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ORIGINAL ARTICLE Table of Contents   
Year : 2006  |  Volume : 12  |  Issue : 3  |  Page : 123-129
The impact of functional dyspepsia on health-related quality of life in Saudi patients


1 Department of Psychiatry, King Faisal University, Al-Khobar, Saudi Arabia
2 Department of Medicine, King Faisal University, Al-Khobar, Saudi Arabia

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   Abstract 

Objective: The purpose of this study was to evaluate the impact of non-ulcer dyspepsia (NUD) on health-related quality of life (HRQOL), which was assessed using the Nepean Dyspepsia Index, the Short Form-12 quality of life (QOL) scale, the general health questionnaire (GHQ-30) and the self-reporting questionnaire (SRQ-20). Materials and Methods: Validated Arabic versions of the four scales were administered to 158 subjects (54 with NUD, 50 with gastroesophageal reflux disease [GERD] and 54 with no history of gastrointestinal [GI] disease), with a mean age of 46.6 years and SD 10.7. Results: Subjects with NUD showed the poorest scores in all indices of general QOL and HRQOL. The differences between the NUD patients and the health control in all HRQOL indices were statistically significant ( P < 0.05 to P < 0.001). Comparison between NUD and GERD patients showed significant differences only in the indices of psychological health related QOL ( P < 0.05) but not in the indices of other components of QOL, including physical health components. The study also showed that the women scored lower than men in HRQOL indices, particularly those of psychological and mental health components ( P < 0.05 to P < 0.001). Finally, it was found that severity of symptoms is associated with the degree of impairments in HRQOL - (r = 0.69) was significant at ( P < 0.001). Conclusion: Results of our study showed that HRQOL was significantly impaired in the NUD group. Psychological and mental health related quality of life was particularly impaired in this group compared to both normal patients and patients with similar GI disease. This magnitude of effects on HRQOL was also found to be associated with the severity of symptoms. The implications of these findings for the management of NUD are discussed.

Keywords: GERD, health-related quality of life, Nepean Dyspepsia Index, non-ulcer dyspepsia, psychological well-being

How to cite this article:
Wahass S, Khalil MS, Al Qurain AA, Yasawy MI. The impact of functional dyspepsia on health-related quality of life in Saudi patients. Saudi J Gastroenterol 2006;12:123-9

How to cite this URL:
Wahass S, Khalil MS, Al Qurain AA, Yasawy MI. The impact of functional dyspepsia on health-related quality of life in Saudi patients. Saudi J Gastroenterol [serial online] 2006 [cited 2019 May 21];12:123-9. Available from: http://www.saudijgastro.com/text.asp?2006/12/3/123/29752


Dyspepsia is one of the most frequently studied gastrointestinal diseases in the medical literature. Interest in this disease covers issues such as prevalence and treatment effectiveness and, recently, the impact of dyspepsia and other types of gastrointestinal reflux diseases on quality of life. Dyspepsia refers to pain or discomfort in the upper abdomen and can include ulcer and reflux disease. Functional dyspepsia (or non-ulcer dyspepsia - NUD) involves similar symptoms but without any organic causes.[1] It is defined as 'the presence of symptoms thought to originate in the gastroduodenal region in the absence of any organic, systemic or metabolic disease that is likely to explain the symptoms.'[2]

There are several reported estimates of the prevalence of NUD. In one review, the prevalence estimate was in the range of 20-25% in the general population in Scandinavian countries.[3] Other surveys in the UK and USA reported prevalence ranges anywhere from 25-40%.[3],[4],[5],[6],[7],[8] The majority of these studies suggest that the prevalence of NUD ranges between 12 and 15%, which represents more than 50% of all dyspepsia patients.[8] A hospital-based study with a limited number of patients reported that the prevalence of NUD in Saudi Arabia is 40%.[9]

Although NUD is not a life-threatening disease, many researchers emphasize its clinical and economic effects and its influence on the quality of life of the patients.[10],[11],[12],[13],[14],[15],[16] However, the impact of functional dyspepsia on quality of life has received little attention. Some studies have examined health-related quality of life (HRQOL) in this group and found that HRQOL is negatively affected and that this effect is associated with the intensity of symptoms as well.[11],[12],[13],[14],[15] Furthermore, the presence of symptoms of NUD has been associated with increased pain and anxiety level.[15],[17] In addition, several studies have also shown that HRQOL is impaired to a greater extent in patients with gastrointestinal conditions compared to healthy reference population[18],[19] and patients with other conditions such as arthritis, hypertension and myocardial infarction.[20]

HRQOL refers to the physical, psychological and social domains of health that influence quality of life and are highly individual concepts, influenced by a person's own experiences, beliefs, expectations and perceptions.[21] HRQOL is generally categorized as generic or disease specific. Generic instruments cover broader aspects of physical, psychological, social and spiritual functioning. They are applicable across various types of diseases and treatments. Disease-specific instruments, on the other hand, are used to assess specific diagnostic groups to measure the impact of disease and treatment on HRQOL.[22]

The most well known and frequently used generic HRQOL instruments are the medical outcomes study, 36-item short-form health survey (SF-36)[23],[24] and the psychological general well-being index.[25] The SF-36 includes new abbreviated versions such as the SF-12, which has been used in the present study. The SF-36 is widely used in gastroenterology and enables general comparisons between different patient groups.[26] There are also other instruments such as the general health questionnaire (GHQ-30)[27] and the self-reporting questionnaire (SRQ-20),[28] which were originally developed to assess general psychological well-being but have also been used as part of the assessment of QOL.[29] Examples of disease-specific instruments that are developed specifically for gastrointestinal diseases include: The quality of life in reflux and dyspepsia,[30] which was developed specifically for evaluation of dyspepsia and gastroesophageal reflux disease (GERD); and Nepean Dyspepsia Index (NDI),[31] which has been validated and used in the present study.

Almost all reviewed studies which examined HRQOL in dyspepsia were carried out in western societies. Studies investigating this issue in Arabic-speaking community were limited by lack of appropriate validated instruments in the Arabic language. Recently we have started a process of examining the linguistic and psychometric validity of the NDI, a newly developed disease-specific measure of quality of life of patients with dyspepsia. Preliminary results indicated that the linguistic and psychometric properties of the NDI are adequate for use in Saudi Arabia.[32]

Consequently, we carried out the present study with the objective of examining how NUD affects HRQOL as compared to other groups, using the NDI and other validated QOL instruments. We further aim to compare the HRQOL of NUD group with that of other groups, namely, GERD group and the healthy control group. Finally we have also examined the correlation of severity of symptoms with the degree of impairment in HRQOL.


   Materials and methods Top


This is a prospective study that was conducted in King Fahad University Hospital in accordance with the guidelines of the medical ethical committee of King Fiasal University and according to Helsinki declaration. The study comprised two subgroups of patients (54 with NUD, 50 with GERD). The diagnoses for all patients were established by two consultant gastroenterologists. This study was part of the validation research of the NDI in Saudi Arabia; we adopted exclusion criteria for the patient selection, similar to those adopted in the original studies.[33] Thus, patients with symptoms of gastrointestinal bleeding or abnormal physical or laboratory findings from prior outpatient visits were excluded. In addition, inability to understand or speak Arabic language, cognitive impairment affecting understanding of the questionnaire, previous gastric surgery, regular use of nonsteroidal anti-inflammatory drugs, history of malignancy or significant systemic disease were also used as exclusion criteria. The control group included 54 subjects with no history of GI disease. The mean age for all subjects in the three groups was 46.6 years and SD was 10.7, with age range of 18 to 60 years. Healthy subjects aged 18 and above were randomly selected from people who were accompanying patients in different outpatient clinics. Subjects who reported that they are currently under active medical treatment or care for gastrointestinal complaints or other medical illnesses were excluded.

The NDI, the SF-12, the SRQ-20 and the GHQ-30 were used in this study to assess HRQOL in NUD patients. The SF-12 is a generic measure of functional status and well-being, which is easy to use and found to fulfil stringent criteria for reliability and validity.[34] This is a shortened version of the SF-36 health survey questionnaire. The SF-12 includes 12 questions from SF-36, which reproduce its physical component summary (PCS) and mental component summary (MCS) scores.[34] Scoring of individual items is identical to the SF-36.[35] This scale has been translated into Arabic, and its initial validity and reliability were reported in a study of QOL with diabetes.[36] The GHQ-30 and the SRQ-20 were also used in this study as criteria measures of general psychological well-being as it related to quality of life. The two scales are among the most widely used scales of general mental health and psychopathology.[27] The GHQ is a self-reporting questionnaire designed to detect psychiatric morbidity in general practice and medical outpatient settings. The 30-item version was used in this study because its Arabic (translated) version has shown adequate clinical and psychometric validity.[27] The Arabic version of the SRQ-20 was also used.[27],[28] The standard scoring method for the GHQ-30 recommended by Goldberg was used in this study.[37] Bowling included the GHQ and the SRQ among the scales that are used to measure QOL.[29]

Finally, the NDI[31] represented the main tolls of disease-specific measure used in our study. The NDI was originally developed in Australia by Talley and his colleagues and has been translated and validated in several European communities, including Australian English, French, Dutch, Italian, German and American English.[31],[38]

The Arabic version of the NDI quality-of-life scale consists of the original questions, measuring health-related quality of life, and covers 17 key areas of life. The questionnaire examines the impact of illness on quality of life by referring to two dimensions of interferences. The first dimension reflects interference with a subject's ability to perform or engage in specific functions, and the second one reflects interference with their enjoyment of the same area of life. A 5-point Likert scale is adopted, ranging from 0 (not at all or not applicable), 1 (a little), 2 (moderately), 3 (quite a lot) to 4 (extremely).

The NDI was translated and validated in a group of healthy Saudi subjects and patients with NUD and GERD. The results supported the linguistic validity and psychometric reliability and validity of the scale.[31] Based on the results of factor analysis in the above mentioned study, the scale was subgrouped into four subscales, which included interferences with daily activities (12 items), knowledge / control (4 items), food / drink, (3 items) and tension / mood, (6 items). The NDI also includes a part that deals with the assessment of severity of dyspepsia symptoms. This part of the scale measures the frequency, severity and bothersomeness of 15 upper gastrointestinal symptoms The scoring system of this part applies a scale of 0 (not at all) to 4 (daily) for frequency, 0 (not at all) to 5 (very severe) for intensity and 0 (not at all) to 4 (extremely bothersome) for bothersomeness. Scores were added over for the three groups of symptoms.[31],[32]

Statistical analysis

The scoring for all scales used in this study followed the original scoring system as described in the accompanying manual of each scale. Comparison between groups was made using the Mann-Whitney or the Chi-square tests for the analysis of ordinal and nominal variables, as appropriate. Spearman rank correlation coefficient was used for the ordinal variables to examine the relationship between symptom severity and the degree of impairment in HRQOL. Statistical analyses were performed with SPSS 10.0 release.


   Results Top


All patients and healthy subjects were interviewed by trained psychologists and have completed all items of the NDI, the SF-12 questionnaire, the GHQ-30 and the SRQ-20. [Table - 1] shows the demographic characteristics of the three groups. Of the total number of subjects, 51.3% were aged below 39 years, compared to 48.7%; and 52.5% were male while 47.5% were female. Regarding marital status, 26.6% were single, 69.6% were married while only 3.8% of the subjects were divorced. Half of the subjects had an educational level of less than 9 years, and the other half were with more than 9 years of education. As regards occupational status, most of the subjects were housewives (40.5%), followed by governmental employees (38.5%), students, (11%) and unemployed (9.5%). However, no significant difference between the patients and the control groups was noted in any of the above-mentioned categories.

[Table - 2] shows the differences between study groups with respect to the main indices of QOL. All tests have shown statistically significant difference between the healthy subjects and NUD patients ( P < 0.01). The total score of the NDI has shown the largest differences between the two groups at ( P < 0.001). With respect to the differences between the GERD and NUD groups in relation to the total QOL scores, only the GHQ-30 and the SRQ-20, which are considered as general mental health as well as generic QOL measures, discriminated between the two groups - ( P < 0.026) and ( P < 0.05) respectively.

The other indices of the NDI, represented by its main component factors, also significantly differentiated between the control and NUD groups but not between the GERD and NUD groups [Table - 3]. The only exception to this is the tension and mood factor, which significantly differentiated between the two 'patient groups.' As shown in [Table - 3], the differences between the NUD and control were highly significant, ranging between ( P < 0.01) for the interferences and the knowledge and control factors; and ( P < 0.001) for the severity, 'eating and drinking' and 'tension and mood' factors.

[Table - 4] presents the comparison between the patients' and the control group's mean and standard deviation in relation to gender differences. For the patient groups, there was a significant difference between males and females in all the indices except for the 'eating and drinking' component of the NDI. This factor did not show in gender effects - neither in the comparisons between groups nor within each group separately. However, for the control group, there were no significant differences in any of the indices of QOL used in this study. In comparing between patients and control and within the patients groups, females always showed higher mean scores than males in the severity ( P < 0.001), the interference factor ( P < 0.000), the knowledge and control factor ( P < 0.005), the mood and tension factor ( P < 0.000) and the total score index of the NDI ( P < 0.000). These differences were also seen in the two indices of the SF-12, the PCS (P < 0.05) and the MCS ( P < 0.001) as shown in [Table - 4].


   Discussion Top


According to our knowledge, this is one of the first studies to examine HRQOL in patients with gastrointestinal disease in an Arabic community. The purpose of this paper was to compare the HRQOL of NUD patients with that of a group of GERD patients and a control group. Evidence for the negative impact of NUD on the general HRQOL has been reported, as well as main differences in some domains between the two 'patient groups.'

The data reported here showed that subjects with NUD experienced impairment in QOL when compared with those who were free from gastrointestinal symptoms. This was clearly shown in the significantly higher scores of the NUD patients in the global index of the NDI, which means poor HRQOL, as well as in the subdomain scores of the same scales. The largest differences between the control and the NUD groups were evident in the total score of NDI, the Severity index, the Interferences and Tension/Mood domains [Table - 2][Table - 3]. Likewise, the other scales of QOL used in this study showed similar results, reflecting a significantly impaired quality of life of the NUD groups as compared to healthy subjects. This finding is consistent with other studies, which have reported that NUD impairs quality of life.[11],[12]

The difference between GERD and NUD groups was not significant - neither in the total score of HRQOL of the NDI nor the generic indices of QOL of the SF-12. However, the mean scores in the NDI subscales and the SF-12 two indices showed that the NUD group is more affected than the GERD group.

The most interesting and significant difference between the GERD and the NUD groups, however, was evident in the indices which involved psychological components. [Table - 2] showed that NUD group had lower scores than the GERD group in the GHQ and the SRQ scales ( P < 0.05), as well as in the two subdomains of the NDI scale represented by the knowledge/control and tension/mood factors ( P < 0.05). These specific differences might be explained by the fact that much of the complaints of NUD are difficult to attribute to specific medical or organic causes. This may create a state of vagueness and a feeling of uncontrollability for the patients, which might consequently increase the level of stress and tax the coping resources of the patients.

The relationship between psychological and social aspects and functional GI disease, especially functional dyspepsia, is well documented.[11],[15],[17],[28],[39],[40] Patients with GERD and those with NUD may share many similar symptoms and both may have impaired HRQOL, but the problems with NUD patients may be further complicated by the presence of increased psychological distress and anxiety that may arise from the lack of knowledge and control over the symptoms. El-Serag and Talley noted similar results in their review of literature and drew the attention to the point that patients with functional dyspepsia may show more impaired HRQOL than the GERD patients.[8],[12] Similar findings were also indicated by Wiklund and his colleagues, who reported increased pain and anxiety levels in patients with negative endoscopy.[15]

Furthermore, our finding is consistent with previous research which investigated the role of several factors on the outcome of QOL measurements, namely, the gender and symptom-severity effects. Our study showed that symptom-severity score significantly correlated with the degree of impairment in QOL as measured by the NDI. The spearman correlation coefficient (r =0.69) was significant at ( P < 0.001). This association between the severity of symptoms and HRQOL indicates that as severity of symptoms increases, the quality of life worsens, and supports findings from previous studies.[26] Additionally, when the symptom severity score was transformed into categorical groups of mild, moderate and severe, Chi-square has shown significant differences between the three levels of severity in relation to degree of HRQOL impairments. These findings highlight the importance of considering the psychological factors and intervention in the assessment and management of NUD.

Finally, comparison between the scores of men and women revealed several differences in our study. Female subjects were found to have consistently poorer scores than male subjects in all quality-of-life measures used in this study. However, the gender-wise difference within the control group was not statistically significant, as shown in [Table - 4]. For the patient groups, all indices showed significant differences between men and women, supporting previous studies, which have also reported poorer quality of life in female as compared to male GI patients.[18],[41] In other studies, it has also been reported that females showed lower scores of well-being than males in normal population and in GERD populations.[30],[42] In all indices which reflect mental health or psychological well-being, women always showed poorer scores than men.. This could be attributed to the general findings in previous research that certain psychological problems, particularly anxiety and depression, are more common in women than in men.[43] Other explanation for women having significantly poorer psychological health related quality of life than men is attributed to the greater ease at which women might express their feelings; as well as to other economic and social factors, such as the number of employed women compared with that of employed men.[42] The latter explanation suits more to the finding of our study as the vast majority of female subjects in this study was represented by housewives.


   Conclusion Top


The present study confirmed findings previously observed in similar studies, that is, a significant impairment of HRQOL of patients with upper GI symptoms, particularly patients with NUD. The ability of the NDI to discriminate between patients with different frequencies of severity and the relationship of this severity to the degree of HRQOL impairment was also demonstrated. This study also showed that NUD patients may show much impaired quality of life as compared to GERD patients, particularly in relation to complaints about mental and psychological well-being; therefore, psychological well-being should be given special attention when examining HRQOL among NUD patients.


   Acknowledgment Top


We are very grateful to the participating patients and co-patients, who took the time to complete the questionnaires; and to Mr. Khalid Al-Mutiary, the psychologist who actively participated in the administration of the questionnaire.

 
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Correspondence Address:
Mohamed S Khalil
Department of Psychiatry, King Faisal University, P.O. Box 40173, Al-Khobar 31952
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.29752

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    Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4]

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