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_______________________________________________________________
_______________________________________________________________Report Information from ProQuest30 October 2011 20:01
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Document 1 of 1Functional Gastrointestinal Disorders Among People With SleepDisturbances: A Population-Based StudySanthi Swaroop Vege; Locke, G Richard, III; Weaver, Amy L; Farmer, Sara A; et al. Mayo ClinicProceedings79.12 (Dec 2004): 1501-6.
_______________________________________________________________AbstractTo determine whether unexplained gastrointestinal (GI) symptoms are more common in people with
self-reported sleep disturbance.
From November 1988 to June 1994, valid self-report questionnaires were mailed to age- and sex-
stratified random samples of Olmsted County, Minnesota, residents aged 20 to 95 years.
Of 2269 study participants (74% response rate), 52% were women (mean age, 45.0 years). The
overall age- and sex-adjusted prevalence of sleep disturbance per 100 population was 13.5% (95%
confidence interval [CI], 11.7%-15.3%). Among study participants with sleep disturbance, the
prevalence of irritable bowel syndrome (IBS) was 33.3% (95% CI, 26.0%-40.5%) and the prevalence
of frequent dyspepsia (FD) was 21.3% (95% CI, 14.4%-28.2%). After adjusting for age, sex, and
somatization score, IBS was significantly more common in those with sleep disturbance (odds ratio,
1.6; 95% CI, 1.1-2.2), but the univariate association with FD was no longer statistically significant
(odds ratio, 1.3; 95% CI, 0.9-1.9).
Both IBS and FD are prevalent in those with self-reported sleep disturbance. Sleep disturbance was
independently associated with IBS but not FD in the general population.
_______________________________________________________________Full TextHeadnote
OBJECTIVE: To determine whether unexplained gastrointestinal (GI) symptoms are more
common in people with self-reported sleep disturbance.
PARTICIPANTS AND METHODS: From November 1988 to June 1994, valid self-report
questionnaires were mailed to age- and sexstratified random samples of Olmsted County,
Minnesota, residents aged 20 to 95 years.
RESULTS: Of 2269 study participants (74% response rate), 52% were women (mean age,
45.0 years). The overall age- and sexadjusted prevalence of sleep disturbance per 100
population was 13.5% (95% confidence interval [Cl], 11.7%-15.3%). Among study
participants with sleep disturbance, the prevalence of irritable bowel syndrome (IBS) was
33.3% (95% Cl, 26.0%-40.5%) and the prevalence of frequent dyspepsia (FD) was 21.3%
(95% Cl, 14.4%28.2%). After adjusting for age, sex, and somatization score, IBS was
significantly more common in those with sleep disturbance (odds ratio, 1.6; 95% Cl, 1.1-2.2),but the univariate association with FD was no longer statistically significant (odds ratio, 1.3;
95% Cl, 0.9-1.9).
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CONCLUSIONS: Both IBS and FD are prevalent in those with selfreported sleep
disturbance. Sleep disturbance was independently associated with IBS but not FD in the
general population.
Mayo Clin Proc. 2004;79(12):1501-1506
BDQ = Bowel Disease Questionnaire; Cl = confidence Interval; EBSQ = Elderly Bowel
Syndrome Questionnaire; FD = frequent dyspepsia; GERD = gastroesophageal reflux
disease; GI = gastrointestinal; IBS = irritable bowel syndrome; OR = odds ratio
Sleep disturbance is a common symptom in the general population, with an estimated 50%
or more of American adults experiencing 1 or more symptoms that indicate insomnia at least
a few nights per week.1 Insomnia, in turn, causes significant morbidity, as evidenced by the
increased need for general medical and mental health treatment for emotional problems.2
Functional gastrointestinal (GI) disorders, including irritable bowel syndrome (IBS), frequent
dyspepsia (FD), and others, are also extremely prevalent in the general population and
cause significant morbidity and substantial consumption of health care resources.3Interestingly, an association between sleep disturbances and functional GI disorders has
been reported by several investigators .4~7 Most of these studies have focused on the
prevalence of sleep disturbance among patients with a functional GI disorder. Indeed, some
reported an association with only IBS56 and others with only FD.4 Conceivably, abdominal
pain could be an etiology of sleep disturbance if it causes patients difficulty going to sleep or
awakens them from sleep. Conversely, a specific sleep disturbance might lead to a functional
GI disturbance. Increased arousal during sleep may play an etiologic role in the chronic
distress and altered viscerosomatic sensitivity of patients who experience functional GIcomplaints.4 Changed sleep patterns have also been associated with altered nocturnal
duodenal motor activity, which, in turn, has been associated with FD.7 Thus, an association
between sleep disturbance and functional GI symptoms is well recognized, but it is unclear
which is the primary process. Moreover, it is possible that both sleep disturbances and
functional GI disturbances may be the result of some other underlying problem, such as
depression, anxiety, or other psychological conditions. Notably, these studies were all clinic
based and evaluated sleep patterns of patients selected according to bowel symptoms; none
of these studies were population based or assessed the prevalence of functional GI
complaints among people with sleep disturbances. To explore this issue further, we sought to
determine whether functional GI disorders are more common among people with self-
reported sleep disturbance.
PARTICIPANTS AND METHODS
The study participants resided in Olmsted County, Minnesota. More than 95% of county
residents receive their medical care from 1 of the 2 group practices in the community (Mayo
Medical Center and Olmsted Medical Center), and 96% of the population will have a medical
encounter with 1 of the 2 in a 3-year period. Because the inpatient and outpatient records of
almost all medical care providers in the county are indexed regularly, this unique medical
records linkage system (the Rochester Epidemiology Project) provides an enumeration of the
county population from which random samples can be drawn.8
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As part of previous investigations,9-14 age- and sexstratified random samples of Olmsted
County residents, 20 to 95 years of age, were mailed valid self-report questionnaires from
November 1988 to June 1994. The Bowel Disease Questionnaire (BDQ) was mailed to
residents 20 to 64 years of age, and the Elderly Bowel Syndrome Questionnaire (EBSQ) was
mailed to residents 65 to 95 years of age. Both questionnaires have been shown to be
understandable, easily completed, and adequately valid.11,12 The BDQ consists of 46 GI
symptom items, whereas the EBSQ has 33 symptom items; 26 of these items are identical
on both questionnaires, and these were considered in the analysis. The BDQ also included
the Somatic Symptom Checklist. This checklist consists of 12 non-GI and 5 GI symptoms or
illnesses, and respondents are instructed to indicate how often each symptom occurred (on a
scale of 0, indicating not a problem, to 4, indicating occurs daily) and how bothersome each
was (on a scale of O, not a problem, to 4, extremely bothersome when occurs) during the
past year, using separate 5-point scales.
DEFINITIONSThe following definitions were applied to the questionnaire to identify each of the entities. For
sleep disturbance, respondents were asked to indicate how often and how bothersome their
"insomnia (difficulty sleeping)" was in the past year. Insomnia at least once a week and at
least moderately bothersome in the previous year was defined as sleep disturbance.
Frequent heartburn was defined as a burning behind the breast bone in the chest at least
once a week or more in the previous year. Ache or pain in the upper abdomen that occurred
more than 6 times in the previous year without frequent heartburn was labeled FD. Defined in
accordance with modified Rome criteria,15 IBS was an ache or pain that occurred more than6 times per year that was either often made better by having a bowel movement or often
associated with more frequent or looser bowel movements when the pain began. In addition,
2 or more of the following symptoms were often present: fewer than 3 bowel movements per
week or more than 3 bowel movements per day; loose, watery stools or hard stools; straining
to have bowel movements; feelings of incomplete rectal evacuation; urgency; mucus; or
bloating with distention. Diarrhea-predominant IBS included the IBS criteria and 1 or more of
the following: more than 3 stools per day; loose, watery stools; urgency; and none of the
following: fewer than 3 stools per week; hard, lumpy stools; or straining (Rome II).15
Constipation-predominant IBS included the IBS criteria and 1 or more of the following: fewer
than 3 stools per week; hard, lumpy stools; straining; and none of the following: more than 3
stools per day; loose, watery stools; or urgency (Rome II).15 The somatization score was
derived from responses to the Somatic Symptom Checklist. Each respondent rated 11
different non-GI symptoms or illnesses (excluding insomnia): headache, backaches, asthma,
high blood pressure, fatigue, depression, general stiffness, heart palpitation, eye pain with
reading, dizziness, and weakness. The sum of the mean score for "how often" and the mean
score for "how bothersome" was calculated.
STATISTICAL ANALYSES
The overall age ^ and sex-adjusted prevalence (per 100 population) of sleep disturbance,
IBS, FD, and frequent heartburn among study participants with and without sleep
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disturbance, respectively, was obtained by direct adjustment of the age- and sex-specific
rates to the 2000 population structure of US whites 20 to 95 years of age. Ninetyfive percent
confidence intervals (CIs) for these rates were calculated based on the binomial distribution.
The association between each condition and sleep disturbance was evaluated by fitting
logistic regression models. The binary end point was the presence vs absence of each
condition, and the presence vs absence of sleep disturbance was included as an
independent variable in each model. Odds ratios (ORs) were calculated based on the
estimated regression coefficients from the logistic regression models. The association of
each condition with sleep disturbance was evaluated after adjusting for age and sex, as well
as potential confounders such as a somatization score and night pain (abdominal pain often
waking the person from sleep). All P values were 2-sided, and P
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have a sleep disturbance. The overall age- and sex-adjusted prevalence, per 100 population,
of sleep disturbance was 13.5 (Table 2).
Compared with the remaining 1953 participants, the 316 participants with sleep disturbance
were older (mean SD age, 47.014.1 years vs 44.713.8 years; P=.004), more likely to be
women (63% vs 50%, P
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DISCUSSION
We report the first population-based study, to our knowledge, that assesses the association
between sleep disturbance and IBS, FD, and frequent heartburn, all of which are common
conditions. Although different definitions have been used, insomnia is a common problem
based on national data. The National Sleep Foundation has defined insomnia as any of the
following: difficulty falling asleep, waking a lot during the night, waking too early with inability
to get back to sleep, or waking up feeling unrefreshed.1 The 2003 Sleep in America poll
included 1506 adults aged 55 to 84 years from various parts of the United States; the
prevalence of insomnia was 48% using this broad definition. The overall age- and sex-
adjusted prevalence of selfreported sleep disturbance, defined as moderately bothersome
insomnia at least once a week, was approximately 14% in the present study. A similar
definition was used by Jarrett et al5 in their study that evaluated the influence of sleep
disturbance on symptoms in women diagnosed as having IBS. We found an association of
sleep disturbance with IBS, FD, and frequent heartburn, respectively, independent of age
and sex. The associations with IBS and frequent heartburn, but not FD, were also
independent of the somatization score.
Prospective studies that evaluated the same associations have used sleep diaries or specific
questionnaires that measure sleep.4-7 These studies were undertaken in clinic patients
diagnosed as having 1 or more functional GI disorders, and they all focused on theprevalence of sleep disturbance among the patients rather than on the prevalence of
functional GI disorders among those with sleep impairment.4-7 Clinic patients may be a self-
selected population by virtue of seeking medical care.3 Hence, the association between
sleep disturbance and functional GI disorders in the general population may be more
important if one is trying to assess cause-and-effect relationships of one with the other.
Some of the earlier studies reported on the association of sleep disturbance with IBS,56
whereas others found a relationship with FD.4 The patients with IBS who had concurrent
dyspeptic symptoms had increased sleep dysfunction and daytime and nighttime GI
symptoms in one study.17 Reports of poor sleep in women with IBS have not been confirmed
by objective testing with polysomnography in some studies.17,18 In contrast, enhancement
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of rapid eye movement sleep was reported in patients with IBS, suggesting an intrinsic
alteration in autonomie and central nervous system functioning in this syndrome.19 Orr et
al20,21 reported abnormal autonomie activity in patients with IBS during rapid eye movement
sleep and suggested subsequently that this may be a useful biological marker to identify IBS
subgroups. Rotem et al22 observed that patients with IBS had more impaired sleep quality,
including a higher sleep fragmentation index, compared with historical controls, which was
not explained by anxiety or depression. Others have observed that patients with IBS who had
sleep dysfunction had slightly higher scores for affective symptoms than those without sleep
dysfunction.4 We could not assess whether any association observed between IBS and
sleep disturbances was explained by comorbid conditions, such as fibromyalgia or chronic
fatigue syndrome.23,24 It is also conceivable that central neurochemical changes could
underlie both sleep disturbances and functional GI complaints.4
When our subgroups with IBS were analyzed, diarrhea-predominant IBS but not constipation-
predominant IBS was associated with sleep disturbance in univariate analyses, but only atrend was seen after adjusting for somatization. Defining IBS subgroups, however, remains
controversial, and well-accepted criteria are lacking.15,25 We used the Rome guidelines, but
a number of IBS patients did not fit into either group, and these guidelines were not
considered sufficiently robust to be made formal criteria.15 Somatization appears to explain,
at least in part, the association of sleep disturbance in the diarrhea-predominant IBS
subgroup, but a type II error cannot be ruled out.
We excluded troublesome heartburn that occurred at least once a week from the definition of
FD because these patients are likely to have gastroesophageal reflux disease (GERD).26 Inour univariate analyses, IBS, FD, and frequent heartburn were all more common in
participants with sleep disturbance, although only IBS and frequent heartburn were
significantly more common after adjusting for age, sex, and somatization score. Whether
previous reports of an association of sleep disturbance with FD4 may have been confounded
by the inclusion of endoscopy-negative GERD is uncertain.
Why somatization specifically explained the association of sleep disturbance with FD but not
with IBS is unclear. Both are characterized by abdominal pain, which can awaken patients
from sleep. Talley et al,11 for example, noted that 76% of the patients with FD experienced
abdominal pain that awoke them from sleep compared with 4% of controls and 44% of
patients with organic GI disease. However, controlling for night abdominal pain did not
influence our results.
Psychological factors could play a role in both sleep disturbance and functional GI disease.
We controlled for somatic complaints by including a somatization score derived from non-GI
symptoms and illnesses, including selfreported depression. However, we did not measure
other personality factors or psychiatric diseases that may account for the association with
IBS.15 An outpatient study that investigated sleep disturbances in women with IBS controlled
for psychological factors by adjusting for psychological distress using the Symptoms
Checklist-90 and found no confounding effect.5
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Our study has several strengths. The BDQ has been developed and validated extensively in
the community with regard to the diagnosis of IBS, FD, and GERD.9-14 We used completed
questionnaires from 2269 study participants obtained from mailings with a response rate of
more than 70%. Similar definitions for FD and IBS have been applied in previous population-
based studies from Olmsted County.9-13 Our study also has corresponding limitations. The
data on sleep are limited because we had to depend on the existing questionnaire and used
self-report items. We could not exclude restless legs syndrome, which may be relevant in
elderly patients.1 Specific questionnaires and prospective sleep diaries would likely give
more detailed information. The diagnosis of IBS, FD, and frequent heartburn from the
questionnaires, although well validated in the past, may not be completely equivalent to clinic
diagnoses, in which organic diseases would be ruled out more definitively by testing.
CONCLUSIONS
Findings from this population-based study show that sleep disturbance, FD, IBS, and
frequent heartburn are all common and that sleep disturbance is associated with IBS andfrequent heartburn but not FD in the general population, adjusting for somatic distress.
Further work to understand the interactions between somatization and psychological distress
with sleep disturbances and functional GI disturbances is warranted.
References
REFERENCES
1. National Sleep Foundation. 2003 Sleep in America Poll. Washington, DC: National Sleep
Foundation; 2003:11. Available at: www.sleepfoundation .org/2003poll.cfm. Accessibility
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6. Goldsmith G, Levin JS. Effect of sleep quality on symptoms of irritable bowel syndrome.
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9. Talley NJ, Zinsmeister AR, Melton LJ III. Irritable bowel syndrome in a community:
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10. Talley NJ, Zinsmeister AR, Van Dyke C, Melton LJ III. Epidemiology of colonie symptoms
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AuthorAffiliation
SANTHI SWAROOP VEGE, MD; G. RICHARD LOCKE III, MD; AMY L. WEAVER, MS;
SARA A. FARMER, BA; L. JOSEPH MELTON III, MD; AND NICHOLAS J. TALLEY, MD,
PnD
AuthorAffiliation
From the Division of General Internal Medicine (V.S.S.), Division of Gastroenterologyand
Hepatology and Internal Medicine (G.R.L., N.J.T.), Clinical Enteric Neuroscience
Translational and Epidemiological Research (G.R.L., N.J.T.), and Department of Health
Sciences Research (A.L.W., S.A.F., L.J.M.), Mayo Clinic College of Medicine, Rochester,
Minn.
Address reprint requests and correspondence to Santhi Swaroop Vege, MD, Division of
General Internal Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN
55905.
2004 Mayo Foundation for Medical Education and Research
_______________________________________________________________Indexing details)MeSH Adult, Age Distribution, Aged, Aged, 80&over, Analysis of
Variance, Comorbidity, Confidence Intervals, Dyspepsia --
diagnosis,Dyspepsia -- epidemiology, Female, Humans, Irritable
Bowel Syndrome --
diagnosis, Irritable Bowel Syndrome -- epidemiology, Male, MiddleAged,Minnesota -- epidemiology, Odds Ratio, Population
Surveillance, Prevalence,
Questionnaires, Severity of Illness Index, Sex
Distribution,Gastrointestinal Diseases -- diagnosis (major),
Gastrointestinal Diseases
-- epidemiology (major), Sleep Disorders -- diagnosis (major),
SleepDisorders -- epidemiology (major)
Title Functional Gastrointestinal Disorders Among People With Sleep
Disturbances: A Population-Based Study
Authors Locke, G Richard, III; Weaver, Amy L; Farmer, Sara A
Publication title Mayo Clinic Proceedings
Volume 79
Issue 12
Pages 1501-6
Number of pages 6
Publication year 2004
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Publication Date Dec 2004
Year 2004
Section ORIGINAL ARTICLE
Publisher Mayo Foundation for Medical Education and Research
Place of Publication Rochester
Country of publication United States
Journal Subjects Medical Sciences
ISSN 00256196
CODEN MACPAJ
Source type Scholarly Journals
Language of Publication English
Document type PERIODICAL
Accession number 15595333
ProQuest Document ID 216864972
Document URL http://search.proquest.com/docview/216864972?accountid=50268
Copyright Copyright Mayo Foundation for Medical Education and Research Dec 2004
Last updated 2011-05-03
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