An Epidemiologic Study of Irritable Bowel Syndrome in Adolescents and Children in China: A School-Based Study
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An Epidemiologic Study of Irritable Bowel Syndrome in Adolescents and
Children in China: A School-Based Study
Liu Dong, MD*; Li Dingguo, MD‡; Xu Xiaoxing, MD§; and Lu Hanming, MD‡
ABSTRACT. Objectives. To explore the prevalence of more attention. In Western countries, the prevalence
irritable bowel syndrome (IBS) and its distribution char- of IBS (Rome criteria) in adults was 8% to 23%;
acteristics of adolescents and children in China and its among them, 10% to 15% in European and North
contributing factors. American countries and 11% to 17% in Oceania. In
Methods. This study was a stratified, randomized Africa, the rate was ⬃10%. In Asia, it was ⬃5%.1–3 In
study by clustering samples, which involved 5403 stu-
dents whose age range was 6 to 18 years from 9 schools,
view of the common understanding about adult IBS,
and was conducted in Heilongjiang Province and Shang- some scholars in Western countries had undertaken
hai. All students studied were requested to fill in a ques- many epidemiologic studies including the preva-
tionnaire. IBS was diagnosed according to Rome II crite- lence of IBS and its risk factors in adolescents, sug-
ria. gesting that IBS in a community-based adolescent
Results. The prevalence of IBS according to Rome II population was also common. An epidemiologic
criteria in adolescents and children in China was 13.25%. study in Italy indicated that the prevalence of IBS in
The ratio of boys to girls was 1:1.8. There was a higher children aged birth to 12 years is 13.9%.4 In the
prevalence (14.02%) of IBS in Heilongjiang province than United states, Walker et al5 tested the hypothesis that
that (11.72%) in Shanghai. The prevalence in children 12 most children with recurrent abdominal pain could
years and younger was not statistically significantly
higher than that of adolescents 13 years and older (11.86%
be classified into 1 or more of the symptom subtypes
and 11.44%, respectively). The prevalence of IBS in mi- defined by the Pediatric Rome Criteria; moreover,
nority students (21.15%) was not statistically signifi- 44.9% of children with recurrent abdominal pain
cantly higher than that in Han race students (16.08%). were consistent with the Pediatric Rome Criteria for
Our study indicated that psychological factors, food IBS. In Moscow, a study by Reshetnikov in students
habit, bad exterior environment, personal habits, and who were 14 to 17 years of age indicated that the
family conditions might be important contributing fac- prevalence of IBS was 14% to 24%; among them, 21%
tors, and exposure to coldness (odds ratio: 2.83) is most had to see doctors in different hospitals. Conse-
prominent. quently, the medical costs were so high that many
Conclusion. IBS was a common disorder in adoles- families could not afford it.6 However, the informa-
cents and children in China. The prevalence of IBS in
adolescents and children was different in different geo-
tion on the prevalence of IBS about adolescents and
graphic areas. Our study indicated that IBS in adoles- children in the Asian population is relatively scanty.
cents and children might have possible relations with A present study in Malaysia indicated that the symp-
psychological factors, food habit, bad exterior environ- toms that are supportive of diagnosis of IBS were
ment, and family condition. Pediatrics 2005;116:e393–e396. common among young Malaysians, with a preva-
URL: www.pediatrics.org/cgi/doi/10.1542/peds.2004-2764; lence of 15.8%.7 Previous data focusing on an epide-
adolescents and children, irritable bowel syndrome, epidemi- miologic study of IBS in adolescents and children in
ology. China were not available. Our study was undertaken
to determine the prevalence of IBS and its distribu-
ABBREVIATIONS. IBS, irritable bowel syndrome; OR, odds ratio. tion characteristics and contributing factors in ado-
lescents and children in China.
I
rritable bowel syndrome (IBS) is a common METHODS
chronic functional gastrointestinal disorder. In
the world, the epidemiologic studies indicate that Students
IBS in adults is a common disorder that deserved This study was a stratified, randomized study by clustering
samples. We estimated by calculating sample formula that this
study required 2800 students according to data of preliminary
investigation in Shanghai. The provided prevalence of IBS was
From the *Department of Gastroenterology, Putuo Hospital Affiliated to 12.5% with a permissible error of 5%, but we attempted to increase
Shanghai University of Traditional Chinese Medicine, and ‡Department of clustering samples to a total of 4200 students to lessen test error;
Gastroenterology and §Epidemiological Center, Xinhua Hospital Affiliated finally, we recruited 5403 students to make the result more con-
to Shanghai Second Medical University, Shanghai, China. vincible. A total of 5403 students were from a town of Hei-
Accepted for publication Mar 31, 2005. longjiang province and a section of Shanghai. Heilongjiang prov-
doi:10.1542/peds.2004-2764 ince is in the northeast of China, and Shanghai in southeast of
No conflict of interest declared. China. Shanghai is a modern metropolis, and Heilongjiang prov-
Reprint requests to (L.D.) Zhongshan Nan Er RD, 1057 Lane, No. 1, RM1503 ince is more rural than Shanghai; the climate in Heilongjiang
Shanghai, China. E-mail: liudong7050@sina.com province is continental, and Shanghai is oceanic. In the addition,
PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Acad- the 2 geographic areas are different in food habits and cultural
emy of Pediatrics. background. The more of the school population in Shanghai can
www.pediatrics.org/cgi/doi/10.1542/peds.2004-2764 PEDIATRICS Vol. 116 No. 3 September 2005
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e393go to college than that in Heilongjiang. According to the above, we
chose to study the 2 areas. The sample size of each investigated
area was in proportion to the population of that area. First, a town
in Heilongjiang province and a section in Shanghai were chosen as
primary sampling units, and, second, 9 schools were selected by
drawing lots in the town and the section.
Questionnaire
In these schools, all of the students were required to fill in the
questionnaire that was designed by us in terms of the official IBS
questionnaire that was used in the United States,8 IBS psychomet-
rics9 and Rome II criteria10 (it is reasonable to use these criteria as
our diagnostic measurement because we are comparing data with
a control group). Meantime, the grade 7 through 12 students were
assisted by the trained teachers to fill in the questionnaire, and the
questionnaires for students in grades 1 through 6 were filled in by
their parents. The questionnaire included demographic data, food Fig 1. Prevalence of IBS in children.
habits, and some symptoms associated with IBS and other gastro-
intestinal tracts, a total of 50 items. We carefully checked these
data in all returned questionnaires, and their reliability was 96.6%.
Diagnostic Criteria
The prevalence of IBS was period prevalence. We used Rome II
criteria published to diagnose IBS, and students who had a diag-
nosis of IBS were suggested to visit a physician to excluded
organic diseases. We excluded organic diseases according to the
information in medical records.
Statistics
Descriptive statistics (frequencies, proportions, means, and
SDs) were calculated for all items of the questionnaire, and con-
fidence intervals for proportions were estimated by standard
methods, with 5% error. Bivariate comparisons between study
groups were evaluated with statistical tests appropriate to the
level of measurement of the dependent variable, including 2 and Fig 2. Prevalence of IBS in adolescents.
t test. Multiple logistic regressions were used to test the contrib-
uting factors of IBS. All P values are 2-tailed.
span. Among them, the prevalence of the subgroup
RESULTS of children who were 8 to 9 years of age was the
highest in children who were 12 years and younger
Demographic Characteristics of the Population Studied
(14.78%), and in adolescents who were 13 years and
The age of 5403 students ranged from 6 to 18 years. older, the prevalence of adolescents who were 15 to
In 5403 students, 2495 were 12 years and younger 16 years was the highest (17.35%). However, the
and 2908 were 13 years and older; 3604 were from prevalence of each age range had no statistical dif-
Heilongjiang province, and 1799 were from Shang- ference.
hai. The number of senior middle school students
(grades 10 –12) was 1579 (mean age: 15.60 ⫾ 0.67 Area-Based Distribution Characteristics
years), of junior middle school students (grades 7–9) There was a statistically significantly higher prev-
was 1749 (mean age: 13.59 ⫾ 1.32 years), and of alence of IBS in Heilongjiang province (14.02%) than
primary school students (grades 1– 6) was 2077 in Shanghai (11.72%; P ⬍ .04).
(mean age: 8.51 ⫾ 1.79 years). The ratio of boys to
girls was 1:1.02. More than 98.00% of the total stu- Ethnic Group–Based Distribution Characteristics
dents were of Han race (ethnic group), and ⬍2% The prevalence of IBS in minority students
were minorities (ethnic group). A total of 94% to 98% (21.15%) was not statistically significantly higher
of students lived in households with both parents. than that in students of Han race (16.08%).
IBS in Adolescents and Children Bowel Movement Habit and Frequency
Prevalence of IBS Among students who received a diagnosis of IBS,
The prevalence of IBS in the adolescents and chil- the prevalence of straining (33.25%) and urgency
dren studied was 13.25% (716 among 5403 students). (23.75%) of defecation in students in grades 1
The ratio of boys (11.56%) to girls (20.86%) was 1:1.8, through 3 was statistically significantly higher than
and the difference between boys and girls had no that of students in other grade (P ⬍ .001), the prev-
statistical significance (P ⬎ .05). alence of the feeling of incomplete evacuation in
students in grades 10 through 12 was the most prev-
Age-Based Distribution Characteristics alent (23.20%; P ⬍ .001). The prevalence of diarrhea
The prevalence of IBS in children who were 12 in students in grades 1 through 3 (frequency ⬎5
years and younger was not statistically significantly times every day and 3–5 times every day) was sta-
higher than that of adolescents who were 13 years tistically significantly higher than that of students in
and older (11.86% and 11.44%, respectively; P ⬎ .05). other grades (2.11% and 4.75%, respectively; P ⫽
Figs 1 and 2 show the prevalence of IBS of each age .001). The prevalence of constipation in students in
e394 IRRITABLE BOWEL Downloaded
SYNDROME IN ADOLESCENTS AND CHILDREN IN CHINA
from www.aappublications.org/news by guest on May 27, 2021TABLE 1. Logistic Analysis of Important Contributing Factors in IBS
Contributing Factors B SE 2 P Value OR 95% CI
Alcoholism 0.22 0.12 3.49 .04 1.25 0.94–1.22
Smoking 0.36 0.30 1.46 .05 1.44 0.95–0.99
Pepper 0.12 0.06 4.26 .04 1.13 0.66–0.87
Dysentery 0.32 0.06 32.22 .00 1.37 0.71–0.81
Abdominal operation 0.49 0.24 4.20 .04 1.63 0.89–0.97
Antibiotics 0.66 0.21 10.31 .00 1.93 0.78–0.87
Coldness 1.04 0.10 101.87 .00 2.83 0.49–0.58
Fatigue 0.10 0.05 3.82 .04 1.10 0.31–0.45
Anxiety 0.10 0.06 2.46 .01 1.07 0.34–0.49
Depression 0.07 0.06 4.47 .03 1.13 0.33–0.47
Introverted personality 0.05 0.07 0.55 .02 1.05 0.82–1.02
CI indicates confidence interval.
grades 7 through 9 was 20.54% (1 time every other over, its prevalence was not uniform in different
3–5 days or 1 time in ⬎5 days), and this was statis- areas, ages, genders, races, occupations, and educa-
tically significantly higher than that of students in tional levels.1–3,11 Here, psychological factors, food
other grades (P ⬍ .001). habits, bad exterior environment, and family condi-
tion were considered to be contributing factors of
Physician Visits for IBS IBS. According to the common understanding of
Among 716 students with IBS, 220 (30.72%) visited adult IBS, some investigators from Hartford Univer-
physicians, and 220 students who had IBS and vis- sity Medical School conducted an epidemiologic
ited doctors, organic diseases were excluded by med- study including the prevalence rate of IBS and its
ical techniques. contributing factors in adolescents, suggesting that
IBS is a common disorder in the community-based
Contributing Factors of IBS adolescent population. According to the Rome II cri-
We explored contributing factors of IBS in adoles- teria, there were 14% of students in grades 10
cents and children by comparing the frequencies of through 12 and 6% of students in grades 7 through 9
these factors in the IBS group with those in the reported experiencing IBS symptoms; in contrast
non–IBS group, using 2, multiple logistic regres- with male students, the female counterparts had a
sions. The data concerned are shown in Table 1. Our higher prevalence. The prevalence of white students
study indicated that IBS in adolescents and children was higher than that of black students. They also
might have possible relations with psychological fac- found that psychological factors (anxiety and depres-
tors (anxiety, depression, and introverted personal- sion) might have possible relations with IBS in ado-
ity), food habits (excessive intake of pepper), per- lescents.12 However, the epidemiologic data about
sonal habits (alcoholism and smoking), and bad IBS were meager in China. Our study has a signifi-
exterior environment (history of dysentery, abdomi- cance of filling in the missing epidemiologic data
nal operation, abuse of antibiotics, exposure to cold- about IBS in adolescents and children of China.
ness, and fatigue), family condition (poor care of Our study found that the prevalence of IBS in
only a single parent) etc. Among 22 factors, alcohol- adolescents and children studied was 13.25%, and
ism (odds ratio [OR]: 1.25), smoking (OR: 1.44), ex- the ratio of boys (11.56%) to girls (20.86%) was 1:1.8
cessive intake of pepper (OR: 1.13), history of dysen- (P ⬎ .05). The above results coincided with those of
tery (OR: 1.37), abdominal operation (OR: 1.63), a study done by Reshetnikov et al6 in Moscow.
abuse of antibiotics (OR: 1.93), exposure to coldness In China, there are 56 ethnic groups, including
(OR: 2.83), fatigue (OR: 1.10), anxiety (OR: 1.07), Han race and other 55 races; the Han population
depression (OR: 1.13), and introverted personality totals 1.04 billion, which is the largest among them,
(OR: 1.05) might serve as important contributing fac- and the other 55 races were called minorities. We
tors (P ⬍ .05). also found that the prevalence in minorities (21.15%)
was not statistically significantly higher than that of
Relationship of IBS in Adolescents and Children to the Hans (16.08%). We thought that the reason might
Headaches, Backaches, and Insomnia be that the minorities and Hans lived together in the
We explored the relationship of IBS in adolescents same region and were exposed to the same living
and children to headaches, backaches, and insomnia environment.
by comparing their occurrence between the IBS The prevalence of IBS between children who were
group and the non–IBS group, using 2 (the data 12 years and younger and adolescents who were 13
concerned are shown in Table 2). The difference of
their occurrence had statistical significance (P ⬍
TABLE 2. Relationship of IBS to Some Symptoms in Adoles-
.001). cents and Children
DISCUSSION Headache Backache Insomnia
In the world, IBS is a common disorder, and its IBS group, % 32.68 22.21 5.95
prevalence tends to be higher in Western countries Non-IBS group, % 14.32 9.26 2.05
P value ⬍.001 ⬍.001 ⬍.001
(⬃10%) than that of Asian countries (⬃5%); more-
www.pediatrics.org/cgi/doi/10.1542/peds.2004-2764
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e395years and older had no statistically significant differ- Our study also found that excessive intake of pep-
ence. This reason might be ascribed to changes in per and cold food was an important contributing
their physiologic and biological states. factor of IBS in adolescents and children. The pepper
Moreover, the prevalence of diarrhea in students and the cold food were especially prevalent food
in grades 1 through 3 was significantly higher than habits in the northern areas of China. This might be
that in students in other grades. The prevalence rate 1 of many reasons for different the prevalence in the
of constipation in students in grades 7 through 9, north and south of China. It was also noted that
however, was significantly higher than that in stu- adolescents and children who lived in a single-par-
dents in other grades (P ⬍ .001). Hence, we could ent household had a higher prevalence of IBS, and
deduce that students in grades 1 through 3 might this may be attributable to abnormality of personal-
take on diarrhea-predominant IBS but that students ity in such household circumstances.
in grades 7 through 9 possibly take on constipation- Recently, several studies suggested a higher prev-
predominant IBS. alence of headaches, backaches, and insomnia in ad-
It was generally thought that there was a different olescents with IBS.13–16 We also noted that 32.68% of
prevalence of IBS in different areas.11 Consequently, students with IBS in our study had headaches,
we also conducted area-based distribution character- 22.21% had backaches, and 5.95% had insomnia. The
istics of IBS in adolescents and children and found rates were statistically significantly higher in adoles-
that there was a higher prevalence rate of IBS in cents and children with IBS (P ⬍ .001), but our study
Heilongjiang province (14.02%) than that in Shang- could not confirm that these were concomitant
hai (11.72%; P ⬍ .05). Multiple factors might be re- symptoms with IBS in adolescents and children or
sponsible for it, including different geographic and just the same as its contributing factors.
climatic conditions, food habits, and different cul-
tural background in China with an immense terrain. ACKNOWLEDGMENTS
However, the stress of school work of adolescents We thank the following individuals, whose help was invaluable
and children in Heilongjiang province seemed to be in the completion of this study: Yun Guangmin, Liu Xiansheng,
heavier that that in Shanghai. The rate of college Wang Shuqin, and Liu Tao.
admission was ⬃60% in Heilongjiang province ver-
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SYNDROME IN ADOLESCENTS AND CHILDREN IN CHINA
from www.aappublications.org/news by guest on May 27, 2021An Epidemiologic Study of Irritable Bowel Syndrome in Adolescents and
Children in China: A School-Based Study
Liu Dong, Li Dingguo, Xu Xiaoxing and Lu Hanming
Pediatrics 2005;116;e393
DOI: 10.1542/peds.2004-2764
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http://pediatrics.aappublications.org/content/116/3/e393#BIBL
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Downloaded from www.aappublications.org/news by guest on May 27, 2021An Epidemiologic Study of Irritable Bowel Syndrome in Adolescents and
Children in China: A School-Based Study
Liu Dong, Li Dingguo, Xu Xiaoxing and Lu Hanming
Pediatrics 2005;116;e393
DOI: 10.1542/peds.2004-2764
The online version of this article, along with updated information and services, is
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