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DOI 10.1007/s11325-014-1051-4
ORIGINAL ARTICLE
Received: 24 April 2014 / Revised: 12 August 2014 / Accepted: 18 August 2014 / Published online: 31 August 2014
# Springer-Verlag Berlin Heidelberg 2014
Subjects (%)
30
symptoms consistent with GER experienced at least once a
week in the last year. Out of 957 OSAS patients, 372 (38.9 %)
had GERD (once a week of heartburn and/or regurgitation), 20
whereas 47 subjects (32.0 %) had GERD in non-OSAS group
and the difference was not statistically significant (p=0.064). 10
As shown in Fig. 2, there was no difference in terms of major
GER symptoms (heartburn, regurgitation) between non-
0
OSAS and mild, moderate, and severe OSAS groups.
No symptoms Occasional GERD
Additional symptoms, namely extraesophageal symptoms, symptoms
alarm symptoms, and epigastric pain of non-OSAS subjects Fig. 2 Gastroesophageal reflux symptoms of non-OSAS and OSAS
and mild, moderate, and severe OSAS patients with GERD, patients (p>0.05 for all comparisons). GERD gastroesophageal reflux
were evaluated. It was found that the patients with OSAS and disease, OSAS obstructive sleep apnea syndrome
GERD reported cough (p=0.046) and odynophagia (p=0.015)
more frequently than non-OSAS patients with GERD (Table 1). Risk factors for GERD in OSAS patients in the multivariate
When the clinical characteristics of non-OSAS subjects with linear regression analysis
GERD were compared to the ones without GERD, no significant
difference was observed (Table 2). However, in OSAS patients The relationship between GERD and other variables was exam-
with GERD, body mass index (p=0.049) was greater, waist (p= ined to determine factors underlying development of reflux in
0.007) and hip (p<0.0001) circumferences were larger, and OSAS patients. There was a significant difference between
Epworth sleepiness scores were higher (p<0.0001) when com- OSAS patients with and without GERD according to female
pared to the patients without GERD as shown in Table 2. gender, daytime sleepiness assessed by Epworth Sleepiness
In OSAS group, the prevalence of GERD was increased in Scale, and circumferences of neck and hip. Consequently, these
female patients (46.6 %) than in male patients (35.7 %) (p= four variables were considered as potential predictors for GERD
0.002). Gender-specific characteristics of OSAS patients were and included in the multivariate linear regression analysis. It was
assessed according to the presence of GERD, and it was found that female gender (p=0.027), Epworth sleepiness score
determined that neck circumference of male OSAS patients (p=0.001), and circumference of hip (p=0.021) were significant-
with GERD was larger than that of the males with no GERD ly associated with GERD (Table 5).
(44.2±3.9 vs. 43.6±3.3, p=0.039). In female OSAS patients
with GERD, waist circumference was larger than in the ones
with no GERD (117.6±14.9 vs. 113.5±14.9, p=0.024). Be-
sides, the prevalence of GERD increased with the increase in Discussion
BMI in females but the difference was not significant (Table 3).
It is claimed that GERD is common in patients with OSAS but
Sleep parameters of non-OSAS and OSAS patients with and prospective and comparative studies are limited and contra-
without GERD dictory. OSAS and GERD share similar risk factors, and it is
unclear whether the co-occurrence of these conditions repre-
As shown in Table 4, there was no difference with regard to sents a causal relationship or is simply a reflection of shared
polysomnographic parameters in non-OSAS subjects with risk factors. In the present large-cohort study, it was shown
and without GERD. In OSAS patients with GERD, the per- that 38.9 % of OSAS patients and 32.0 % of non-OSAS
centages of sleep efficiency (p=0.044) and stage N2 sleep (p= subjects reported GERD, and the prevalence of GERD was
0.017) were higher, and the percentage of stage N1 sleep considerably increased compared to the general population.
(p<0.0001) was lower than in OSAS patients without GERD. There was no relationship between the severity of OSAS and
However, the indicators of OSAS severity including AHI, the presence of GERD. In OSAS patients with GERD, mea-
oxygen desaturation index, lowest nocturnal oxygen saturation surements of obesity including BMI and circumferences of
(SpO2) (%), sleep time with SpO2 <90 % (min), and sleep time waist and hip were greater and daytime sleepiness was higher
with SpO2 <90 % (%) did not correlate with GERD. In addi- than in the patients without GERD. Besides, the prevalence of
tion, reflux symptoms were not associated with sleep position GERD was increased in female OSAS patients. The present
assessed by position sensor during polysomnography. results support that OSAS was not likely a causative factor,
Sleep Breath (2015) 19:585–592 589
Symptoms, n (%) Non-OSAS (n=47) Mild OSAS (n=77) Moderate OSAS (n=78) Severe OSAS (n=215) Total (n=417) p value
Extraesophageal symptoms 40 (85.1) 62 (80.5) 67 (85.9) 161 (74.9) 330 (79.1) 0.132
Cough 25 (56.8) 48 (64.0) 53 (71.6) 112 (53.8) 238 (59.4) 0.046
Hoarseness 23 (48.9) 29 (40.3) 25 (34.7) 84 (42.0) 161 (41.2) 0.478
Chest pain 29 (63.0) 43 (58.1) 38 (52.1) 97 (47.8) 207 (52.3) 0.188
Alarm symptoms 23 (48.9) 43 (57.3) 48 (61.5) 112 (52.1) 226 (54.5) 0.409
Dysphagia 22 (47.8) 42 (56.0) 46 (60.5) 111 (53.4) 221 (54.6) 0.549
Odynophagia 5 (11.1) 19 (25.7) 17 (23.0) 24 (12.1) 65 (16.6) 0.015
Epigastric pain 32 (72.7) 51 (67.1) 49 (67.1) 117 (57.4) 249 (62.7) 0.131
GERD gastroesophageal reflux disease, NS not significant, OSAS obstructive sleep apnea syndrome
p<0.05 was considered significant and written in boldface
but female gender, obesity, and sleepiness were related with research area (n=694) [29]. Since all three studies revealed very
the prevalence of GERD in OSAS patients. similar results with the same questionnaire, it is possible to claim
In our large cohort referred for sleep studies, 419 of the 1,104 that GERD prevalence was significantly increased compared to
subjects (38.0 %) reported symptoms consistent with GER ex- the general population. In a study with a similar design, the
perienced at least once at a week in the last year. The prevalence prevalence of symptomatic GER was investigated in 135 sub-
of GERD was 38.9 % in OSAS and 32.0 % in non-OSAS jects with obstructive sleep apnea (OSA) and 93 with snoring. It
subjects, and there was no significant difference between two was found that symptomatic GER is common in subjects with
groups. In our previous studies, the prevalence of GERD was SDB, but there was no difference between those with OSAS and
20 % in a small town near the study area (n=630) [10], 22.8 % in snoring [19]. Additionally, Shepherd et al. [30] showed that the
a country-wide study (n=3,200) [28], and 19.4 % in the same prevalence of nocturnal reflux symptoms is increased in OSA
Table 2 Characteristics of the non-OSAS and OSAS patients with and without GERD
GERD (−) (n=100) GERD (+) (n=47) GERD (−) (n=585) GERD (+) (n=372)
Male, n (%) 67 (71.3) 27 (28.7) 0.261 437 (64.3) 243 (35.7) 0.002
Female, n (%) 33 (62.3) 20 (37.7) 148 (53.4) 129 (46.6)
Age (years) 46.5±13.0 46.1±13.9 0.863 52.7±10.9 51.4±11.3 0.098
Smoking history, n (%)
Never smoker 50 (50.0) 18 (38.3) 0.414 259 (44.3) 188 (50.6) 0.149
Former smoker 24 (24.0) 16 (34.0) 194 (33.1) 111 (29.8)
Current smoker 26 (26.0) 13 (27.7) 132 (22.6) 73 (19.6)
Alcohol consumption, n (%) 19 (19.0) 9 (19.1) 0.952 124 (21.2) 70 (18.8) 0.378
Body mass index (kg/m2) 29.2±4.7 29.9±5.4 0.369 33.1±6.8 34.0±7.0 0.049
Neck circumference (cm) 40.7±3.8 39.5±3.4 0.127 42.6±3.8 42.9±4.3 0.249
Waist circumference (cm) 104.5±12.2 102.9±12.0 0.449 113.1±13.4 115.5±13.9 0.007
Hip circumference (cm) 108.0±11.0 110.0±11.1 0.314 114.2±12.8 117.9±13.7 <0.0001
Comorbidities n (%)
Coronary artery disease 6 (6.0) 5 (10.6) 0.364 56 (9.6) 57 (15.3) 0.007
Congestive heart failure 9 (9.0) 3 (6.4) 0.522 40 (8.8) 37 (9.9) 0.077
Hypertension 21 (21.0) 8 (17.0) 0.553 224 (38.3) 158 (42.5) 0.194
Diabetes mellitus 17 (17.0) 8 (17.0) 0.997 113 (19.3) 86 (23.1) 0.152
Epworth sleepiness score 6.9±5.5 7.1±6.1 0.846 8.8±5.6 10.3±6.0 <0.0001
Table 3 Gender-specific prevalence of GERD according to BMI in non- Table 5 Multivariate linear regression analysis between GERD and
OSAS and OSAS patients other variables
Table 4 Sleep parameters of non-OSAS and OSAS patients with and without GERD
GERD (−) (n=100) GERD (+) (n=47) GERD (−) (n=585) GERD (+) (n=372)
associated with hip circumference. To the best of our knowledge, and had been applied in large population-based studies. Second-
this is the first study evaluating the relation between GERD and ly, our study samples were recruited from sleep disorder centers
obesity measurements other than BMI in OSAS. Furthermore, and they had a SDB. The control group would have been
GERD prevalence increased with a higher BMI in females, recruited from the general population but then control subjects
although the difference was not significant. It is of interest that could have been undiagnosed of SDB and they could have been
men were less likely than women to have GERD in our study. less obese. Thirdly, GERD was significantly associated with
This could have been due at least in part to our women subjects daytime sleepiness in the present study, and frequent arousals
manifesting a higher BMI. An investigation with 136 patients caused by nocturnal reflux could be an explanation for increased
utilizing a validated reflux questionnaire established a relation- sleepiness. However, we could not evaluate the arousal index of
ship between obesity and GERD [33], and a positive correlation the patients. Finally, the severity of GERD and its complications
was observed between GERD and BMI in SDB subjects [30]. like erosive disease and Barrett’s esophagus could not be inferred
In a population-based large cohort, 15,314 subjects completed as we evaluated the subjects with a GERD questionnaire.
questions about heartburn during sleep and 24.9 % reported this In conclusion, it was demonstrated in this large cohort that
symptom. In a multivariate analysis, daytime sleepiness was a the prevalence of GERD was significantly increased in sub-
predictor of heartburn during sleep [34]. In another study, 564 jects with primary snoring and OSAS compared to the general
subjects referred to sleep laboratory completed a GERD ques- population, but the severity of OSAS did not influence GERD
tionnaire. The patients with GERD had higher scores in Epworth prevalence. The present results support that female gender,
Sleepiness Scale and a positive association was observed be- obesity, and daytime sleepiness were related with the preva-
tween sleepiness and GERD risk [32]. We also found that lence of GERD. Therefore, it can be proposed that a simple
daytime sleepiness was higher in OSAS patients with GERD, causal link does not exist between OSAS and GERD, but
and the multivariate analysis showed that GERD was significant- rather that they are common problems with shared risk factors.
ly associated with sleepiness. It is known that daytime sleepiness Further investigations are required to elucidate a potential
may increase with the severity of OSAS. However, the severity bidirectional relationship between OSAS and GERD.
of OSAS did not influence the GERD prevalence in this study.
Therefore, frequent arousals caused by nocturnal reflux could be Conflict of interest The manuscript entitled “Obstructive sleep apnea
an explanation for increased sleepiness. syndrome and gastroesophageal reflux disease: the importance of obesity
It is plausible that with increasing severity of OSAS, more and gender” which we submit for consideration to be published in Sleep
and Breathing is not under consideration for publication nor published
GERD would have occurred in a dose-response relationship. elsewhere.
The relation between the prevalence of GERD and the factors The investigation was performed at the Ege University Faculty of
that served as surrogate indicators of OSAS severity like AHI Medicine, Dr. Suat Seren Chest Diseases and Surgery Training and
or nocturnal hypoxemia were examined in several studies. Research Hospital, and Katip Celebi University Faculty of Medicine.
The work has been seen and approved by all coauthors. The authors have
There was no difference in terms of major GER symptoms no proprietary, financial, professional, or other personal interest of any
between primary snoring and mild, moderate, and severe nature or kind in any product, service, and/or company that could be
OSAS groups in the present study. Besides, other indicators construed as influencing the position presented in, or the review of, the
of OSAS severity including AHI, oxygen desaturation index, manuscript.
lowest nocturnal oxygen saturation, and sleep time with oxy-
gen saturation <90 % did not correlate with GERD. These
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