, abdominal pain, or epigastric pain at least once per week also reported bloating at least once a week. As expected, bloating was also more common among those meeting Rome IV criteria for one or more of 22 DGBI, with the prevalence ranging from 21% (functional diarrhea) to 74% (epigastric pain syndrome). Finally, we found that bloating prevalence was lower in older age groups, and that women were about twice as likely as men to report experiencing bloating weekly, both of which are consistent with previous reports2,3.
Previous research estimated the prevalence of bloating as a symptom to be up to 30% in the general population5,7,10, although most studies used different definitions to determine the presence/absence of bloating. For example, one recent study in the United States (n=88,795) reported that 13.9% of the sample reported bloating within the last week6 and another (n=21,128) found that 4.5% reported bloating at least once per week5. Another study reported that 27% of patients (n=1050) receiving medical care at a hospital in South Korea had “significant” bloating,7 and a study in Australia found that 31% of individuals in the population reported “often” having bloating in the last year4. In the current study, we found that 18% of individuals in the United States reported bloating at least once per week, which is slightly higher than the 13.9% prevalence of “bloating in the last 7 days” recently reported in a large national survey in the US6, and substantially higher than the previously reported prevalence of 4.5% experiencing bloating at least once per week5. Our finding of 18% prevalence of bloating in the US was also consistent with the rates reported in 25 other countries in this global survey. It is possible that discrepancies in reported prevalence of bloating as a symptom may be related to the wording of the question in Rome IV “how often did you feel bloated or notice that your belly looked unusually large” compared to the way this question may have been asked in previous studies or how surveys were conducted (e.g., internet-based vs. computer-assisted telephone survey vs. face-to-face interview).
The findings of this study suggest that bloating is strongly associated with abdominal pain, which is consistent with previous reports12,17. Seventy one percent of individuals who reported epigastric pain and 62% of those who reported abdominal pain at least once per week also reported bloating at least weekly. The prevalence of bloating was higher among individuals with epigastric and/or abdominal pain compared to other chronic GI symptoms such as diarrhea, constipation, nausea, or early satiety. In the logistic regression, abdominal pain and epigastric pain had the strongest association with bloating (ORs = 2.65 and 2.03, respectively) when compared to other GI symptoms, and after controlling for demographics, diet, and psychological burden. Furthermore, when identifying prevalence of bloating among specific DGBI, the DGBI with the highest prevalence of bloating included: epigastric pain syndrome, reflux hypersensitivity, and IBS, all of which are associated with pain or discomfort. Our finding that IBS-C and IBS-D had higher rates of bloating (71% and 64%, respectively) compared to functional constipation and functional diarrhea (36% and 21%, respectively) further supports the finding above that bloating is associated with abdominal pain, and that this association appears to be stronger than the association between bloating and bowel habits. This may support the conclusion that bloating in DGBI is likely to be attributable to visceral hypersensitivity18–20 and that this symptom could therefore potentially respond to neuromodulators or brain-gut behavioral therapy.
Similar to other research, our study showed that female sex, constipation, psychological distress, and somatic symptoms were all associated with increased likelihood of reporting frequent bloating10–12,21. Additionally, we observed those reporting abdominal pain at least 1x/week had much higher odds of bloating (OR=2.90), and those reporting epigastric pain had twice the odds (OR=2.07) of also reporting bloating. Once again, this highlights the finding that pain, discomfort, and upper GI symptoms appear to have the strongest association with bloating, whereas constipation alone, which is often thought to be highly comorbid with bloating, had a statistically significant but weaker predictive association (OR=1.75).
The association between bloating and psychological distress highlights the multifaceted nature of the symptom of bloating. As shown in supplement table 4, bloating is associated with higher levels of depression and anxiety, with lower global mental health, and lower global physical health, in comparison with subjects without bloating. This indicates that many people suffering from frequent bloating are psychologically and physically impaired.
The results of this study also indicated that more frequent milk consumption was associated with higher chances of reporting frequent bloating. The findings regarding dairy are consistent with previous reports22–24. In order to further understand dietary factors related to bloating, we can look to frequency of foods consumed in the regions with the highest and lowest reported bloating. For example, compared to East Asia, which had the lowest prevalence of bloating, participants from Latin America, which had the highest prevalence of bloating, reported more frequent consumption of pasta (twice as high as East Asia), milk, and bread. This is interesting because these foods are generally high in FODMAPs (fructans and lactose) which are known to exacerbate bloating in patients with DGBI. Moreover, a diet low in FODMAPs has been shown to reduce bloating severity in patients with IBS25. Thus, regional variation in diet could, in part, explain the differences seen in bloating prevalence globally. However, our questions were not designed to specifically address the nuances of dietary triggers for bloating (e.g., have you restricted any food group consumption due to bloating, do you identify dietary triggers for bloating, etc.). Finally, there could be other factors (e.g., genetics, linguistic differences in the meaning/interpretation of various words for ‘bloating’) that could also explain the regional differences in bloating.
This study has several strengths, most notably the large and global sample size provided by the RFGES internet survey. As a result, it provides the first global estimate of bloating as a symptom worldwide, by country, and among a wide range of DGBI. Despite these strengths, there are some limitations to acknowledge. First, this survey relied entirely on patient reported data, which could not be verified with any clinical information. Second, this study only included data from those countries that were surveyed via internet and, therefore, may not be generalizable to countries with more limited internet access. Third, although the study included a large, world-wide sample, the number of individuals in each of the 26 countries was comparatively low (<3000 cases per country). Fourth, this is a cross-sectional study and, therefore, directionality of associations cannot be ascertained. Fifth, the questions for bloating were not framed to differentiate it from abdominal distention, and therefore the current study does not provide any insight into differences (if any) in the clinical and demographic factors associated with abdominal bloating or distention. Sixth, the questions about dietary patterns were based on an unvalidated measure, rendering it difficult to make clear conclusions about dietary risk factors for bloating. Seventh, the data in this study were collected prior to the COVID-19 pandemic, which may have impacted the worldwide prevalence of DGBIs and associated symptoms26,27. Finally, there were no data available to measure bloating severity.
In summary, bloating is common throughout the world and across a wide range of cultures and dietary patterns. Nearly 18% of the general population and 21–74% of DGBI experience bloating at least once per week. Reported bloating prevalence is lower in older age groups, is most common in women, and is strongly associated with abdominal pain. These findings can inform clinical practice in several ways. First, our findings that bloating is very common in the general population and is particularly common among patients with DGBIs, suggests that this is a symptom that should be screened thoroughly by both general practitioners and gastroenterologists. Second, our findings suggest that abdominal pain is more strongly associated with bloating than constipation. Therefore, it is possible that treating pain and/or reducing visceral hypersensitivity (e.g., with neuromodulators and/or brain gut behavioral therapy) might improve bloating severity , especially among patients with DGBI.
Supplementary Material
What you need to know.
Background and context:
Bloating is a common symptom in the general population and among disorders of gut-brain interaction, but its global prevalence has not been well characterized.
New Findings:
Nearly 18% of the worldwide population experience bloating at least once per week. Prevalence is lower in older age, most common in women, prevalent among DGBI, and strongly associated with abdominal pain.
Limitations:
This survey relied entirely on patient reported data. Second, these findings may not be generalizable to countries with limited internet access. Finally, bloating was not differentiated from distension.
Clinical research relevance:
Bloating is a symptom that should be screened thoroughly by both general practitioners and gastroenterologists. Treating abdominal pain might improve bloating severity, especially among patients with DGBI
Basic research relevance:
The pathophysiology of bloating is poorly understood. In the current study, we have identified demographic, dietary and psychological factors associated with bloating. Future studies should seek to identify underlying mechanisms.
Lay summary:
Bloating is common throughout the world. Bloating prevalence is highest in women, younger age groups, and among individuals who also report chronic gastrointestinal pain.
Funding:
PS was supported by NIH grant K23DK129327; GG was supported by a grant from the Amherst College Loeb Center through the Charles Hamilton Houston program. The RFGES was conducted under the auspices of the Rome Foundation Research Institute
Footnotes
Conflict of interest statement: The authors disclose no conflicts
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Data Statement:
Requests for RFGES data and materials may be submitted to the Rome Foundation.
References
- 1.Lewis MJ, Reilly B, Houghton LA, et al. Ambulatory abdominal inductance plethysmography: towards objective assessment of abdominal distension in irritable bowel syndrome. Gut 2001;48:216–220. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Palsson OS, Whitehead W, Törnblom H, et al. Prevalence of Rome IV Functional Bowel Disorders Among Adults in the United States, Canada, and the United Kingdom. Gastroenterology 2020;158:1262–1273.e3. [DOI] [PubMed] [Google Scholar]
- 3.Sandler RS, Stewart WF, Liberman JN, et al. Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact. Dig Dis Sci 2000;45:1166–1171. [DOI] [PubMed] [Google Scholar]
- 4.Talley NJ, Boyce P, Jones M. Identification of distinct upper and lower gastrointestinal symptom groupings in an urban population. Gut 1998;42:690–695. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Camilleri M, Dubois D, Coulie B, et al. Prevalence and Socioeconomic Impact of Upper Gastrointestinal Disorders in the United States: Results of the US Upper Gastrointestinal Study. Clin Gastroenterol Hepatol 2005;3:543–552. [DOI] [PubMed] [Google Scholar]
- 6.Oh JE, Chey WD, Spiegel B. Abdominal Bloating in the US: Results of a Survey of 88,795 Americans Examining Prevalence and Healthcare Seeking. Clin Gastroenterol Hepatol 2022:S1542356522010205. [DOI] [PubMed] [Google Scholar]
- 7.Ryu MS, Jung H-K, Ryu J, et al. Clinical Dimensions of Bloating in Functional Gastrointestinal Disorders. J Neurogastroenterol Motil 2016;22:509–516. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Neri L, Iovino P, Laxative Inadequate Relief Survey (LIRS) Group. Bloating is associated with worse quality of life, treatment satisfaction, and treatment responsiveness among patients with constipation-predominant irritable bowel syndrome and functional constipation. Neurogastroenterol Motil Off J Eur Gastrointest Motil Soc 2016;28:581–591. [DOI] [PubMed] [Google Scholar]
- 9.Talley NJ, Dennis EH, Schettler-Duncan VA, et al. Overlapping upper and lower gastrointestinal symptoms in irritable bowel syndrome patients with constipation or diarrhea. Am J Gastroenterol 2003;98:2454–2459. [DOI] [PubMed] [Google Scholar]
- 10.Houghton LA, Whorwell PJ. Towards a better understanding of abdominal bloating and distension in functional gastrointestinal disorders. Neurogastroenterol Motil Off J Eur Gastrointest Motil Soc 2005;17:500–511. [DOI] [PubMed] [Google Scholar]
- 11.Jiang X, Locke GR, Choung RS, et al. Prevalence and risk factors for abdominal bloating and visible distention: a population-based study. Gut 2008;57:756–763. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Gardiner CP, Singh P, Ballou S, et al. Symptom severity and clinical characteristics of patients with bloating. Neurogastroenterol Motil Off J Eur Gastrointest Motil Soc 2022;34:e14229. [DOI] [PubMed] [Google Scholar]
- 13.Sperber AD, Bangdiwala SI, Drossman DA, et al. Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology 2021;160:99–114.e3. [DOI] [PubMed] [Google Scholar]
- 14.Löwe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord 2010;122:86–95. [DOI] [PubMed] [Google Scholar]
- 15.Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;64:258–266. [DOI] [PubMed] [Google Scholar]
- 16.Hays RD, Bjorner JB, Revicki DA, et al. Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items. Qual Life Res Int J Qual Life Asp Treat Care Rehabil 2009;18:873–880. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Said H, Nee J, Iturrino J, et al. Clinical Characteristics of Patients Presenting With Bloating as a Predominant Symptom. J Clin Gastroenterol 2022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Agrawal A, Houghton LA, Reilly B, et al. Bloating and distension in irritable bowel syndrome: the role of gastrointestinal transit. Am J Gastroenterol 2009;104:1998–2004. [DOI] [PubMed] [Google Scholar]
- 19.Sullivan SN. A prospective study of unexplained visible abdominal bloating. N Z Med J 1994;107:428–430. [PubMed] [Google Scholar]
- 20.Posserud I, Syrous A, Lindström L, et al. Altered rectal perception in irritable bowel syndrome is associated with symptom severity. Gastroenterology 2007;133:1113–1123. [DOI] [PubMed] [Google Scholar]
- 21.Delgado-Aros S, Locke GR, Camilleri M, et al. Obesity is associated with increased risk of gastrointestinal symptoms: a population-based study. Am J Gastroenterol 2004;99:1801–1806. [DOI] [PubMed] [Google Scholar]
- 22.Lomer MCE, Parkes GC, Sanderson JD. Review article: lactose intolerance in clinical practice--myths and realities. Aliment Pharmacol Ther 2008;27:93–103. [DOI] [PubMed] [Google Scholar]
- 23.Grand RJ, Montgomery RK. Lactose malabsorption. Curr Treat Options Gastroenterol 2008;11:19–25. [DOI] [PubMed] [Google Scholar]
- 24.Nilholm C, Larsson E, Sonestedt E, et al. Assessment of a 4-Week Starch- and Sucrose-Reduced Diet and Its Effects on Gastrointestinal Symptoms and Inflammatory Parameters among Patients with Irritable Bowel Syndrome. Nutrients 2021;13:416. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Pessarelli T, Sorge A, Elli L, et al. The low-FODMAP diet and the gluten-free diet in the management of functional abdominal bloating and distension. Front Nutr 2022;9:1007716. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Ebrahim Nakhli R, Shanker A, Sarosiek I, et al. Gastrointestinal symptoms and the severity of COVID-19: Disorders of gut-brain interaction are an outcome. Neurogastroenterol Motil Off J Eur Gastrointest Motil Soc 2022;34:e14368. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Marasco G, Cremon C, Barbaro MR, et al. Post COVID-19 irritable bowel syndrome. Gut 2022:gutjnl-2022-328483. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Requests for RFGES data and materials may be submitted to the Rome Foundation.