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Gastrointestinal Symptoms May Be Associated With Obesity

  • Authors: News Author: Jennifer Garcia
    CME Author: Penny Murata, MD
  • CME Released: 4/25/2012
  • Valid for credit through: 4/25/2013
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Target Audience and Goal Statement

This article is intended for primary care clinicians, gastroenterologists, endocrinologists, and other specialists who provide care to adults who are overweight or obese.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Report gastrointestinal tract symptoms that are associated with increasing body mass index or obesity.
  2. Report gastrointestinal tract symptoms that are not associated with increasing body mass index or obesity.


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  • Jennifer Garcia

    Jennifer Garcia is a freelance writer for Medscape.


    Disclosure: Jennifer Garcia has disclosed no relevant financial relationships.


  • Brande Nicole Martin, MA

    CME Clinical Editor, Medscape, LLC


    Disclosure: Brande Nicole Martin, MA, has disclosed no relevant financial relationships.

CME Author(s)

  • Penny Murata, MD

    Clinical Professor, Pediatrics, University of California, Irvine, California
    Pediatric Clerkship Director, University of California, Irvine, California


    Disclosure: Penny Murata, MD, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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Gastrointestinal Symptoms May Be Associated With Obesity

Authors: News Author: Jennifer Garcia CME Author: Penny Murata, MDFaculty and Disclosures

CME Released: 4/25/2012

Valid for credit through: 4/25/2013


Clinical Context

Obesity is a major public health problem that is associated with comorbidities, as reported by Brawer and colleagues in the September 2009 issue of Primary Care. Gastrointestinal (GI) tract symptoms are common in the general population, as noted by Eslick in the March 2010 issue of Gastroenterology Clinics of North America, but the association between GI symptoms and obesity is not clear.

This meta-analysis by Eslick evaluates which GI symptoms are or are not associated with increasing body mass index (BMI) or obesity in adults.

Study Synopsis and Perspective

A new meta-analysis of studies found a significant association between specific GI symptoms and increasing BMI and obesity, with upper abdominal pain almost 3 times more likely to occur among obese individuals. These findings were published in the May issue of Obesity Reviews.

The final analysis included information from 21 studies comprising data from 77,538 individuals and found significant associations between the following symptoms and increasing BMI:

  • Upper abdominal pain (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.23 - 5.72);
  • Gastroesophageal reflux (OR, 1.89; 95% CI, 1.70 - 2.09);
  • Diarrhea (OR, 1.45; 95% CI, 1.26 - 1.64);
  • Chest pain/heartburn (OR, 1.74; 95% CI, 1.49 - 2.04);
  • Vomiting (OR, 1.76; 95% CI, 1.28 - 2.41);
  • Retching (OR, 1.33; 95% CI, 1.01 - 1.74); and
  • Incomplete evacuation (OR, 1.32; 95% CI, 1.03 - 1.71).

The study author, Guy D. Eslick, PhD, from the Whiteley-Martin Research Centre, the University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia, found no significant association with lower abdominal pain, bloating, constipation/hard stools, fecal incontinence, nausea, and anal blockage.

Dr. Eslick examined the variation in GI symptoms due to such factors as patient age, study year, percentage of male participants, response rate, and sample size by using meta-regression analysis. "The only statistically significant results were for those patients with acid regurgitation and included age (P< 0.0001), year of publication (P = 0.04), percent male (<0.0001), response rate (<0.0001) and sample size (<0.0001)," writes Dr. Eslick. This symptom appeared to decrease with age, but the risk for acid regurgitation increased among more recent studies. The author notes that this may be related to the increasing incidence of obesity.

Using a prospectively developed protocol, Dr. Eslick searched the major electronic databases (PubMed, MEDLINE, EMBASE, and Current Contents [1950 to November 2011]) using the keywords GI, symptoms, obesity, and overweight. The studies evaluated in the analysis included only adults (men and women); had a cross-sectional, case-control, or cohort design; were population- or patient-based; included any GI symptoms or complex of symptoms; and were published in any language.

Studies in which patients were part of a weight loss program, those not providing data that could be recalculated into ORs and CIs, and those that did not meet the previously established inclusion criteria were excluded from the evaluation.

The risk as determined by OR or relative risk was used to compare the BMI groups for each study reviewed, and each BMI group was compared for each GI symptom.

Why Is Obesity Linked to GI Symptoms?

Dr. Eslick discussed possible explanations for some of the GI symptoms in this population. For example, upper abdominal pain in these patients may be related to postprandial stomach distention or delayed gastric emptying, and diarrhea may be related to increased food intake leading to increased osmotic loads and poor stool consistency. Patients with gastroesophageal reflux disease may also have confounding factors, such as hiatal hernia, and require further endoscopic evaluation.

A strength of the analysis, notes Dr. Eslick, is the large number of patients evaluated in these studies. This provided the statistical power necessary to detect differences among BMI groups. He also acknowledges study limitations, such as the heterogeneity among studies of gastroesophageal reflux disease and missing data on mean age and percentage of male participants from some studies.

Noting that further research in this area is still required, Dr. Eslick concluded, "The findings in this meta-analysis could have implications for clinical practice, especially in regard to future guideline development for the management and understanding of GI disorders among obese individuals."

Dr. Eslick is supported by the International Union Against Cancer and the American Cancer Society with an International Fellowship for Beginning Investigators. Dr. Eslick has disclosed no relevant financial relationships.

Obes Rev. 2012;13:469-479. Abstract

Study Highlights

  • The author identified 21 articles from a search of PubMed, MEDLINE, EMBASE, Current Contents (1950-November 2011), and the reference lists.
  • Study inclusion criteria were adult male or female participants; cross-sectional, case-control, or cohort design; population- or patient-based studies; any GI symptoms or symptom complexes; and English and non-English.
  • Study exclusion criteria were inability to recalculate data into ORs and 95% CIs, and a weight loss program being part of the study.
  • Data extracted included age, response rate, year of publication, country, study design, sample population, language, journal, sample size, number of cases, and GI symptoms.
  • Subgroup analysis variables were age, percent male, year of publication, response rate, and sample size.
  • All studies were published in English.
  • 77,538 individuals participated. 37% were men, the mean age was 39 years, and the average response rate was 68%.
  • Increasing BMI or obesity was associated with the following GI symptoms:
    • Upper abdominal pain, based on 4 studies (OR, 2.65)
    • Gastroesophageal reflux, based on 21 studies (OR, 1.89 for increasing BMI; OR, 4.60 for BMI > 35.0 kg/m2)
    • Diarrhea, based on 12 studies (OR, 1.45 for increased BMI; OR, 1.22 for overweight; OR, 1.70 for obese; OR, 2.80, for morbidly obese)
    • Chest pain or heartburn, based on 8 studies (OR, 1.74; OR, 1.54 for overweight; OR, 2.30 for obese)
    • Vomiting (OR, 1.76 for increasing BMI; OR, 1.24 for overweight; OR, 2.60 for obese; OR, 4.40 for morbidly obese)
    • Retching was based on 2 studies: one focused on overweight patients and the other on obese subjects (results were statistically significant only with BMI > 30.0 kg/m2)
    • Incomplete evacuation, based on 2 studies (OR, 1.32)
  • Increasing BMI or obesity was not associated with the following GI symptoms:
    • Overall abdominal pain, based on 16 studies (OR, 1.14)
    • Lower abdominal pain, based on 4 studies (OR, 0.99)
    • Bloating, based on 8 studies (OR, 1.21)
    • Constipation or hard stools, based on 10 studies (OR, 0.92)
    • Fecal incontinence, based on 2 studies (OR, 1.15)
    • Nausea, based on 6 studies (OR, 1.24)
    • Anal blockage, based on 2 studies (OR, 0.68)
  • Publication bias was noted.
  • Meta-regression analysis showed that heterogeneity for acid regurgitation was associated with age, year of publication, percent male, response rate, and sample size.
  • Study limitations included missing data on mean age and percent male, potential for publication bias, and heterogeneity.

Clinical Implications

  • GI symptoms that are associated with increasing BMI or obesity include upper abdominal pain, gastroesophageal reflux, diarrhea, chest pain or heartburn, vomiting, retching, and incomplete evacuation.
  • GI symptoms that are not associated with increasing BMI or obesity include overall abdominal pain, lower abdominal pain, bloating, constipation or hard stools, fecal incontinence, nausea, and anal blockage.

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