J Neurogastroenterol Motil 2024; 30(4): 491-500  https://doi.org/10.5056/jnm22067
Differences in Prevalence and Psychosocial Characteristics of Irritable Bowel Syndrome According to Rome III and Rome IV Criteria in Medical and Nursing Students
Ji Hwan Park,1 Hyeok Jun Jeong,1 Ka Eun Lee,1 Hong Sub Lee,2* Seung Jung Yu,2 Jun Sik Yoon,2 Eun Jeong Choi,2 Jung Ho Park,3 Ki Bae Bang,4 Ju Seok Kim,5 and Yong Sung Kim6; IBS Research Study Group of the Korean Society of Neurogastroenterology and Motility
1College of Medicine, Inje University, Busan, Korea; 2Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea; 3Department of Internal Medicine, Sungkyunkwan University Kangbuk Samsung Hospital, Seoul, Korea; 4Department of Internal Medicine, Dankook University Hospital, Cheonan, Chungcheongnam-do, Korea; 5Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea; 6Digestive Disease Research Institute, Wonkwang University, Iksan, North Jeolla Province, Korea; and IBS Committee, The Korean Society of Neurogastroenterology and Motility
Correspondence to: *Hong Sub Lee, MD, PhD
Department of Internal Medicine, Inje University Busan Paik Hospital, 75 Bokji-ro, Busanjin-gu, Busan 47392, Korea
Tel: +82-51-890-6898, E-mail: epoch0123@naver.com
Ji Hwan Park and Hyeok Jun Jeong contributed equally to this work.
Received: May 10, 2022; Revised: June 2, 2023; Accepted: May 12, 2024; Published online: October 30, 2024
© The Korean Society of Neurogastroenterology and Motility. All rights reserved.

cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background/Aims
In Korea, changes in the prevalence of irritable bowel syndrome (IBS) after the Rome IV update have not been extensively studied. The aim of this study is to compare the prevalence and psychosocial risk factors of IBS according to Rome III and Rome IV criteria in medical and nursing students.
Methods
From August 13, 2021 to October 22, 2021, participants were enrolled and surveyed online. The survey includes general and specific questions for disease diagnosis and regarding participants’ social and psychological characteristics using the 36-item short form survey, the Brief Encounter Psychosocial Instrument-Korean version, and the Hospital Anxiety and Depression Scale.
Results
In total, 338 medical students and 102 nursing students completed the survey. IBS was diagnosed in 78 students (17.7%) using Rome III criteria and in 51 students (11.6%) using Rome IV criteria. Significant differences in physical functioning score and severity score were observed between patients diagnosed using Rome IV criteria and patients diagnosed using Rome III criteria. Multiple logistic regression revealed that severity score (adjusted odds ratio = 1.01; 95% confidence interval: 1.00-1.21; P = 0.022) is the only predictor of IBS that differentiates Rome IV criteria from Rome III criteria.
Conclusions
Even after updating the Rome IV diagnostic criteria, the prevalence of IBS in medical and nursing students in Korea remained high. Patients who met the Rome IV criteria had more severe symptoms and lower quality of life than patients who met the Rome III criteria.
Keywords: Diagnosis; Irritable bowel syndrome; Prevalence; Students, medical
Introduction

Irritable Bowel Syndrome (IBS) is a functional gastrointestinal disease that onsets with abdominal pain and change in bowel habit. It has a reported incidence of 4.7% in Korea1 and 2.0-33.0% worldwide.1,2 It is one of the main reasons patients visit gastroenterologists at hospitals. However, there are no specific symptoms that differentiate IBS from other common bowel diseases, and there are no biological markers for IBS diagnosis. The Rome criteria, which were established in 1978 and revised in 1999, 2006, and 2016, are the basis for IBS diagnosis.3,4

Chronic abdominal pain or discomfort of at least 3 days per month is a diagnostic criterion in Rome III. In the latest update from Rome III to Rome IV, the term “discomfort” was removed, leaving abdominal pain as the only criterion for IBS diagnosis. In addition, frequency of abdominal pain was increased to at least 1 day per week.4 These changes in criteria mean that some patients who were diagnosed with IBS using the Rome III criteria will not be diagnosed with IBS when the Rome IV criteria are used. In several earlier studies, it was reported that the incidence of IBS in all populations decreased when the Rome IV criteria were used for diagnosis.5-8 With the omission of abdominal discomfort as a criterion and the increase of abdominal pain standards, patients diagnosed using the Rome IV criteria may have more severe symptomatology, higher grades of psychiatric comorbidity, and lower quality of life than patients diagnosed using the Rome III criteria.7,8

For reasons such as heavy academic load, sleep deprivation, irregular schedule, and competitive environment, medical and nursing students have higher stress levels than other groups in the general population.9 Although the etiology of IBS remains unclear, previous studies reported a positive correlation between psychophysiological stress level and IBS incidence.10-13 This correlation explains the high prevalence rate of IBS in medical and nursing students. According to a study of medical students from different countries, the prevalence of IBS diagnosed using the Rome III criteria is as high as 31.8%.9 Following the update from the Rome III to Rome IV, it is necessary to investigate changes in the prevalence of IBS in medical and nursing students and to determine the epidemiological, psychological, and sociodemographic differences between patients with IBS diagnosed using Rome III criteria and those diagnosed using the Rome IV criteria.

Materials and Methods

Participants and Settings

The study participants were adult Korean students at colleges of medicine and nursing in the Republic of Korea who can understand the survey. Patients with organic diseases (eg, gastric ulcer, duodenal ulcer, gastric cancer, reflux esophagitis, colorectal cancer, inflammatory bowel disease, colitis, and 3 or more diverticulitis) were excluded from the study. Subjects willing to participate in the study completed an online survey, and their responses were stored in an online database. The study was approved in July 2021 by the Institutional Review Board of Inje University Busan Paik Hospital (IRB No. 2021-06-036).

Questionnaire

The questionnaire, which consists of 113 questions, includes several general and specific questions for IBS diagnosis and regarding participants’ sociodemographic characteristics. The general questions include basic demographic data such as age, sex, height (centimeters), weight (kilograms), tobacco and alcohol use, use of nutritional supplements, allergies, and dietary habits. The sociodemographic characteristics include quality of life, stress level, anxiety level, level of depression, and physical activity level. The Rome IV diagnostic questionnaire, Irritable Bowel Syndrome Severity Scoring System (IBS-SSS), 36-item short form survey (SF-36), Brief Encounter Psychosocial Instrument (BEPSI), and Hospital Anxiety and Depression Scale (HADS) were used for evaluation. SF-36 is a general health-based survey of quality of life, and it consists of 8 scales, namely physical functioning, physical health, bodily pain, general health, vitality, social functioning, emotional well-being, and mental health.14,15 The Korean version of the modified BEPSI (BEPSI-K) is used to evaluate stress levels, and it consists of 5 questions.16 HADS is a self-report questionnaire designed to screen for anxiety and depression in patients in nonpsychiatric settings.17 All questionnaires and the guidelines specific to each questionnaire were translated into Korean. Pretranslated questionnaires provided by researchers were used.

Statistical Methods

Data analysis was performed using SPSS version 25.0 (IBM Corp, Armonk, NY, USA). Using Rome IV-K, a self-report questionnaire, the difference in IBS prevalence between patients diagnosed using the Rome III criteria (Rome III group) and patients diagnosed using the Rome IV criteria (Rome IV group) was determined. One-way analysis of variance (ANOVA) was performed to evaluate the differences between the Rome IV, Rome III, and non-IBS groups. Differences in continuous variables between the Rome III and Rome IV groups were analyzed using unpaired Student’s t test and Mann–Whitney U test. Differences in categorical variables between the 2 groups were analyzed using χ2 test and Fisher’s exact test. Logistic regression was used to predict the independent factor between Rome III and Rome IV groups. We performed multivariate analysis for factors with P-value of less than 0.2 in the univariate analysis. In our data analysis, P-values < 0.05 were considered statistically significant.

Data Collection

Data for this study were collected from August 13, 2021 to October 22, 2021. There were 4 interviewers: 1 professor of Internal Medicine (Gastroenterology) at Busan Paik Hospital and 3 students of the College of Medicine, Inje University. The survey involved anonymous non-face-to-face evaluation with self-diagnosis of participants using an online form. To avoid duplicate data entry, the survey was set up such that each subject can participate only once. The participants were asked to complete the survey of self-diagnosis, and the interviewers provided assistance on questions the participants found difficult to answer. Data were collated from the online form and stored as a Microsoft Excel file.

Results

Prevalence of Rome III-positive Irritable Bowel Syndrome and Rome IV-positive Irritable Bowel Syndrome

Figure shows the proportion of students according to diagnosis criteria. A total of 440 students completed the survey. Of the 440 students, 215 were students of the College of Medicine of Inje University, 70 were students of the College of Nursing of Inje University, 122 were students of Colleges of Medicine of 11 other universities, and 33 were students of Colleges of Nursing of 4 other universities. The Rome III group consisted of 78 participants (17.7%): 60 medical students (17.8% of all 338 medical students) and 18 nursing students (17.6% of all 102 nursing students). The Rome IV group consisted of 51 participants (11.6%): 40 medical students (11.8% of all 338 medical students) and 11 nursing students (10.8% of all 102 nursing students). Twenty-seven students (6.1%) were diagnosed with IBS according to the Rome III criteria only (Rome III-only group). We defined Rome III only patients who met only Rome III criteria, excluding patients who met Rome IV criteria among Rome III patients. These 27 students consisted of 20 medical students (5.9%) and 7 nursing students (6.9%). Based on Rome III criteria only, the IBS subtypes are constipation (22.2%), diarrhea (63.0%), mixed (7.4%), and unspecified (7.4%).

Figure 1. Chart showing irritable bowel syndrome (IBS) prevalence and subgroup proportion in medical and nursing students according to Rome III and Rome IV criteria. IBS-C, constipation-predominant IBS; IBS-D, diarrhea-predominant IBS; IBS-M, mixed IBS; IBS-U, unspecified IBS.

Demographic Data of Rome IV and Rome III-only Groups

Table 1 shows the responses to questions on baseline characteristics between the Rome IV group, Rome III-only group, and healthy students (non-IBS group). No significant differences in age, gender, major, body mass index, alcohol consumption, smoking status, dietary habits, or exercise habits were observed between the groups. Smoking rate was higher in the Rome IV group than in the Rome III-only group, but the difference was not significant (15.7% vs 7.4%, P = 0.060). The prognostic factors associated with Rome IV IBS group and the non-IBS group are presented in Supplementary Table. In multivariate analysis, there were significant differences in SF-36 score (role limitations due to physical functioning, pain, and general health).

Table 1 . Demographic Data of Survey Participants

CharacteristicsTotal (N = 440)IBS group (n = 78)Non-IBS group (n = 362)P-valuea
Rome IV group (n = 51)Rome III-only group (n = 27)
Age (yr)22.0 ± 2.221.8 ± 2.222.8 ± 2.721.9 ± 2.10.120
Gender (male)195 (44.3)20 (39.2)14 (51.9)161 (44.5)0.559
Major0.910
Medicine338 (76.8)40 (78.4)20 (74.1)278 (76.8)
Nursing102 (23.2)11 (21.6)7 (25.9)84 (23.2)
BMI (kg/m2)21.5 ± 3.121.1 ± 2.821.1 ± 3.221.5 ± 3.10.569
Alcohol consumption (yes)328 (74.5)41 (80.4)21 (77.8)266 (73.5)0.526
Smoking (yes)33 (7.5)8 (15.7)2 (7.4)23 (6.4)0.060
Breakfast0.367
0 times a wk152 (34.5)21 (41.2)7 (25.9)124 (34.3)
1-2 times a wk86 (19.5)10 (19.6)8 (29.6)68 (18.8)
3-4 times a wk95 (21.6)13 (25.5)4 (14.8)78 (21.5)
5-7 times a wk107 (24.3)7 (13.7)8 (29.6)92 (25.4)
Exerciseb (yes)249 (56.6)28 (54.9)12 (44.4)209 (57.7)0.392

aP-value for independent samples from one-way analysis of variance.

bAt least 150 minutes of moderate-intensity physical activity, 75 minutes of high-intensity physical activity per week, or an equivalent amount of moderate- to high-intensity activity.

IBS, irritable bowel syndrome; BMI, body mass index.

Data are presented as mean ± SD or n (%).



Comparison of Survey Results Between Rome IV and Rome III-only Groups

Table 2 shows a comparison of all survey results between the Rome IV group and the Rome III-only group. Regarding clinical characteristics, the score on IBS-SSS in the Rome IV group was significantly higher than that in the Rome III-only group (195.7 ± 77.5 vs 147.8 ± 77.7, P = 0.011). Further, the score on IBS-SSS was higher in the Rome III group than in the Rome III-only group (179.1 ± 80.4 vs 147.8 ± 77.7). Regarding physical functioning and psychosocial scores, significant differences between the Rome IV and Rome III-only groups were observed only in SF-36 physical functioning score (P = 0.009), which was lower in the Rome IV group (80.1 ± 12.6) than in the Rome III-only group (86.1 ± 7.3). There were no significant differences in the other subset scores of SF-36, in BEPSI-K score, and in HADS score between the 2 groups.

Table 2 . Comparison of Survey Results Between Rome IV and Rome III-only Groups

ParametersRome IV group (n = 51)Rome III-only group (n = 27)P-valuea
IBS subgroup0.125
IBS-C3 (5.9)6 (22.2)
IBS-D33 (64.7)17 (63.0)
IBS-M9 (17.6)2 (7.4)
IBS-U6 (11.8)2 (7.4)
Score on IBS-SSS195.7 ± 77.5147.8 ± 77.70.011
SF-36 score74.3 ± 14.176.2 ± 9.30.481
SF-36 score (physical functioning)80.1 ± 12.686.1 ± 7.30.009
SF-36 score (role limitations due to physical health)87.3 ± 23.685.2 ± 25.20.720
SF-36 score (role limitations due to emotional problems)83.0 ± 30.874.1 ± 36.20.256
SF-36 score (energy/fatigue)50.5 ± 16.250.7 ± 17.60.950
SF-36 score (emotional well-being)65.1 ± 17.869.6 ± 14.10.255
SF-36 score (social functioning)72.5 ± 22.873.2 ± 20.20.888
SF-36 score (pain)78.7 ± 21.679.5 ± 16.60.857
SF-36 score (general health)59.2 ± 19.963.3 ± 19.60.383
BEPSI-K score2.1 ± 0.82.1 ± 0.70.724
HADS score13.6 ± 7.412.4 ± 7.10.522

aP-value for independent samples from t test for continuous data and Pearson χ2 for comparison of categorical data.

IBS, irritable bowel syndrome; IBS-C, constipation-predominant IBS; IBS-D, diarrhea-predominant IBS; IBS-M, mixed IBS; IBS-U, unspecified IBS; IBS-SSS, Irritable Bowel Syndrome Severity Scoring System; SF-36, 36-item short form survey; BEPSI-K, Brief Encounter Psychosocial Instrument-Korean version; HADS, Hospital Anxiety and Depression Scale.

Data are presented as n (%) or mean ± SD.



Factors Associated With Irritable Bowel Syndrome in the Rome IV and Rome III-only Groups

Table 3 shows results of logistic regression analysis of the Rome IV and Rome III-only groups to determine the factors significantly associated with IBS prevalence. Univariate analysis revealed that score on IBS-SSS (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00-1.02; P = 0.015) and SF-36 physical functioning score (OR, 0.94; 95% CI, 0.87-0.99; P = 0.038) significantly affect the prevalence of Rome IV-positive IBS. Multivariate analysis revealed that score on IBS-SSS (OR, 1.01; 95% CI, 1.00-1.02; P = 0.022) is the only factor that significantly affects the prevalence of Rome IV-positive IBS. It was also found that the prevalence of Rome IV-positive IBS is affected by SF-36 physical functioning score, but not significantly (OR, 0.94; 95% CI, 0.87-1.00; P = 0.071).

Table 3 . Factors associated With Rome IV-positive Irritable Bowel Syndrome and Rome III-only Irritable Bowel Syndrome

VariablesUnivariate analysisMultivariate analysis
OR (95% CI)P-valueaaOR (95% CI)P-valuea
Age (yr)0.85 (0.69-1.03)0.0960.84 (0.66-1.05)0.139
Gender (male)1.6 (0.65-4.33)0.286
Major0.79 (0.27-2.42)0.664
BMI (kg/m2)1.00 (0.85-1.18)0.999
Alcohol consumption1.17 (0.36-3.61)0.786
Smoking2.33 (0.53-6.22)0.309
Breakfast0.75 (0.49-1.14)0.1810.62 (0.37-0.99)0.053
Exerciseb1.52 (0.60-3.95)0.380
IBS subgroup0.327
IBS-D3.88 (0.91-20.25)
IBS-M9.00 (1.30-91.39)
IBS-U6.00 (0.81-63.13)
Score on IBS-SSS1.01 (1.00-1.02)0.0151.01 (1.00-1.02)0.049
SF-36 score0.99 (0.95-1.03)0.528
SF-36 score (physical functioning)0.94 (9.87-0.99)0.0380.94 (0.87-1.00)0.077
SF-36 score (role limitations due to physical health)1.00 (0.98-1.02)0.717
SF-36 score (role limitations due to emotional problems)1.01 (0.99-1.02)0.255
SF-36 score (energy/fatigue)1.00 (0.97-1.03)0.949
SF-36 score (emotional well-being)0.98 (0.95-1.01)0.254
SF-36 score (social functioning)1.00 (0.98-1.02)0.886
SF-36 score (pain)1.00 (0.97-1.02)0.855
SF-36 score (general health)0.99 (0.96-1.01)0.379
BEPSI-K score1.12 (0.62-2.07)0.720
HADS score1.02 (0.96-1.09)0.516

aP-value for independent variables from logistic regression analysis.

bAt least 150 minutes of moderate-intensity physical activity, 75 minutes of high-intensity physical activity per week, or an equivalent amount of moderate- to high-intensity activity.

aOR, adjusted odds ratio; BMI, body mass index; IBS, irritable bowel syndrome; IBS-D, diarrhea-predominant IBS; IBS-M, mixed IBS; IBS-U, unspecified IBS; IBS-SSS, Irritable Bowel Syndrome Severity Scoring System; SF-36, 36-item short form survey; BEPSI-K, Brief Encounter Psychosocial Instrument-Korean version; HADS, Hospital Anxiety and Depression Scale.



Comparison of Physical Functioning and Psychosocial Scores Between the Non-irritable Bowel Syndrome group and the Rome IV and Rome III groups

Table 4 shows the response to the psychosocial questionnaires (ie, SF-36, BEPSI-K, and HADS) in the Rome IV, Rome III, and non-IBS groups. SF-36 and some of its subset scores (including physical functioning, energy/fatigue, pain, and general health) were significantly lower in the Rome IV group than in the non-IBS group. Furthermore, SF-36 and some of its subset scores (including physical functioning, energy/fatigue, social functioning, pain, and general health) were significantly lower in the Rome III group than in the non-IBS group.

Table 4 . Comparison of Results Between the Rome IV, Rome III, and Non-irritable Bowel Syndrome Groups

ParametersTotal
(N = 440)
Rome IV group
(n = 51)
Non-IBS group
(n = 389)
P-valueaTotal
(N = 440)
Rome III group
(n = 78)
Non-IBS group
(n = 362)
P-valuea
IBS subgroup< 0.001< 0.001
IBS-C3 (0.7)3 (5.9)0 (0.0)9 (2.0)9 (11.5)0 (0.0)
IBS-D33 (7.5)33 (64.7)0 (0.0)50 (11.4)50 (64.1)0 (0.0)
IBS-M9 (2.0)9 (17.6)0 (0.0)11 (2.5)11 (14.1)0 (0.0)
IBS-U6 (1.4)6 (11.8)0 (0.0)8 (1.8)8 (10.3)0 (0.0)
Score on IBS-SSS195.7 ± 77.5195.7 ± 77.5179.1 ± 80.4179.1 ± 80.4
SF-36 score79.2 ± 11.474.3 ± 14.179.8 ± 10.80.00979.2 ± 11.475.0 ± 12.680.1 ± 10.9< 0.001
SF-36 score (physical functioning)84.5 ± 9.380.1 ± 12.685.0 ± 8.60.00984.5 ± 9.382.2 ± 11.485.0 ± 8.70.045
SF-36 score (role limitations due to physical health)89.7 ± 20.387.3 ± 23.690.0 ± 19.80.35789.7 ± 20.386.5 ± 24.190.4 ± 19.30.187
SF-36 score (role limitations due to emotional problems)84.4 ± 30.783.0 ± 30.884.6 ± 30.80.73284.4 ± 30.779.9 ± 32.885.4 ± 30.20.156
SF-36 score (energy/fatigue)55.9 ± 17.750.5 ± 16.256.6 ± 17.80.02155.9 ± 17.750.6 ± 16.657.0 ± 17.80.004
SF-36 score (emotional well-being)68.8 ± 15.665.1 ± 17.869.3 ± 15.30.07068.8 ± 15.666.7 ± 16.669.3 ± 15.40.179
SF-36 score (social functioning)78.2 ± 19.072.5 ± 22.879.0 ± 18.40.05678.2 ± 19.072.8 ± 21.879.4 ± 18.20.014
SF-36 score (pain)87.1 ± 16.478.7 ± 21.688.2 ± 15.30.00487.1 ± 16.479.0 ± 19.988.8 ± 15.1< 0.001
SF-36 score (general health)67.8 ± 18.259.2 ± 19.969.0 ± 17.7< 0.00167.8 ± 18.260.6 ± 19.869.4 ± 17.5< 0.001
BEPSI-K score2.0 ± 0.82.1 ± 0.82.0 ± 0.80.1892.0 ± 0.82.1 ± 0.82.0 ± 0.80.163
HADS score12.1 ± 6.813.6 ± 7.411.9 ± 6.70.09312.1 ± 6.813.2 ± 7.311.8 ± 6.60.111

aP-values for independent samples from t test of continuous data and from Pearson χ2 for comparison of categorical data.

IBS, irritable bowel syndrome; IBS-C, constipation-predominant IBS; IBS-D, diarrhea-predominant IBS; IBS-M, mixed IBS; IBS-U, unspecified IBS; IBS-SSS, Irritable Bowel Syndrome Severity Scoring System; SF-36, 36-item short form survey; BEPSI-K, Brief Encounter Psychosocial Instrument-Korean version; HADS, Hospital Anxiety and Depression Scale.

Data are presented as n (%) or mean ± SD.



Comparison of Medical Students and Nursing Students

Table 5 shows the comparison of baseline characteristics, IBS prevalence, score on IBS-SSS, physical functioning, and psychosocial survey results between medical students and nursing students. Apart from the expected differences in baseline characteristics (for example, gender differences), no significant differences were observed between medical students and nursing students.

Table 5 . Comparison of Medicine and Nursing Students

VariablesTotal
(N = 440)
Medicine
(n = 338)
Nursing
(n = 102)
P-valuea
Age (yr)22.0 ± 2.221.9 ± 2.022.3 ± 2.60.122
Gender (male)195 (44.3)175 (51.8)20 (19.6)< 0.001
BMI (kg/m2)21.5 ± 3.121.6 ± 3.120.9 ± 3.00.046
Alcohol consumption (yes)328 (74.5)259 (76.6)69 (67.6)0.090
Smoking (yes)33 (7.5)25 (7.4)8 (7.8)1
Breakfast0.533
0 times a wk152 (34.5)115 (34.0)37 (36.3)
1-2 times a wk86 (19.5)62 (18.3)24 (23.5)
3-4 times a wk95 (21.6)75 (22.2)20 (19.6)
5-7 times a wk107 (24.3)86 (25.4)21 (20.6)
Exerciseb (yes)249 (56.6)210 (62.1)39 (38.2)< 0.001
Rome IV IBS51 (11.6)40 (11.8)11 (10.8)0.909
Rome III IBS78 (17.7)60 (17.8)18 (17.6)> 0.999
Score on IBS-SSS179.1 ± 80.4178.3 ± 79.4181.7 ± 86.10.879
SF-36 score79.2 ± 11.479.6 ± 11.378.0 ± 11.60.211
SF-36 score (physical functioning)84.5 ± 9.384.5 ± 9.584.3 ± 8.60.851
SF-36 score (role limitations due to physical health)89.7 ± 20.390.2 ± 20.288.2 ± 20.40.401
SF-36 score (role limitations due to emotional problems)84.4 ± 30.783.9 ± 30.985.9 ± 30.20.561
SF-36 score (energy/fatigue)55.9 ± 17.756.4 ± 17.754.0 ± 17.70.219
SF-36 score (emotional well-being)68.8 ± 15.669.6 ± 15.266.4 ± 16.80.068
SF-36 score (social functioning)78.2 ± 19.078.6 ± 18.676.8 ± 20.40.403
SF-36 score (pain)87.1 ± 16.487.9 ± 15.584.2 ± 19.00.077
SF-36 score (general health)67.8 ± 18.268.4 ± 17.966.1 ± 19.10.263
BEPSI-K score2.0 ± 0.82.0 ± 0.82.1 ± 0.80.060
HADS score12.1 ± 6.812.0 ± 6.712.3 ± 7.00.744

aP-value for independent samples from t test for continuous data and Pearson χ2 for comparison of categorical data.

bAt least 150 minutes of moderate-intensity physical activity, 75 minutes of high-intensity physical activity per week, or an equivalent amount of moderate- to high-intensity activity.

BMI, body mass index; IBS, irritable bowel syndrome; IBS-SSS, Irritable Bowel Syndrome Severity Scoring System; SF-36, 36-item short form survey; BEPSI-K, Brief Encounter Psychosocial Instrument-Korean version; HADS, Hospital Anxiety and Depression Scale.

Data are presented as mean ± SD or n (%).


Discussion

To the best of our knowledge, this study is the first in Korea to show a significant increase in IBS severity in medical and nursing students due to a change in the Rome IV criteria for IBS using a validated modality. Our results show that the prevalence rates of Rome III-positive IBS and Rome IV-positive IBS in all the participants are 17.7% and 10.6%, respectively; these figures are significantly higher than the prevalence rates in healthy Asian population, which are reported to be 9.0% and 4.0%, respectively.18,19 This difference in prevalence rate is thought to be due to increased study time, psychological stress, and workload in medical and nursing schools.20,21 The relationship between psychological stress/stressors and IBS prevalence is well documented in several previous studies.22,23 Our results are consistent with those of a previous study that reported an IBS prevalence of 9.3-43.5% in medical and nursing students.9,24 The relatively low prevalence in our study participants may be explained by the relatively low IBS prevalence rate in Asian populations or by differences in the method and criteria of IBS diagnosis.

In this study, the rate of Rome IV-positive IBS in the Rome III group was 65.4%. Several studies have evaluated the impact of the changes in IBS diagnostic criteria. According to some western studies of patients with Rome III-positive IBS or self-identified patients with IBS, 73.5-85.0% of the patients met the criteria for Rome IV-positive IBS.5,8 However, in a large online survey study of 29 606 participants worldwide,1 the rate of Rome IV-positive IBS in the Rome III group was 37.6%. In a Chinese study of outpatients in a tertiary hospital, it was reported that only 50% of patients with Rome III-positive IBS met the Rome IV criteria.6 Considering that the medical students of Eastern origin in this study may have severe symptoms, the rate of Rome IV-positive IBS in the Rome III group is appropriate.

There were no significant differences in age, gender, major, body mass index, alcohol consumption, smoking status, dietary habit, and exercise habit between the Rome IV and Rome III-only groups. However, scores on IBS-SSS was significantly higher in the Rome IV group than in the Rome III-only group. Given that Rome IV criteria is more restrictive than Rome III criteria, the results of our study are consistent with those of previous studies.6,8 Univariate analysis revealed significant differences only in SF-36 physical functioning score, but no such differences were observed in logistic regression analysis. The SF-36 physical functioning subscale includes questions on the limits of activities such as vigorous and moderate physical activity, carrying groceries, climbing stairs, walking, and kneeling. Although controversial, several studies reported that patients with IBS have low physical activity levels.25,26 It can be assumed that, due to their more severe symptoms, the Rome IV group might have more physical activity restrictions than the Rome III-only group. No significant differences in BEPSI-K score and HADS score were observed between the Rome IV and Rome III-only groups. This finding correlated well with no significant differences between the Rome IV and Rome III-only groups in another study.8

Although comparison of the IBS and non-IBS groups did not reveal significant differences in demographic factors, significant differences in most physical functioning scores and in psychosocial scores were observed. This finding reaffirms the common knowledge that, regardless of diagnostic criteria, patients with IBS have lower psychological and social quality of life than healthy individuals. SF-36 social functioning score was found to be significantly lower in the Rome III group than in the non-IBS group, but was not significantly lower in the Rome IV group than in the non-IBS group. Given that the study sample size was not large enough to demonstrate a difference in SF-36 social functioning score between the Rome IV and non-IBS groups, it is necessary to conduct further studies with larger sample sizes. In this study, the HADS score of IBS patients was similar to those of the previous study, and the HADS score was higher in the non-IBS group, compared to the general population. (non-Rome IV IBS: 11.9 non-Rome III: 11.8 vs 8.9)8,27 It is possible that a special group that is under a lot of stress may have similar levels of stress regardless of whether they have IBS or not, which could explain why there was no difference in BEPSI-K and HADS scores between IBS and non-IBS participants in the study. These findings could be also explained by small number of participants and symptom fluctuation, heterogeneous populations. Nevertheless, it is necessary to validate the clinical implications of this study in the future.

This study has some limitations. First, due to the small number of subjected surveyed, analysis of differences in the factors affecting IBS diagnosis based on Rome III criteria versus Rome IV criteria was limited. Second, due to the survey design of the study, there are limitations pertaining to the maintenance of the objectivity of the investigator’s answers. To minimize these limitations, we used a questionnaire that guarantees the objectivity of the questions. Third, since blood tests and colonoscopy were not conducted during this study, we cannot rule out other organic diseases in the participants. However, similar to this study, many previous studies on IBS and the Rome criteria used a self-report questionnaire to collect demographic, sociodemographic, and symptom data.5,28-30 Moreover, it is highly unlikely for college students to have organic bowel diseases; therefore, our study results can be considered acceptable. Forth, the grades of subjects were not investigated in the survey. Medical students and nursing students have different stresses depending on their grade and education schedule. In addition to academic stress, there is a lot of stress including relationships with staff in the ward, and the death of patients during clinical practice.31 In Systematic Review and Meta-Analysis, The prevalence of IBS was 8.18% for junior college students and 12.14% for university students.32 Therefore, in future Korean studies, it is necessary to compare students in premedical, medical, and clinical practice.

In conclusion, the prevalence of IBS diagnosed based on the Rome IV criteria in medical and nursing students in Korea is 11.6%. Patients with Rome IV-positive IBS have higher scores on IBS-SSS and lower SF-36 subset scores than patients with Rome III-only IBS. In other words, patients with Rome IV-positive IBS have more severe symptoms and lower quality of life than patients with Rome III-positive IBS. Also, compared to the general population, medical and nursing students are thought to have the effect on the prevalence of IBS due to stress caused by academic and clinical practice. For students diagnosed with ROME IV IBS, it is thought that stress relief, regular breakfast, and exercise will be helpful to control the symptoms caused by IBS, including abdominal pain.

Financial support

None.

Conflicts of interest

None.

Author contributions

Ji Hwan Park, Ka Eun Lee, and Hyeok Jun Jeong contributed to the planning, conducting the study, and drafting the manuscript; Hong Sub Lee contributed to the study concept, design and revision; Seung Jung Yu, Jun Sik Yoon, and Eun Jeong Choi contributed to the statistical analysis and revision; and Jung Ho Park, Ki Bae Bang, Ju Seok Kim, and Yong Sung Kim contributed to the revision.

Supplementary Material

Note: To access the supplementary table mentioned in this article, visit the online version of Journal of Neurogastroenterology and Motility at http://www.jnmjournal.org/, and at https://doi.org/10.5056/jnm22067.

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