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A Case-Control Study of Association of Helicobacter Pylori Infection with Morbid Obesity in Taiwan

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A Case-Control Study of Association of Helicobacter Pylori Infection with Morbid Obesity in Taiwan ORIGINAL INVESTIGATION d A Case-Control Study of Association of Helicobacter pylori Infection With Morbid Obesity in Taiwan Ming-Shiang Wu, MD; Wei-Jei Lee, MD; Hsih-Hsi Wang, MD; Shi-Pei Huang, MD; Jaw-Town Lin, MD Background: Obesity is an increasing health problem in Results: The overall seropositivity was significantly lower developed countries, where the prevalence of Helicobacter in obese patients (181 [43.7%] of 414) than controls (410 pylori infection is decreasing. Recent studies suggested colo- [60.0%] of 683) (OR, 0.50; 95% CI, 0.39-0.65; PϽ.001). nization of the stomach by H pylori might affect gastric ex- Differences in the estimated risk of the presence of H py- pression of appetite- and satiety-related hormone and pa- lori were more pronounced in younger age groups, with tients cured of H pylori infection gained weight. It was ORs of 0.32 (95% CI, 0.10-1.00; P=.05) in those aged hypothesized that H pylori could be a contributing patho- 10 to 19 years, 0.55 (95% CI, 0.34-0.89; P=.01) in those genic factor in childhood and adult obesity. aged 20 to 29 years, 0.49 (95% CI, 0.30-0.80; P=.007) in those aged 30 to 39 years, and 0.58 (95% CI, 0.33- Methods: To determine whether H pylori infection is 1.00; P=.05) in those aged 40 years or older. linked to obesity, a case-control study composed of 414 patients with morbid obesity (a body mass index [cal- Conclusions: Our data indicated an inverse relation- culated as weight in kilograms divided by the square of ship between morbid obesity and H pylori seropositiv- height in meters] of Ն35 with serious comorbidity or a ity. These findings raise the hypothesis that a lack of body mass index of Ն40) and 683 control subjects (a body mass index of Ͻ25) with a comparable socioeconomic H pylori infection, especially during childhood, might status was conducted. Immunoglobulin G antibodies enhance the risk of the development of morbid against H pylori were measured from frozen serum samples obesity. by an enzyme-linked immunosorbent assay. Logistic re- gression was used to calculate the odds ratio (OR) and 95% confidence interval (CI). Arch Intern Med. 2005;165:1552-1555 BESITY HAS BECOME A MA- multiple studies show that the genetic con- jor public health prob- tribution is significant, our genes have not lem of global signifi- changed appreciably during this period. An cance. Health conditions increasing obesigenic lifestyle of excessive caused or exacerbated by caloric intake and decreased physical activ- obesity include hypertension, diabetes ity are assumed to play a central role in this O 2 mellitus, sleep apnea, obesity-related hy- epidemiologic trend. Whether there are poventilation, back and joint problems, other environmental factors likely to ex- cardiovascular disease, and gastroesopha- plain the epidemic of obesity remains to be geal reflux disease. The body mass index elucidated. (BMI) (calculated as weight in kilograms di- Helicobacter pylori is a gram-negative ba- Author Affiliations: vided by the square of height in meters) is cillus. It was estimated that half of the Department of Primary Care the most commonly accepted measure- world’s adult population harbors H pylori Medicine, College of Medicine, ment for obesity. A BMI exceeding 25 is con- in their stomach. In developing countries, National Taiwan University, and sidered overweight, while obesity is de- the infectious process occurs early and Department of Internal fined as a BMI of 30 or more. A BMI of 35 reaches 60% to 80% in adulthood. The an- Medicine, National Taiwan or more with serious comorbidity or a BMI nual incidence of H pylori acquisition by University Hospital, Taipei of 40 or more is considered morbid obe- adults is much lower in developed coun- (Drs Wu, Huang, and Lin); and sity.1 The incidence of obesity has in- tries. The increase by age largely reflects a Departments of Surgery 3 (Dr Lee) and Internal Medicine creased rapidly during the past 2 decades. birth cohort phenomenon. Helicobacter py- (Dr Wang), En-Chu Kong This increase had been most dramatic in af- lori is the main causative factor of chronic Hospital, Taipei Hsien, Taiwan. fluent countries. The factors underlying this gastritis. Epidemiologic studies have con- Financial Disclosure: None. increase are largely unknown. Although sistently linked H pylori infection to peptic (REPRINTED) ARCH INTERN MED/ VOL 165, JULY 11, 2005 WWW.ARCHINTERNMED.COM 1552 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 ulcer and gastric malignancies.4 The diverse outcomes of freezer at −20°C until studied concomitantly in a random or- H pylori infection are ascribed to the difference in extent der. The fasting glucose concentration was determined using and severity of gastritis, which leads to variation in the an enzymatic colorimetric method (Sigma Chemical, St Louis, amount of gastric secretion and creates a permissive lumi- Mo). Serum insulin levels were measured by an immune lu- nal milieu for disease to develop.5 Recently, the spectrum minescence assay (Access; Beckman Coulter, Brea, Calif). In- sulin resistance was estimated by the homeostasis model of as- of H pylori–related diseases has expanded to include gas- sessment based on the following formula: [fasting insulin level troesophageal reflux disease and obesity. The parallel epi- (measured in micro–international units per milliliter) demic of gastroesophageal reflux disease and obesity com- ϫfasting glucose level (measured in milligrams per milliliter)]/ bined with decreasing H pylori infection in western countries 22.5. High-sensitivity C-reactive protein was measured using suggests H pylori might play a protective role in the devel- immunonephelometry (Nephelometer Analyzer II; Dade Beh- opment of obesity and gastroesophageal reflux disease.6,7 ring, Deerfield, Ill). A commercially available enzyme-linked Based on the findings that eradication of H pylori could in- immunosorbent assay kit (IBL, Hamburg, Germany) with re- fluence the dynamic of ghrelin and increase body weight,8-11 ported sensitivity and specificity of more than 95% was used Blaser and Atherton12 proposed that H pylori infection might to investigate the prevalence of H pylori infection. All assays influence food intake and calorie homeostasis through de- were performed in duplicate and interpreted by a single labo- ratory investigator (M.-S.W.) unaware of sample status to avoid fective signaling of appetite-related hormone in the stom- the possibility of interobserver variability. ach. A possible inverse relationship between exposure to H pylori and the occurrence of obesity has been further ad- dressed in studies of morbid obesity.13-15 Preliminary data STATISTICAL ANALYSIS by histological examinations have shown that the infec- tion rate of H pylori in these patients ranged from 24% to All data for cases and controls were computerized, and statis- 38%.13-15 However, controversial results existed, and whether tical analysis was performed using a commercially available soft- ␹2 H pylori infection plays a role in childhood and adult adi- ware program (SPSS, version 11.0; SPSS Inc, Chicago, Ill). posity remains to be determined.12-18 And t tests were used for categorical and continuous data, re- spectively. Nonparametric tests (Kruskal-Wallis) have been used Taiwan is a newly industrialized country where the for cases of nonnormality. The strength of association be- incidence of obesity is accelerating and H pylori infec- tween H pylori and sex or age was measured by binary logistic 19,20 tion is prevalent. A recent mass screening program regression to estimate the odds ratio and 95% confidence in- even showed the increase of childhood diabetes melli- terval (CI). tus on this island is due to obesity.21 To clarify the rela- tionship between obesity and H pylori infection, we in- RESULTS vestigated, in a case-control study, the seroprevalences of H pylori among patients with morbid obesity and con- The seroprevalence of H pylori was 43.7% (181/414) for trol subjects with a normal weight. cases of morbid obesity and 60.0% (410/683) for con- trols (odds ratio, 0.50; 95% CI, 0.39-0.65; PϽ.001). The METHODS distributions of seropositivity of H pylori with respect to age and sex in cases and controls are summarized in STUDY SUBJECTS Table 1. Differences in the estimated risk of the pres- ence of H pylori were more pronounced in younger age Studied concomitantly in a random order,22 we selected con- groups, with odds ratios of 0.32 (95% CI, 0.10-1.00; secutive patients affected by morbid obesity between January P=.05) in those aged 10 to 19 years, 0.55 (95% CI, 0.34- 1, 2001, and December 31, 2003. A case was defined as a pa- 0.89; P=.01) in those aged 20 to 29 years, 0.49 (95% CI, tient with a BMI of 35 or more with a serious comorbidity or 0.30-0.80; P=.007) in those aged 30 to 39 years, and 0.58 with a BMI of 40 or more who was admitted to En-Chu Kong (95% CI, 0.33-1.00; P=.05) in those aged 40 years or older. Hospital for evaluation of the possibility of weight reduction On the other hand, sex has no effect on the distribution surgery. Blood samples for a prospective investigation of the of H pylori seropositivity. The clinical, demographic, and effect of surgery on these patients were collected. Finally, 414 eligible patients (115 men and 299 women; mean±SD age, metabolic variables were further compared between H py- 31.9±9.2 years) were enrolled. In the same period, we also en- lori–positive and H pylori–negative patients with mor- rolled controls from healthy subjects with a BMI of less than bid obesity.
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