European Journal of Cardiovascular Medicine

Patients with non-acute abdominal symptoms form a formidable number of the total patients visiting the hospital. Globally, studies have reported varying rates of gastrointestinal problems, ranging from 14% to 54%.1,2 The study aims to explore the demographic and clinical profile as well as the impact of healthcare services in these patients. This will help the medical community to identify the trends of abdominal symptoms and risk factors such that the medical community have clarity and ways to provide targeted interventions beyond the generic advices about lifestyle modifications and medications given to patients

This was an observational cross-sectional study conducted in Vydehi Institute of Medical Sciences and Research Centre, Bangalore over a period of 6 months and was designed to explore the clinical and demographic profiles of patients presenting with abdominal symptoms. 100 patients who reported abdominal symptoms that were outlined in the structured questionnaire were included in the study.

Demographic details like age, sex, and Body Mass Index (BMI) were collected along with details of their symptoms (heartburn, abdominal pain, straining during defecation, etc.), associated risk factors (comorbidities, spicy food, eating late in the night, etc.) and the measures they took to reduce symptoms (using over-the-counter antacids, consulting doctor, bringing some diet modifications, etc.). The questionnaire was administered in both online and hard copy formats.

Statistical methods:

The data were analyzed using JASP version 0.18.3. Continuous variables were expressed as mean ±standard deviation (SD). Test of normality (Shapiro-Wilk test) was used to determine whether the continuous variables were normally distributed. Non-parametric Chi-square test, and Standardized residuals were used for performing statistical analysis. Statistical significance was assumed with a P-value of ＜ 0.05. Standardized residual values greater than ±1.96 were considered as significant contributors to the Chi-square test.

Demographic results:

A total of 100 participants were included in this study. The mean age of study population was 37.48 years (SD = 12.12), with a minimum age of 19 years and a maximum age of 70 years. The majority of participants (37%) were aged between 31 and 40 years, and 83% belonged to ages between 21 and 50 years (Table 1). The mean height was 162.76 cm (SD = 11.55) and the mean weight was 67.22 kg (SD = 13.52). The mean Body Mass Index (BMI) was 25.33 kg/m² (SD = 4.37), with a minimum BMI of 14.1 and a maximum of 37.0. Overall, 73% of participants had a BMI above normal (Table 2). 81 participants were non-vegetarians and 19 were vegetarians (Table 3). 12 participants in the study had diabetes and 14 participants had hypertension.

BMI was not equally distributed across different age groups (p = 0.045) (Figure 1). Underweight individuals (BMI < 18.5) were more prevalent in the 11-20 years age group (standardized residual [SR] = 3.127). The mean BMI for females was 26.112 (SD = 4.399) and for males was 24.295 (SD = 4.162) (Table 2). There was no significant difference in BMI between males and females (p = 0.109) (Figure 2). No significant difference in BMI was found between vegetarians and non-vegetarians (p = 0.420) (Figure 3), nor between diabetic and non-diabetic populations (p = 0.417), or between hypertensive and non-hypertensive populations (p = 0.104).

There was no significant difference in the number of males and females across different age groups (p = 0.339) and no difference in diet across age groups (p = 0.555).

Diabetes was not equally distributed across age groups (p < 0.001) (Figure 4). The mean age of patients with diabetes was 53.67 (SD = 10.91) years. The prevalence of diabetes was lower in the 21 to 30 years age group (SR = 2.246) and higher in the 51-60 (SR = 2.605) and 61-70 (SR = 3.811) age groups.

Hypertension was also not equally distributed across age groups (p < 0.001), with lower prevalence again noted in the 21 to 30 years age group (SR = 2.454) and higher prevalence in the 51-60 (SR = 3.411) and 61-70 (SR = 2.282). The mean age of patients with hypertension was 51 (SD = 9.30) years.

Among males, 39 out of 43 (90.7%) were non-vegetarians, while 42 out of 57 (73.68%) females were non-vegetarians. The percentage difference in non-vegetarian consumption between males and females was statistically significant (p = 0.032).

There were no significant differences in diabetes prevalence between males and females (p = 0.602) or in hypertension prevalence (p = 0.568). Additionally, there was no difference in diabetes prevalence between vegetarians and non-vegetarians (p = 0.826) or in hypertension prevalence (p = 0.628).

Symptom profile

The top 5 abdominal symptoms in the study population were bloating, feeling uncomfortably full after food, heartburn, abdomen pain and sense of incomplete evacuation of stools with 54, 47, 42, 40 and 39 number of participants reporting the symptoms respectively (Table 4).

No significant differences in symptom prevalence were observed across different age groups, except for blood and mucus in stools. Blood in stool were commonly reported in the 51-60 (SR = 2.608) and 61-70 (SR = 2.608) age groups (p = 0.003). Mucus in stool were commonly reported in the 41-50 age group (SR = 3.631) (p = 0.022).

No significant differences in symptom prevalence between males and females were found, except that males more commonly reported halitosis (SR = 2.727) (p = 0.006), straining during defecation (SR = 2.702) (p = 0.007), and mucus in stool (SR = 2.025) (p = 0.043).

Halitosis was more commonly reported in Obese I (SR = 2.465) and Underweight (BMI < 18.5) (SR = 2.052), while it was less commonly reported in Normal BMI participants (SR = -2.224) (p = 0.011). Abdominal pain was more commonly reported in Underweight category participants (SR = 2.154) and was less common in Overweight category participants (SR = -2.828) (p = 0.012). Cramps was also most commonly reported in Underweight category participants (SR = 2.624) (p = 0.049). Participants with Normal BMI also less commonly reported symptoms of feeling uncomfortably full after food (SR = -2.008) (p = 0.025) and bloating (SR = -2.330) (p = 0.048).

     No significant differences in symptom prevalence between vegetarians and non-vegetarians were found, except that the non-vegetarians more commonly reported nausea (SR = 2.572) (p = 0.010).

     No significant differences in symptom prevalence between patients with or without diabetes were noted, except that heartburn (SR = 2.469) (p = 0.014) and mass per rectum (SR = 2.314) (p = 0.021) were more common in participants with diabetes.

No significant differences in symptom prevalence between patients with or without hypertension were found for any of the symptoms.

Risk profile

Irregular Mealtimes (64 participants), Stress at Home or Workplace (62 participants), Eating Spicy Foods (57 participants), Eating Late at Night (54 participants) and Habit of Skipping Meals (50 participants) were the top 5 commonly reported risk factors (Table 5).

No significant differences in risk factors were observed across various age groups, except that the behavior of sleeping immediately after food was significantly less common among participants aged 21-30 years (SR = -2.332) and was more common in those aged 41-50 years (SR = 2.280) (p = 0.027).

Behavior of eating sweets was more common in females (SR = 2.002) (p = 0.045). Males commonly reported risk factors like eating too quickly (SR = 2.116) (p = 0.034), excessive intake of meat (SR = 2.213) (p = 0.027) and consuming alcohol (SR = 2.821) (p = 0.005). More females reported that they had been dealing with issues of overweight (SR = 2.144) (p = 0.032).

No significant differences in risk factors were found across various BMI groups. However, it was noted that 16% of participants classified as Overweight (BMI 23-24.9) did not consider themselves overweight (p < 0.001; SR = -2.828).

No significant differences in risk factors were observed between vegetarians and non-vegetarians, except for eating high-fat foods (SR = 2.007) (p = 0.045), having irregular mealtimes (SR = 3.271) (p < 0.001), consumption of carbonated Drinks (SR = 2.058) (p = 0.040) and alcohol (SR = 2.114) (p = 0.035) were frequent among non-vegetarians.

Risk factors like diet low in fruits and vegetables (SR = 2.553) (p = 0.011) and consuming peppermints (SR = 1.977) (p = 0.048) were reported more frequently by patients with diabetes. Patients with diabetes were less likely to consume carbonated drinks (SR = -2.417) (p = 0.016). Also aspirin use was more common in patients with diabetes (SR = 1.977) (p = 0.048). Use of over-the-counter painkillers was more common in patients with hypertension (SR = 2.165) (p = 0.030). No significant differences in other risk factors were found between patients with and without diabetes or hypertension.

Measures to reduce symptoms:

Over-the-Counter Antacid Use

Fifty-five (55) participants used over-the-counter antacids. No significant differences in antacid use were observed across age groups (p = 0.467), between males and females (p = 0.138), across BMI groups (p = 0.352) or between patients with or without diabetes (p = 0.711) or hypertension (p = 0.451). Non-vegetarians were more likely to use over-the-counter antacids (p = 0.023; SR = 2.280).

Antacid use was common among patients with symptoms of heartburn (p = 0.016; SR = 2.403; 69.05%), water brash (p = 0.028; SR = 2.196; 76.19%), belching (p = 0.009; SR = 2.612; 76.92%) and cramps (p = 0.031; SR = 2.151; 70.97%).

Antacid use was commonly reported in patients with risk factors like eating high-fat foods (p = 0.013; SR = 2.477), eating sweets (p = 0.006; SR = 2.754), eating late at night (p = 0.011; SR = 2.541), eating at irregular mealtimes (p = 0.044; SR = 2.010), habit of skipping meals (p = 0.009; SR = 2.613), sleeping immediately after food (p = 0.034; SR = 2.121), and use of over-the-counter painkillers (p = 0.007; SR = 2.690).

Hospital Visits

Forty-five (45) participants visited a hospital for consultation. No significant differences in hospital visits were found across age groups (p = 0.074), between males and females (p = 0.503), across BMI groups (p = 0.870), between vegetarians and non-vegetarians (p = 0.069), or between patients with or without diabetes (0.322). However, patients with hypertension were more likely to have visited the hospital (p = 0.006; SR = 2.723; 78.57% of participants with hypertension).

Patients with cramps were more likely to visit hospital (p = 0.009; SR = 2.629). 5 out of 8 participants with mass per rectum, 5 out of 6 participants with blood in stools and all 3 patients with mass per rectum and blood in stool had visited hospital. However, statistically the visits by participants with mass per rectum (p 0.300) or blood in stool (p 0.052) or both mass per rectum and blood in stool (p 0.052) were not significant.

Hospital visits was common in participants who used over-the-counter painkillers (p = 0.006; SR = 2.739).

Dietary Modifications

Forty-one (41) participants tried some diet modifications. No significant differences were found in the prevalence of dietary modifications across age groups (p = 0.794), between males and females (p = 0.136), across BMI groups (p = 0.130), or between patients with or without diabetes (p = 0.230) or hypertension (p = 0.879).

Vegetarians were more likely to try dietary modifications (p = 0.001; SR = 3.219). Patients with flatulence as the symptom were less likely to try dietary modifications (p = 0.042; SR = -2.029). Dietary modifications were common in participants who ate large meals (p = 0.002; sr = 3.027) or who were dealing with overweight issues (p = 0.020; sr = 2.324). Participants who had the habit of exercising after food (p = 0.023; sr = 2.268) were likely to try modifying their diet to reduce the symptoms.

Vegan Diet

Ten (10) non-vegetarian participants had tried switching to a completely vegan diet. However, overall non-vegetarians were less likely to switch to a vegan diet (p = 0.008; SR = -2.634). Especially, participants aged 21-30 years were less likely to switch to a vegan diet (p = 0.027; SR = -2.027).

Patients with hypertension (p = 0.013; SR = 2.498), patients with symptom of water brash (p = 0.018; SR = 2.373) and patients who consumed peppermints (p = 0.022; SR = 2.294) were more likely to switch to a vegan diet.

Keto Diet

Six (6) participants practiced the Keto diet. Patients with sense of incomplete evacuation of bowels (p = 0.043; SR = -2.020) were less likely to practice the Keto diet. Keto diet was commonly practiced by participants who had risk factors or habits like Eating large meals (p = 0.040; SR = 2.058), Habit of skipping meals (p = 0.012; SR = 2.526), dealing with overweight (p = 0.025; SR = 2.235), or Stress at the workplace (p = 0.010; SR = 2.560). Patient who tried Keto diet were more likely to have the habit of exercising after food (p = 0.002; SR = 3.149).

Intermittent Fasting

Twenty-eight (28) participants had tried intermittent fasting. Vegetarians (p = 0.001; SR = 3.225) and non-diabetic patients (p = 0.021; SR = -2.303) were more likely to practice intermittent fasting. Patients without symptoms of water brash (p = 0.034; SR = -2.122), halitosis (p = 0.045; SR = -2.004), or vomiting (p = 0.050; SR = -1.961) were more likely to practice intermittent fasting.

Intermittent fasting was tried by participants who had the habit of eating large meals (p = 0.026; SR = 2.231), exercising after food (p = 0.038; SR = 2.078), or sleeping without pillows (p = 0.048; SR = 1.977). Patients who slept immediately after food were less likely to practice intermittent fasting (p = 0.039; SR = -2.059).

Regular Fasting

Twenty-three (23) participants practiced regular fasting. Patients without flatulence were more likely to practice regular fasting (p = 0.019; SR = -2.350). Regular fasting was commonly tried by participants with risk factors or habits of eating sweets (p = 0.019; SR = 2.336), eating large meals (p = 0.014; SR = 2.453), habit of skipping meals (p = 0.032; SR = 2.139), dealing with overweight (p = 0.005; SR = 2.813), exercising after food (p = 0.008; SR = 2.635), or sleeping without pillows (p = 0.010; SR = 2.589)

Other Findings

Patients who had visited hospitals were more likely to use over-the-counter antacids (p < 0.001; SR = 3.333). Hospital visit did not make any difference in the number of participants who would try dietary modifications (p = 0.553) or in the number of participants dealing with stress (p = 0.649).

The mean age of participants was 37.48 years (SD =12.12), with a notable concentration (37%) in the 31-40 age group. This finding aligns with another study conducted in India which has reported 45-54 years as common age distribution among individuals experiencing gastrointestinal issues suggesting a trend of increasing prevalence with age, particularly in middle-aged populations.¹

In terms of Body Mass Index (BMI), the mean BMI in this study was 25.33 kg/m², indicating a significant proportion (73%) of participants were classified as overweight or obese. This finding is consistent with the National Family Health Survey (NFHS-5), which reported that over 50% of adults in India, particularly women, suffer from abdominal obesity. The prevalence of obesity is a growing concern in India due to changing lifestyle and dietary habits contribute significantly to this trend.³

In the study, 81% of participants were non-vegetarians, which is consistent with findings from other research indicating a high prevalence of non-vegetarian diets in urban Indian populations.4 The study found no significant difference in BMI between vegetarians and non-vegetarians, suggesting that dietary choices alone may not fully account for variations in body weight. The impact of diet on gastrointestinal health remains complex as studies have reported both increased and decreased BMI in people practicing vegetarianism compared to non-vegetarians.^5,6 

Additionally, the prevalence of comorbid conditions such as diabetes (12%) and hypertension (14%) among participants with abdominal symptoms were comparable to other studies that reported similar prevalence of comorbid diabetes and hypertension in the general adult population with hypertension having higher prevalence than diabetes.7,8 Studies have shown that the prevalence of diabetes increases significantly with age, particularly in the 51-70 age group, mirroring the findings of this study.9 The study also found no significant differences in the prevalence of diabetes and hypertension between genders, which contrasts with some international studies that report higher rates of these conditions in men compared to women.¹⁰

Prevalence of Symptoms

In the study, the top five abdominal symptoms reported were bloating (54 participants), feeling uncomfortably full after food (47), heartburn (42), abdominal pain (40), and a sense of incomplete evacuation of stools (39). These findings align with other research indicating that bloating and discomfort are prevalent symptoms among patients with gastrointestinal disorders. For instance, a study focusing on irritable bowel syndrome (IBS) in India found that bloating was one of the most common complaints, highlighting its significance in the symptomatology of functional gastrointestinal disorders (FGIDs) in the region.11 It should be noted that the study addresses patients with non-acute abdomen symptoms and therefore symptom profile of patients visiting emergency departments may vary with symptoms like nausea and vomiting topping the list.12 Understanding this difference will support physicians while evaluating specific patient population.

Age and Gender Differences

The study found no significant differences in symptom prevalence across different age groups, except for blood and mucus in stools, which were more commonly reported in older age groups (51-60 and 61-70 years). This finding is consistent with other studies that have reported an increased prevalence of gastrointestinal symptoms with advancing age, particularly in older adults who often present with more severe symptoms and comorbidities.1,11

Not much of gender differences in symptom reporting were noted in the study except for halitosis, straining during defecation, and mucus in stool that were more frequently reported by males. Studies report increased prevalence of irritable bowel syndrome (IBS) among females than males in the West. Indian studies having given mixed picture with some clinical studies reporting increased prevalence in males and community studies showing close male to female ratio. These results point towards the complex interactions of lifestyle, dietary habits, local healthcare seeking patterns, and physiological differences that may be influencing the gender differences found in different regions.¹¹

Impact of BMI and Dietary Habits

The study revealed that halitosis was more commonly reported among individuals with obesity and underweight participants, while abdominal pain and cramps were more prevalent in the underweight category. This finding is supported by research that has shown that both obesity and underweight conditions can lead to distinct gastrointestinal issues.13,14

Interestingly, the study found no significant differences in symptom prevalence between vegetarians and non-vegetarians, except for a higher report of nausea in non-vegetarians. This contrasts with findings from another study that suggested health benefits in people practicing plant-based diet. This lack of difference in symptom prevalence between vegetarians and non-vegetarians may be attributed to general increase in consumption of unhealthy processed foods by both categories.^15,16

Comorbidities

The prevalence of heartburn and mass per rectum was higher in participants with diabetes, indicating a potential link between diabetes and gastrointestinal symptoms. This is supported by literature suggesting that diabetes can exacerbate gastrointestinal symptoms.1 However, the study found no significant differences in symptom prevalence between patients with or without hypertension, which may reflect the impact of individual factors influencing gastrointestinal health and hypertension.^1,10

Risk profile

The top five commonly reported risk factors in the study were irregular mealtimes (64 participants), stress at home or workplace (62), eating spicy foods (57), eating late at night (54), and the habit of skipping meals (50). These findings align with other research indicating that lifestyle factors, such as irregular eating patterns and stress, are significant contributors to gastrointestinal issues in India.¹

Age and Gender Differences

The study found no significant differences in risk factors across various age groups, except for the behavior of sleeping immediately after food, which was less common among participants aged 21-30 years and more common in those aged 41-50 years. A study explains that this lack of difference in most risk factors could be due to the increased awareness toward a healthy diet in all age groups.1 This also suggests that certain risk factors may be more prevalent in particular age groups highlighting the need for specific targeted interventions in different age groups.

Gender differences in risk factor prevalence were also noted, with females more commonly reporting the behavior of eating sweets and dealing with overweight issues, while males more frequently reported eating too quickly, excessive intake of meat, and consuming alcohol. These findings align with other studies that have suggested that gender-specific differences in dietary habits and lifestyle factors may contribute to variations in gastrointestinal health.17,18 This highlights the need for evidence-based gender-specific strategies to manage their symptoms. 

BMI and Dietary Habits

The study found no significant differences in risk factors across various BMI groups, but it was noted that 16% of participants classified as overweight did not consider themselves overweight. This suggests a potential disconnect between actual BMI status and perceived weight. This finding is supported by another study that warns about the implications of such underestimation of current body weight resulting in obesity-associated health problems.19 Differences in risk factors were observed between vegetarians and non-vegetarians, with non-vegetarians more frequently reporting consumption of high-fat foods, irregular mealtimes, consumption of carbonated drinks, and alcohol. These findings are consistent with other studies that have suggested that dietary patterns, particularly the consumption of processed and high-fat foods, may significantly influence gastrointestinal health.^3,5

Comorbidities

The study found that patients with diabetes more frequently reported risk factors such as a diet low in fruits and vegetables and consuming peppermints, while they were less likely to consume carbonated drinks. Patients with diabetes also more commonly used aspirin. These findings emphasize the similar finding in other studies that have suggested a link between diabetes and diet low in fruits and vegetables.20 The lesser consumption of carbonated drinks in patients with diabetes could be explained by increased awareness of excess sugars in these beverages.21 Increased use of aspirin was seen in patients with diabetes, an established risk factor for coronary artery disease.7,8 However, the study didn’t find aspirin use as a common risk factor for abdominal symptoms in general population. The study found that the use of over-the-counter painkillers, a known risk factor for hypertension, was common in patients with hypertension.22 No significant differences in other risk factors were found between patients with and without diabetes or hypertension.

Measures taken to reduce symptoms

Over-the-Counter Antacid Use

In the study, 55 participants reported using over-the-counter antacids.  These were particularly common among those experiencing symptoms like heartburn (69.05%), water brash (76.19%), and belching (76.92%). This emphasizes the need for clinicians to educate patients regarding this widespread, ineffective and potentially dangerous practice of over-the-counter antacids use for symptomatic relief.23 The study also found that antacid use was common in participants consuming non-vegetarian food which can exacerbate symptoms of acid reflux and indigestion.²⁴

Hospital Visits

A total of 45 participants had visited a hospital for consultation, with no significant differences across age groups or between genders. However, patients with hypertension were more likely to seek hospital care, which suggests like another study that comorbidities may influence health-seeking behavior.25 Moreover, patients experiencing cramps were also more likely to visit the hospital, indicating that severity of symptoms influenced healthcare utilization.

Dietary Modifications

Dietary modifications were attempted by 41 participants, with vegetarians, participants without diabetes, participants with habit of consuming large meals, participants without symptoms like sense of incomplete evacuation or flatulence, and those who were dealing with overweight issues were more likely to try changes in food habits. This aligns with findings from studies that indicate that vegetarians are more likely to be conscious of dietary restrictions and practice them whereas non-vegetarians may often find dietary restrictions unessential. This suggests that individuals may be more inclined to adopt dietary restrictions when they are conscious of their food, dealing with symptoms like overweight issues, or when they are generally healthy and do not experience certain symptoms like sense of incomplete evacuation or flatulence, which may reflect a lack of motivation in the absence of severe symptoms.26,27 The study reported that younger participants (aged 21-30) were less likely to make the switch from non-vegetarian to vegetarian food. This can be expected to change in the coming years with growing popularity of plant-based diet and forms of dietary restriction practices for health benefits.28 Interestingly, the number of participants trying to modify their dietary habits were same, irrespective of whether they had visited a hospital or not. This may be an evidence for the lack of impact of generic advices regarding diet and lifestyle given to hospital visiting patients further reinforcing the need for tailored management strategies.

Limitations:

Some participants had attempted multiple dietary modifications and the structured questionnaire used in the study was insufficient to draw more useful details like whether these modifications alleviated symptoms or when compared, which specific dietary restrictions provided them more benefit. Recall bias was another limitation inherent to the design of the study as it relied on details reported by patients.

The study emphasizes that the understanding the demographic and clinical profiles of the patients presenting with abdominal symptoms is crucial for effective diagnosis and treatment, and to tailor management strategies and improve outcomes. Future research should continue to explore these relationships across India, and also periodically, to provide relevant targeted interventions to effectively address the growing burden of gastrointestinal symptoms in diverse populations.

Table 1: Age categories, Sex distribution, and BMI of study population

Table 2: Mean BMI with respect to Age categories, Sex distribution, and diet of study population

Table 3: Type of diet consumed by females and males in the study

Figure 1: Body Mass Index (BMI) Across Age Categories

Figure 2: Comparison of Body Mass Index (BMI) Between Males and Females

Figure 3: Comparison of Body Mass Index (BMI) Between Vegetarian and Non-Vegetarian Diets

Figure 4: Age Distribution of Individuals with and without Diabetes

Figure 5: Age Distribution of Individuals with and without Hypertension

Table 4: Symptom profile of the participants

Table 5: Risk profile of the participants

1. Dawoodi S, Dawoodi I, Dixit P. Gastrointestinal problems among Indian adults: Evidence from a national survey. NCBI. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9549910/
2. Ami DS, Shrikant IB, Douglas AD, et al. Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology. Available from: https://doi.org/10.1053/j.gastro.2020.04.014
3. Monika C, and Priyanshu S. Abdominal obesity in India: analysis of the National Family Health Survey. The Lancet. 2023. Available from: https://doi.org/10.1016/j.lansea.2023.100208
4. Khara T, Ruby MB. Meat Eating and the Transition from Plant-Based Diets among Urban Indians. M/C J [Internet]. 2019Apr.24 [cited 2024Aug.6];22(2). Available from: https://www.journal.media-culture.org.au/index.php/mcjournal/article/view/1509
5. Turaga AH. Vegetarianism and Its Implications for Body Mass Index, Health, and Dietary Awareness in a Metropolitan City in India: A Cross-Sectional Study. Cureus. 2023 Jul 20;15(7):e42187. doi: 10.7759/cureus.42187. PMID: 37602009; PMCID: PMC10439670.
6. Fontes T, Rodrigues LM, Ferreira-Pêgo C. Comparison between Different Groups of Vegetarianism and Its Associations with Body Composition: A Literature Review from 2015 to 2021. Nutrients. 2022 Apr 28;14(9):1853. doi: 10.3390/nu14091853. PMID: 35565820; PMCID: PMC9104728.
7. Tripathy JP, Thakur JS, Jeet G, Jain S. Prevalence and determinants of comorbid diabetes and hypertension: Evidence from non communicable disease risk factor STEPS survey, India. Diabetes Metab Syndr. 2017 Nov;11 Suppl 1:S459-S465. doi: 10.1016/j.dsx.2017.03.036. Epub 2017 Mar 31. PMID: 28395951.
8. Ramani, Vinod K, Suresh, K.P. Prevalence of hypertension and diabetes morbidity among adults in a few urban slums of Bangalore city, determinants of its risk factors and opportunities for control – A cross-sectional study. Journal of Family Medicine and Primary Care 9(7):p 3264-3271, July 2020. | DOI: 10.4103/jfmpc.jfmpc_234_20
9. Yan Z, Cai M, Han X, Chen Q, Lu H. The Interaction Between Age and Risk Factors for Diabetes and Prediabetes: A Community-Based Cross-Sectional Study. Diabetes Metab Syndr Obes. 2023 Jan 11;16:85-93. doi: 10.2147/DMSO.S390857. PMID: 36760587; PMCID: PMC9843502.
10. Mohanty P, Patnaik L, Nayak G, Dutta A. Gender difference in prevalence of hypertension among Indians across various age-groups: a report from multiple nationally representative samples. BMC Public Health. 2022 Aug 10;22(1):1524. doi: 10.1186/s12889-022-13949-5. PMID: 35948916; PMCID: PMC9364494.
11. Ghoshal, U.C., Sachdeva, S., Pratap, N. et al. Indian consensus statements on irritable bowel syndrome in adults: A guideline by the Indian Neurogastroenterology and Motility Association and jointly supported by the Indian Society of Gastroenterology. Indian J Gastroenterol 42, 249–273 (2023). https://doi.org/10.1007/s12664-022-01333-5
12. Kumar, N. Ratna1; Krishna, B. Sivarama1; Satyanarayana, V.1; Reddy, V. Venkatrami2; Madhusudhan, M.3,; Subramanyam, P.1. Study of clinical features and outcomes in patients presenting to the emergency department with acute abdomen. Journal of Clinical and Scientific Research 8(4):p 172-176, Oct–Dec 2019. | DOI: 10.4103/JCSR.JCSR_110_19
13. Alkhowaiter S, Alotaibi RM, Alwehaibi KK, Aljohany A, Alruhaimi B, Almasaad M, Alshammari SA, Alsahafi MA. The Effect of Body Mass Index on the Prevalence of Gastrointestinal Symptoms Among a Saudi Population. Cureus. 2021 Sep 6;13(9):e17751. doi: 10.7759/cureus.17751. PMID: 34659964; PMCID: PMC8493314.
14. Nam SY. Obesity-Related Digestive Diseases and Their Pathophysiology. Gut Liver. 2017 May 15;11(3):323-334. doi: 10.5009/gnl15557. PMID: 27890867; PMCID: PMC5417774.
15. Wang T, Masedunskas A, Willett WC, Fontana L. Vegetarian and vegan diets: benefits and drawbacks. Eur Heart J. 2023 Sep 21;44(36):3423-3439. doi: 10.1093/eurheartj/ehad436. PMID: 37450568; PMCID: PMC10516628.
16. Jenko Pražnikar, Z., Šik Novak, K., Bogataj Jontez, N. et al. Inflammatory and intestinal permeability biomarkers in healthy participants on long term vegan, vegetarian, omnivore and low-carbohydrate high-fat diet. Sci Rep 13, 17286 (2023). https://doi.org/10.1038/s41598-023-44233-0
17. Alkazemi D. Gender differences in weight status, dietary habits, and health attitudes among college students in Kuwait: A cross-sectional study. Nutr Health. 2019 Jun;25(2):75-84. doi: 10.1177/0260106018817410. Epub 2018 Dec 17. PMID: 30554554; PMCID: PMC6542002.
18. Warren A (2024) The relationship between gender differences in dietary habits, neuroinflammation, and Alzheimer’s disease. Front. Aging Neurosci. 16:1395825. doi: 10.3389/fnagi.2024.1395825
19. Shabu, S.A., Saka, M.H., Boya, M.N. et al. Association between body weight perception and actual body mass index among adult women in Erbil city, Iraq. J Health Popul Nutr 43, 15 (2024). https://doi.org/10.1186/s41043-024-00512-8
20. Halvorsen RE, Elvestad M, Molin M, Aune D. Fruit and vegetable consumption and the risk of type 2 diabetes: a systematic review and dose-response meta-analysis of prospective studies. BMJ Nutr Prev Health. 2021 Jul 2;4(2):519-531. doi: 10.1136/bmjnph-2020-000218. PMID: 35028521; PMCID: PMC8718861.
21. Rifath, Ahamed & Jemziya, Fathima. (2021). Consumption Pattern of Soft Drinks and Awareness on Traffic Light Labelling System of Prepacked Soft Drinks Among Young Adults in the Ampara District.
22. Iain MM, Emma JT. Regular Acetaminophen Use and Blood Pressure in People With Hypertension: The PATH-BP Trial. Volume 145, Issue 6, 8 February 2022; Pages 416-423. https://doi.org/10.1161/CIRCULATIONAHA.121.056015
23. Robinson M, Earnest D, Rodriguez-Stanley S, et al. Heartburn Requiring Frequent Antacid Use May Indicate Significant Illness. Arch Intern Med. 1998;158(21):2373–2376. doi:10.1001/archinte.158.21.2373
24. Wenzl, Elisabeth & Riedl, Regina & Borenich, Andrea & Petritsch, Wolfgang & Wenzl, Heimo. (2021). Low prevalence of gastroesophageal reflux symptoms in vegetarians. Indian Journal of Gastroenterology. 40. 10.1007/s12664-021-01156-w.
25. Gabrani J, Schindler C and Wyss K (2021) Health Seeking Behavior Among Adults and Elderly With Chronic Health Condition(s) in Albania. Front. Public Health 9:616014. doi: 10.3389/fpubh.2021.616014
26. Ui-Jeen Yu, DeMay TD, Nnakwe N, Schumacher J. Examination of Nutrition Knowledge, Attitude, and Dietary Behaviors of College Student Vegetarians, Semi-Vegetarians, and Non-Vegestarians. Sci J Food Sc Nutr. 2019; 5(1): 006-014
27. Mazzolani BC, Smaira FI, Esteves GP, et al. Disordered Eating Attitudes and Food Choice Motives Among Individuals Who Follow a Vegan Diet in Brazil. JAMA Netw Open. 2023;6(6):e2321065. doi:10.1001/jamanetworkopen.2023.21065
28. Tancrède A, Emilie C, et al. Vegetarianism and eating disorders: The subjective experience of healthcare professionals, Appetite,Volume 193,2024,107136,ISSN 0195-6663, https://doi.org/10.1016/j.appet.2023.107136.