Risk Factors for Gastrointestinal Disorders Among Iraqi Americans in Southeast Michigan, United States
To study the prevalence of gastrointestinal disorders, understand the compliance to treatment among Iraqi Arabs and Iraqi Chaldeans, and predict risk factors for gastrointestinal disorders.
350 random samples of Iraqi Americans, who immigrated to United States from Iraq at different times reported gastrointestinal disorders. Compliance to treatment was evaluated. Chemical environmental exposure and Non-Chemical environmental exposure scores were calculated. Different tests of significance were used.
In general, the prevalence rate of all subgroups of gastrointestinal disorders for the total population was 72.1%, while for Arab, it was 83.7%, and for Chaldean 58.2%, and the difference was significant. Age, employment, health insurance, and smoking status were a significant difference between the two groups. There were significant differences between Arabs and Chaldeans in the prevalence of gastrointestinal disorders and its subgroup, except in GI diseases, Chemical environmental, and Non-Chemical environmental exposure scores, and compliance to treatment. Chemical and Non-Chemical Environmental exposure and self-rated health were risk factors for gastrointestinal disorders and its subgroup, and there were different risk factors according to type of subgroup of gastrointestinal disorder.
The prevalence of gastrointestinal disorders was significantly lower among Chaldeans compared to Arabs. Arabs were more compliant to gastrointestinal disorders treatments. Several risk factors were predicted for each of the gastrointestinal disorders in which the Chemical and Non-Chemical environmental exposure and self-rated health were common among all.
Chemical environmental exposure, Non-chemical environmental exposure, Ethnicity, Arab, Chaldean, Prevalence rate, Compliance rate to treatment
GID: Gastrointestinal Disorders; US: United State; GI Diseases: Gastro Intestinal Diseases; GI Functional: Gastrointestinal Functional Disorders; GI Psycho: Gastrointestinal Psycho-Somatization Symptoms; SRH: Self-Rated Health; H. pylori: Helicobacter Pylori; ChE: Chemical Environmental Exposure; NChE: Non-Chemical Exposure/Stressor; Ch+NCh: Combine both ChE and NChE
Gastrointestinal disorders (GID) have different prevalence rates among ethnic groups, irrespective of their country of origin [1-4]. The multiracial communities in the United States (US), although living together, have exclusive habits, cultural practices, and lifestyles peculiar to their own culture, which could affect presentation of gastrointestinal symptoms according to Miwa and Hongo [5,6]. However, the study results of Holmboe-Ottesen and Wande differ from ours, because they studied low income South Asians who migrated to Europe . GID is a common complaint among people in the US, with differences in the presenting symptoms of these disorders .The pattern of GID varied according to cultural differences between those ethnic groups . Other concerns pertaining to GID in different ethnic groups are people's ability to access medical health-care and treatment . The Arab and Chaldean population has been increasing during the past three decades (660,000 in 1980 to 1,189,731 in 2000 - an 80% increase). Michigan is home to the highest concentration of Arabs and Chaldeans compared to any other state . According to US Census data in the year 2000, > 100,000 people living in Michigan identified themselves as Chaldean or Arab . One of the major drawbacks of studying different ethnic groups is that some groups were not clearly defined and identified as a separate entity for categorization in major studies in which those groups where arbitrarily allocated to wider scoped groups . Although "White" is usually used as the reference category for health comparisons in the US, Whites are a heterogeneous group . According to the Office of Management and Budget, "Whites" are persons having origins in Europe, North America, or the Middle East . Therefore, using Whites as the reference group may miss variations in the health status of other groups within the White category, such as individuals from the Middle East. Because of the homogeneity assumption assigned to the White category, little attention has been paid to the health status of subgroups within the White category. Arabs/Chaldeans, a subgroup within the White category, may exhibit better or worse health outcomes compared to Whites as a whole [14,15]. The relationship between ethnicity and GID could be in part related to genetics , medication use habits such as "NSAIDS" , and bacterial colonization such as in H. pylori . H. pylori is the most prominent cause of GIulcers [19,20] in which stress  and life events  could also play a role. GI functional disorders occur among people of all races, but it seems to affect Whites disproportionately . Lifestyle and stress can also affect gastrointestinal function [24,25]. De Vries found gastritis varies among different ethnic groups , and Lipowski found similar variations in enteritis and colitis . Other symptoms of GI somatization disorders could relate to substantial emotional stress [28,29,24]. Escobar showed a high prevalence of gastrointestinal somatization in immigrants, especially among those who were of lower socioeconomic status and a lower level of education . Latinos [30-32] have a higher risk of gastrointestinal somatization compared to Caucasians in the US. There is a large Iraqi immigrant community in southeast Michigan. There are mainly two ethnicities living in this community, Iraqi Chaldeans, who are Christians, migrated to the US in the late 50 s and early 60 s. They represent much of this community. Iraqi Arabs, who are mostly Muslims, in large, migrated after the 1991 gulf war. There are vast cultural, lifestyle, and diet differences between the two groups; for example, Muslim people do not eat Pork or any other animal meat unless it is butchered according to their religious ways. Participants, mostly, do not drink alcohol. Note that many Arabs in the study are Muslim, and alcohol is prohibited by religious texts. In addition, many Muslims try to avoid gatherings of different sexes, especially in their homes, while Chaldean take no issue with everything mentioned above. The aim of the work was to: 1) estimate the prevalence of GID among Iraqi Arabs and Chaldeans, 2) examine the compliance rate to treatment, 3) identify risk factors of GID among Iraqi Arabs and Chaldeans.
In 2004-2005, an elaborate community-based project was initiated to identify Iraqis residing in Southeast Michigan, US, home to one of the largest populations of Iraqi immigrants and refugees in the country. The project was announced in Arabic and English using several means of communication, such as Arabic radio and television channels. Flyers with project information were handed out at various Arab and Chaldean American community centers and faith-based facilities, convenience stores, restaurants, gas stations, hair salons, and community centers. The local Iraqi directory was also used in identifying potential participants.
A list of 5490 possible Iraqi addresses was constructed, coded, and entered into an SPSS program. A 7.5% random sample was generated. Of 411 addresses selected, 44 residents did not fit the study criteria (Male or Female, Age 18 years and above, Born in Iraq, and resident in Southeast Michigan). Of 367 eligible candidates, 17 (4.6%) declined participation. The reasons were: nine due to lack of time, seven due to lack of interest in the study, and one no reason provided. A total of 350 qualified people, representing a response rate of 95%, accepted to participate in the study. Thirteen Iraqi participants were dropped from the study; they were not considered Arab or Chaldean. The final participants were 337 Iraqi Americans classified into 153 Chaldeans and 184 Arabs.
A cross-sectional self-reported study was conducted among these participants at the home, and an outreach research assistant trained for such data collection was present. The data used in this study was part of a health assessment survey. The questionnaire was developed initially through collaboration between an Iowa Persian Gulf war study group and the Center for Disease Control, and it was used among American veterans and Iraqi immigrants/refugees [33,34]. The survey questionnaire was used in a series of studies [35-37]. All survey questions were administered in Arabic by two Iraqi-born, Arabic-speaking physicians. The inclusion criteria were that participants were Iraqi born and 18 years of age or older when they arrived from Iraq. We chose one person from each household, based on the first eligible person we got in contact with after the household door was opened. The survey contained 33 medical conditions, including gastrointestinal disorders (GID). The participant had to state whether any medical condition had been diagnosed by a primary health care physician and if they received any treatment for that condition. After that, GID were subgrouped into three groups: gastro intestinal diseases (GI diseases), which include ulcer, gastritis, enteritis, and colitis; gastrointestinal functional disorders (GI functional), which include nausea and upset stomach, abdominal pain, vomiting, diarrhea; and gastrointestinal psycho-somatization symptoms (GI Psycho), which include chronic headaches, migraines, chronic fatigue syndrome, difficulty breathing, and sleep disturbance. Participants indicated if they were taking any medications related to their GID. Participants were asked to rate their health at the time of the interview, based on the self-rated health (SRH) scale, which is a Likert-type scale ranging from one for poor health to five for excellent health. It has been shown to predict future health and mortality in healthy persons [12,38]. The responses were grouped into two categories: responses of excellent to good were given code "1" vs. responses of fair to bad were given code "0". The survey included questions related to Non-Chemical Exposure (NChE) and some may refer to psychosocial stressors and Chemical Environmental exposure (ChE) . The validated exposures were aggregate NChE dose and aggregate ChE dose .The NChE scale comprises eight questions. Each question consists of two parts (a & b); part (a) asked if the person was exposed to certain stress. If the answer was yes, code "1" was assigned; if the answer was no, code "0" was assigned. Part (b) of the question was answered only if the person marked yes for part (a) of the question. Part (b) asked about the period of exposure (code "1" indicates the period is five or less days, code "2" indicates the period range from six to thirty days, and code "3" indicates the period is thirty-one or more days). Question examples were: having been under small arms fire, witnessed anyone dying, exposure to dead bodies, etc. The range of the stressor scale was 0 to 24 points.The ChE scale included fifteen questions (Each question also comprised two parts, and each part follows the pattern of stressor exposure). Example of questions: smoke from oil well fires, chemicals, and other petrochemical fuels. The range of the scale for ChE was 0 to 45 points.
Study protocol was submitted to the Wayne State University Institutional Review Board. Review and approval was obtained from the Human Investigation Committee (HIC #: 086903B3E).
For independent continuous variables, we used t-test and chi-square test for independent discrete variables. Several Binary logistic regression analyses were used to predict the risk factors of all types of GID (GI diseases, GI functional and GI psycho), separately and combined, and for SRH. The NChE and ChE scales exhibited excellent psychometric properties with a Cronbach's alpha of > 85. The ChE score and ChE score (ChE+ChE) were combined to be used in the Binary logistic regression analysis, because it was found that no significant predictor came out if we used them separately in any one analysis. However, it showed significant predictors if we entered them individually or combined them. The period of living in the US was used, because it may affect the results of different dietary habits among these groups.
The prevalence rate of all subgroups of GID for the total population was 72.1 (GI diseases 22.6%, GI Functional 22.6%, and GI Psycho 59.1%). Demographic variables are noted in table 1. There were significant differences between the two ethnic groups in their ChE and NChE scores and the number of years lived in the US (Table 1). Table 2 illustrates the prevalence rate of all subgroups of GID by ethnicity. It also shows prevalence of GID by different demographic variables between the two ethnic groups. The prevalence of all GIDs was significantly higher among Arabs (83.7), compared to Chaldeans (58.2%). GI psycho and GI Functional were also significantly higher among Arabs, while there were no significant differences in GI diseases among the two groups. There were significant differences in the prevalence rate of GID between the two ethnic groups when tested for age, employment status, health insurance, smoking status, and SRH. Table 3 illustrates the treatment compliance rate of each subgroup of the GID. There were no significant differences between the two groups regarding treatment compliance in all GI diseases, although the compliance rates varied between the two groups. There were significant differences between the two groups in GI Functional disorders, where Iraqi Arab had a significantly higher treatment compliance rate for sore throat, nausea, and abdominal pain. With GI Psycho- treatment compliance, Iraqi Arabs had a significantly higher treatment compliance rate for sleep disturbance, chronic fatigue, and difficulty breathing (Table 3). Binary logistic regression analysis was performed to identify risk factors for all GID, GI diseases, GI functional, and GI psycho. Only significant risk factors are noted in table 4. Adjusting for different demographic variables and ChE+NChE exposure, being an Iraqi Arab was the highest risk factor (OR 2.5, 95% CI 1.34-4.80). When each GID subgroup was analyzed, risk factors were different. The combined ChE+NChE were a predictor for GID, GI diseases, and GI Functional; while SRH was a predictor in all GIDs and its subgroup, other risk predictors were found. Some share in more than one analysis or only found in one analysis. The Arab was predictor in GID, female was predictor in GI diseases and GI Psychosomatic symptoms, years in US in GIDs and GI disease, employment in GI disease and age in GI Functional disorders, and married in GI Psychosomatic symptoms (Table 4).
The overall results of this study show GID overall are more prevalent among Iraqi Arabs (83.7%), compared to Iraqi Chaldeans (58.2%). This was based on a random sample of two ethnic groups, who immigrated from the same country, share a common culture, a common lifestyle, and reside in Southeast Michigan, but are different in religion, as Chaldean are Christian, while the Arab was mainly Muslim. There were no significant differences between the two ethnicities concerning compliance to treatment for GI diseases but for other disorders. Iraqi Arabs were more likely to comply with GI Functional symptoms, GI psycho, Ethnicity, and most of the GI disease. SRH were risk factors when testing all GIDs. When GID subgroups were tested, risk factors were identified. SRH (Worse to Bad) was a risk factor among all GIDs and its subgroup.
The prevalence rate of all subgroups of GID in our study group was 72.1%. However, the prevalence rate of GID in the Arab group was higher (83.7%) than in the Chaldean group (58.2%), and the difference was significant. One explanation is that most of the Iraqi Arabs who live in the US entered the country after the 1991 Gulf War. This could explain the significant differences of the combined ChE and NChE exposure between the two ethnic groups. Although 76.6% of Iraqi Arabs have health insurance, compared to 58.2% of Iraqi Chaldeans, the prevalence rate of all types of GID was significantly higher among Arabs. Such differences were in agreement with Zuckerman (1996), who found a significant difference in health-care-seeking behaviors related to bowel complaints between Hispanics versus non-Hispanic whites. Doll's (1951) study showed differences in ethnicity in relation to gastric and duodenal ulcers and concluded differences could be related to genetic predisposition, while Gurjeet (2003) showed differences could be related to distribution of H. pylori infection among Endoscope patients in the North Eastern Peninsular of Malaysia. On the other hand, Antony's  study showed no relation between ethnicity and pressure ulcers. Gastritis has also been shown to vary between different ethnicities [3,4] and Gurjeet  showed difference in GI disorders among different ethnic groups, while Campbell showed a significant difference in H. pylori rate of colonization regarding ethnicity. In addition, certain ethnicities are more prone to certain GI diseases, such as colitis, compared to people of other ethnicities [41,42]. The significant differences between those two ethnic groups concerning all subgroups of GID and their risk factors and most subgroups of the GID will help primary health care, public health institutes, and non-profit community organizations consider the results when they deal with the Iraqi Arab/Chaldean community, in particular, and other ethnic groups, in general, or in establishing educational programs to help the community. This was the recommendation from De Vries's (De Vries, 2008)study, which showed migrant communities constitute a possible target population for primary prevention of H. pylori-related complications in low incidence countries, and Ekblad  showed the importance of immigrant status in health care and social insurance and its effects on the community.
Limitations and Strength of the Study
The survey of the original study assessed the health of the Iraqi community in Southeast Michigan. Several questions, which could relate to identified risk factors for GID, were not included in the survey. Also, the responses of the participants were, naturally, self-reported answers. However, the strength of the study was based on having a random sample of participants. Iraqi Arabs and Iraqi Chaldean (the two groups of the study) descend from the same country, share a common culture, and reside in Southeast Michigan. The only difference between the two groups was in ethnicity.
The study was based on a random sample of participants who emigrated to the US from Iraq at different times, and although they share a lot of common things, they differ in ethnicity (Arab and Chaldean). The data analysis of the participants indicates differences between the two ethnic groups in most of their demographic variables, ChE, NChE exposure, and even in reporting SRH. The prevalence rate of all GID was 72.1%; however, there was a significant difference in GID, including GI functional symptoms and GI psycho between Iraqi Arabs and Iraqi Chaldeans, with Chaldeans having a lower prevalence rate in all subgroups of GID. Significant impact differences of ChE and NChE exposure on the two ethnic groups could explain the difference impact on GID. Also, treatment compliance was different between the two groups in some GI psycho, where Iraqi Arabs were more compliant, but Chaldeans reported better health than Arabs at the time of the interview. The difference was significant. Applying Binary logistic regression analysis for each GID and each of its subgroups showed several risk predictor factors, such as age, gender, marital status, years in the US, which should be considered in any educational preventive program for the community and could help primary healthcare when dealing with such problems.
The authors thank Pfizer Corporation for providing financial support to collect the original survey data (Health Assessment of Iraqi People Residing in Southeast Michigan 2003-3004). Thanks go also to Pierre Yaldo who reviews the language of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Pfizer Corporation.
- Kaur G, Nye Naing N (2003) Prevalence and Ethnic Distribution of Helicobacter Malaysia. Malays J Med Sci 10: 66-70.
- Halder G, Locke III R, Schleck CD, et al. (2007) Natural History of Functional Gastrointestinal Disorders: A 12-year Longitudinal Population-Based Study. Gastroenterology 133: 799-807.
- Abdullah M, Ohtsuka H, Rani AA, et al. (2009) Helicobacter pylori infection and gastropathy: A comparison between Indonesian and Japanese patients. World J Gastroenterol 15: 4928-4931.
- Zhou H, Yao M, Cheng GY, et al. (2011) Prevalence and Associated Factors of Functional Gastrointestinal Disorders and Bowel Habits in Chinese Adolescents: A School-based Study. J Pediatr Gastroenterol Nutr 53: 168-173.
- Miwa H (2011) Life style in persons with functional gastrointestinal disorders--large-scale internet survey of lifestyle in Japan. Neurogastroenterol Motil 24: 464-471.
- Hongo M (2011) Epidemiology of FGID symptoms in Japanese general population with reference to life style. J Gastroenterol Hepatol 3: 19-22.
- Holmboe-Ottesen G, Wandel M (2012) Changes in dietary habits after migration and consequences for health: a focus on South Asians in Europe. Food Nutr Res 56.
- Sobieraj DM, Coleman SM, Coleman CI (2011) US prevalence of upper gastrointestinal symptoms: a systematic literature review. Am J Manag Care 17: 449-458.
- Everhart, James E (2008) Abdominal Wall Hernia. In: James E, Everhart, The Burden of Digestive Diseases in the United States, National Institute of Diabetes and Digestive and Kidney Diseases 93-95.
- Zuckerman MJ, Guerra LG, Drossman DA, et al. (1996) Health-care-seeking behaviors related to bowel complaints. Hispanics versus non-Hispanic whites. Dig Dis Sci 41: 77-82.
- De la Cruz GP, Brittingham A (2003) The Arab Population 2000. US Department of Commerce; Economics and Statistics Administration 62: 1-12.
- Skrondal A, Rabe-Hesketh S (2008) Classical latent variable modeling. Statistical Methods in Medical Research 17.
- (2010) Office of Management and Budget. Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity 1-3.
- Dallo FJ, Borrell LN (2006) Self-reported diabetes and hypertension among Arab Americans in the United States. Ethn Dis 16: 699-705.
- Jamil H, Fakhouri M, Dallo F, et al. (2008) Self-Reported Heart Disease among Arab and Chaldean American Women Residing in Southeast Michigan. Ethn Dis 18: 19-25.
- Doll R, Kellock TD (1951) The separate inheritance of gastric and duodenal ulcers. Ann Eugen 16: 231-240.
- Kaur G, Raj SM (2002) Study of the concordance between endoscopic gastritis and histological gastritis in an area with a low background prevalence of Helicobacter pylori infection. Singapore Med J 43: 90-92.
- Campbell, Gary D, Mary E, et al. (2004) Racial and Ethnic Identification, Official Classifications, and Health Disparities. National Research Council (US) Panel on Race, Ethnicity, and Health in Later Life; Anderson NB, Bulatao RA, Cohen B, editors. Washington (DC): National Academies Press (US).
- Ciociola AA, McSorley DJ, Turner K, et al. (1999) Helicobacter pylori infection rates in duodenal ulcer patients in the United States may be lower than previously estimated. Am J Gastroenterology 94: 1834-1840.
- Guo G, Jia K, Shi Y, et al. (2009) Psychological stress enhances the colonization of the stomach by Helicobacter pylori in the BALB/c mouse. Stress 12: 478-485.
- Bennet E, Beaurepaire J, Langeluddecke P, et al. (1991) Life stress and non-ulcer dyspepsia: a case-control study. J Psychosom Res 35: 579-590.
- Haug TT, Wilhelmsen I, Berstad A, et al. (1995) Life events and stress in patients with functional dyspepsia compared with patients with duodenal ulcer and healthy controls. Scand J Gastroenterol. 30: 524-530.
- Li BU, Misiewicz L (2003) Cyclic vomiting: A brain-gut disorder. Gastroenterol Clin North Am 32: 997-1019.
- Escobar JI, Rubio-Stipec M, Canino G, et al. (1989) Somatic symptom index (SSI): a new and abridged somatization construct. Prevalence and epidemiological correlates in two large community samples. J Nerv Ment Dis 177: 140-146.
- Pinto C, Lele MV, Joglekar AS, et al. (2000) Stressful life-events, anxiety, depression and coping in patients of irritable bowel syndrome. J Assoc Physicians India 48: 589-593.
- De Vries AC, Van Driel HF, Richardus JH, et al. (2008) Migrant communities constitute a possible target population for primary prevention of Helicobacter pylori-related complications in low incidence countries. Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, the Netherlands 43: 403-409.
- Lipowski J (1988) Somatization: The concept and its clinical application. Am J Psychiatry 145: 1358-1368.
- Kleinman A (1982) Neurasthenia and depression: a study of somatization and culture in China. Cult Med Psychiatry 6:117-190.
- Escobar JL, Randolph ET, Hill M (1986) Symptoms of schizophrenia in Hispanic and Anglo veterans. Cult Med Psychiatry 10: 259-276.
- Mezzich JE, Raab ES (1980) Depressive symptomatology across the Americas. Arch Gen Psychiatry. 37: 818-823.
- Kohn R, Flaherty JA, Levav I (1989) Somatic symptoms among older Soviet immigrants: an exploratory study. Int J Soc Psychiatry 35: 350-360.
- Hsu LK, Folstein MF (1997) Somatoform disorders in Caucasian and Chinese Americans. J Nerv Ment Dis 185: 382-387.
- Jamil H, Nassar-McMillan S, Lambert RG, et al. (2010) Sustained Stress and Health among Iraqi U.S. Refugees and Immigrants: Relationship to Pre-Displacement Societal Conditions. Journal of Medicine, Conflict & Survival 26: 210-225.
- Arnetz B, Drutchas A, Sokol R, et al. (2013) 1991 Gulf War Exposures and Adverse Birth Outcomes. US Army Med Dep J 58-65.
- Jamil H, Nassar-McMillan S, Lambert R, et al. (2006) Brief Note: Health Assessment of Iraqi Immigrants. Journal of Immigrant & Refugee Studies. 4: 69-74.
- Nassar-McMillan SC, Jamil H, Lambert RG. (2010) Chemical, Environmental, and Trauma Exposures and Corresponding Health Symptoms among Iraqi American Women. Journal of Applied Biobehavioral Research.
- Kroenke K, Koslowe P, Roy M (1998) Symptoms in 18,495 Persian Gulf War veterans. Latency of onset and lack of association with self-reported exposures. J Occup Environ Med 40: 520-528.
- Templin T, Pieper B (2003) Causal Modeling in WOC Nursing Research. J Wound Ostomy Continence Nur 30: 168-174.
- Baron RM, Kenny DA (1986) The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 51: 1173-1182.
- Anthony D, Johnson M, Reynolds T, et al. (2002) Ethnicity in pressure ulcer risk assessment, with specific relation to the Pakistani ethnic minority in Burton, England. J Adv Nurs 38: 592-597.
- Gurjeet K, Nyi N (2003) Prevalence and Ethnic Distribution of Helicobacter Pylori Infection Among Endoscoped Patients in North Eastern Peninsular Malaysia. Malays J Med Sc 10: 66-70.
- Ekblad S, Oxenstierna G, Akpinar (1998) The importance of immigrant status in health care and social insurance: A public health report for Stockholm County.
- Campbell S, Fraser A, Holliss B, et al. (1997) Evidence for ethnic tropism of Helicobacter pylori. 65: 3708-3712.
Hikmet J Jamil, Department of Family Medicine, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA, Tel: 248-798-4900.
© 2017 Jamil LH, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.