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Original Research (Original Article) 


Talal Abdullah Alzahrani et al, 2019;3(8):710–715.

International Journal of Medicine in Developing Countries

A cross-sectional study on the risk factors for inflammatory bowel disease among medical students and interns in Saudi Arabia

Talal Abdullah Alzahrani1, Abdullah Sitr Aljuaid1, Tariq Mesfer Alharthi1, Alwaleed Saeed Aljabir1, Khaled Abdullah Alqurashi1, Mohammad Eid Mahfouz1, Naif Alomairi1, Ibrahim Masoodi1*

Correspondence to: Ibrahim Masoodi

*College of Medicine, Taif University, Taif, Saudi Arabia.

Email: ibrahimmasoodi [at] yahoo.co.in

Full list of author information is available at the end of the article.

Received: 09 April 2019 | Accepted: 14 April 2019


ABSTRACT

Background:

Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine. The incidence of IBD has increased in several regions of the world including Saudi Arabia. The present study aimed to estimate the prevalence of various risk factors for IBD among medical students and interns in Saudi Arabia.


Methodology:

This cross-sectional study was carried out using a self-administered IBD questionnaire during the period from May 1, 2018 to July 1, 2018 across various regions of Saudi Arabia. The association of risk factors for IBD, including abdomen pain with altered bowel habits, stress, non-steroidal anti-inflammatory drugs (NSAIDs) intake, and family history were assessed among the study cohort. A total of 856 participants (medical students and interns) from different cities of Saudi Arabia took part in the study. Statistical Package for the Social Sciences program version 21.0 was used for statistical analysis. Comparisons of categorical variables between the subgroups (cross-tabulation) were done using Chi-square test. A p-value of less than 0.05 was considered as significant.


Results:

The statistical analysis revealed that the most significant risk factors for IBD development were stress (94.2%), a high-protein food intake (79.1%), foods high in sugar content (75.1%), spicy food (72.8%), and use of NSAIDs (42.2%). The female participants were found to have higher risk factors compared to male study subjects. The family history of IBD was found to be an independent risk factor for both the genders. Body mass index and high altitude showed no significant correlation (p = 0.402, 0.111, respectively).


Conclusion:

The present study findings highlight that use of NSAIDs, excessive intake of junk food, and avoidance of stress must be addressed to circumvent the increasing trend of IBD among the studied population.


Keywords:

IBD, risk factors, stress, NSAIDS.


Introduction

Inflammatory bowel disease (IBD) with its chronic remitting and relapsing course has multiple risk factors and may include an abnormal immunological response to the intestinal microflora in a genetically susceptible host [1,2]. The incidence of IBD is on rise for the past few decades, especially in newly industrialized countries in Asia, Africa, and South America [1]. Several studies conducted in Saudi Arabia in the past have revealed that the incidence of IBD has gradually increased over the past five decades [25]. IBD symptoms and its extra-intestinal manifestations have a significant negative impact on patients’ quality of life [68]. Hence, it becomes imperative to identify the risk factors and improve health education among the susceptible population. The data on 693 IBD patients over a period of 17 years from Saudi Arabia revealed that Crohn’s disease (CD) is more frequent than Ulcerative colitis (UC) (65.7% vs. 34.3%) among Saudi Arabian population [9,10]. The risk factors for IBD include male gender, smoking, history of appendectomy, various medications [contraceptive pills, non-steroidal anti-inflammatory drugs (NSAIDs), and antibiotics] dietary habits, stress, and family history of IBD [8,1116]. Stress levels among medical students and interns are also reported to be higher when compared with their age and gender-matched population [17]. There are multiple reasons for this association. First, the longer duration of the medical course and frequent exams during the tenure. The newly recruited doctors face clinically challenging cases compounding their existent stress regarding their career advancement. We believed these as an additional risk factor for IBD; hence, the medical students and interns were considered as the specific cohort for the current study.


Subjects and Methods

This cross-sectional study was carried out using a self-administered IBD questionnaire during the period from May 1, 2018 to July 1, 2018 across various regions of Saudi Arabia. The association of risk factors for IBD, including abdomen pain with altered bowel habits, stress, NSAIDs intake, and family history, were assessed among the study cohort. A total of 856 participants (medical students and interns) from different cities of Saudi Arabia took part in the study. Comparison of categorical variables between the subgroups (cross-tabulation) was done using Chi-square test. A p-value of less than 0.05 was considered as significant. The structured questionnaire was explained by data collectors and completed through interviews at medical colleges, primary health care centers, universities, and hostels. The responses were also collected through an online questionnaire shared via social media applications, such as WhatsApp and Telegram. Prior to data collection, all participants were informed about the nature of the study, assured of the confidentiality of the data obtained, and their participation was voluntary. Data collected included socio-demographic characteristics [age, sex, study year, family income, weight, height, and body mass index (BMI)], personal habits (smoking, alcohol use, dietary habits, and stress), use of medications (NSAID or antibiotics or use of oral contraceptives in females), past medical history of abdominal tuberculosis, diabetes, and family history of IBD. Weight and height measurements were inquired from the study participants to calculate their respective BMI. BMI was then used to classify the participants into four categories based on WHO guidelines, 1998 [18]: underweight (BMI < 18.5 kg/m²), normal weight (BMI = 18.5–24.9 kg/m²), over-weight (BMI = 25–29.9 kg/m²), and obese (BMI ≥ 30 kg/m²) participants. The collected data were entered using Microsoft Excel 2010 and analyzed using Statistical Package for the Social Sciences program version 21.0. Data were statistically described in terms of frequencies (number of cases) and valid percentages for categorical variables. Mean, standard deviations, minimum and maximum were used to describe the numerical variable. Comparison of categorical variables between the subgroups (cross-tabulation) was done using Chi-square test. A p value of less than 0.05 was considered as significant.


Results

Eight hundred fifty-six participants (medical students and interns) from different cities in Saudi Arabia participated in the study. Around half of the participants (46.5%) were from the western region, 20.0% were from the central region and 15.9% from the southern region. Among the total, 8.9% and 8.8% were from the eastern and northern regions respectively. Furthermore, out of 856 study participants, 46.3% were male and 7.6% were married. The mean age of study participants was 23.3 ± 1.5 (range 19–30 years). Less than one-quarter of the participants (22.9%) were fourth-year medical students, 22.1% were fifth-year students, 33.1% were sixth-year students, and 22.0% were interned, doctors. One-half of the participants were of normal weight (50.1%) followed by overweight (24.4%), obese participants (16.0%), and underweight (9.5%). The mean ± SD body weight was 68.4 ± 19.7 kg and the mean ± SD height was 165.3 ± 9.2 cm. Mean ± SD BMI was 24.8 ± 5.9 kg/m2 as shown in Figure 1.

The majority of participants (72.5%) were not living at high altitude and 27.5% were inhabitants of high altitude cities. Most of the participants (84.1%) denied smoking and 93.6% denied alcohol intake. On the other hand, the vast majority (94.2%) said that reported stress as one of the pre-clinical risk factors for IBD (Table 1). When dietary habits were considered, 72.8% of participants consumed spicy food, 85.5% consumed vegetables, 79.1% were taking diets rich in proteins, and 75.1% consumed a diet high in sugar content. Around 3.5% of participants had a history of appendectomy in the past and 12.1% reported having a family history of IB (Table 1). It was found that participants with a family history of IBD had a significantly higher prevalence of IBD (diagnosed cases of IBD based on colonoscopy & histology) compared to those without a family history (p = 0.042).

More than half of the participants (55.1%) reported abdominal pain with varying frequencies associated with changes in stool form and/or frequency. In addition, 40.2% reported to have experienced changes in appetite, 31.2% suffered from increased flatulence, and 7.4% had bloody stools (Figure 2).

The prevalence of abdominal pain associated with disturbed bowel habits among females was significantly higher than males (62.6% vs. 53.5%, p < 0.001). When medications were considered, less than half (42.2%) of the participants had used NSAIDs in the past 6–12 months, 15.2% had used antibiotics in the last 4 weeks and among females, only 2.9% used contraceptives. NSAIDS, antibiotics, and use of oral contraceptive pills (among females) showed significant association (p < 0.001, p = 0.011 and p = 0.002, respectively). The details are provided in Table 2.

Figure 1. BMI categories of participants (N = 856).

Table 1. Prevalence of pre-clinical risk factors for IBD among the medical students and interns (N = 856).

Preclinical risk factors of IBD Prevalence percent (CI)
BMI
Underweight 9.5% (7.5%: 11.4%)
Normal 50.1% (46.8%: 53.5%)
Obese 16.0% (13.5%: 18.5%)
Overweight 24.4% (21.5%: 27.3%)
Residence at high altitude 27.5% (24.5%: 30.4%)
Smoking tobacco products 15.9% (13.4%: 18.3%)
Alcohol intake 6.4% (4.8%: 8.1%)
Stress in life 94.2% (92.6%: 95.7%)
Spicy food intake 85.5% (83.2%: 87.9%)
Vegetables & fruit intake 79.1% (76.4%: 81.8%)
Protein rich diet 75.1% (72.2%: 78.0%)
High sugar diet 42.2% (38.9%: 45.5%)
Use of NSAIDs > 6–12 months 2.9% (1.8%: 4.1%)
Antibiotic use > 3–4 weeks 3.5% (2.3%: 4.7%)
Oral contraceptive intake 12.1% (10.0%: 14.3%)
Past history of appendectomy 50.1% (46.8%: 53.5%)
Family history of IBD 16.0% (13.5%: 18.5%)

Discussion

IBD has been observed to be increasing in the Saudi Arabian population due to unknown reasons. Although genetic factors are known to play a key role in the development of IBD, modification of established risk factors could go a long way in curbing the prevalence of this chronic disease having a huge impact on the patient and society. Retrospective data on IBD patients diagnosed and followed up in tertiary care centers across Saudi Arabia revealed that 48.7% of the patients were males, 11.1% had a positive family history of IBD, and 18.8% were current or former smokers [4,18,19]. Our study showed a significant relationship between IBD and family history of IBD which is in cognizance with the previously reported studies [1517]. The prevalence of abdominal pain associated with bowel disturbance was significantly higher among females [62.6% vs. 46.5% (p < 0.001)] reflecting a higher predisposition of IBD among them. These results are in agreement with the results of Betteridge et al. who demonstrated a higher prevalence of IBD (both UC and CD) among females [20]. While studying the relationship between dietary habits and IBD, Tragnone et al. showed that patients with CD and UC had a higher intake of sugar in their diet steeping their IBD relative risk (p < 0.001). The authors demonstrated significantly higher protein intake among UC but not among CD patients compared to controls. They also demonstrated that fiber consumption had no significant effect on the prevalence of CD or UC [21]. In this study, 79.1% of the participants were found to consume diets rich in protein and sugars as shown in Table 1. Our results reflect that there is a need to increase the dietary awareness among youth, especially regarding the consumption of junk food, to curb the ongoing surge of IBD. Several studies suggest that medications, such as NSAID’s, oral contraceptive pills, and antibiotics, increase the risk of IBD [811]. As shown in Table 2, a significant association was observed in this study as well. The family history of IBD (reported among 12.1% of the participants) significantly correlated to confirmed cases of IBD (based on colonoscopy and histology) in this study cohort (p = 0.042). Although obesity has been linked to inflammatory diseases, there exist few arguments regarding the relationship between obesity and the clinical outcome among IBD patients [22]. Results of a meta-analysis by Hu et al. revealed that the obesity can be associated with less severe symptoms and complications of IBD [23]. Our results showed that overweight and obese participants comprised less than half (40.4%) of the study cohort; however, no significant correlation was observed.

It is increasingly recognized that environmental factors play a crucial role in the development and prognosis of IBD. One important factor is living at a high altitude as hypoxia is thought to increase the risk of inflammation [24]. In our study, almost one-quarter of the participants (27.5%) were living at high altitudes but no significant association (p = 0.111) was observed. However, the study findings warrant further studies to confirm these results. The relationship between smoking and IBD is dichotomous as it is positively associated with CD but negatively with UC [2426]. While 84.1% of our study participants were non-smokers, there is a high prevalence of smoking in Saudi population and invariably 20%–50% begin smoking at the age of 15 years [27], emphasizing a greater anti-smoking drive in the region. There was a positive association of stress and IBD in this study as shown in Table 1. Brzozowski et al. demonstrated an increased bacterial translocation following changes in intestinal permeability due to stress. This phenomenon leads to a surge in microbial load and cytokines steep up in the colonic tissue leading to an obtunded immune response in response to stress and consequent negative impact on IBD [28]. The strength of the present study includes the relatively large sample size from wide geographical regions of Saudi Arabia. The limitations include the study was not population-based and the age range was limited (19–30 years) and the present study did not use multivariable analysis; hence, the authors could not control the effect of confounding variables in this study.

Figure 2. Reported bowel disturbances among study participants (N = 856).

Table 2. Prevalence of abdominal pain as a preclinical IBD risk factor (n = 856).

Abdominal pain with disturbed bowel habits Yes (%) No (%) p value*
Gender Male 46.5 53.5 <0.001
Female 62.6 37.4
Marital status Married 60.0 40.0 0.246
Unmarried 54.7 45.3
Region East region 51.3 48.7 0.199
Middle region 53.8 46.2
North region 54.7 45.3
South region 47.8 52.2
West region 59.0 41.0
BMI grade Underweight 55.6 44.4 0.402
Normal weight 54.5 45.5
Overweight 52.2 47.8
Obese 61.3 38.7
High altitude Yes 58.7 41.3 0.111
No 53.8 46.2
Smoking Yes 58.1 41.9 0.255
No 54.6 45.4
Drinking alcohol Yes 60.0 40.0 0.272
No 54.8 45.2
NSAIDs Yes 65.1 34.9 <0.001
No 47.9 52.1
Antibiotics Yes 64.6 35.4 0.011
No 53.4 46.6
Oral contraceptive pills Yes 84.0 16.0 0.002
No 54.3 45.7
The family history of IBD Yes 63.5 36.5 0.042
No 54.0 46.0

*Chi-square test was used to compare the prevalence of abdominal pain in the different subgroups.


Conclusion

The present study reports that more than half of the study participants experienced abdominal discomfort with varying frequencies and altered bowel habits which could be significant risk factors for IBD in a genetically susceptible population. Stress and family history of IBD were other significant risk factors assessed among the study cohort. On the other hand, high altitude and BMI did not show any significant correlation. The results of this study highlight the need for awareness regarding the preclinical risk factors for IBD so that a prompt evaluation could be initiated at an early stage.


List of Abbreviations

CD Crohns disease
IBD Inflammatory bowel disease
NSAID Nonsteroidal anti-inflammatory drugs
UC Ulcerative colitis

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

The study was approved by the Research Department at Taif University, Taif, Saudi Arabia. Approval number no 39-36-0051 dated 09-02-2018


Author details

Talal Abdullah Alzahrani1, Abdullah Sitr Aljuaid1, Tariq Mesfer Alharthi1, Alwaleed Saeed Aljabir1, Khaled Abdullah Alqurashi1, Mohammad Eid Mahfouz1, Naif Alomairi1, Ibrahim Masoodi1

  1. College of Medicine, Taif University, Taif, Saudi Arabia

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How to Cite this Article
Pubmed Style

Alzahrani TA, Aljuaid AS, Alharthi TM, Aljabir AS, Alqurashi KA, Mahfouz ME, Alomairi N, Masoodi I. A cross-sectional study on the risk factors for Inflammatory Bowel Disease among medical students and interns in Saudi Arabia.. IJMDC. 2019; 3(8): 710-715. doi:10.24911/IJMDC.51-1554227998


Web Style

Alzahrani TA, Aljuaid AS, Alharthi TM, Aljabir AS, Alqurashi KA, Mahfouz ME, Alomairi N, Masoodi I. A cross-sectional study on the risk factors for Inflammatory Bowel Disease among medical students and interns in Saudi Arabia.. http://www.ijmdc.com/?mno=41277 [Access: July 23, 2019]. doi:10.24911/IJMDC.51-1554227998


AMA (American Medical Association) Style

Alzahrani TA, Aljuaid AS, Alharthi TM, Aljabir AS, Alqurashi KA, Mahfouz ME, Alomairi N, Masoodi I. A cross-sectional study on the risk factors for Inflammatory Bowel Disease among medical students and interns in Saudi Arabia.. IJMDC. 2019; 3(8): 710-715. doi:10.24911/IJMDC.51-1554227998



Vancouver/ICMJE Style

Alzahrani TA, Aljuaid AS, Alharthi TM, Aljabir AS, Alqurashi KA, Mahfouz ME, Alomairi N, Masoodi I. A cross-sectional study on the risk factors for Inflammatory Bowel Disease among medical students and interns in Saudi Arabia.. IJMDC. (2019), [cited July 23, 2019]; 3(8): 710-715. doi:10.24911/IJMDC.51-1554227998



Harvard Style

Alzahrani, T. A., Aljuaid, . A. S., Alharthi, . T. M., Aljabir, . A. S., Alqurashi, . K. A., Mahfouz, . M. E., Alomairi, . N. & Masoodi, . I. (2019) A cross-sectional study on the risk factors for Inflammatory Bowel Disease among medical students and interns in Saudi Arabia.. IJMDC, 3 (8), 710-715. doi:10.24911/IJMDC.51-1554227998



Turabian Style

Alzahrani, Talal Abdullah, Abdullah Sitr Aljuaid, Tariq Mesfer Alharthi, Alwaleed Saeed Aljabir, Khaled Abdullah Alqurashi, Mohammad Eid Mahfouz, Naif Alomairi, and Ibrahim Masoodi. 2019. A cross-sectional study on the risk factors for Inflammatory Bowel Disease among medical students and interns in Saudi Arabia.. International Journal of Medicine in Developing Countries, 3 (8), 710-715. doi:10.24911/IJMDC.51-1554227998



Chicago Style

Alzahrani, Talal Abdullah, Abdullah Sitr Aljuaid, Tariq Mesfer Alharthi, Alwaleed Saeed Aljabir, Khaled Abdullah Alqurashi, Mohammad Eid Mahfouz, Naif Alomairi, and Ibrahim Masoodi. "A cross-sectional study on the risk factors for Inflammatory Bowel Disease among medical students and interns in Saudi Arabia.." International Journal of Medicine in Developing Countries 3 (2019), 710-715. doi:10.24911/IJMDC.51-1554227998



MLA (The Modern Language Association) Style

Alzahrani, Talal Abdullah, Abdullah Sitr Aljuaid, Tariq Mesfer Alharthi, Alwaleed Saeed Aljabir, Khaled Abdullah Alqurashi, Mohammad Eid Mahfouz, Naif Alomairi, and Ibrahim Masoodi. "A cross-sectional study on the risk factors for Inflammatory Bowel Disease among medical students and interns in Saudi Arabia.." International Journal of Medicine in Developing Countries 3.8 (2019), 710-715. Print. doi:10.24911/IJMDC.51-1554227998



APA (American Psychological Association) Style

Alzahrani, T. A., Aljuaid, . A. S., Alharthi, . T. M., Aljabir, . A. S., Alqurashi, . K. A., Mahfouz, . M. E., Alomairi, . N. & Masoodi, . I. (2019) A cross-sectional study on the risk factors for Inflammatory Bowel Disease among medical students and interns in Saudi Arabia.. International Journal of Medicine in Developing Countries, 3 (8), 710-715. doi:10.24911/IJMDC.51-1554227998