School of Medicine, Akita 010 ‑ 8543, Japan

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LI FESTYLE‑RELATED RI SK FACTORS FOR PEPTI C ULCER DI SEASE:A HOSPI TAL‑BASED

CASE‑CONTROL STUDY I N AKI TA PREFECTURE

Mas ahi de Wada and Yut aka Mot ohas hi (Recei ved 24 June 2004,Accept ed 13 Sept ember 2004) Division of Public Health, Depar tment of Social Medicine, Akita Univer sity

School of Medicine, Akita 010 ‑ 8543, Japan

Abs t ract

A cas e‑cont r ol s t udy was car r i ed out t o det er mi ne l i f es t yl e‑r el at ed r i s k f act or s f or pept i c ul cer di s eas e(PUD). The s ubj ect s ,who r es i ded i n Aki t a,Japan,wer e 161 pat i ent s wi t h PUD and 322 cont r ol s ubj ect s wi t hout PUD who under went medi cal checkups ,mat ched wi t h pat i ent s by gender and age. Al l of t he s ubj ect s under went endos copy and pr ovi ded i nf or mat i on on ps ychos oci al f act or s and l i f es t yl e pr act i ces t hr ough s el f ‑admi ni s t er ed ques t i onnai r es . Bl ood s ampl es wer e col l ect ed f or det er mi nat i on of Helicobacter pylor i ( H. pylor i)s t at us . Li f es t yl e‑r el at ed var i abl es wer e as s es s ed f or t hei r as s oci at i ons wi t h PUD and H. pylor i i nf ect i on by us i ng mul t i pl e l ogi s t i c r egr es s i on anal ys i s . The pr eva- l ences of H. pylor i i nf ect i on wer e 97. 5% i n t he pat i ent s and 84. 8% i n t he cont r ol s ,whi ch wer e hi gher t han t hos e i n Japanes e adul t s(i . e. ,f r om 23% t o 73%). Si gni f i cant r i s k f act or s f or PUD wer e pos i t i ve H. pylor i s t at us(odds r at i o(OR)＝14. 1),l eannes s(OR＝

2. 68),ur ban r es i dency(OR＝2. 57),i r r egul ar meal t i mes(OR＝2. 17),s moki ng habi t (OR＝1. 98),s hi f t wor k (OR＝2. 15),non‑pr of es s i onal occupat i on(OR＝2. 64),l ack of mor al e i n j ob(OR＝2. 13),and di f f i cul t y i n mood change(OR＝2. 20). Si gni f i cant r i s k f act or s f or H. pylor i i nf ect i on wer e age of 40 year s or over(OR＝4. 28)and r ur al or i gi n (OR＝3. 17).

Thes e f i ndi ngs s ugges t t hat s moki ng,l eannes s ,and ps ychos oci al s t r es s i n dai l y l i f e ar e as s oci at ed wi t h PUD i n t he nor t heas t er n r egi on of Japan wher e t he pr eval ence of H.

pylor i i nf ect i on i s cons i der abl y hi gh.

Key words :l i f es t yl e,r i s k f act or s ,pept i c ul cer di s eas e, Helicobacter pylor i ,cas e

‑cont r ol s t udy

I nt roduct i on

Si nce t he i dent i f i cat i on of Helicobacter pylor i ( H.

pylori) i n 1982, t here have been many epi demi ol ogi cal s t udi es on H. pylor i i nf ect i on . H. pylor i i nf ect i on i s now cons i der ed t o be a maj or f act or cont r i but i ng t o t he occur r ence of pept i c ul cer di s eas e(PUD) . However ,i n pr evi ous s t udi es ,

t he pr eval ence of PUD i n H. pylor i ‑i nf ect ed i ndi vi d- ual s i n popul at i ons ,whos e pr eval ence of H. pylor i i nf ect i on r anged f r om 53. 7% t o 59. 2%,wer e onl y 2. 0% and 5. 7% ,r es pect i vel y. The pr eval ence of PUD i s i nf l uenced not onl y by H. pylor i i nf ect i on but al s o by l i f es t yl e‑r el at ed f act or s . Li f es t yl e‑

r el at ed r i s k f act or s f or PUD have been r epor t ed t o be s moki ng ,s al t y f ood i nt ake ,and s el f ‑

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Aki t a J Med 31 :211‑220,2004

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per cei ved s t r es s . However , t he as s oci at i on bet ween H. pylor i i nf ect i on and PUD was not exami ned i n mos t of t hos e s t udi es . The s t udi es al s o l acked endos copi c ver i f i cat i on of PUD s t at us . Regar di ng t he r el at i ons hi p bet ween s el f ‑per cei ved s t r es s and PUD,pr evi ous s t udi es i n gener al deal t wi t h maj or s t r es s f ul l i f e event s or s t r es s ,but not ps ychos oci al s t r es s es encount er ed i n dai l y l i f e . Fur t her mor e,t her e have been onl y a f ew cas e‑cont r ol s t udi es on l i f es t yl e‑r el at ed r i s k f act or s f or PUD i n Japan . I n t he pr es ent s t udy, t he aut hor s f ocus ed on t he i mpact of s t r es s es r el at ed t o ur ban r es i dency and wor k envi r onment on PUD pr eval ence. H. pylor i i nf ect i on i t s el f may be i n- f l uenced by l i f es t yl e‑r el at ed f act or s .

The ai m of t he pr es ent s t udy was t o det er mi ne l i f es t yl e‑r el at ed r i s k f act or s f or PUD and f or H.

pylor i i nf ect i on,as wel l as whet her t her e ar e i nt er ac- t i ons bet ween f act or s r el at i ng t o t he occur r ence of PUD. I n t hi s cas e‑cont r ol s t udy,we anal yzed var i - ous l i f es t yl e‑r el at ed f act or s ,i ncl udi ng wor k‑r el at ed s t r es s ,i n s ubj ect s who under went upper gas t r oi nt es - t i nal endos copy and pr ovi ded bl ood s ampl es f or H.

pylor i s t at us . The s ubj ect s al l l i ved i n Aki t a Pr e- f ect ur e i n nor t heas t er n Japan wher e t he pr eval ence of H. pylor i i nf ect i on r anked among t he hi ghes t i n t he wor l d .

Subj ect s and Met hods Sel ect i on of pat i ent popul at i on

The s t udy popul at i on i ncl uded 161 i npat i ent s and out pat i ent s who had pept i c ul cer s di agnos ed endos - copi cal l y bet ween December 1997 and November 1998 at t he Gas t r oent er ol ogi cal Di vi s i on of H hos pi - t al i n Honj o Ci t y,l ocat ed i n t he Tohoku di s t r i ct of Japan. Act i ve ul cer s wer e r egar ded as gas t r i c ul cer s when cr at er s of appr eci abl e dept h wer e l ocat - ed i n t he s t omach(f undal ,cor pal or ant r al ar ea), and ul cer s wi t h cr at er s i n t he pyl or i c canal or i n t he duodenum wer e r egar ded as duodenal ul cer s . Ul cer s wi t h cr at er s bot h i n t he s t omach and i n t he pyl or i c canal or duodenum wer e r egar ded as gas - t r oduodenal ul cer s . Ni net y‑f our pat i ent s had gas -

t r i c ul cer s ,39 had duodenal ul cer s and 28 had gas - t r oduodenal ul cer s . Pat i ent s wer e excl uded i f t hey had neopl as mi c l es i ons(gr oup 3 or hi gher accor d- i ng t o pat hol ogi cal di agnos t i c cr i t er i a),i f t hey had pr evi ous l y under gone es ophagogas t r i c s ur ger y,or i f ot her over hel mi ng phys i cal or ment al di s eas es wer e pr es ent . The s ubj ect s us ed i n t hi s s t udy wer e 117 mal es(72. 7%)and 44 f emal es(27. 3%)wi t h a mean age 50. 1±10. 9 year s . I nf or med cons ent was obt ai ned f r om al l pat i ent s .

Sel ect i on of cont rol popul at i on

Cont r ol s wer e s el ect ed f r om per s ons who under - went medi cal checkups at H hos pi t al dur i ng t he s ame per i od(Dec.1997‑Nov.1998)and i n whom nei t her pept i c ul cer s nor ul cer s car s wer e det ect ed endos copi cal l y. The 161 pat i ent s wer e i ndi vi dual l y mat ched wi t h t he 322 cont r ol s by gender and age wi t hi n 5 year s . The excl us i on cr i t er i a f or t he pat i ent s wer e al s o us ed f or t he s el ect i on of cont r ol s . The cont r ol s wer e 234 mal es(72. 7%)and 88 f emal es(27. 3%)wi t h a mean age 50. 3±10. 4 year s , not s i gni f i cant l y di f f er ent f r om t hat of t he pat i ent s . I nf or med cons ent was obt ai ned al s o f r om al l con- t r ol s .

Met hods f or det ermi nat i on of H.pyl ori s t at us Bl ood s ampl es wer e col l ect ed f or det er mi nat i on of H. pylor i s t at us .Level s of s peci f i c ant i ‑ H. pylor i I gG ant i bodi es i n s er a wer e meas ur ed wi t h an enzyme‑l i nked i mmunos or bent as s ay(ELI SA)ki t us i ng s ol i d‑phas e ant i gens der i ved f r om i nact i vat ed H. pylor i (HEL‑pTEST s uppl i ed wor l dwi de by Amr ad Co. ,Mel bour ne,Aus t r al i a). A t i t er of mor e t han 50 U/ml was j udged pos i t i ve f or ant i ‑ H. pylor i I gG ant i bodi es . Bas ed on t he r es ul t s of hi s t ol ogy and ur eas e t es t i ng of gas t r i c bi ops i es i n an As i an popul at i on,t he as s ay has been s hown t o be 93. 5%

s ens i t i ve and 92. 5% s peci f i c f or act i ve i nf ect i on . I n t he pr es ent s t udy, H. pylor i i nf ect i on was def i ned as a pos i t i ve ELI SA r es ul t .

St udy vari abl es

A s el f ‑admi ni s t er ed ques t i onnai r e was compl et ed Ri s k f act or s f or pept i c ul cer di s eas e i n Aki t a

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on t he s ame day as t he bl ood exami nat i on or on a day bef or e t he pat i ent ʼ s next at t endance. The s t udy var i abl es as s es s ed i n t he s t at i s t i cal anal ys es ar e l i s t ed i n Tabl e 1.

St at i s t i cal anal ys es

Al l dat a f or t he var i abl es wer e di vi ded i nt o t wo cat egor i es and conver t ed i nt o bi nar y dat a by as s i gn- i ng a val ue of 0 t o 1 t o each of t he t wo cat egor i es . St at i s t i cal anal ys es wer e per f or med us i ng t he chi ‑ s quar ed t es t . Odds r at i os(OR)and 95% conf i - dence i nt er val s(CI )wer e cal cul at ed. P val ues l es s t han 0. 05 wer e r egar ded as s i gni f i cant . Uni var - i at e anal ys es f or t he as s oci at i on of t he s t udy var i - abl es wi t h PUD and H. pylor i i nf ect i on wer e per f or -

med. Bas ed on t he r es ul t s ,mul t i var i at e anal ys es wer e per f or med us i ng s t epwi s e l ogi s t i c r egr es s i on wi t h backwar d el i mi nat i on. Var i abl es wi t h p val - ues l es s t han 0. 1 i n uni var i at e anal ys es wer e us ed i n mul t i var i at e anal ys es . The i ndependent var i abl es us ed i n mul t i var i at e anal ys i s f or PUD s t at us wer e BMI ,r es i dency,occupat i on,number of meal s a day, r egul ar i t y of meal t i me,s moki ng habi t ,s hi f t wor k, wor ki ng t i me,s t r es s i n j ob,decr eas e i n s l eep qual - i t y,mor al e i n j ob,s el f ‑conf i dence,f ami l y di s cor d, eas i nes s of mood change,and H. pylor i s t at us . The i ndependent var i abl es us ed i n mul t i var i at e anal ys i s f or H. pylor i s t at us wer e gender ,age,bi r t hpl ace, s oybean pas t e s oup cons umpt i on f r equency, decr eas e i n s l eep qual i t y,anger ,and PUD s t at us . 秋田医学

Tabl e 1 Var i abl es as s es s ed i n uni var i at e anal ys es f or pept i c ul cer di s eas e and Helicobacter pylor i i nf ect i on

1) Soci odemogr aphi c f act or s:gender ,age 2) BMI(body mas s i ndex)

3) Soci oeconomi c s t at us:r es i dency,bi r t hpl ace,number of s i bl i ngs ,educat i onal bas e,pr es ent mai n occupat i on

4) Di et ar y habi t s:

a. s al t y f ood i nt ake(dai l y cons umpt i on of s oybean pas t e s oup and weekl y cons umpt i on of pi ckl es and ot her s al t y f ood)

b. number s and r egul ar i t y of meal s

c. al cohol i nt ake(weekl y cons umpt i on of Japanes e s ake,di s t i l l ed l i quor ,beer ,whi s ky,and wi ne)

d. cof f ee and gr een t ea i nt ake(number of cups dr unk dai l y or weekl y) 5) Li f es t yl e pr act i ces :

a. wor ki ng condi t i ons(f r equency of s hi f t wor k,wor ki ng t i me,r es t i ng t i me,home‑ar r i val t i me,commut i ng means and t i me,and number s of mont hl y hol i days )

b. f at i gabi l i t y(degr ee of f at i gue and eas i nes s of r ecover y f r om f at i gue,s l eepi ng t i me) c. l ei s ur e‑t i me phys i cal act i vi t y(hobbi es ,s por t s )

d. degr ee of s t r es s(s t r es s i n wor k,eas i nes s of mood change) e. mor al e i n j ob

f . behavi or al char act er(t ype A behavi or pat t er n) g. f ami l y condi t i ons(s t r es s i n f ami l y,s at i s f act i on i n l i f e) h. changes i n l i f e wi t hi n t he pr evi ous year

i . s moki ng habi t(cumul at i ve number s of ci gar et t es s moked dai l y,cumul at i ve year s of s moki ng).

BMI val ues wer e cal cul at ed by hei ght(met er )and wei ght(ki l ogr am),and a val ue l es s t han 19. 8 was j udged pos i t i ve f or l eannes s .

Regar di ng r es i dency,t he hos pi t al s er ves r es i dent s of mai nl y Honj o Ci t y(ur ban)and i t s s at el l i t e 10 t owns of Yur i Count y(r ur al ).

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I ndependent var i abl es wi t h p val ues gr eat er t han 0. 1 wer e r emoved s t epwi s e i n mul t i var i at e anal ys es . Al l dat a wer e anal yzed us i ng t he s t at i s t i cal package SPSS 11. 0 f or Wi ndows(SPSS I nc. ,USA).

Res ul t s Preval ence of i nf ect i on

Fi g.1 s hows t he di s t r i but i ons of H. pylor i s er o- pr eval ence by age cl as s es i n t he pat i ent s and con- t r ol s . One hundr ed f i f t y‑s even pat i ent s(97. 5%) wer e pos i t i ve f or H. pylor i i nf ect i on and 273 con- t r ol s(84. 8%)wer e pos i t i ve f or H. pylor i i nf ect i on.

The pr eval ence of H. pylor i i nf ect i on was 89. 0% i n t he s ubj ect s over al l . The pr eval ence of H. pylor i i nf ect i on i n t he cont r ol s i n t he pr es ent s t udy was hi gher t han t he aver age r at es i n Japanes e adul t s , whi ch r anged f r om 23% (i n heal t hy adul t s aged 20

〜29 year s )t o 73% (i n heal t hy adul t s aged≧70 year s ) .

Fact ors rel at ed t o PUD s t at us

Tabl e 2 s hows t hos e var i abl es whi ch wer e r el at ed t o PUD s t at us( p ＜0. 1)i n t he uni var i at e anal ys i s . Tabl e 3 s hows t hos e var i abl es whi ch wer e s i gni f i - cant l y r el at ed t o PUD s t at us( p ＜0. 05)i n t he mul t i var i at e anal ys i s . They wer e H. pylor i s t at us , BMI ,r es i dency,occupat i on,meal t i me,s moki ng

habi t ,s hi f t wor k,mor al e i n j ob and eas i nes s of mood change.

Fact ors rel at ed t o s t at us

Tabl e 4 s hows t hos e var i abl es whi ch wer e r el at ed t o H. pylor i s t at us( p ＜0. 1)i n t he uni var i at e anal y- s i s . Of t hes e var i abl es ,age and bi r t hpl ace wer e s i gni f i cant l y r el at ed t o H. pylor i s t at us i n t he mul t i var i at e anal ys i s(Tabl e 5).

Di s cus s i on

The hos pi t al f r om whi ch s ubj ect s wer e enr ol l ed i n t hi s cas e‑cont r ol s t udy s er ves r es i dent s mai nl y of t he Honj o‑Yur i ar ea,l ocat ed i n Aki t a Pr ef ect ur e.

Thi s ar ea i ncl udes Honj o Ci t y(popul at i on of 45, 491 i n Mar ch 2004)and Yur i Count y(popul at i on of 77, 025 i n Mar ch 2004). The hos pi t al i s one of t he t hr ee maj or hos pi t al s i n t he ar ea. Ther ef or e,t he pat i ent popul at i on i n t he pr es ent s t udy i s t hought t o r epr es ent PUD pat i ent s i n t hi s ar ea. PUD s t at us was ver i f i ed by endos copy i n t he s ame hos pi t al i n bot h t he pat i ent and cont r ol gr oups . PUD pr eva- l ence bas ed on cl i ni cal hi s t or y i s i naccur at e and may under es t i mat e or over es t i mat e t he r eal pr eva- l ence . Lack of endos copi c pr oof of ul cer s has been poi nt ed out as a weaknes s of epi demi ol ogi c s t udi es on PUD . Endos copi c ver i f i cat i on of PUD s t at us i n a cont r ol gr oup coul d excl ude appar ent l y heal t hy s ubj ect s wi t h ul cer s car s who have a r i s k of r ecur r ent PUD. Si ngh et al. r epor t ed t hat t he poi nt pr eval ence and l i f et i me pr eval ence of act i ve pept i c ul cer i n t he gener al popul at i on wer e 3. 4% and 8. 8%, r es pect i vel y ,accor di ng t o t he r es ul t s of t hei r endos copi c s t udy on PUD pr eval ence.

I n t he pr es ent s t udy,t he aut hor s r econf i r med an as s oci at i on bet ween l eannes s and PUD. Kat o et al.

r epor t ed a hi gher pr eval ence of PUD i n l ean per s ons and s pecul at ed t hat t hi s i s becaus e l ean per s ons have gr eat er s us cept i bi l i t y t o s t r es s .

Regar di ng t he ur ban‑r ur al di f f er ence i n PUD pr eval ence,t he aut hor s f ound hi gher pr eval ence i n ur ban r es i dent s t han i n r ur al r es i dent s . Thi s f i nd- i ng i s s i mi l ar t o t he f i ndi ng i n a communi t y‑bas ed

Fi g.1 Di s t r i but i ons of Helicobacter pylor i s er o- pr eval ence by age cl as s es i n bot h pat i ent s and cont r ol s accor di ng t o r es ul t s of i mmunogl obul i n G enzyme‑l i nked i mmunos or bent as s ays .

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s t udy i n Aki t a Pr ef ect ur e by Kami yama et al.,who r epor t ed t hat t he f r equency of pas t hi s t or y of PUD i n ur ban wor ker s was s i gni f i cant l y hi gher t han t hat i n r ur al f ar mer s .

Regar di ng t he as s oci at i on bet ween di et ar y pr ac- t i ces and PUD,t he aut hor s r econf i r med t he i mpor - t ance of meal t i me r egul ar i t y and coul d not pr ove t he as s oci at i on bet ween di et ar y i t ems and PUD. I t

has been r epor t ed t hat PUD was i nf l uenced by bot h ci r cadi an and ul t r adi an var i at i ons i n gas t r i c aci d s ecr et or y pat t er n ,and meal t i me i r r egul ar i t y coul d des ynchr oni ze t hes e var i at i ons .

I n t he pr es ent s t udy,s moki ng habi t was f ound t o be r el at ed t o PUD s t at us . Bot h epi demi ol ogi c and cl i ni cal s t udi es have s hown a s t r ong as s oci at i on bet ween s moki ng and PUD . Var i ous pos s i bl e

Tabl e 2 Odds r at i os wi t h 95% conf i dence i nt er val s ,adj us t ed f or age and gender ,f or t he as s oci at i on bet ween pept i c ul cer di s eas e and s t udy var i abl es ,i ncl udi ng Helicobacter pylor i s t at us

Var i abl es OR p val ue 95%CI

H. pylor i s t at us

Pos i t i ve/Negat i ve 7. 05 0. 00 2. 50‑19. 9 BMI

＜19. 8/≧19. 8 2. 90 0. 00 1. 70‑4. 93 Res i dency

Ur ban/Rur al 2. 63 0. 00 1. 77‑3. 90 Occupat i on

Non‑pr of es s i onal /Pr of es s i onal 1. 89 0. 05 0. 97‑3. 70 Number of meal s

≦2 t i mes a day/3 t i mes a day 2. 17 0. 01 1. 22‑3. 88 Meal t i me

I r r egul ar /Regul ar 2. 39 0. 00 1. 62‑3. 54 Smoki ng habi t

Pr es ent s moker /Never or ex‑s moker 2. 55 0. 00 1. 73‑3. 76 Shi f t wor k

Yes /No 2. 45 0. 00 1. 53‑3. 98 Wor ki ng t i me

≧9 hour s a day/＜9 hour s a day 2. 03 0. 00 1. 27‑3. 25 St r es s i n j ob

Yes /No 2. 04 0. 01 1. 24‑3. 37 Deceas e i n s l eep qual i t y

Yes /No 2. 04 0. 01 1. 24‑3. 37 Mor al e i n j ob

No/Yes 1. 78 0. 04 1. 01‑3. 17

Eas i nes s of mood change

No/Yes 2. 52 0. 00 1. 42‑4. 47 Sel f ‑conf i dence

No/Yes 1. 82 0. 01 1. 16‑2. 85 Fami l y di s cor d

Yes /No 1. 68 0. 01 1. 14‑2. 47

OR,odds r at i o;CI ,conf i dence i nt er val; H. pylor i , Helicobacter pylor - i ;BMI ,body mas s i ndex.

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mechani s ms under l yi ng t he adver s e ef f ect of s mok- i ng have been pr opos ed. Smoki ng i s as s oci at ed wi t h decr eas ed gas t r i c mucos al bl ood f l ow,de- cr eas ed mucus s ecr et i on, decr eas ed epi der mal gr owt h‑f act or s ecr et i on,and i ncr eas ed gas t r i c aci d and peps i n s ecr et i on . Addi t i onal l y,s moki ng i s t hought t o expr es s a f or m of copi ng wi t h s t r es s negat i vel y,r es ul t i ng i n an i ncr eas e i n PUD pr eva- l ence .

I n t he pr es ent s t udy,wor k‑r el at ed f act or s s uch as non‑pr of es s i onal occupat i on,s hi f t wor k and no mor al e i n t he j ob s i gni f i cant l y af f ect ed PUD pr eva- l ence. Regar di ng t he as s oci at i on bet ween occupa- t i on and PUD,our r es ul t was i n accor dance wi t h r es ul t s of pr evi ous s t udi es . Regar di ng t he as s o- ci at i on bet ween s hi f t wor k and PUD,wor ker s on ear l y mor ni ng s hi f t or ni ght s hi f t ar e l i kel y t o have meal t i me i r r egul ar i t y and s l eep di s t ur bance,devel -

opi ng PUD . Sano has s ugges t ed on t he bas i s of r es ul t s of s i mul t aneous pol ys omnogr aphy and mea- s ur ement of i nt r agas t r i c pH i n heal t hy s ubj ect s and duodenal ul cer pat i ent s t hat s l eep di s t ur bance i nduces an i ncr eas e i n noct ur nal gas t r i c aci d s ecr e- t i on and can r es ul t i n ul cer ogenes i s . Mos hal r epor t ed t hat duodenal ul cer pat i ent s wer e f ound i n t he l owes t gr oup i n t er ms of occupat i onal aut hor i t y compar ed wi t h cont r ol s ubj ect s ,s i mi l ar t o our f i ndi ng. Lack of occupat i onal aut hor i t y coul d i ncr eas e s el f ‑per cei ved s t r es s of wor ker s ,r es ul t i ng i n t he devel opment of PUD.

I n t he pr es ent s t udy,a f act or s uch as di f f i cul t y i n mood change s i gni f i cant l y af f ect ed PUD pr eva- l ence. I t was t hought t o expr es s a f or m of copi ng wi t h s t r es s negat i vel y,t oo.Anda et al. f ound i n t he cohor t s t udy wi t h s el f ‑r epor t ed PUD pr eval ence t hat t he r i s k of PUD due t o s ubj ect i ve s t r es s was

Tabl e 3 Mul t i var i at e adj us t ed odds r at i os wi t h 95% conf i dence i nt er val s f or t he as s oci at i on bet ween pept i c ul cer di s eas e and s t udy var i abl es

Var i abl es OR p val ue 95%CI

H. pylor i s t at us

Pos i t i ve/Negat i ve 14. 1 0. 00 3. 15‑63. 1 BMI

＜19. 8/≧19. 8 2. 68 0. 01 1. 31‑5. 51 Res i dency

Ur ban/Rur al 2. 57 0. 00 1. 55‑4. 28 Occupat i on

Non‑pr of es s i onal /Pr of es s i onal 2. 64 0. 03 1. 13‑6. 14 Meal t i me

I r r egul ar /Regul ar 2. 17 0. 00 1. 27‑3. 69 Smoki ng habi t

Pr es ent s moker /Never or ex‑s moker 1. 98 0. 01 1. 20‑3. 28 Shi f t wor k

Yes /No 2. 15 0. 01 1. 21‑3. 83 Mor al e i n j ob

No/Yes 2. 13 0. 04 1. 03‑4. 39 Eas i nes s of mood change

No/Yes 2. 20 0. 03 1. 08‑4. 48

Odds r at i os mut ual l y adj us t ed f or al l var i abl es i n Tabl e 2 us i ng l ogi s t i c r egr es s i on anal ys i s .

OR, odds r at i o;CI , conf i dence i nt er val; H. pylor i, Helicobacter pylor i ;BMI ,body mas s i ndex.

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i ncr eas ed wi t h i ncr eas e i n t he ext ent of s t r es s per - cei ved . However ,i ndi vi dual s t r es s f ul f act or s i n t he wor kpl ace or i n t he f ami l y,as demons t r at ed i n t he pr es ent s t udy,wer e not anal yzed i n t hei r s t udy.

Helicobacter pylor i i s one of t he mos t common i nf ect i ons wor l dwi de . I n t he pr es ent s t udy,t he pr eval ence of H. pylor i i nf ect i on i n heal t hy adul t s i n t hi s ar ea of Japan(84. 8%)was hi gher t han t hos e i n l ar ge ci t i es s uch as Tokyo(55. 7%) or Sappor o (62. 7%) . The r i s k f act or s f or H. pylor i i nf ect i on i dent i f i ed i n t he pr es ent s t udy ar e age≧40 year s and

r ur al bi r t hpl ace. The r es ul t f or age was i n accor - dance wi t h r es ul t s of pr evi ous s t udi es . Regar di ng bi r t hpl ace,per s ons bor n i n r ur al ar eas may have been br ought up under r el at i vel y poor per s onal hygi ene condi t i ons compar ed t o per s ons bor n i n ur ban ar eas . I n t he pr es ent s t udy,as s o- ci at i ons of di et ar y f act or s or l i f es t yl e pr act i ces wi t h H. pylor i i nf ect i on wer e not f ound. Res ul t s r egar d- i ng as s oci at i ons of s moki ng,al cohol dr i nki ng,or ot her di et ar y habi t s wi t h H. pylor i i nf ect i on i n pr evi - ous s t udi es have been i ncons i s t ent . Mos t H.

pylor i i nf ect i ons ar e acqui r ed dur i ng chi l dhood bef or e t hes e habi t s ar e s t ar t ed.

I n concl us i on, H. pylor i i nf ect i on i s ubi qui t ous i n t hi s ar ea. Pept i c ul cer di s eas e occur s r ar el y i n H.

pylor i‑negat i ve i ndi vi dual s i n t hi s popul at i on.

However , l eannes s , s moki ng, and ps ychos oci al s t r es s i n dai l y l i f e,i ncl udi ng ur ban r es i dency and wor k envi r onment ,ar e s i gni f i cant l y as s oci at ed wi t h PUD i n t hi s ar ea.

Acknowl edgment s

The aut hor s woul d l i ke t o t hank Kanj i Komat s u

Tabl e 4 Unadj us t ed odds r at i os wi t h 95% conf i dence i nt er val s f or t he as s oci at i on bet ween Helicobacter pylor i i nf ect i on and s t udy var i abl es ,i ncl ud- i ng pept i c ul cer s t at us

Var i abl es OR p val ue 95%CI

PUD s t at us

Pat i ent s /Cont r ol s 7. 05 0. 00 2. 50‑19. 9 Gender

Mal e/Femal e 2. 23 0. 01 1. 26‑4. 05 Age

≧40/＜40 2. 97 0. 00 1. 57‑5. 63 Bi r t hpl ace

Rur al /Ur ban 2. 03 0. 04 1. 03‑4. 00 Soybean pas t e s oup cons umpt i on f r equency

≧1 cup a day/＜1 cup a day 1. 76 0. 09 0. 89‑3. 47 Decr eas e i n s l eep qual i t y

Yes /No 1. 96 0. 07 0. 92‑4. 19 Anger

Yes /No 1. 68 0. 08 0. 93‑3. 01

OR,odds r at i o;CI ,conf i dence i nt er val;PUD,pept i c ul cer di s eas e.

Tabl e 5 Mul t i var i at e adj us t ed odds r at i os wi t h 95% conf i dence i nt er val s f or t he as s oci at i on bet ween Helicobacter pylor i i nf ect i on and s t udy var i abl es

Var i abl es OR p val ue 95%CI Age

≧40/＜40 4. 28 0. 00 1. 86‑9. 84 Bi r t hpl ace

Rur al /Ur ban 3. 17 0. 00 1. 44‑6. 98

Odds r at i os mut ual l y adj us t ed f or al l var i abl es i n Tabl e 4 us i ng l ogi s t i c r egr es s i on anal ys i s .

OR,odds r at i o;CI ,conf i dence i nt er val .

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M. D. ,Di r ect or of Honj o Dai i chi Hos pi t al ,f or hi s f i nanci al s uppor t and encour agement . We woul d al s o l i ke t o t hank t he s t af f of t he Gas t r oent er - ol ogi cal Di vi s i on,Endos copy Uni t ,and Heal t h‑

pr omot i ng Uni t at t he hos pi t al f or t hei r as s i s t ance i n t hi s s t udy.

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