Can we make any recommendations about physical activity and peptic ulcerdisease?

Acid peptic disease is a common disorder that accounts for between 4 and 5million new or recurrent cases per year in the United States alone.¹ The direct and indirect costs are substantial and are estimated at $12 to $15 billion annually.²

In the past 3 decades, our understanding of the causation and treatment of peptic ulcer disease has changed dramatically. The proven association betweenHelicobacter pylori and gastroduodenal ulceration is perhaps the most significant finding,³ and some researchers now consider peptic ulcer disease to be infectious. The other major causal relationship is between the development of mucosal damage and the ingestion of nonsteroidal anti-inflammatory agents.⁴

Additional risk factors for peptic ulceration can be classified into those that are well founded, such as smoking and chronic obstructive pulmonary disease; those that are possible risks, such as high stress levels⁵; and those of questionable importance, such as genetics, ingestion of alcohol, cirrhosis, and rheumatoid arthritis. Although this last group has previously been considered to have a definite association with ulcer disease, the data were largely obtained in the era when H pylori status was not evaluated.Certain chronic disease states may be associated with either different rates of H pylori infection or an alteration of the effect on mucosal changes caused by this bacterium.

Cheng and colleagues present data suggesting that physical activity may provide a nonpharmacologic method of reducing the incidence of duodenal ulcers in men. They note that despite the large number of people worldwide who harborH pylori, ulcer disease develops in only a small percentage, and they suggest that some additional lifestyle factors may be involved.

Some 36,000 men and women were evaluated at the Cooper Clinic in Dallas from 1970 through 1990. Baseline information was obtained, including degree of physical activity, smoking habits, alcohol use, self-reported stress levels, age, and body mass index. A questionnaire was then sent out in 1990 to all subjects, except those who had reported a history of peptic ulcer at the time of their initial visit. The respondents, a total of 63% of those mailed a questionnaire, were asked if they had been diagnosed by a physician as having had an ulcer at any time since their baseline evaluation. After those with“incomplete data” were excluded, only 31% of the total group was included.

The results implied that physical activity provided a protective effect for duodenal ulcer in men only. No significant effect was seen for men with gastric ulcers or for women with either gastric or duodenal ulcer disease.Smoking and high levels of stress were risk factors for duodenal ulcers among men, and high levels of stress were a risk factor for gastric ulcer for both men and women. For men, smoking was also associated with an increased risk of gastric ulcer. But before we can suggest to our male patients that they can“run away” from ulcer disease, more data are needed.

Many questions in this study remain unanswered. How was the diagnosis of ulcer made? What about the role of H pylori and nonsteroidal anti-inflammatory drugs? To a great extent, the epidemiologic features of peptic ulcer disease have, over the past several decades, paralleled those ofH pylori. During this period, the prevalence of H pyloriinfection in developed countries has been rapidly declining, and along with this, we have also seen a decrease in the incidence of peptic disease. The patients seen at the Cooper Clinic were predominantly men, white, well educated, and of high socioeconomic status. This group would be expected to have a low rate of H pylori infection, although they would not be totally free of the infection. With no data presented on H pyloristatus or the use of nonsteroidal anti-inflammatory drugs, the results are subject to alternative explanations. The baseline data recorded levels of physical activity, as did the 1990 questionnaire. Did all these subjects maintain the same level of activity over the entire 19.5 years? If not, how long is exercise needed to be protective? Were the men in the“activity” group smokers? Did they use more or fewer nonsteroidal anti-inflammatory drugs than the reference group?

Possible mechanisms whereby exercise may reduce ulcer rates are offered, including effects on the immune system and reducing or better coping with stress. Several studies have examined these factors and have been either inconclusive or yielded contrary results. Exercise has been demonstrated to reduce acid secretion, but the effect is modest and short-lived. It isunlikely to have a beneficial effect on a process where healing rates are standardly measured in time scales of 4 to 8 weeks.

So what advice can we give our patients who are anxious to avoid ulcer disease? Physical exercise, in moderation, has been shown to have beneficial effects and should be encouraged, but it benefits the cardiopulmonary and musculoskeletal systems more than the gastrointestinal tract. What can be said with confidence is that a recommendation to stop smoking and avoid using nonsteroidal anti-inflammatory drugs will go a long way.