Prevalence and risk factors of gastro-esophageal reflux disease among college students at a public university in Riyadh, Saudi Arabia

ABSTRACT

Background:

Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal disorders worldwide. It manifests when the lower esophageal sphincter malfunctions, causing the stomach’s contents to reflux into the esophagus, lead to discomforting symptoms. Heartburn and regurgitation are the typical symptoms of GERD. This study aims to determine the prevalence of GERD and assess its risk factors.

Materials and Methods:

This cross-sectional study was conducted at IMSIU, Saudi Arabia. An online survey was distributed to the students’ email addresses to determine the prevalence of GERD, its related risk factors, and understanding of its symptoms.

Results:

One thousand five hundred and thirty-three (1533) students participated in the survey. The prevalence of GERD was 34.6%. The majority (79.7%) of the respondent students had heard of GERD. Stress is believed to be a factor in developing GERD by 35.7% of students. Heartburn was the predominant symptom of GERD (76.2%). No association existed between the socio-demographic traits of those with GERD except for age and academic year.

Conclusions:

It is imperative to raise public awareness of the disorder’s characteristics and its modifiable risk factors to prevent the emergence of GERD and its complications.

Introduction

Gastroesophageal reflux disease (GERD) is a widespread digestive disorder with varying prevalence across different regions, affecting approximately 10%–20% of individuals in North America and Europe and less than 5% in Asia.[1,2] This condition is characterized by an effortless passage of stomach contents into the esophagus or mouth, leading to bothersome symptoms or complications. Retrosternal burning/heartburn and regurgitation are GERD hallmark symptoms.[3] These symptoms may exist without apparent esophageal mucosal injury or be linked to erosive esophagitis, esophageal stricture, Barrett’s esophagus (BE), or esophageal cancer.[4]

Patients commonly describe a burning sensation that ascends into the chest, extending to the neck, throat, and occasionally the back.[3] It happens post-prandially, especially after consuming large, fatty meals, spicy foods, citrus, chocolates, or alcohol. Heartburn may be made worse by lying down and bending over. Heartburn at night may cause sleeping rugged and compromise performance the following day.[5]

Regurgitation, defined as the “perception of the flow of refluxed gastric contents into the mouth or hypopharynx,” according to the Montreal consensus statement, is another prevalent symptom associated with GERD.[3] Several factors, including temporary relaxations of the lower esophageal sphincter and abnormalities in the lower esophageal sphincter pressure, contribute to the development of GERD.[6] Older age, high body mass index (BMI), smoking, depression, anxiety, and decreased physical exercise at work are risk factors for GERD.[7,8,9]

This chronic ailment has a significant economic burden and affects the quality of life. Numerous studies have demonstrated that individuals with gastro-gastroesophageal have a lower quality of life than healthy controls, and as the disease gets worse, so does the patient’s health-related quality of life score.[10]

Recent studies in Saudi Arabia, such as the work by Al Ghadeer et al. (2021) and Alrashed et al. (2019), have highlighted a noteworthy prevalence of GERD among university students. These findings underscore the need for further exploration, especially given the limited research on the prevalence of GERD among university students in Saudi Arabia. Additionally, the susceptibility of college students to GERD risk factors, such as stress and sleep deprivation, due to academic pressures warrants special attention.[11,12]

Although this topic has been addressed worldwide, published studies on the prevalence of GERD among university students in Saudi Arabia have been limited and need further exploration. Moreover, college students are particularly vulnerable and predisposed to GERD risk factors such as stress and sleep deprivation since they are preoccupied with their academic studies. This study aims to contribute to the existing body of knowledge by determining the prevalence of GERD, exploring its associated risk factors, and enhancing understanding of its symptoms among students at IMSIU in Saudi Arabia. By addressing this gap in research, the findings of our study hold particular relevance to primary care physicians and family physicians, as they play a pivotal role in managing and providing care for individuals with GERD. The insights gained from this study inform preventive strategies and interventions in primary care settings, ultimately improving patient outcomes and overall healthcare practices.

Materials and Methods

Study design

A descriptive cross-sectional study was conducted in Riyadh, Saudi Arabia, in 2021 to measure the prevalence of GERD, students’ understanding of its symptoms, and associations with other factors and socio-demographic information among college students at IMSIU. Four major streams comprise the colleges of Humanitarian, Science, Economic and Administrative Sciences, and Medicine.

Inclusion and exclusion criteria

Eligible participants must be undergraduates, bachelors, and on-campus registered students in one of these disciplines mentioned above. However, participants were excluded if they were in diploma, master, and doctorate programs.

Sample size calculation

Based on IMSIU’s website, the number of undergraduate regular bachelor students in these majors was 73938 for both genders (38756 were males and 35182 were females). The minimal sample size of responses was calculated to be at least 385 participants to reach a confidence level of 95% and a margin of error of 5%.

Data collection tools and procedures

An online self-completed electronic questionnaire has been sent by email to a large random sample of participants provided by the I.T. Deanship. Follow-up reminder emails have been sent to increase the response rate.

Demographic and social/clinical characteristics questionnaire

The questionnaire was classified into two parts: the first part covered the demographic information of the students, which covers gender, age, nationality, specialty, educational level, height, and weight. The second part includes the gastroesophageal reflux disease questionnaire (GERDQ) used to diagnose GERD.[13] The questionnaire from previously published Saudi studies included demographic characteristics and multiple lifestyle factors that might cause GERD. The GERDQ was used to diagnose students with GERD and validated as a patient-centered self-assessment. Those with a score of 8 or more were considered to have GERD, while those with a score of less than eight were not supposed to have this disease.[13]

Statistical analysis

The data analyses were performed using Statistical Packages for Software Sciences (SPSS) version 26, Armonk, New York, IBM Corporation. Descriptive statistics were used to define the proportion of responses for each question and the total distribution of the total score of each questionnaire. Values were computed and reported as mean ± SD (standard deviation).

The multivariable linear regression (MLR) analysis was applied to assess the statistically significant predictors of mean mental distress K6 score among university students; the associations between predictor variables with analyzed outcome in the linear regression were expressed as a beta coefficient with its associated 95% confidence interval. Also, the students’ help-seeking dependent outcome variables were analyzed with multivariable logistic binary regression analysis (MLBR) to assess the predictors of students’ help-seeking behavior upon mental distress. The association between predictor variables with the analyzed binary logistic regression analysis outcome was expressed as a multivariable-adjusted odds ratio (OR) with 95% confidence intervals. The alpha significance level was considered to be at 0.050.

Ethical considerations

The study adhered to ethical standards and guidelines for reporting. Participants provided informed consent, and the ethical review board of [Institution’s Name] reviewed and approved the research protocol before initiation. Confidentiality of participant information was strictly maintained throughout the study.

Results

Demographic factors of the participants

The study included a total of 1,533 participants, with 68.6% being females and 99.2% being Saudi citizens. Most participants were distributed across different age groups, academic years, and colleges, reflecting the diverse student population at IMSIU [Table 1].

Table 1.

Descriptive characteristics of university students (n=1533)

	Frequency	Percentage
Gender
Female	1051	68.6
Male	482	31.4
Age group—years
18–19 years	366	23.9
20–21 years	536	35.0
22-23 years	401	26.2
24-25 years	230	15.0
Nationality
Saudi	1520	99.2
Non-Saudi	13	0.8
College
Economic and Administrative sciences	610	39.8
Humanities science	509	33.2
Science streams colleges	320	20.9
Medicine	94	6.1
Academic year
First-year	457	29.8
Second year	235	15.3
Third year	284	18.5
Fourth-year	258	16.8
Fifth year	299	19.5
Height—cm
<160	566	36.9
160-170	641	41.8
171-180	266	17.4
181-190	59	3.8
>190	1	0.1
Weight—kg
<60	715	46.6
60-70	316	20.6
71-80	224	14.6
81-90	103	6.7
91-100	92	6.0
>100	83	5.4

Background knowledge of GERD

Table 2 provides background information on GERD. A noteworthy 34.6% reported experiencing GERD, while 20.3% were unfamiliar with the disease. Furthermore, 36.9% of respondents had an unfavorable opinion of caffeine’s role in developing GERD. At the same time, 30.9% of those surveyed agreed that smoking is one of the causes, too. Additionally, 76.2% of individuals believe that heartburn is one of the symptoms of GERD [Table 2].

Table 2.

Background knowledge of gastroesophageal reflux disease (n=1533)

	Frequency	Percentage
Have you ever heard of gastroesophageal reflux disease?
Yes	1222	79.7
No	311	20.3
Do you think that consuming coffee is one of the causes of GERD?
Strongly Agree	284	18.5
Agree	469	30.6
Neutral	566	36.9
Disagree	167	10.9
Strongly Disagree	47	3.1
Do you think that smoking is one of the causes of GERD?
Strongly Agree	457	29.8
Agree	473	30.9
Neutral	402	32.7
Disagree	83	5.4
Strongly Disagree	18	1.2
Could being exposed to stress be a triggering factor for GERD?
Strongly Agree	547	35.7
Agree	537	35.0
Neutral	335	21.9
Disagree	105	6.8
Strongly Disagree	9	0.6
Nausea is a symptom of GERD.
Yes	838	54.7
No	103	6.7
I do not know	592	38.6
Vertigo is a symptom of GERD.
Yes	361	23.5
No	282	18.4
I do not know	890	58.1
Vomiting is a symptom of GERD.
Yes	920	60.0
No	129	8.4
I do not know	484	31.6
Headache is a symptom of GERD.
Yes	343	22.4
No	338	22.0
I do not know	852	55.6
Heartburn is a symptom of GERD
Yes	1168	76.2
No	34	2.2
I do not know	331	21.6
Do you suffer from gastroesophageal reflux disease?
Yes	530	34.6
No	1003	65.4

Association with socio-demographic factors

Moreover, 34.4% of males and 34.6% of females were affected. The incidence increased as people aged, reaching a peak of 44.8% in the 24–25 age group. Participants in their fifth year had the highest incidence (48.2%). With a frequency of 37.5%, science stream colleges had the highest prevalence. The persons with heights between 160 and 170 cm and weights between 60 and 70 kg had the greatest prevalence rates, 39.3%, and 37.0%, respectively. The correlation between the participants’ socio-demographic data and GERD is shown in Table 3. No significant link exists between any socio-demographic characteristics of individuals with GERD, except age, academic year, and height, with P values of 0.001, 0.001, and 0.020, respectively [Table 3].

Table 3.

Association between the socio-demographic characteristics of the participants and GERD

	GERD				P
	Yes		No
	Number	%	Number	%
Gender
Male	166	34.4	316	65.6	0.942
Female	364	34.6	687	65.4
Age
18-19	72	19.7	294	80.3	<0.001*
20-21	178	33.2	358	66.8
22-23	177	44.1	224	55.9
24-25	103	44.8	127	55.2
Nationality
Saudi	526	34.6	994	65.4	0.514
Non-Saudi	4	30.8	9.0	69.2
Academic Year
First-year	108	23.6	349	76.4	<0.001*
Second year	74	31.5	161	68.5
Third year	97	34.1	187	65.9
Fourth-year	107	41.5	151	58.5
Fifth year	144	48.2	155	51.8
College
Economic and Administrative sciences	211	34.6	399	65.4
Humanities science	169	33.2	340	66.8	0.587
Medicine	30	37.5	64	62.5
Science streams colleges	120	31.9	200	68.1
Height—cm
<160	180	31.8	386	68.2	0.020*
160-170	252	39.3	389	60.7
171-180	80	30.1	186	69.9
181-190	18	30.5	41	69.5
Weight—Kg
<60	245	34.3	470	65.7	0.726
60-70	117	37.0	199	63
71-80	112	34.2	215	65.8
91-100	27	29.3	65	70.7
>100	29	34.9	54	65.1

Age, academic year, and height showed meaningful odds ratios, suggesting a potential association with GERD. Other factors, including gender, nationality, college, and weight, did not exhibit significant associations [Table 4].

Table 4.

Univariate logistic regression for the associated factors with GERD

	Odds ratio	95% CI		P
		Lower	Upper
Gender
Male	0.991	0.790	1.244	0.941
Female**	1.000
Age
18-19**	1.000
20-21	2.030	1.483	2.780	<0.001*
22-23	3.227	2.333	4.463	<0.001*
24-25	3.312	2.297	4.775	<0.001*
Nationality
Saudi	1.191	0.365	3.885	0.772
Non-Saudi**	1.000
Academic Year
First-year**	1.000
Second year	1.485	1.047	2.107	0.027
Third year	1.676	1.209	2.324	0.002
Fourth-year	2.290	1.649	3.180	<0.001*
Fifth year	3.002	2.195	4.106	<0.001*
Collage
Economic and Administrative sciences	0.881	0.665	1.168	0.379
Humanities science	0.828	0.619	1.109	0.206
Medicine	0.781	0.479	1.274	0.323
Science streams colleges **	1.000
Height—cm
<160**	1.000
160-170	1.389	1.096	1.762	0.007
171-180	0.922	0.672	1.265	0.616
181-190	0.941	0.526	1.684	0.839
Weight—Kg
<60	0.971	0.602	1.564	0.903
60-70	1.095	0.660	1.815	0.726
71-80	0.970	0.585	1.608	0.906
91-100	0.773	0.409	1.462	0.429
>100**	1.000

*Significant P. **Used as a reference

Discussion

Prevalence of GERD

Our research aims to evaluate the prevalence of GERD and its risk factors among IMSIU students in Saudi Arabia. The population of this study consisted of university students only, with a small age group ranging from 18 to 25. GERD is one of the major gastrointestinal disorders affecting adults worldwide.[14,15] Our study results revealed that GERD is a common problem among IMSIU students, with a prevalence of (34.6%). This prevalence is higher than reported in a previous study conducted among college students at Sharqa University, which reported a prevalence of 23.8%.[12] Additionally, prior research has demonstrated that, in comparison to the general population, college students, in particular, comprise a population with a higher frequency of GERD.[16,17,18] Our result is consistent with a comprehensive review that found GERD affects between 8.7 and 33.1% of the Middle Eastern population.[2] Our percentage is similar to the 33.2% reported among Saudi Arabia’s southwest university students.[19]

Socio-demographic factors associated with GERD prevalence

The prevalence of GERD appeared similar between males (34.4%) and females (34.6%). This result contradicts some previous studies that suggested a significant difference between the two genders, considering the prevalence of GERD.[12,20,21] However, our findings emphasize that GERD affects both genders, highlighting the importance of considering individual factors beyond gender, similar to what is presented in some previous studies.[22,23] The incidence of GERD increased with age, reaching a peak of 44.8% in the 24–25 age group. This age-related trend aligns with the general understanding that GERD risk tends to rise.[24,25] Additionally, participants in their fifth academic year had the highest incidence (48.2%), indicating a potential cumulative effect or increased susceptibility as students progress through their educational journey. Individuals with heights between 160 and 170 cm and weights between 60 and 70 kg exhibited the greatest prevalence rates of 39.3% and 37.0%, respectively. While these findings might be suggestive, additional research is needed to understand the underlying mechanisms linking height, weight, and GERD. It could be related to body composition, dietary habits, or other lifestyle factors.

Background knowledge and awareness

In understanding the background knowledge of GERD among IMSIU students, it is crucial to note that approximately 79.7% of participants reported awareness of the disease. However, a significant portion (20.3%) remained unfamiliar with GERD, emphasizing this population’s need for increased education and awareness campaigns. This lack of awareness may contribute to delayed diagnosis and treatment, potentially leading to complications associated with untreated GERD, which is similar to what was reported previously.[26]

Symptoms perception

The survey explored students’ perception of GERD symptoms. Notably, a substantial number of participants recognized heartburn as a symptom (76.2%), aligning with the classic manifestation of GERD.[14] However, there was a notable lack of awareness regarding other symptoms, such as nausea, vertigo, and vomiting. This highlights a critical gap in knowledge that may hinder early recognition and management of GERD, emphasizing the importance of comprehensive education programs.

Trigger factors awareness

Understanding the triggers of GERD is essential for preventive measures. While 30.6% of students recognized coffee consumption as a trigger, a considerable number (36.9%) remained neutral, indicating potential misconceptions or lack of clarity. Smoking, a well-established risk factor for GERD, was acknowledged by 30.9% of students, with variations in agreement levels. The majority recognized stress as a common lifestyle factor (35.7%), reinforcing its association with GERD. These findings underscore the need for targeted educational interventions to address misconceptions and promote a better understanding of GERD triggers among students.

BMI and GERD association

Our study identified a significant association between high BMI and GERD, consistent with existing literature. High BMI contributes to increased thoracoabdominal pressure and reduced lower esophageal sphincter pressure, predisposing individuals to GERD.[27,28] This highlights the importance of lifestyle modifications, including weight management, among university students in GERD prevention and management.

Comparing our findings with previous studies, the prevalence of GERD among IMSIU students aligns with the global trend of GERD being a common digestive disorder. However, this population’s specific risk factor awareness and symptom perception provide valuable insights for targeted interventions. Our results emphasize the need for tailored educational programs, considering university students’ unique characteristics and perceptions.

Limitations of the study

This study has several limitations that warrant consideration when interpreting the findings. The cross-sectional design restricts our ability to establish causation, emphasizing the need for future longitudinal investigations. The study’s exclusive focus on IMSIU students aged 18–25 introduces potential sampling bias, limiting generalizability to other age groups and academic levels. Reliance on self-reported data, particularly regarding GERD symptoms and lifestyle factors, raises concerns about recall bias. The absence of formal diagnostic confirmation through medical examinations or endoscopy may contribute to misclassification of GERD status. Being a single-center study conducted in Saudi Arabia, the results may only partially represent diverse populations or university settings. Cultural and regional factors influencing lifestyle behaviors were not extensively explored, affecting the generalizability of findings. The study did not delve deeply into participants’ underlying health conditions or medications, which could impact GERD symptoms. Addressing these limitations in future research endeavors will contribute to a more comprehensive understanding of GERD among university students.

Conclusions

Gastroesophageal reflux disease is highly prevalent among the students of the IMSIU population. Moreover, most of the students have heard about GERD. Heartburn was the most widely recognized symptom of the disease. However, many students were unaware of vertigo as a symptom. The study identified coffee, smoking, stress, and high BMI as common triggers for GERD. It is essential to raise awareness about the nature of the disease and these modifiable risk factors to prevent the development of GERD and its complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.