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Irritable bowel syndrome in Egyptian medical students, prevalence and associated factors: a cross-sectional study

Irritable bowel syndrome in Egyptian medical students, prevalence and associated factors: a cross-sectional study

Shimaa Mahmoud El Sharawy1, Ibrahim Fathi Amer2, Mahmoud Zaki Elkadeem1,&

 

1Department of Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt, 2Department of Hepatology, Gastroenterology and Infectious Diseases, Faculty of Medicine, Kafr El Sheikh University, Kafr El Sheikh, Egypt

 

 

&Corresponding author
Mahmoud Zaki Elkadeem, Department of Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt

 

 

Abstract

Introduction: irritable bowel syndrome is a recurrent chronic gastrointestinal functional disorder. Despite it is not dangerous; it carries a significant feedback on self-confidence and quality of life. Medical students are expected to develop irritable bowel syndrome because they are subjected to stress due to over academic pressure. The objectives were to investigate irritable bowel syndrome prevalence, and to detect the related risk factors in this specific group of Egyptian people.

 

Methods: this cross-sectional study performed in two faculties of medicine in Nile Delta, Egypt. It had been built on self-administered questionnaires including Rome III criteria for diagnosis of irritable bowel syndrome, as well as several questions for gathering socio-demographic information and manifestations suggesting irritable bowel syndrome.

 

Results: fifty (27.5%) of 182 evaluated medical students achieved criteria of irritable bowel syndrome, 64% of them were mixed type. Irritable bowel syndrome had a significant relationship with coffee, milk products, fewer vegetables, and fruits intake (P=0.034, P=0.044, P<0.001 respectively). Depression, anxiety, and food intolerance were detected to be significantly related to irritable bowel syndrome (p<0.001, p=0.005, p=0.04) respectively.

 

Conclusion: it was demonstrated that many Egyptian medical students were suffering from irritable bowel syndrome. Some dietary habits, anxiety, and depression of the students could be risk factors related to development of irritable bowel syndrome.

 

 

Introduction    Down

Irritable bowel syndrome (IBS) is described as recurrent chronic gastrointestinal functional disturbances. IBS patients are often presented with abdominal discomfort, distension, and alteration in bowel behaviour in the form of constipation, diarrhoea, or both predominant [1, 2]. At present, the Rome III criteria are the main method for IBS diagnosis without the need for any biochemical markers, provided that warning signs have to be excluded [3, 4]. While IBS is not actually a life-threatening problem, it has been recorded that its symptoms significantly undermine the quality of life associated with health including psychological status and manifestation of fears [5, 6].

IBS affects approximately (10-25) percent of the global population [2]. Besides this, its symptoms are among the most common causes of primary health care consultations [7]. Nevertheless, in the United States alone, 2.4-3.5 million persons visit doctors yearly because of IBS [8]. Recently, prevalence of IBS has been reported to 9.2 percent in fifty-three studies made in 38 countries and included 395,385 participants [9]. In western nation's general population, prevalence of IBS was estimated to be between 10 to 18% [10, 11]. Whereas in non-western countries, IBS has earned less attention. The prevalence of IBS reaches 35-43% in some developing countries [12, 13].

IBS seems to be more likely to affect younger individuals overall [14]. Many university students; notably those studying medicine, may be affected by depression and anxiety [15]. Medical students are suffering from many factors including high levels of psychological stress due to large concentrated study, examination load, increased fierce work competitive environment, uncomfortable living, dietary practices, and patient management responsibilities [16]. There is a little knowledge about the spread of IBS in Egypt as well as other Arabian countries, specifically among university students. In addition, there are really limited data about the prevalence and contributing factors of IBS in university students, particularly in the medical field [17]. So the study aimed to seek for the prevalence of IBS and to identify risk factors associated with it among medical students in two faculties of medicine in both Tanta and Kafr El-Sheikh Universities.

 

 

Methods Up    Down

Study design, setting and participants: this was a cross-sectional study carried out in January and February 2021. The study included 182 medical students whether under or postgraduate and aged 18 years or more in Tanta and Kafr El-Sheikh Universities, Egypt, in the academic year (2020/2021). All participants signed an informed consent form prior to participation, after explanation of the study. The Ethical Review Board of Kafr El-Sheikh University has approved the study (Approval code: MKSU 9-12-20). The study protocol was in line with the ethical guidelines of the 1975 Declaration of Helsinki. Students with known organic gastrointestinal diseases or complaining of alarming gastrointestinal symptoms as weight loss or bloody stools, or individuals who did not desire to participate in the study, were excluded. The sample size was calculated by Raosoft Sample Size Calculator for this study according to 95% confidence interval, hypothesized percentage of IBS in the population =13%, and margin of error 5% as 174.

Study variables and data sources: some variables were evaluated through a confidential, self-administered, and reliable, questionnaire consisted of historical data and sociodemographic data (e.g. age, gender, academic year, special habits, hours of sleeping, food habits, food intolerance, family history, number of siblings, and birth order). In addition, participants were asked if they complained of some symptoms (e.g. abdominal pain, heartburn, vomiting, bowel habits, urinary symptoms), and asked about history of chronic diseases, and medications they were used to taking.

Data collection and processing: the questionnaires were in English language to maintain clarity and uniformity. Ten students were pre-tested before collection of data, and the data of pre-test were excluded from final analysis. The participants were approached by going from class-to-class. Irritable bowel syndrome (IBS) was diagnosed by application of English version of Rome III Criteria [18]: recurrent abdominal pain or discomfort remaining three days or more monthly and has been reported in the last three months plus two or more of these criteria: (a) associated with altered frequency of stool, (b) altered stool appearance or consistency with the onset of the condition, and (c) the condition relieved after defecation. Symptoms suggesting IBS included altered frequency of stool, urgency, straining, abdominal bloating, and change in stool consistency. The participants of the study were grouped as one group had IBS and another group without IBS.

Statistical methods: statistical analysis was done using SPSS (version 22.0, IBM, New York, USA). Categorical data were analysed using the Chi-square test with Yate's (continuity) correction. Fisher's exact test was used if one or more expected value <5. Multivariate analysis using binary logistic regression was done to evaluate the significance of risk factors for associated with irritable bowel syndrome. The results of the regression analysis were reported using adjusted odds ratio and a 95% confidence interval.

 

 

Results Up    Down

Criteria of participants: this research was conducted on 182 medical students. They were between 21-30 years old, with a mean age (22.87+1.64). Males were 76 (41.8%), and females were 106 (58.2%). There were 62 (34.1%) from rural areas and 120 (65.9%) from urban areas. One hundred seventy (93.4%) were single.

Prevalence of irritable bowel syndrome: according to Rome III Criteria, irritable bowel syndrome (IBS) was diagnosed in 50 (27.5%) of the study sample. As regards the IBS group, 8 (16%) students had constipation dominant IBS, 10 (20%) had diarrhoea dominant IBS, and 32 (64%) had mixed IBS. No significant statistical difference between the IBS patients and non-IBS ones as regard to age, gender, residence and family history (Table 1).

Associates of irritable bowel syndrome: as demonstrated in (Table 2), no significant association was revealed between IBS and age, sex, marriage, smoking status, family status, and academic degree. From (Table 3), it could be detected that IBS was significantly associated with some feeding habits (number of daily meals (P =0.011), food intolerance (P =0.04), caffeine intake (P =0.034), milk products' intake (P =0.044), and vegetables and fruits intake (P< 0.001)). However, habits like drinking within meals, fried and seafood intake and chocolate intake were not significantly associated with IBS.

IBS was detected to be associated with other symptoms and medical disorders. Gastrointestinal symptoms in the form of epigastric pain, early satiety, heartburn and vomiting were significantly predominant in the IBS group than others. Some participants had chronic diseases. Four students had hypertension, 4 had hyperthyroidism, 22 had anaemia, 8 had depression, and 22 had anxiety. Thirty-two students were on chronic medications including antacids, proton pump inhibitors, antidepressants, and laxatives. Psychiatric disorders like anxiety and depression were also significantly associated with IBS (P< 0.001, P =0.005) respectively. A high percentage of IBS students were on chronic medical therapy (P =0.03). However, no significant association between IBS and hypertension, hyperthyroidism or anaemia was detected (Table 3). Multivariate logistic regression demonstrated that anxiety, depression, taking caffeine, low fruits and vegetable intake, chronic medications' intake were significant predictors for the development of IBS symptoms (Table 4).

 

 

Discussion Up    Down

The significant heterogeneity in IBS prevalence had been noticed in different areas of the world and different sectors of peoples [19, 20]. In the Arab countries, out of 12 studies, a systematic review reports for IBS prevalence were ranging from 8.9% to 79.7% [21]. Moreover, of IBS prevalence is 9.3-35.3% among medical students worldwide [22].

According to Rome III criteria, IBS was prevailing among the medical students and residences in 27.5% of our study sample. This was in agreement with a study carried out in Al-Neelain University College of Medicine Sudan which revealed that 27.2% of medical students had IBS [23]. Nevertheless, 31.7% of Ain Shams University medical students had IBS [17] In Saudi Arabia; IBS achieved the highest prevalence among medical students. Out of 90 medical students, 38 (42.22%) were affected by the IBS [24]. While in another study in Saudi Arabia in Al Maarefa University, 28.5% of medical students were suffering from IBS [25]. However, the results were different when the studies were carried on all students (medical and nonmedical) in Damascus University, Damascus, Syria [26], and Lebanon [27] as the recorded IBS prevalence was much lower (17% and 20% respectively). This might be due to the longer duration of courses, too many exams, and lots of study materials faced by medical students during their study period.

On the other hand, two studies in Malaysia, one in Melaka-Manipal Medical College [28], and another in Malaysian Private University [29], assessed that 10% and 14.7% of medical students suffered from IBS, respectively. In the previous study of medical students in Canada [30], China [31], Nigeria [32], Korea [16], and Iran [15], the prevalence of IBS were 20.5%, 33.3%, 14.4, 29.2% and 12.6% respectively. In different countries, these variations in prevalence might be due to cultural, dietary, and ethnic patterns. Also, these variations could be related to the sample sizes, age ranges, and diagnostic criteria used throughout various studies [33].

Our study was parallel to Muneer et al. who showed no statistically significant association between IBS and gender [34]. However, Elhosseiny et al. detected that the majority of IBS cases were females (P =0.006) [17]. Furthermore, studies in Saudi Arabia [24] and Malaysia [29] demonstrated that males reported IBS symptoms more than female medical students. Consistent with several other studies [31, 32, 35]; we found the IBS-mixed subtype (64%) more prevalent among our sample population.

This study showed no significant associations between smoking status, family status, and academic degree on one side and IBS symptoms on another side, which were compatible with the results of Elhosseiny et al. [17]. On the contrary, research was carried out in Saudi Arabia showed a strong relation between smoking and IBS among medical students [36]. This difference could be explained that a little number of smokers was in our study sample. Our findings were also in the accordance with Jemilohun et al. as we found no significant relationship between age, marital status and IBS prevalence among medical students [32]. Directly opposed to our observations, a study in Saudi Arabia found that sleeping less than 8 hours/day was more associated with development of IBS [33]. The Malaysian survey, however, did not find statistically significant IBS among students with sleep disturbances [29].

Regarding feeding habits, the present study detected a statistically significant relationship between IBS and consumption of some foods and drinks such as coffee, milk products, vegetables and fruits intake. These findings were in line with the study in Saudi Arabia, which found that dietary factors caused 15.5% of IBS symptoms [37]. However, Jung et al. Elhosseiny et al. and Wani et al. failed to find the relationship between IBS and consumption of foods among medical students who were supposed to be less cautious with their diet [16, 17, 24]. Regarding food allergy, our study detected that IBS manifestations were more prevalent in people with food intolerance to special types. Similar findings were reported by Chatila et al. who observed; in their study; that IBS patients reported more likely food intolerance [38]. The impact of food allergy is quite well established in activating or intensifying IBS symptoms and is the basis for the low FODMAP diet [39].

In the present analysis, the students with IBS were significantly presented by epigastric pain (P<0.001), early satiety (P=0.032), heartburn (P=0.004), and vomiting (P<0.001). However, Dissanayake et al. found diarrhoea to be the most common symptom (40%), followed by vomiting, abdominal distension/bloating (33.6%) then abdominal pain (32.9%) [28]. There was a significant association between anxiety, depression and IBS (P<0.001 and P=0.005 respectively). The results of many other previous studies affirmed our result [17, 29, 32]. Furthermore, Dissanayake et al. revealed that medical students with depression were 16.91 times more likely to get IBS [28]. This could be explained by, the immense academic load making medical students under excessive stress [40]. Furthermore, rising attention is being given to the actual impact of psychological distress on IBS pathogenesis, intensity, course, and outcome. IBS symptoms worsen the quality of life of medical students; hence, the associated risk factors should be studied. Curative therapy for IBS is still not known. However, preventive measures against risk factors, raising awareness of the society, and dietary adjustments will be helpful. [41].

There were few limitations, first, our survey was voluntary to participate in, and the response rate was 70%, which led to a small sized sample. Second, the results were assessed through a self-administered questionnaire (Rome III), without performing gastrointestinal endoscopy to confirm the absence of organic colonic disorders. However, these scores have been largely used with good reliability [18]. Third, this survey was restricted to medical students, who are knowledgeable about IBS. So we can't generalize our findings to the general Egyptian populations.

 

 

Conclusion Up    Down

In conclusion, 27.5% of Egyptian medical students, in this study, met the Rome III criteria for IBS diagnosis. Risk factors for IBS among them included anxiety, depression, taking caffeine, low fruits and vegetables intake, and chronic medications' intake. We recommend; regarding medical students, constructing educational programs in Egyptian medical colleges from the first year. So that the students can be aware of this functional condition and its risk factors they may face as stress and an unbalanced diet. Also, more studies are required in the future to demonstrate the existing prevalence of IBS and its related factors including different levels and cultures of Egyptian populations.

What is known about this topic

  • Irritable bowel syndrome has higher prevalence in medical field students in comparison to general population;
  • Psychological factors and sleep disorders are associated with IBS.

What this study adds

  • Medical students in Egypt are in high risk for IBS because stress of study and frequent examinations, bad food habits, and excessive caffeine intake;
  • Anxiety and depression are associated with IBS in Egyptian medical students.

 

 

Competing interests Up    Down

The authors declare no competing interests.

 

 

Authors' contributions Up    Down

Shimaa El Sharawy and Ibrahim Amer: conception and study design, Mahmoud Elkadeem and Shimaa El Sharawy: data collection, Mahmoud Elkadeem: data analysis and interpretation, Shimaa El Sharawy, Ibrahim Amer, and Mahmoud Elkadeem: manuscript drafting and manuscript revision. All authors read and approved the final version of this manuscript and equally contributed to its content.

 

 

Acknowledgments Up    Down

Thanks to the medical students of the Tanta and Kafr El Sheikh Universities for their participation in this study.

 

 

Tables Up    Down

Table 1: baseline demographic criteria of the studied groups

Table 2: feeding habits of the studied groups

Table 3: clinical data of the studied groups

Table 4: multivariate analysis of risk factors for irritable bowel syndrome

 

 

References Up    Down

  1. Abbasnezhad A, Amani R, Hajiani E, Alavinejad P, Cheraghian B, Ghadiri A. Effect of vitamin D on gastrointestinal symptoms and health related quality of life irritable bowel syndrome patients: a randomized double-blind clinical trial. Neurogastroentrol Motil. 2016;28(10):1533-1544. PubMed | Google Scholar

  2. Canavan C, West J, Card T. The epidemiology of irritable bowel syndrome. Clin Epidemiol. 2014;6:71-80. PubMed | Google Scholar

  3. Thomaidis T, Goetz M, Gregor SP, Hoffman A, Kouroumalis E, Moehler M et al. Irritable bowel syndrome and organic diseases: a comparative analysis of esophageal motility. World J Gastroenterol. 2013;19(38):6408-15. PubMed | Google Scholar

  4. Lacy BE, Patel NK. Rome Criteria and a Diagnostic Approach to Irritable Bowel Syndrome. J Clin Med. 2017;6(11):99. PubMed | Google Scholar

  5. Frank L, Kleinman L, Rentz A, Ciesla G, Kim JJ, Zacker C. Health-related quality of life associated with irritable bowel syndrome: comparison with other chronic diseases. Clin Ther. 2002;24(4):675-689; discussion 674. PubMed | Google Scholar

  6. Agarwal N, Spiegel BM. The effect of irritable bowel syndrome on health-related quality of life and health care expenditures. Gastroenterol Clin North Am. 2011;40(1):11-9. PubMed | Google Scholar

  7. Soubieres A, Wilson P, Poullis A, Wilkins J, Rance M. Burden of irritable bowel syndrome in an increasingly cost-aware National Health Service. Frontline Gastroenterol. 2015;6(4):246-251. PubMed | Google Scholar

  8. International foundation for Gastrointestinal Disorders About, IBS. Statistics. Accessed 4th February 2021.

  9. Oka P, Parr H, Barberio B, Black CJ, Savarino EV, Ford AC. Global prevalence of irritable bowel syndrome according to Rome III or IV criteria: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2020;5(10):908-917. PubMed | Google Scholar

  10. Jung HK, Hander S, McNally M, Locke GR III, Schleck CD, Zinsmeister AR et al. Overlap of gastro-oesophageal reflux disease and irritable bowel syndrome: prevalence and risk factors in the general population. Aliment Pharmacol Ther. 2007;26(3):453-61. PubMed | Google Scholar

  11. Olafsdottir LB, Gudjonsson H, Jonsdottir HH, Thjodleifsson B. Stability of the irritable bowel syndrome and subgroups as measured by three diagnostic criteria - a 10-year follow-up study. Aliment Pharmacol Ther. 2010;32(5):670-80. PubMed | Google Scholar

  12. Schmulson M, Ortiz O, Santiago Lomeli M, Gutiérrez-Reyes G, Gutiérrez-Ruiz MC, Robles-Díaz G et al. Frequency of functional bowel disorders among healthy volunteers in Mexico City. Digest Dis. 2006;24(3-4):342-347. PubMed | Google Scholar

  13. Quigley EM, Locke GR, Mueller-Lissner S, Paulo LG, Tytgat GN, Helfrich I et al. Prevalence and management of abdominal cramping and pain: a multinational survey. Aliment Pharmacol Ther. 2006;24(2):411-419. PubMed | Google Scholar

  14. Minocha A, Johnson WD, Abell TL, Wigington WC. Prevalence, sociodemography, and quality of life of older versus younger patients with irritable bowel syndrome: a population-based study. Dig Dis Sci. 2006;51(3):446-53. PubMed | Google Scholar

  15. Mansour-Ghanaei F, Fallah MS, Heidarzadeh A, Jafarshad R, Joukar F, Ghasemipour R et al. Prevalence and characteristics of irritable bowel syndrome (IBS) amongst medical students of Gilan Northern Province of Iran. MEJDD. 2011;1:100-105. Google Scholar

  16. Jung HJ, Park MI, Moon W, Park SJ, Kim HH, Noh EJ et al. Are food constituents relevant to the irritable bowel syndrome in young adults? A Rome III based prevalence study of the Korean medical students. J Neurogastroenterol Motil. 2011;17(3):294-299. PubMed | Google Scholar

  17. Elhosseiny D, Mahmoud NE, Manzour AF. Factors associated with irritable bowel syndrome among medical students at Ain Shams University. J Egypt Public Health Assoc. 2019 Dec 4;94(1):23. PubMed | Google Scholar

  18. Drossman DA, Corazziari E, Delvaux M, Spiller RC, Talley NJ, Thompson WG et al. Rome III; the functional gastrointestinal disorders. 3rd ed. McLean: Degnon Associates; 2006. p. 917-951.

  19. Lovell RM, Ford AC. Global prevalence of and risk factors for irritable bowel syndrome: A meta-analysis. Clin Gastroenterol Hepatol. 2012;10(7):712-721. PubMed | Google Scholar

  20. Chang FY, Lu CL, Chen TS. The current prevalence of irritable bowel syndrome in Asia. J Neurogastroenterol Motil. 2010;16(4):389-400. PubMed | Google Scholar

  21. Alosaimi M, Ali A, Abdul Razzak H. Epidemiology of Irritable Bowel Syndrome; A Systematic Review of Literature. Journal of Health Informatics in Developing Countries. 2016;10(1). Google Scholar

  22. Ibrahim NK. A systematic review of the prevalence and risk factors of irritable bowel syndrome among medical students. Turk J Gastroenterol. 2016;27(1):10-16. PubMed | Google Scholar

  23. Eltayeb LB. A Questionnaire-based Survey on Irritable Bowel Syndrome among Medical and Non-Medical Students at Al-Neelain University, Khartoum, Sudan. J Biochem Technol. 2020;11(3):43-48. Google Scholar

  24. Wani FA, Almaeen AH, Bandy AH, Thirunavukkarsu A, Al-Sayer TA, Flah A et al. Prevalence and risk factors of IBS among medical and nonmedical students in the Jouf University. Niger J Clin Pract. 2020;23(4):555-560. PubMed | Google Scholar

  25. Khalifa AF, Alqassem AA, Aljubour ZA, Alzahrani HS, Almuhaidib MA, Almutairi SS et al. The prevalence of irritable bowel syndrome among Almaarefa University. Indo American Journal of Pharmaceutical Sciences. 2019;6(2):2993-3003.

  26. Al Saadi T, Idris A, Turk T, Alkhatib M. Epidemiology and risk factors of uninvestigated dyspepsia, irritable bowel syndrome, and gastro esophageal reflux disease among students of Damascus University, Syria. J Epidemiol Glob Health. 2016;6(4):285-293. PubMed | Google Scholar

  27. Costanian C, Tamim H, Assaad S. Prevalence and factors associated with irritable bowel syndrome among university students in Lebanon: findings from a cross-sectional study. World J Gastroenterol. 2015;21(12):3628-3635. PubMed | Google Scholar

  28. Dissanayake R, Nawas SMM, Johari AZ, Narowi NM, Mei Hua MBS. A Cross-sectional Study on Prevalence and predictors of irritable bowel syndrome among medical students of Melaka-Manipal Medical College, Malaysia. International Journal of Biomedical and Clinical Sciences. 2020;5(2):95-104.

  29. Seger S, Nasharuddin NNB, Fernandez SL, Yunus SRBM, Shun NTM, Agarwal P et al. Prevalence and factors associated with irritable bowel syndrome among medical students in a Malaysian private university: a cross sectional study. Pan Afr Med J. 2020 Oct 13;37:151. PubMed | Google Scholar

  30. Wells M, Roth L, McWilliam M, Thompson K, Chande N. A cross-sectional study of the association between overnight call and irritable bowel syndrome in medical students. Can J Gastroenterol. 2012;26(5):281-284. PubMed | Google Scholar

  31. Liu Y, Liu L, Yang Y, He Y, Zhang Y, Wang M et al. A school-based study of irritable bowel syndrome in medical students in beijing, china: prevalence and some related factors. Gastroenterol Res Pract. 2014;2014:124261. PubMed | Google Scholar

  32. Jemilohun A, Abayomi O, Adebayo P. Prevalence of Irritable Bowel Syndrome, Psychological Ill-Health and Health-Seeking Behavior in a Population of Nigerian Medical Students. Journal of Advances in Medicine and Medical Research. 2018;25(4):1-9. Google Scholar

  33. Ibrahim NK, Battarjee WF, Almehmadi SA. Prevalence and predictors of irritable bowel syndrome among medical students and interns in King Abdulaziz University, Jeddah. Libyan J Med. 2013;8:212-287. PubMed | Google Scholar

  34. Muneer A, Moayad A, Abdullah A, Mohannad A, Moeen Z. Prevalence of irritable bowel syndrome and its associated factors among medical students. International Journal of Medical Research & Health Sciences. 2017;6(2):1-10. Google Scholar

  35. Al Ameel T, Roth LS, Al Sulais E. The prevalence of irritable bowel Syndrome among board-certified medical doctors in Saudi Arabia: A Cross-sectional Study. J Can Assoc Gastroenterol. 2019;3(6):e32-e36. PubMed | Google Scholar

  36. Murad MA, Abousada HJ, Zamzami YM, Alkaf MA, Sagga BKM, Alhrany AN et al. prevalence and risk factors of irritable bowel syndrome among medical students. Int J of Adv Res. 2019;7(12):1008-1016. Google Scholar

  37. Al-Turki YA, Aljulii MZ, Al Murayshid A, Al Omaish HR, Al Daghiri KS, Al Seleemi AY et al. Prevalence of irritable bowel syndrome among students in King Saud University, Riyadh, Saudi Arabia. World J Fam Med. 2011;9:17-20. Google Scholar

  38. Chatila R, Merhi M, Hariri E, Sabbah N, Deeb ME. Irritable bowel syndrome: prevalence, risk factors in an adult Lebanese population. BMC Gastroenterol. 2017 Dec 2;17(1):137. PubMed | Google Scholar

  39. Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2014;146(1):67-75. PubMed | Google Scholar

  40. Jafri W, Yakoob J, Jafri N, Islam M, Ali QM. Frequency of irritable bowel syndrome in college students. J Ayub Med Coll Abbottabad. 2005;17(4):9-11. PubMed | Google Scholar

  41. Liu L, Xiao QF, Zhang YL, Yao SK. A cross-sectional study of irritable bowel syndrome in nurses in China: prevalence and associated psychological and lifestyle factors. J Zhejiang Univ Sci B. 2014;15:590-597. PubMed | Google Scholar