AMJ Vol 10 No 2 June 2023(1).indd


Althea Medical Journal. 2023;10(2)

93

Prevalence of Gastroesophageal Reflux Disease among Diabetic 
Patients at Sharif Medical City Hospital, Lahore, Pakistan 

Syed Muslim Mehdi,1 Usman Baig,1 Muhammad Shahid Iqbal2
1Department of Medicine, Sharif Medical City Hospital, Lahore, Pakistan, 2Department of 

Community Medicine, Sharif Medical and Dental College, Lahore, Pakistan

Correspondence: Dr. Usman Baig, MBBS, Department of Medicine, Sharif Medical City Hospital, Sharif Medical City Road, Off 
Raiwind Road, Jati Umra, Lahore, Pakistan, E-mail: usman.baig1147@gmail.com

Introduction

Diabetes mellitus is a group of metabolic 
diseases characterized by chronic 
hyperglycemia, resulting from defects in 
insulin secretion, insulin action, or both. 
Insulin is an anabolic hormone that is released 
by the Islets of Langerhans in the pancreas. 
In pancreatic B cells, insulin secretion is 
stimulated by the alteration of cellular array 
of messenger molecules. Type 1 diabetes 
mellitus, also known as insulin-sensitive 
diabetes mellitus, results when the pancreas 
produces little or no insulin. Children between 
the age of 10 and 14 years old are most likely to 
develop it; whereas in type 2 diabetes mellitus, 
also called insulin resistant, the tissues resist 
the effects of insulin, followed by insufficient 
insulin production by the pancreas later in life. 
It occurs most often in middle-aged and older 
people, however, there has been an increase 
in the prevalence of type 2 diabetes mellitus 

among children.1–3
As in diabetes mellitus, long-term 

hyperglycemia is linked with a number of 
co-morbidities including cardiovascular 
diseases, nerve damage (neuropathy), renal 
disease, retinopathy, and skin conditions.4 It 
is one of the causes of several gastrointestinal 
motility disorders, including gastroesophageal 
reflux disease (GERD) and gastroparesis. 
The mechanism of development of GERD in 
diabetics is multifactorial and is linked with 
obesity, neuropathy and hormonal imbalance 
of ghrelin and motilin. Obesity causes higher 
intra-abdominal pressure leading to hiatal 
herniation, which reduces lower esophageal 
tone and causes acid reflux. Diabetes induces 
neuropathy causes gastropathy and esophageal 
dysmotility.5 Chronic gastroesophageal reflux 
disease can lead to Barrett’s esophagus 
and esophageal adenocarcinoma as well 
as negatively affecting the patient’s living 
conditions, productivity and sleep.6

Althea Medical Journal. 2023;10(2):93–98

Abstract

Background: Diabetes mellitus has been linked to various gastrointestinal motility disorders, 
including gastroesophageal reflux disease (GERD). This study aimed to determine the proportion of 
GERD in patients with diabetes mellitus.
Methods: This descriptive cross-sectional study was conducted at the medical outpatient department 
of Sharif Medical City Hospital, Lahore, from October to December, 2020. Patients previously diagnosed 
with type II diabetes were included using non-probability consecutive sampling, and the GERDQ 
questionnaire was used to determine the frequency. IBM SPSS statistics version 23 was used for the 
analysis of data.
Results: Of the 273 participants, 183 (67.0%) were male and the mean age was 51.13±12.8 years. 
The mean duration of diabetes was 6.97±4.76 years and oral hypoglycemic agents were used by 133 
(48.7%) participants. Overall, 133 (48.7%) of the participants had GERD with a mean GERDQ score of 
10.8(±1.4). 
Conclusions: Almost half of the participants have GERD; the most common symptom is regurgitation 
of stomach contents. Awareness should be raised, and early screening should be done to prevent long-
term complications.
 
Keywords: Diabetes mellitus, gastroesophageal reflux disease, GERDQ questionnaire, obesity, Pakistan

https://doi.org/10.15850/amj.v10n2.2881



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The worldwide prevalence of diabetes 
is 9.3%, and in Pakistan it is 14.6%.7,8 The 
prevalence of GERD among the population 
of Pakistan ranges from 22–24%.9,10 The aim 
of this study was to determine the frequency 
of GERD in the diabetic population as a 
recent meta-analysis showed that there is 
a significant association between diabetes 
and GERD.11 This study is essential due to 
variations in frequencies of GERD in the 
diabetic population of different countries. 
Our study will fill the literature gap and help 
physicians in early detection and treatment 
of GERD and this will also reduce the risk of 
the development of Barrett’s esophagus and 
esophageal adenocarcinoma.

Methods

It was a descriptive cross-sectional study 
conducted in medical outpatient department 
of Sharif Medical City Hospital, Lahore from 
October to December, 2020 after approval 
from the Ethics Committee of Sharif Medical 
and Dental College, Lahore (Ref No. SMDC/
SMRC/138-20). The location of Lahore city 
on the map of Pakistan is shown in Figure 1. 
Sample size of 273 was calculated with the 
help of WINPEPI Statistical program, with 
confidence of 95% with acceptable difference 
of 0.05 and assumed proportion of 0.23.12,13 

Patients previously diagnosed with type II 

diabetes were included using non-probability 
consecutive sampling. Patients with gestational 
diabetes mellitus, Crohn’s disease, ulcerative 
colitis and diabetes insipidus were excluded. 
Informed consent was taken from the patients 
and GERDQ questionnaire was filled out on 
spot. It was a six-item, Likert scale-based 
questionnaire consisting symptoms in the last 
week which included frequency of heartburn, 
epigastric pain, nausea, sleep disturbance, 
regurgitation and use of additional medicine 
besides the prescribed ones. The presence 
of GERD was determined based on summing 
up the individual score of all questions and 
comparing the total with a cut-off value of 9, 
having a sensitivity of 66% and specificity of 
64%.14

For analysis of data, SPSS version 23 was 
used. For quantitative variables, like age, 
BMI, duration of diabetes and GERDQ score, 
mean±SD were calculated. Frequency was 
calculated for qualitative variables like gender, 
education, and occupational status. Body mass 
index (BMI) cut-off values used to classify the 
nutritional status of participants were of the 
Asian population. The normal BMI range was 
18.5–22.9 kg/m2. Patients with BMI between 
23–24.9 kg/m2 were considered overweight 
and those with BMI greater than 25 kg/m2 
were obese.15 Post-stratification chi-square 
was applied and value ≤0.05 was considered 
significant.

Althea Medical Journal June 2023

Figure 1 Location of Lahore on the Map of Pakistan*
*Source: Wikipedia/NordNordWest



Althea Medical Journal. 2023;10(2)

95Syed Muslim Mehdi et al.: Prevalence of Gastroesophageal Reflux Disease among Diabetic Patients at Sharif 
Medical City Hospital, Lahore, Pakistan 

Table 1 Sociodemographic Characteristics of Participants 
Characteristics Frequency (n) Percentage (%)

Age group of participants (in years) ≤40
41–50
51–60
61–70
≥71

50
46

127
44
6

18.3
16.9
46.5
16.1
2.2

Gender Male
Female

183
90

67.0
33.0

Educational status Primary
Secondary
Post-secondary
Graduation/Higher

25
41

112
95

9.2
15.0
41.0
34.8

Occupational status Employed
Unemployed

100
173

36.6
63.4

Total family income (in PKR)
1 USD= 160PKR

<30,000
30,000–50,000
>50,000

37
37

199

13.6
13.6
72.8

Note: PKR= Pakistan Rupee

Results

There were 273 participants, of which 183 
(67.0%) were male. The most common age 
group was between 51 to 60 years. Complete 
sociodemographic characteristics are shown 
in Table 1. The duration of diabetes in most 
subjects was between 5–10 years and they 
were Obese I. Almost half (48.7%) were using 
oral medications for glycemic control. History 
of smoking was absent in 258 (94.5%) and 94 
(34.4%) exercised regularly and were following 
nutritional recommendations offered by their 
physicians. Among the other medications used 
by participants, the most common were anti-
hypertensives which were being used by 43 
(15.8%). Clinical characteristics of participants 
and their comparison between those with and 
without GERD are shown in Table 2.

The participants had an average GERDQ 
score of 8.96 (±2.1). GERD was present in 133 
(48.7%) participants with a mean score of 
10.8 (±1.4). The most common symptom in the 
study was regurgitation of stomach contents 
and night sleep disturbance; the frequency of 
symptoms is shown in Table 3.

Discussions

The frequency of GERD in diabetics is greater 
when compared with that of the normal 
population of America (18.1% to 27.8%), 
Europe (25.9%), Australia (11.6%) and 
Nigeria (7.6%).16–19 Diabetics also have a 

higher frequency of GERD than the general 
population of Asian countries, including 
Pakistan, supporting that diabetes-associated 
induced neuropathy could be the cause of 
GERD in diabetic population.9,10,20,21

The result of the study is close to those 
conducted in America and Saudi involving 
diabetic population.22,23 However, the 
frequency of GERD in diabetics in the study 
is greater than those of Indonesia, China and 
Mexico.24–26 GERD frequency in Indonesian 
diabetics is 30.2% and is less than the 
frequency among participants of this study. 
This could be due to the fact that the mean 
BMI (24.07±4.32 kg/m2 ) of the participants 
and the duration of diabetes (median=2 years) 
is less than that of our study (BMI=28.4±5.18 
kg/m2, median duration=6 years).24 Mexican 
study also showed less frequency, this could 
be possibly due to racial and geographical 
factors.25 In Chinese study, a different 
questionnaire (Reflux Disease Questionnaire) 
was used which could be accountable for the 
differences in results.26 

Studies conducted in Turkey and 
Bangladesh showed increased frequency of 
GERD in diabetics compared to this study.27,28  
This could be because the study conducted 
in Bangladesh only involved participants 
admitted in hospital and among those, most 
of them had co-morbidities.27 Whereas, a self-
devised questionnaire was used in Turkish 
study which could have led to the differences 
in results of both studies.28 



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There is a higher proportion of individuals 
between the ages of 51 and 60 years old, 
suggesting that the majority of diabetes-
related comorbidities begin to manifest in this 
age range, resulting in frequent hospital visits. 
The higher number of male participants in 
the study could be due to the limited access of 
women in rural areas to tertiary care hospitals 
and their reliance on male family members for 
transportation. This could be a contributor to 
the gender disparity in the study. There was a 
higher number of participants with diabetes 
for more than five years who had symptoms of 
GERD compared to those with diabetes for less 
than five years, indicating that an increased 
duration of diabetes may be a contributing 
factor, as observed in other studies.11 However, 
the results were not consistent for those with 
a duration of diabetes greater than 10 years 
due to the small number of participants in this 
group.

The limitations of this study included a 

small sample and being limited to a single 
site. More hospitals could have been involved 
to have a large number of patients and to 
have patients from different localities. The 
latest studies in this regard should be done 
using 24-hour esophageal pH monitoring and 
manometry. 

In conclusion, awareness regarding GERD 
symptoms should be raised in diabetics as 
almost half of the participants had GERD 
in the study. The most common symptom 
being regurgitation of stomach contents and 
sleep disturbance. Screening should be done 
to devise early strategy and management. 
This could lower the risk of development of 
complications of GERD. 

Source of Funding: No funding to declare.

Disclaimer: None

Conflict of Interests: None to declare. 

Althea Medical Journal June 2023

Table 2 Clinical Characteristics of Participants with and without GERD (n= 273) 

Clinical Characteristics GERD (n)
Non-
GERD 

(n)
X2 p-value

Nutritional status (BMI) Normal range (18.5–22.9)
Overweight at risk (23–24.9)
Obese I (25–29.9)
Obese II (≥30)

6
43
39
45

18
8

79
35

44.67 <0.001

Duration of diabetes (years) <5
5–10
>10

33
88
12

52
65
23

10.98 0.004

Diet control Yes
No

109
24

116
24

0.38 0.84

Exercise Yes
No

67
66

52
88

4.85 0.028

Medication for diabetes None
Oral medication
Oral medications and insulin

9
77
47 

20
56
64

9.19 0.007

Table 3 Frequency of GERD Symptoms among the Participants 

Symptoms
0 Day

(Never)
1 Day
(Mild)

2–3 Days
(Moderate)

4–7 Days
(Severe)

n (%) n (%) n (%) n (%)
Heartburn
Acid regurgitation
Stomach pain or discomfort
Nausea
Night sleep disturbance

94 (34.4)
78 (28.6)

121 (44.3)
145 (53.1)
83 (30.4)

69 (25.3)
92 (33.7)
46 (16.8)
63 (23.1)
65 (23.8)

74 (27.1)
82 (30.0)
83 (30.4)
57 (20.9)
87 (31.9)

36 (13.2)
21 (7.7)
23 (8.4)
8 (2.9)

38 (13.9)



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Medical City Hospital, Lahore, Pakistan 



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