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BMC Gastroenterology

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Prevalence and risk factors of Helicobacter pylori infection in Korea: Nationwide multicenter study over 13 years

  • Seon Hee Lim1,
  • Jin-Won Kwon2,
  • Nayoung Kim3, 4Email author,
  • Gwang Ha Kim5,
  • Jung Mook Kang1,
  • Min Jung Park1,
  • Jeong Yoon Yim1,
  • Heung Up Kim6,
  • Gwang Ho Baik7,
  • Geom Seog Seo8,
  • Jeong Eun Shin9,
  • Young-Eun Joo10,
  • Joo Sung Kim1, 4 and
  • Hyun Chae Jung4
Contributed equally
BMC Gastroenterology201313:104

https://doi.org/10.1186/1471-230X-13-104

Received: 14 January 2013

Accepted: 21 June 2013

Published: 24 June 2013

Abstract

Background

The aim of this study was to evaluate the time trend of seropositivity of Helicobacter pylori (H. pylori) over the period of 13 years in an asymptomatic Korean population, and investigate associated risk factors.

Methods

This cross-sectional nationwide multicentre study surveyed anti-H. pylori IgG antibodies in 19,272 health check-up subjects (aged [greater than and equal to]16 years) in 2011. Risk factors for H. pylori infection were investigated using logistic regression. Seropositivity in asymptomatic subjects without H. pylori eradication was compared between the years 1998 and 2005. Birth cohort effects were also evaluated.

Results

After exclusion of subjects with a history of H. pylori eradication therapy (n = 3,712, 19.3%) and gastric symptoms (n = 4,764, 24.7%), the seroprevalence of H. pylori infection was 54.4% in 10,796 subjects. This was significantly lower than the seroprevalence of 59.6% in 2005 and that of 66.9% in 1998, and this decrease of seropositivity of H. pylori became widespread across all ages and in most areas of the country. This decreasing trend could be explained by cohort analysis. All younger birth cohorts had a lower seroprevalence of H. pylori than older birth cohorts at the same age. Decreased seroprevalence within the same birth cohorts also accounted for this phenomenon. Clinical risk factors of H. pylori infection were higher cholesterol level ([greater than and equal to] 240 mg/dl) (OR = 1.33; 95% CI = 1.14-1.54), male gender, older age, low income, and residence in a rural area.

Conclusions

A decreasing trend of H. pylori seroprevalence due to a birth cohort effect requires further studies on its related human host factors as well as socio-economic and hygienic factors. In addition, the relationship between H. pylori infection and high cholesterol level needs more investigation regarding underlying pathogenesis.

Keywords

Helicobacter pyloriSeroprevalenceEpidemiologyCohort

Background

Helicobacter pylori (H. pylori), a cause of peptic ulcer disease, gastric adenocarcinoma, and low-grade gastric mucosa associated lymphoid tissue (MALT) lymphoma [1] has been falling due to improved sanitation and better living conditions [2, 3]. However, its prevalence is reported to be still high, especially in Asia including South Korea. From the public health perspective, observation of prevalence trends and confirmation of risk factors for H. pylori infection are important to establish health policies to prevent H. pylori related diseases.

There are many studies regarding the prevalence and risk factors of H. pylori infection, and older age was commonly considered as the main risk factor [4, 5]. One study mentioned that adults have a continuous risk of H. pylori infection, resulting in increased seroprevalence during lifetime as a function of age [6]. However, this does not mean that young people have a higher seroprevalence when they get older, showing that cross sectional presentation does not necessarily give an accurate picture of lifetime trends. Also, there are limited studies on lifetime trends for H. pylori seroprevalence [7, 8].

In South Korea, previous study also indicated a decreasing pattern of H. pylori infection during a time period between 1998 and 2005 [9]. As Korea is in a dynamic state of progression from a developing country into a developed country, it may be valuable to evaluate the seroprevalence of H. pylori in Korea. In accordance with this point of view, the aim of this study was to investigate the trends of seropositivity of H. pylori in asymptomatic Korean subjects over 16 years of age together with cohort effects between the years 1998 and 2011, and to find factors related to H. pylori infection.

Methods

Study population

This is a cross-sectional nationwide multicentre study of adult subjects aged 16 years or older who visited healthcare centers for routine health check-up between January and December 2011 in South Korea. The subjects were enrolled prospectively in 2011 under a predefined protocol. The institutions participating in this study were healthcare centers located in Seoul and in the seven provinces of South Korea.

Informed consent was obtained from each subject. All subjects were invited to answer the questionnaire which was the same as previous study’s [9] under the supervision of a well-trained interviewer. The questionnaire included information regarding demographic data (i.e. age, sex, and residence), socioeconomic data (i.e. monthly income and education level), medical history (such as H. pylori eradication therapy, history of gastric operation, and family history of gastric cancer (GC)), and upper gastrointestinal (GI) symptoms (such as indigestion, bloating, epigastric soreness, regurgitation, or heartburn), that persisted for at least one month within the last 3 years.

Subjects were categorized into 3 education levels: low (middle school graduate or less), middle (high school graduate or university dropout), and high (university graduate or graduate of a postgraduate course). Monthly family income was classed as 3 groups: low household income (< US $ 3,000 per month), middle income (US $ 3,000 to 10,000 per month), and high income (> US $ 10,000 per month).

Clinical and laboratory evaluations

Anthropometric measurements (weight and height) were done by trained nurses using a standardized protocol.

Blood samples were obtained from the antecubital vein in the morning after overnight fasting, and serum samples were separated after centrifugation. Serum cholesterol, triglyceride, and fasting glucose were measured by an automatic analyser, Alisei® (Seac, Pomezia, Italy). To compare these results according to seropositivity of H. Pylori, we categorized the level of total cholesterol (TC) as normal (≤240 mg/dl) and abnormal (>240 mg/dl), trigryceride (TG) as ≤150 mg/dl and >150 mg/dl, and fasting glucose as ≤100 mg/dl and >100 mg/dl, respectively.

Anti-H. pylori IgG was measured using H. pylori-EIA-Well in Healthcare System Gangnam Center and Genedia H. pylori ELISA at the remaining centers using the same kits as those in the previous studies [9, 10]. Genedia H. pylori ELISA, developed from Korean H. pylori strains showed a sensitivity of 97.8% and a specificity of 92% [11]. H. pylori-EIA-Well showed a sensitivity of 95.6% and a specificity of 97.8% when Genedia H. pylori ELISA was used as the gold standard [9].

Statistical analysis

Evaluation of risk factors of each group according to eradication of H. pylori

Demographic and clinical information were summarized by descriptive statistics. To investigate risk factors for H. pylori seropositivity and influential factors having a history of H. pylori eradication, multivariable logistic regression was used. A significance level of p < 0.05 was used for all analyses.

Comparison of trends of seroprevalence of H. pylori in 1998, 2005, and 2011

Trends of seroprevalence of H. pylori were compared using the published data of 1998 [10] and 2005 [9]. For this comparison, study subjects in each time period were restricted to asymptomatic subjects without a history of H. pylori eradication and gastric operation. For statistical comparison of trends of seroprevalence of H. pylori in 1998, 2005, and 2011, the Cochrane-Armitage trend test, which is a modified Pearson chi-square test to examine the association between a binary outcome and a variable with multiple categories with order, was conducted.

Analysis of cohort effects

In addition, the seroprevalence of H. pylori by birth cohort group was also drawn. To examine birth cohort effects, we created synthetic cohorts from the successive cross-sectional data of 1998, 2005, and 2011. For this analysis, relevant raw data in 1998 and 2005 were obtained from the authors and reconstructed for the analysis of birth cohort. Data from 1998 was considered to be those in 1999 because the successive cross-sectional data should span with same interval. The interval of three cross-sectional data was 6 years. The aggregate birth cohort from 1930 to 1972 was restructured into 8 groups using the standard approach for cohort analysis [12]. In detail, a birth cohort was obtained by subtracting age from year (i.e. Birth cohort of 1974.5 (birth cohort of 1972–77) = Year of 1998 – Age of 24.5 (22–27 years old)). For example, people aged 22–27 years in 1998 (considered as data in 1999), those aged 28–33 years in 2005, and those aged 34–39 years in 2011 were considered to be in the same birth cohort, born between 1972 and 1977. Using this approach for other age groups in each year, eight birth cohorts (1972–77, 1966–71, 1960–65, 1954–59, 1948–53, 1942–47,1936-41,1930-35) had three estimates of H. pylori seroprevalence at 6 year intervals for 12 years.

Ethics statement

The protocol of this study was approved by the main Institutional Review Board of Seoul National University Hospital (IRB No. H-1011-038-339).

Results

Seroprevalence and eradication history of H. pyloriin total subjects

The seroprevalence of H. pylori was 52.8% (8,216/15,560) after exclusion of H. pylori eradicated history in 19,272 eligible subjects and 54.4% (5,882/10,796) after exclusion of symptomatic subjects (Figure 1).
Figure 1

Study flowchart in 2011.

The demographics and clinical characteristics by group are presented in Table 1.
Table 1

Baseline characteristics of subjects

 

Subjects without GI operation history

Subjects without history of H. pylorieradication

Asymptomatic subjects without history of H. pylorieradication

n

(%)

n

(%)

n

(%)

Total

 

19,272

(100.0)

15,560

(100.0)

10,796

(100.0)

Sex

Male

10,557

(54.8)

8,311

(53.4)

6,085

(56.4)

Female

8,715

(45.2)

7,249

(46.6)

4,711

(43.6)

 

Subtotal

19,272

(100.0)

15,560

(100.0)

10,796

(100.0)

Age (years)

16-19

34

(0.2)

33

(0.2)

17

(0.2)

20-29

798

(4.1)

777

(5.0)

421

(3.9)

30-39

2,853

(14.8)

2,607

(16.8)

1,659

(15.4)

40-49

5,087

(26.4)

4,198

(27.0)

2,913

(27.0)

50-59

6,176

(32.0)

4,709

(30.3)

3,403

(31.5)

60-69

3,358

(17.4)

2,493

(16.0)

1,840

(17.0)

≥70

966

(5.0)

743

(4.8)

543

(5.0)

Subtotal

19,272

(100.0)

15,560

(100.0)

10,796

(100.0)

Geographic area

Seoul

10,755

(55.8)

8,515

(54.8)

5,829

(54.0)

Gyeonggi

3,025

(15.7)

2,403

(15.5)

1,683

(15.6)

Chungcheong

863

(4.5)

740

(4.8)

536

(5.0)

Kyungsang

1,630

(8.5)

1,313

(8.4)

914

(8.5)

Cholla

1,807

(9.4)

1,553

(10.0)

1,194

(11.1)

Kangwon

588

(3.1)

466

(3.0)

331

(3.1)

Jeju

589

(3.1)

555

(3.6)

299

(2.8)

Subtotal*

19,257

(100.0)

15,545

(100.0)

10,786

(100.0)

Household income**

low

2,114

(12.5)

1,838

(13.5)

1,247

(13.2)

medium

11,049

(65.2)

8,843

(65.1)

6,197

(65.6)

high

3,781

(22.3)

2,910

(21.4)

2,005

(21.2)

Subtotal*

16,944

(100.0)

13,591

(100.0)

9,449

(100.0)

Education level***

low

1,743

(9.5)

1,458

(9.9)

984

(9.7)

medium

3,667

(20.0)

3,004

(20.4)

1,981

(19.4)

high

12,928

(70.5)

10,250

(69.7)

7,223

(70.9)

Subtotal*

18,338

(100.0)

14,712

(100.0)

10,188

(100.0)

Body mass index (kg/m2)

<18.5

840

(4.4)

736

(4.8)

412

(3.9)

18.5 - <23.0

7,696

(40.6)

6,245

(40.7)

4,237

(39.8)

23.0 - <25.0

4,818

(25.4)

3,821

(24.9)

2,759

(25.9)

≥25.0

5,625

(29.6)

4,530

(29.5)

3,249

(30.5)

Subtotal*

18,979

(100.0)

15,332

(100.0)

10,657

(100.0)

Cholesterol (mg/dl)

<240

16,671

(90.5)

13,417

(90.4)

9,228

(90.1)

≥240

1,755

(9.5)

1,428

(9.6)

1,013

(9.9)

Subtotal*

18,426

(100.0)

14,845

(100.0)

10,241

(100.0)

TG (mg/dl)

<150

14,651

(79.7)

11,873

(80.1)

8,118

(79.4)

≥150

3,736

(20.3)

2,941

(19.9)

2,102

(20.6)

Subtotal*

18,387

(100.0)

14,814

(100.0)

10,220

(100.0)

Glucose (mg/dl)

<100

12,999

(70.7)

10,667

(72.0)

7,206

(70.5)

100 - <126

4,438

(24.1)

3,399

(22.9)

2,459

(24.1)

≥126

955

(5.2)

747

(5.0)

555

(5.4)

Subtotal*

18,392

(100.0)

14,813

(100.0)

10,220

(100.0)

Family history of gastric cancer

No

16,470

(86.6)

13,418

(87.5)

9,473

(88.2)

Yes

2,556

(13.4)

1,910

(12.5)

1,270

(11.8)

Subtotal*

19,026

(100.0)

15,328

(100.0)

10,743

(100.0)

GI symptoms

No

13,121

(68.8)

10,796

(70.3)

  

Yes

5,954

(31.2)

4,568

(29.7)

  

Subtotal*

19,075

(100.0)

15,364

(100.0)

  

*Subjects with missing values were excluded.

**Household income was classified as low (less than US $ 3,000), medium (US $ 3,000 to 10,000), or high (more than US $ 10,000).

***Education level was classified as low (middle school graduates or less), middle (high school graduates or university dropouts), or high (university graduates or graduates of a postgraduate course).

GI gastrointestinal.

Among the 19,272 subjects, 19.3% reported a history of eradication therapy for H. pylori infection. By logistic regression modeling, the influencing factors for having a history of eradication therapy for H. pylori infection were male, older age, higher income, living in Seoul (Capital area), the presence of GI symptom and GC family history (Table 2).
Table 2

Multivariate analysis of factors affecting H. pylori eradication therapy

 

Total

Subjects with history of H. pylori eradication

Odds ratio

95% CI

n

%

Total

 

19,272

3,712

19.3

   

Sex

Male

10,557

2,246

21.3

Ref

  
 

Female

8,715

1,466

16.8

0.77

0.71

0.84

Age (years)

16-19

34

1

2.9

2.27

0.28

18.21

20-29

798

21

2.6

Ref

  

30-39

2,853

246

8.6

4.22

2.44

7.31

40-49

5,087

889

17.5

9.32

5.44

15.94

50-59

6,176

1,467

23.8

14.33

8.39

24.48

60-69

3,358

865

25.8

16.91

9.87

28.97

≥70

966

223

23.1

16.73

9.58

29.20

Geographic area

Seoul

10,755

2,240

20.8

Ref

  

Gyeonggi

3,025

622

20.6

0.97

0.87

1.08

Chungcheong

863

123

14.3

0.76

0.61

0.94

Kyungsang

1,630

317

19.4

0.85

0.74

0.99

Cholla

1,807

254

14.1

0.68

0.58

0.80

Kangwon

588

122

20.7

1.30

1.04

1.64

Jeju

589

34

5.8

0.27

0.19

0.39

Household income*

Low

2,114

276

13.1

0.70

0.58

0.83

Medium

11,049

2,206

20.0

0.96

0.87

1.05

High

3,781

871

23.0

Ref

  

Education level**

Low

1,743

285

16.4

0.70

0.59

0.84

Medium

3,667

663

18.1

0.87

0.78

0.97

High

12,928

2,678

20.7

Ref

  

GI symptoms

No

13,121

2,325

17.7

Ref

  

Yes

5,954

1,386

23.3

1.60

1.47

1.73

Family history of gastric cancer

No

16,470

3,052

18.5

Ref

  

Yes

2,556

646

25.3

1.34

1.21

1.49

*, **, GI, same as those of Table 1.

CI confidence Interval, Ref reference.

Total subject number of multivariable logistic regression was 16,770.

Risk factors for H. pylori infection in asymptomatic subjects without a history of H. pylorieradication

The risk factors for H. pylori infection in asymptomatic subjects without a history of H. pylori eradication were significantly associated with gender, age, geographic area, economic status, education level, and cholesterol level (Table 3). Seropositivity of H. pylori was significantly lower in females than in males (OR = 0.79, 95% CI = 0.71-0.87). By age, seroprevalence increased in a nearly linear fashion from 20 to 59 years of age. However, the prevalence remained steady from 60 years of age. Regarding residence, when compared with Seoul, other provinces except for Gyeonggi and Kangwon had a higher risks of H. pylori seropositivity. Subjects with high income and high education level had a lower likelihoods of having H. pylori seropositivity. Subjects with a higher TC level (≥240 mg/dl) had a 30% higher likelihood of having H. pylori seropositivity compared with subjects with a lower TC (<240 mg/dl) (OR = 1.33, 95% CI = 1.14-1.54) after adjustments for BMI, age, and income level. However, blood glucose level and TG level did not affect the seropositivity of H. pylori infection after adjustment for other variables. Family history of GC and BMI level did not affect the seropositivity of H. pylori.
Table 3

Risk factors for H. pylori seropositivity in asymptomatic subjects without a history of H. pylori eradication and gastric operation (Multivariable logistic regression)

  

Total

H. pylori Seropositivity

  

N

%

Odds ratio

95% CI

Total

 

10,796

5,882

54.5

   

Sex

Male

6,085

3,472

57.1

Ref

  

Female

4,711

2,410

51.2

0.79

0.71

0.87

Age (years)

16-19

17

2

11.8

0.55

0.11

2.68

20-29

421

111

26.4

Ref

  

30-39

1,659

698

42.1

1.55

1.18

2.04

40-49

2,913

1,531

52.6

2.39

1.83

3.11

50-59

3,403

2,088

61.4

3.52

2.70

4.60

60-69

1,840

1,134

61.6

3.57

2.70

4.71

≥70

543

318

58.6

3.11

2.24

4.31

Geographic area

Seoul

5,829

2,917

50.0

Ref

  

Gyeonggi

1,683

898

53.4

1.07

0.95

1.21

Chungcheong

536

297

55.4

1.29

1.05

1.58

Kyungsang

914

595

65.1

1.29

1.06

1.57

Cholla

1,194

790

66.2

1.66

1.41

1.96

Kangwon

331

200

60.4

1.19

0.92

1.54

Jeju

299

176

58.9

1.36

1.05

1.77

Household Income*

Low

1,247

785

63.0

1.21

1.00

1.45

Medium

6,197

3,416

55.1

1.07

0.96

1.19

High

2,005

1,042

52.0

Ref

  

Education**

Low

984

629

63.9

1.01

0.84

1.23

Medium

1,981

1,165

58.8

1.13

1.00

1.28

High

7,223

3,779

52.3

Ref

  

Body Mass Index (kg/m2)

<18.5

412

180

43.7

1.03

0.81

1.31

18.5 - <23.0

4,237

2,224

52.5

Ref

  

23.0 - <25.0

2,759

1,565

56.7

0.98

0.88

1.10

≥25

3,249

1,830

56.3

0.95

0.84

1.06

Cholesterol (mg/dl)

<240

9,228

4,882

52.9

Ref

  
 

≥240

1,013

624

61.6

1.33

1.14

1.54

Triglyceride (mg/dl)

<150

8,118

4,316

53.2

Ref

  
 

≥150

2,102

1,179

56.1

0.98

0.87

1.10

Glucose (mg/dl)

<100

7,206

3,786

52.5

Ref

  

100 − <126

2,459

1,378

56.0

0.93

0.84

1.04

≥126

555

328

59.1

0.98

0.80

1.19

Family history of gastric cancer

No

9,473

5,152

54.4

Ref

  

Yes

1,270

700

55.1

0.96

0.84

1.09

*, **, GI, CI, Ref, same as those of Table 2.

Total subject number of multivariable logistic regression was 8,688.

Comparison of seroprevalence of H. pylori among 2011, 2005, and 1998 in asymptomatic subjects without a history of H. pylorieradication

Comparison of seroprevalence of H. pylori from 1998, 2005 and 2011 was performed, and the data from 1998 and 2005 were investigated by the Korean H. pylori Study Group [10] and our group [9], respectively. The overall seroprevalence of H. pylori infection was 54.4% (95% CI: 53.5-55.4%) in 2011 which is significantly decreased from 66.9 % (95% CI: 65.4-68.6%) in 1998, and 59.6 % (95% CI: 58.5-60.7%) in 2005 (p < 0.001) (Panel A of Figure 2). There was a statistically significant reduction between 1998 and 2005, and between 2005 and 2011.
Figure 2

Trends of seroprevalence of H. pylori infection in asymptomatic subjects without a history of H. pylori eradication in 1998[10], 2005[9], and 2011. (* p < 0.05) Seroprevalence by sex (Panel A), by geographic area (Panel B) and by age (Panel B).

According to geographic area, the seroprevalence showed a significant downward trend in most of areas over time except in Kyungsang and Kangwon. (Panel B of Figure 2).

The seroprevalence of H. pylori and 95% CI at intervals of 10 years of age in 1998, 2005, and 2011 were plotted in Panel C of Figure 2. The seroprevalence of H. pylori was decreased in the all age groups over time with statistical significance from 1998 to 2011. A steep decreasing pattern was observed for subjects under 40 years of age between 1998 and 2005. However, when the time period was extended to 2011, the declining trend was more prominent in older age groups, resulting in an overall decrease for all age groups.

The birth cohort effects

To observe lifetime trends, the seroprevalence of H. pylori of categorized birth cohorts against age were plotted as shown in Figure 3. Each line connects the values for the same cohort-group in different age groups. For example, a line first represents a birth cohort of 1972–77 in all graphs. At the same age of 28–33 years (mean 30.5 years old), a younger birth cohort of 1972–77 had a lower seroprevalence of H. pylori when compared with a older birth cohort of 1966–71. Likewise, all younger birth cohorts at the same age had a lower seroprevalence of H. pylori compared with older birth cohorts. Within the same birth cohort, most birth cohorts had decreasing pattern of seropositivity of H. pylori except for a birth cohort of 1972–1977. This birth cohort showed a decreasing pattern from 22–27 to 28–33 years of age, but it showed a very slight increase (from 41% to 43%) from 28–33 to 34–39 years of age.
Figure 3

Seroprevalence of H . pylori infection in asymptomatic subjects without a history of H . pylori eradication in birth cohort against age. Each line connects the values for the same cohort-group in different age group. For example, the first line shows the seroprevalence of H. pylori in a birth cohort of 1972–77 for ages of 22–39 years, and the second line shows the seroprevalence of H. pylori in a birth cohort of 1966–71 for ages of 28–45 years. All younger birth cohorts at the same age have a lower seroprevalence of H. pylori than older birth cohorts.

Discussion

The decreasing trend (from 66.9% to 54.4%) of seroprevalence of H. pylori over 13 years was explained by birth cohort analysis, and a relationship between H. pylori infection and high cholesterol level was found in this large cohort.

A drop in the seroprevalence of H. pylori infection has been observed in previous studies [2, 3, 13]. This trend was most often explained by a combination of various factors including rapid economic growth, improved sanitation, and widespread use of antibiotics and proton pump inhibitors [2, 3]. Similarly, the overall seroprevalence of H. pylori significantly decreased in the last survey of the Korean population in 2005 [9] compared with that in 1998 [10], but the declining trend was different depending on the age groups and areas. Although the drop in H. pylori infection was bigger in younger age groups of subjects 40 years old or less for seven years from 1998 to 2005, the difference of seroprevalence in older groups during same periods was smaller, as shown in the upper two lines of figure 2C. In addition, regarding areas, only subjects who lived in Seoul (capital) and Gyeonggi province which surrounds the capital, showed a clear declining trend during the same periods, but not in all districts in previous study [9]. Furthermore, subjects who lived in Chungcheong province showed a slight increase between 1998 and 2005.

However, when we extended the time period to 2011 in this study, this decreasing trend was more prominent for all ages over 13 years. Similarly, a Japanese study of seropositivity trends of H. pylori over a period of 10 years from 1992 to 2002–2006 also found declining trends of seropositivity for all age groups [13]. Regarding province, there was no increasing pattern in any province, and a statistically significant decreasing trend was observed in all provinces except two provinces, Kyungsang and Kangwon areas.

We also analyzed birth cohort effects. In the cross sectional study, the prevalence of H. pylori infection increased till 40 – 49 years of age, after which it remained steady. When we graphically drew the prevalence in H. pylori infection by birth cohort to differentiate the increase of infection during aging, the seroprevalence was lower in younger birth cohort (i.e. people who were born later) than the older birth cohort (people who were born earlier) at the same age, showing a clear cohort effect in subjects up to 40–45 years of age. This phenomenon could be explained by continuous influx of younger birth cohorts [7]. A similar birth cohort effect for H. pylori infection was observed in Western studies [2, 3, 7, 8]. In addition, H. pylori infection in adults is mostly acquired by the age of 15 years [7, 8]. One study which followed children (1–3 years old) for 21 years indicated that the annual seroconversion rate had a highest risk at the age of 4–5 years, and newly acquired H. pylori infections mostly occurred by the age of 10 years [14]. However, there is a doubt whether only a birth cohort effect could explain this pattern. That is, one study in Canada mentioned that an increasing pattern of H. pylori infection with advancing age may be due to the continuous risk of infection in adults rather than cohort effects [6]. The decrease of H. pylori seroprevalence with advancing age within the same birth cohort in our study strongly suggests that aging is not likely to raise risk of H. pylori infection. There was a decreasing effect with advancing age within the same birth cohorts. This might have occurred as a result of cases taking antibiotics or proton pump inhibitors even without formal eradication therapy of H. pylori[15].

There have been several studies regarding risk factors of H. pylori infection [9, 14, 1618], but their results are still unclear, except socioeconomic status as the risk factors. Our results also showed that lower social economic status is associated with the risk of H. pylori infection in a cross sectional analysis. Furthermore, subjects with lower social economic status had a lower likelihood of taking H. pylori eradication therapy in the present study. Interestingly, our study showed a relationship between cholesterol level and seropositivity of H. pylori. Subjects who had a TC level of ≥240 mg/dl were 1.3 times more likely to be seropositive for H. pylori. In frequency analysis, higher levels of TG and glucose as well as TC were also associated with H. pylori infection, but after adjusting for demographic variables, clinical information, and socioeconomic status(i.e. age, BMI, income and etc.), only TC among metabolic parameters was related to H. pylori infection. So far, the results regarding the relationship between lipid parameters such as TC, TG and low-density lipoprotein cholesterol (LDL-C) levels and H. pylori seropositivity have not been consistent. Some studies [1921] reported no relationship, but several studies reported higher atherogenic lipid parameter levels in H. pylori seropositive subjects in comparison with seronegative ones [2224] as seen in the present study. Our study results could be convincing for demonstrating the effect of H. pylori infection on atherosclerotic disease because the positive relationship between TC and H. pylori seropositivity was persistent even after adjustment for BMI and age in a large cohort. The mechanism of how H. pylori infection modifies the serum lipid profiles is still not clear, but a plausible explanation is that systemic inflammatory response to the bacterium induces changes in lipid and lipoprotein metabolism [25]. That is, chronic H. pylori infection has been postulated to shift the lipid profile toward an atherogenic direction via the action of proinflammatory cytokines, such as interleukins 1 and 6, interferon-alpha, and tumor necrosis factor-alpha. These cytokines are capable of affecting lipid metabolism in various ways, including activation of adipose tissue lipoprotein lipase, stimulation of hepatic fatty acid synthesis, influencing lipolysis and the increasing hepatic HMG-CoA reductase activity [26, 27]. Thus, H. pylori infection could play a role in the atherosclerotic process and may be a reliable indicator for the assessment of cardiovascular disease risk.

There are several limitations which should be acknowledged in this study. First, the relationship between H. pylori infection and its risk factors in the cross sectional study could not be proven conclusively. However, this is an unavoidable limitation in the cross sectional study. Second, we compared the time trends of seroprevalence of H. pylori using two previous studies [9, 10]. However, the responsible author (N.K.) did play main role in these previous studies, and the population in 2011 study was restricted to have comparability of H. pylori seroprevalence. In other words, the subjects in 2011 study were restricted to asymptomatic people without a history of H. pylori eradication and GI operation. Moreover, this study was carried out nationwide, so our findings represent a national trend, not a local phenomenon. Nonetheless, the study subjects in 1998 involved a relatively lower population from Seoul and Gyeonggi, (capital city and its near city) compared with the population in 2005 and 2011. Generally people in capital cities have higher socioeconomic conditions than those living in other areas. It may account for much higher seroprevalence in 1998 compared with 2005/2011. However, the change of seroprevalence by the strata (e.g. age, sex, region, etc.) over time periods may indicate that our overall result is not much influenced by a different proportion of subjects from provinces. Third, for the generation of synthetic cohort, cross-sectional data should have the same interval. However, our data did not have the same interval as the previous data. This is the reason why we considered the data from 1998 as equivalent to those from 1999. This intentional modification could have caused bias, but we think that the bias may be negligible because H.pylori seroprevalence was not changed much by one-year.

Conclusion

In conclusion, we confirmed that the seropositivity of H. pylori declined across all age groups from 1998 to 2011 using nationwide data, an effect which originated from birth cohort effects and continuous risk reduction of H. pylori infection during one’s life time. In addition, we found that high TC level as well as lower social economic status had a relationship with H. pylori infection. These results may suggest the importance of management of H. pylori infection in younger age and the effect of H. pylori infection on atherosclerosis.

Notes

Abbreviations

GC: 

Gastric cancer

GI: 

Gastrointestinal

H. pylori: 

Helicobacter pylori

TG: 

Triglyceride

TC: 

Total cholesterol.

Declarations

Acknowledgments

This work was supported by the National Research Foundation of Korea (NRF) grant for the Global Core Research Center (GCRC) funded by the Korea government (MSIP) (No. 2011-0030001).

Authors’ Affiliations

(1)
Seoul National University Hospital, Healthcare System Gangnam Center, Healthcare Research Institute
(2)
College of Pharmacy, Kyungpook National University
(3)
Department of Internal Medicine, Seoul National University Bundang Hospital
(4)
Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine
(5)
Department of Internal Medicine, Pusan National University School of Medicine
(6)
Department of Internal Medicine, School of Medicine, Jeju National University
(7)
Department of Internal Medicine, Hallym University College of Medicine
(8)
Department of Internal Medicine, Wonkwang University Hospital
(9)
Department of Internal medicine, Dankook University College of Medicine
(10)
Department of Internal Medicine, Chonnam National University Medical School

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  28. Pre-publication history

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© Lim et al.; licensee BioMed Central Ltd. 2013

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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