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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

verified October 21, 2004.2. Weissman MM, Greenwald S, Nino-Murcia G, Dement WC. The morbidity of insomnia

uncomplicated by psychiatric disorders. Gen Hosp Psychiatry. 1997; 19:245-250.

3. Locke GR III. The epidemiology of functional gastrointestinal disorders in North America.

Gastroenterol Clin North Am. 1996;25:1-19.

4. Pass R, Fullerton S, Tung S, Mayer EA. Sleep disturbances in clinic patients with

functional bowel disorders. Am J Gastroenterol. 2000;95:1195-1200.

5. Jarrett M, Heitkemper M, Cain KC, Burr RL, Hertig V. Sleep disturbance influences

gastrointestinal symptoms in women with irritable bowel syndrome. Dig Dis Sci. 2000;45:952-

959.

6. Goldsmith G, Levin JS. Effect of sleep quality on symptoms of irritable bowel syndrome.

Dig Dis Sci. 1993;38:1809-1814.

7. David D, Mertz H, Fefer L, et al. Sleep and duodenal motor activity in patients with severe

non-ulcer dyspepsia. Gut. 1994;35:916-925.

8. Melton LJ III. History of the Rochester Epidemiology Project. Mayo Clin Proc.

1996;71:266-274.

9. Talley NJ, Zinsmeister AR, Melton LJ III. Irritable bowel syndrome in a community:

symptom subgroups, risk factors, and health care utilization. Am J Epidemiol. 1995;142:76-

83.


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10. Talley NJ, Zinsmeister AR, Van Dyke C, Melton LJ III. Epidemiology of colonie symptoms

and the irritable bowel syndrome [published correction appears in Gastroenterology.

1992;102:746]. Gastroenterology. 1991;101: 927-934.

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to identify bowel disease. Ann Intern Med. 1989; 111: 671-674.

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13. Talley NJ, Zinsmcister AR, Schleck CD, Melton LJ III. Dyspepsia and dyspepsia

subgroups: a population-based study. Gastroenterology. 1992; 102(4, pt 1): 1259-1268.

14. Talley NJ, O'Keefe EA, Zinsmeister AR, Melton LJ III. Prevalence of gastrointestinal

symptoms in the elderly; a population-based study. Gastroenterology. 1992;102:895-901.

15. Drossman DA, Corazziari E, Talley NJ, Thompson WG, Whitehead WE, eds. Rome II:

The Functional Gastrointestinal Disorders: Diagnosis, Pathophysiology, and Treatment: A

Multinational Consensus. 2nd ed. McLean, Va: Degnon Associates; 2000.16. Melton LJ III. The threat to medical-records research. N Engl J Med. 1997;337:1466-

1470.

17. Eisenbruch S, Thompson JJ, Harnish MJ, Exton MS, Orr WC. Behavioral and

physiological sleep characteristics in women with irritable bowel syndrome. Am J

Gastroenterol. 2002;97:2306-2314.

18. Eisenbruch S, Harnish MJ, Orr WC. Subjective and objective sleep quality in irritable

bowel syndrome. Am J Gastroenterol. 1999;94:2447-2452.

19. Orr WC, Crowell MD, Lin B, Harnish MJ, Chen JD. Sleep and gastric function in irritablebowel syndrome: derailing the brain-gut axis. Gut. 1997; 41:390-393.

20. Thompson JJ, Eisenbruch S, Harnish MJ, Orr WC. Autonomie functioning during REM

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21. Orr WC, Eisenbruch S, Harnish MJ. Autonomie regulation of cardiac function during

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23. Chang L, Berman S, Mayer EA, et al. Brain responses to visceral and somatic stimuli in

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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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-ProQuest Medical Library

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