Aliment Pharmacol Ther 2004; 20: 705–717.
Systematic review: geographical and ethnic differences in gastro-
oesophageal reflux disease
J. Y. K ANG
Department of Gastroenterology, St George’s Hospital, London, UK
Accepted for publication 8 July 2004
SUMMARY
1 Background: Many observers believe that gastro-oeso-
phageal reflux disease is more common among white
individuals compared with Asians and Afro-Caribbean
subjects.
Aim: To perform a asystemic review regarding geo-
graphical and ethnic factors in the prevalence of reflux
symptoms, endoscopic oesophagitis, hiatus hernia and
Barrett’s oesophagus.
Results: Differences in definitions and methodology
make comparison between studies difficult. Overall,
however, the community prevalence of reflux symp-
toms, as well as the prevalence of endoscopic oesopha-
gitis, hiatus hernia and Barrett’s oesophagus among
2 INTRODUCTION
While gastro-oesophageal reflux disease (GERD) is a
major problem in the western world, many observers
believe that it is uncommon in oriental and African
countries.1–3 Ethnic and geographical differences in
disease frequency are of interest because they may
highlight environmental or genetic influences in aetiol-
ogy and possibly increase understanding of pathogen-
esis and management. It is, however, uncertain if the
purported ethnic and geographical variation in GERD is
genuine or artefactual, resulting from differences in
Correspondence to: Dr J. Y. Kang, Department of Gastroenterology,
St George’s Hospital, Blackshaw Road, London SW17 0QT, UK.
E-mail: jykang@sghms.ac.uk

2004 Blackwell Publishing Ltd
doi: 10.1111/j.1365-2036.2004.02165.
patients undergoing upper endoscopy, were lower
among Asian and Afro-Caribbean subjects compared
with white individuals. There may also be a north–
south gradient in the prevalence of gastro-oesophageal
reflux disease among western countries. Gastro-oeso-
phageal reflux disease may be moderately common in
the Middle East. There are suggestions that the preval-
ence of gastro-oesophageal reflux disease is increasing
in the Far East.
Conclusions: More data are required, especially
from Africa, South America, the Middle East, and
the Indian subcontinent. Suggestions are made
regarding definitions and methodology to facilitate
comparison between future studies from different
countries.
definitions, referral patterns and diagnostic practices. A
systematic review of the literature was performed to
examine the evidence for the effect of geography and
ethnicity in GERD.
METHODS
A Medline search was conducted from the 1966 to
February 2004 database, limited to the English language
and using the following keywords: GERD, hiatus hernia,
Barrett’s oesophagus, prevalence, incidence, time trends,
ethnic differences and geographical differences. Other
publications known to the author were also reviewed.
Studies on paediatric subjects were excluded.
All studies on the prevalence of reflux symptoms
among unselected individuals in the community, rather
705
706 J. Y. KANG

than on specific occupational groups or institutionalized a female predominance14 or male predominance.7

populations, were identified.4 To be included in the
main analysis, sample sizes and response rates must
have been described and prevalence rates have to be
reported per unit time [day, week, month(s) or year].
Follow-up studies were excluded.
Studies on the prevalence rates of reflux oesophagitis,
hiatus hernia and classical long-segment Barrett’s oeso-
phagus among patients undergoing upper endoscopy
were identified. Those studies reporting inclusion criteria,
sample sizes and describing diagnostic criteria for endo-
scopic oesophagitis, hiatus hernia and Barrett’s oesopha-
gus were included in the main analyses. Short-segment
Barrett’s oesophagus was not considered in this study.
RESULTS
Prevalence of GERD symptoms, oesophagitis, hiatus hernia
and Barrett’s oesophagus in different populations
Details of published studies satisfying the inclusion
criteria on the prevalence of symptoms associated with
GERD, i.e. heartburn and regurgitation, are listed in
Tables 1–3.5–16 Most studies include male and female
subject across a range of ages, but one included only
subjects aged 65 and over.14 They generally use postal
questionnaires or interviews by telephone or face-
to-face. The number of studies is small and the time
denominators are not always comparable.
Studies which examined the influence of gender on the
prevalence of GERD symptoms found no difference,5, 10, 15
Likewise, most studies found no effect of age on the
prevalence of GERD symptoms,5, 14, 15 although two
reported a negative association.7, 10
The prevalence of GERD symptoms seems higher in
western countries compared with the orient. For
example, monthly prevalence rates of heartburn and/
or regurgitation under 10% were reported for Singa-
pore11 and Hong Kong,12 compared with weekly or
monthly prevalence rates generally >20% in the
western studies tabulated.10, 14, 15 The 9.8% weekly
prevalence for the Spanish study15 appears lower than
for the other western studies. In a community survey in
England, subjects of south Asian origin had an
increased risk of weekly heartburn compared with
whites (OR: 1.61, P ¼ 0.02).16
The industry sponsored Domestic/International Gas-
troenterology Surveillance Study17 examined the pre-
valence of GERD symptoms ‘at least of moderate severity
and/or occurring at least once per week’. This unusual
quantification of symptoms makes the data unable to be
compared with those from other studies. However, as a
standardized symptom questionnaire was administered
to randomly selected members of the general population
in 10 countries, intercountry comparisons could be
made within the study. GERD symptoms were most
common in North America and Scandinavian countries,
followed by Italy, Switzerland and Japan (Table 4).
Published studies on the prevalence of endoscopic
oesophagitis, hiatus hernia and long-segment Barrett’s
oesophagus which satisfy our inclusion criteria, are

Table 1. Community prevalence of heartburn (%) over various time periods in different populations

Age
Sample group Response Three
Author Country Reference size (years) rate (%) Method Daily Weekly Monthly monthly Annually

Western countries
Drossman et al. USA 5 5430 ‡18 66 Postal 32.6
(1993)
Agreus et al. (1994) Sweden 6 1156 19–79 89.6 Postal 16.7
Kay et al. (1994) Denmark 7 3608 30–60 79 Questionnaire M 38.2,
at health F 38.4
examination
Locke et al. (1997) USA 8 1511 25–74 73 Postal 17.8 42.4
Deltenre et al. (1998) Belgium 9 3000 35 and 67.4 Phone 4.1 11.3 28.1
above
Locke et al. (1999) USA 10 1524 25–74 72 Postal 18 41
Oriental countries
Ho et al. (1998) Singapore 11 696 21–95 93 Interview 1.1
Wong et al. (2003) China 12 2209 ‡18 61.3 Phone 8.9

2004 Blackwell Publishing Ltd, Aliment Pharmacol Ther 20, 705–717

 SYSTEMATIC REVIEW: GEOGRAPHICAL AND ETHNIC DIFFERENCES IN GERD 707

Table 2. Community prevalence of regurgitation (%) over various time periods in different populations

Three
Country Reference Sample size Age group Response rate Method Weekly Monthly monthly Annually

Western countries
Agreus et al. (1994) Sweden 6 1156 19–79 89.6 Postal 8.8
Locke et al. (1997) USA 8 1511 25–74 73 Postal 6.3 45
Locke et al. (1999) USA 10 1524 25–74 72 Postal 7 45
Oriental countries
Ho et al. (1998) Singapore 11 696 21–95 93 Interview 1.0
Wong et al. (2003) China 12 2209 ‡18 61.3 Phone 25.9

Table 3. Community prevalence of heartburn and/or regurgitation (%) over various time periods in different populations

Sample Age group Response Three

Country Reference size (years) rate (%) Method Daily Weekly Monthly monthly Annually

Western countries
Agreus et al. (2001) Sweden 13 1156 18.9
4 Raiha et al. (1993) Finland 14 516 ‡65 92 Postal M 7.7 26.4 53.5
F 14.9 32.8 66.2
Locke et al. (1999) USA 10 1524 25–74 72 Postal 20 57
Diaz-Rubio et al. Spain 15 2500 40–79 71.2 Phone 9.8 31.6
(2004)
Mohammed et al. England 16 1533 >18 59 Postal 21
(2004)
Oriental countries
5 Ho et al. (1998) Singapore 11 696 21–95 93 Interview 1.6
Wong et al. (2003) China 12 2209 ‡18 61.3 Phone 2.5 8.9 29.8

Table 4. Three-month prevalence (%)* of heartburn and regur- For all oesophagitis, i.e. including non-erosive chan-
gitation in different countries using a single questionnaire ges, both studies from the orient gave prevalence rates
(Stanghellini17)
of around 5%,34, 42 compared with values of over 10%
Number Heartburn (%) Regurgitation (%) for four of the six western studies.18, 19, 21–24 The
prevalence of erosive oesophagitis varied from 11 to
USA 1020 22.2 18.7
Canada 1036 16.8 10.5
28.5% for the four western studies,20, 25–27 compared
Nordic countries  1010 13.6 10.3 with 5.233 and 14.5%32 for two Japanese series, 16.3%
The Netherlands 502 10.6 6.0 3 for a study from Taiwan31 and 2.5–13.4% for studies
Italy 999 8.7 9.5 from Malaysia.38, 39 It is uncertain why there is a wide
Switzerland 514 5.1 4.5 range of prevalence rates for reflux oesophagitis (2.5–
Japan 500 9.8 3.6
14.5%) for the various oriental studies. It may be
* Symptoms ‘at least of moderate severity and/or occurring at least relevant that the 13.4 and 14.5% prevalence rates of
once per week’. reflux oesophagitis were reported very recently from
  Nordic countries include Denmark, Finland, Norway and Sweden.
Japan35 and Malaysia,39 countries in which GERD is
thought to be increasing in frequency. Further, the
listed in Tables 5 and 6.18–41 Several reports found Taiwanese31 and Japanese35 reports quoting high
endoscopic oesophagitis to be commoner among prevalence rates of oesophagitis, and the Norwegian
men,21, 26, 34 although other authors described female report quoting a low prevalence of oesophagitis,22 were
predominance14 or no difference.42 The prevalence of among the smaller studies quoted here, each recruiting
endoscopic oesophagitis was reported to be either <500 patients. The only other western study with a low
positively correlated with age21, 33, 42 or to be unre- prevalence rate of endoscopic oesophagitis at 3.9% was
lated.34 Barrett’s oesophagus was commoner in males.24 from Italy.18

2004 Blackwell Publishing Ltd, Aliment Pharmacol Ther 20, 705–717

 Table 5. Frequency of oesophagitis and hiatus hernia (%) in patients undergoing upper endoscopy
708

Hiatus Hiatus
All Erosive hernia hernia
Reference Country Patient group Number oesophagitis oesophagitis (‡1.5 cm) (‡2 cm)

Western countries
Baldi et al. (1985) 18 Italy Consecutive OGDs in 89 818 3.9
J. Y. KANG

34 centres
Berstad et al. (1986) 19 Norway All referrals for OGDs 670 15.1 16.6
Scobie (1988) 20 New Zealand Consecutive OGDs by 1635 11
one operator
Stene-Larson et al. 21 Norway Consecutive OGDs 1224 16 20
(1988)
Kagevi et al. (1989) 22 Sweden All patients with dyspepsia but not 172 6
those with jaundice, haemorrhage
or acute abdominal pain
Petersen et al. (1991) 23 Norway All OGDs except those with jaundice, 930 14.1 17.1
haemorrhage or acute abdominal pain
Hirota et al. (1999) 24 USA Consecutive OGDs 889 21.6*
Voutilainen et al. (2000) 25 Finland Consecutive OGDs 1128 13.5
Martynen et al. (2002) 26 Finland Consecutive OGDs excluding 3378 28.5
acute GI bleeding
Todd et al. (2002) 27 Scotland All OGDs in region
1980 3599 11.8
1995 9620 9.6
Middle Eastern countries
Nasseri-Moghaddam et al. 28 Iran Consecutive OGDs, excluding patients 269 76.9*
6 (2003) with varices, GI cancer, concomitant
illness or bleeding tendency
Toruner et al. (2004) 29 Turkey All OGDs except patients with cancer, 395 15.4 40
previous surgery,
GI bleed or coagulation defects
Far Eastern countries
Scobie et al. (1987) 37 Fiji: Fijians All OGDs on Fijians and Indians 91 4
Indians 79 5
7 Kang et al. (1993) 42 Singapore Consecutive OGDs 11943 4.5 2.9
Yeh et al. (1997) 31 Taiwan Consecutive OGDs 455 14.5 6.9
Maekawa et al. (1998) 33 Japan All OGDs for GI symptoms 2278 5.2
Yeom et al. (1999) 34 Korea All OGDs for upper GI symptoms 1010 5.3 4.1
except patients with cancer,
varices and previous surgery
Salem et al. (2000) 38 Malaysia Consecutive OGDs for dyspepsia 363 2.5
8 Rosaida and Goh (2001) 36 Malaysia All patients undergoing OGD 3774 7.5
Inamori et al. (2003) 35 Japan OGDs for upper GI symptoms 392 13.8
except cancer and achalasia
9 Rosaida and Goh (2004) 40 Malaysia Consecutive OGDs for dyspepsia 1000 13.4 6.7

* Patients on proton pump inhibitors excluded.

OGD, oesophago-gastro-duodenoscopy; GI, gastrointestinal.

2004 Blackwell Publishing Ltd, Aliment Pharmacol Ther 20, 705–717

 Table 6. Frequency of Barrett’s oesophagus (%) in patients undergoing upper endoscopy

CLO CLO CLO

Reference Country Number Patient group (‡2 cm + IM) (‡3 cm) (‡3 cm + IM)

Western countries
Hirota et al. (1999) 24 USA 889 Consecutive OGDs 1.6
Todd et al. (2002) 27 Scotland
1980 3599 All OGDs in region 0.08
1995 9620 1.45
Ford et al. (2004) 41 England
White 15 063 4.6
Asian 5297 0.8

2004 Blackwell Publishing Ltd, Aliment Pharmacol Ther 20, 705–717

Middle East
10 Nasseri-Moghaddam et al. 28 Iran 269 Consecutive OGDs, 3.7
(2003) excluding patients with varices,
GI cancer, concomitant illness or
bleeding tendency
Toruner et al. (2004) 29 Turkey 395 All OGDs except patients 1.5
with cancer, previous surgery,
GI bleed or coagulation defects
Oriental countries
Lee et al. (2003) 43 Korea 1553 Consecutive OGDs 0.77 0.32

CLO, columnar-lined oesophagus; IM, intestinal metaplasia; OGD, oesophago-gastro-duodenoscopy; GI, gastrointestine.
SYSTEMATIC REVIEW: GEOGRAPHICAL AND ETHNIC DIFFERENCES IN GERD
709
710 J. Y. KANG
As regard the prevalence of hiatus hernia diagnosed at
endoscopy, however defined, all three western
studies tabulated reported prevalence rates of over
15%,19, 21, 23 compared with 2.9–6.9% for the four
studies from the orient.31, 34, 39, 42
Data on the prevalence of Barrett’s oesophagus among
patients attending for upper endoscopy are scant, and
definitions of Barrett’s oesophagus vary. However, a
single oriental study from Korea gave a figure of 0.77%,
declining to 0.32% if only those with histological
verification were included.43 In contrast, three western
studies included in this analysis gave prevalence rates of
between 1.45 and 4.6%24, 27, 41 but only 0.8% for
patients of Asian origin.41
A study from Iran, comprising 269 patients undergo-
ing upper endoscopy in a teaching hospital, reported
that 76.9% of patients had erosive oesophagitis while
3.7% had classical Barrett’s oesophagus with intestinal
metaplasia.28 In another study from Turkey on 395
dyspeptic patients undergoing endoscopy, 15.4% had
oesophagitis, 40% had hiatus hernia and 1.5 long-
segment Barrett’s oesophagus with intestinal metapla-
sia.29
A number of studies on the prevalence of GERD
symptoms were excluded from the present analysis for
the following reasons: restricted to hospital staff or other
occupational or family groups,44–47 quantification of
symptoms not comparable with other studies48–50 or
not stated,51 composite score for symptoms,52 and
response rates not stated.53–55 Most of the excluded
western studies gave relatively high prevalence rates of
reflux symptoms.45–49, 53, 54 An Iranian study gave a
2.7% prevalence rate of heartburn occurring more than
three times in the last 2 weeks,50 while a Malaysian
study gave a unexpectedly high annual prevalence of
33.6% for heartburn.55
Several studies on patients undergoing upper endoscopy
were excluded, because diagnostic criteria were not
defined,39, 56–64 the inclusion criteria were not des-
cribed65 or because subjects attending for health check-
ups were included.30, 66, 67 It is noteworthy that most of
the western studies thus excluded gave relatively high
prevalence rates of 9–22.8% for oesophagitis and 14.5
and 22% for hiatus hernia.56, 58, 62, 63 One single study
from Saudi Arabia also reported prevalence rates of
11.7% for oesophagitis and 6.7% for hiatus hernia.60
Most oriental studies excluded because diagnostic criteria
were not described gave prevalence rates on the low side
for oesophagitis and hiatus hernia.39, 57, 64 However, a

2004 Blackwell Publishing Ltd, Aliment Pharmacol Ther 20, 705–717
Korean study, excluded because endoscopy was per-
formed for health checkup purposes, gave a relatively
high prevalence rate of 11.2% for hiatus hernia although
the prevalence of erosive oesophagitis was on the low side
at 3.4%.67 Another Japanese study on subjects attending
for health checkup reported a relatively high prevalence
rate for Barrett’s oesophagus66 of 0.62%. One would have
expected subjects attending for health checkups to have
lower prevalence rates of disease compared with patients
suspected of having upper gastrointestinal disease. A
single South African study reported a prevalence rate for
endoscopic oesophagitis of 0.7% although the definition
of oesophagitis was not given.61
Heartburn is common in pregnancy, possibly related to
hormonal and mechanical factors. Studies on the
frequency of pregnancy heartburn are difficult to
interpret as subjects in different countries were ques-
tioned at different stages of pregnancy about symptoms
experienced at different times. Some studies were cross-
sectional and others longitudinal (Table 7). While most
western studies showed a high prevalence of pregnancy
heartburn,68, 69 and the Singapore study showed a
particularly low frequency,70 studies comparing women
of different ethnicity had either shown a higher rate
among whites compared with Asians and Afro-Carib-
beans,71, 72 or no difference.73, 74 Factors underlying
ethnic differences in GERD in the general population
may not be applicable in pregnancy.
Studies and anecdotal reports comparing different ethnic
groups
Among 2477 consecutive patients who underwent
upper endoscopy at a hospital clinic in USA, GERD
complications such as ulcers, strictures and Barrett’s
oesophagus were more common in white patients
(12.3%) compared with blacks (2.8%), West Asians
including Indians and Pakistanis (4.8%) and East
Asians (0%) (P < 0.001).75 Only 2.6% of East Asian
patients admitted to heartburn at least once a month,
compared with 34.6% of whites and 46.1% of blacks
(P < 0.01).75
Of 1101 patients with reflux oesophagitis diagnosed at
endoscopy in a teaching hospital in England, 81.9%
were white, 14% were Indian and 5% were blacks.76
The proportions of Indian and black patients were
significantly less than the proportions in the catchment
population of the hospital: 30% for Indians and 11% for
blacks.76
 SYSTEMATIC REVIEW: GEOGRAPHICAL AND ETHNIC DIFFERENCES IN GERD 711

Table 7. Frequency of symptoms of GERD (%) in pregnancy

Heartburn Regurgitation Heartburn and/

Country Reference Sample size (%) (%) or regurgitation (%)

11 Nagler and Spiro (1962)* USA 69 563 48

Atlay et al. (1973)  England 73 Whites 100 68
USA Blacks 42 71
Bassey (1977)  England 72 Whites 66 79
Blacks 20 0
Nigeria Blacks 123 11
Bainbridge et al. (1983)à England 71 Whites 200 78.5 50.5 47
Asians 100 54 64 38
Marrero et al. (1992)  England 74 Caucasians 394 50
Asians 98 45
Afro-Caribbeans 85 50
Knudsen et al. (1995)* Denmark 68 120 84
Ho et al. (1998)* Singapore 70 35 23 34 40

* Longitudinal study.
  Cross-sectional studies.
à Interviewed within 1 week of delivery.

In an endoscopic database study comprising 20 455
patients from three centres in England, Barrett’s oeso-
phagus, defined as at least 3 cm of columnar-lined
oesophagus with or without intestinal metaplasia,
occurred in 4.6% of white individuals compared with
0.8% of Asians.41 Logistic regression analysis, adjusting
for age and sex, showed white race to be a strong risk
factor with an odds ratio (OR) of 4.5.41
In a consecutive series of patients undergoing upper
endoscopy in the Zaanstreek region in Holland, reflux
oesophagitis occurred in 33% of ethnically Dutch
people compared with 9.7% of individuals of Turkish
descent (P < 0.001).77 All the Turkish patients with
reflux oesophagitis had mild, Savary-Miller grades I–II
disease while none had Barrett’s oesophagus. The
prevalence of hiatus hernia was also lower among
Turkish individuals compared with the ethnically
Dutch.
A single endoscopist compared 212 consecutive dys-
peptic patients seen personally in England with 173
seen in Singapore.78 Reflux oesophagitis and hiatus
hernia were found in 52 (25%) and 50 (24%) of the
English patients, but only 12 (6%) and seven (4%) of the
Singapore patients, respectively (P < 0.005 in each
case). Although body mass index, age and sex were risk
factors for oesophagitis and hiatus hernia, with ORs
varying from 1.02 to 1.11, race was by far the most
important risk factor (4.04 for oesophagitis and 3.07 for
hiatus hernia respectively).
Among community subjects in Singapore, the pre-
valence of heartburn and/or regurgitation occurring
more than once a month was significantly higher at
7.5% for Indians compared with 0.8% for Chinese and
3.0% for Malays.11 Similarly, in a community study
in neighbouring Malaysia, reported only in letter
form,55 the prevalence of annual heartburn was
greater for Indians (42.4%) than for Chinese
(29.3%) and Malays (29%). In Malaysia, reflux
oesophagitis was more common among Indians
compared with Chinese.36, 39
Anecdotal reports suggest that hiatus hernia and GERD
is rare among black Africans. Of 1319 barium meals
performed by a single radiologist in Kenya, East Africa
from 1961 to 1965, hiatus hernia was detected in only
one patient (0.07%) and gastro-oesophageal reflux (GER)
also in one patient (0.07%), although these conditions
were specifically looked for.79 A prospective study
examining the frequency of hiatus hernia and GER in
1030 consecutive barium meal examinations in Nigeria,
West Africa, from 1970 to 1972, found only four cases of
hiatus hernia (0.39%) and 23 patients with GER
(2.2%).80 Of 216 consecutive patients with Barrett’s
oesophagus in an oesophageal clinic in Johannesburg,
South Africa, only 11 (5%) were black, although the ratio
of black to white individuals in the city was 5:1.81
Similarly, in Cape Town, South Africa, 69 black patients
with GERD were seen over a 25-year period, compared
with 1867 cases in whites and 785 in ‘coloureds’. Thus,

2004 Blackwell Publishing Ltd, Aliment Pharmacol Ther 20, 705–717

712 J. Y. KANG
blacks constituted only 2.5% of the GERD population,
compared with 12% of all admissions.82
DISCUSSION
There is no gold standard for the diagnosis of GERD. A
number of surrogate markers have been used to
ascertain the frequency of but each has its own
problems.
Symptoms
Heartburn and regurgitation are generally regarded as
indicative of GERD and the community prevalence of
these symptoms has been used as an index of the
frequency of GERD. Klauser et al. studied patients
presenting with suspected GERD to secondary care
and found heartburn and regurgitation more common
in GERD, as defined by pH monitoring, than among
patients without GERD.83 In particular, when these two
symptoms clearly dominated the patients’ complaints,
they were highly specific although insensitive for the
diagnosis of GERD.83 As GERD must be less prevalent in
the community compared with secondary care, we
would expect the positive predictive value of these
symptoms to be also lower in the community setting.84
Further, questionnaire studies do not differentiate
between subjects in whom heartburn and regurgitation
were the predominant or only symptoms, from others
who had predominantly dyspeptic symptoms.
The term ‘heartburn’ is not universally understood.
Indeed, there is no word for ‘heartburn’ in Mandarin
Chinese or Malay. Among white American subjects only
35% understood the meaning of ‘heartburn’, and the
figure dropped to 13% for Asians living in USA.75 This
term is often not defined in published studies. Most
authors report the proportions of subjects with symp-
toms occurring daily, weekly, monthly or yearly but
others study the proportion of subjects symptomatic in
the last week, month or year. Vague terms such as
‘frequent’ have been used as have composite scores
combining symptom frequency and severity. Most of the
questionnaires used have not been validated. Results
from these studies cannot therefore be compared with
other studies in the literature. Clear definitions of
‘heartburn’ and ‘regurgitation should ideally be stated
in the questionnaire in future studies and the results
should be presented as prevalence rates of one or both
symptoms per unit time. General adoption of a common

2004 Blackwell Publishing Ltd, Aliment Pharmacol Ther 20, 705–717
questionnaire, e.g. those recommended by the Rome II
committee,85 will also make studies from different
centres more comparable.
Endoscopic oesophagitis and hiatus hernia
Reflux oesophagitis is fairly specific for GERD although
the majority of patients with GERD have non-erosive
disease. The prevalence of endoscopic oesophagitis
among patients presenting for upper endoscopy has
been used as an index of the frequency of GERD in a
population. However, the proportions of patients with
GERD seeking medical attention are unknown, and
probably vary with time and place. The indications for
endoscopy referral are likewise variable, and increasing
number of procedures are being carried out in recent
years. The denominator populations may not therefore
be comparable across different centres and at different
times.
Endoscopic criteria for the diagnosis of oesophagitis
have not been standardized until recently with the
advent of the Los Angeles classification.86 In particular,
there is considerable interobserver variation in the
recognition of mucosal erythema and friability,
although the identification of erosive and ulcerative
oesophagitis was much more reliable.87 The presence or
absence of endoscopic oesophagitis at a given time is
also dependent to some extent on whether or the patient
is taking acid suppressant treatment, especially proton
pump inhibitors. These considerations have to be taken
into account in using the frequency of endoscopic
oesophagitis as a measure of the prevalence of GERD.
However, some of these objections can be overcome in
studies comparing the prevalence of reflux oesophagitis
in different ethnic groups diagnosed in the same
institution, or by the same authors in different institu-
tions. Future studies on the prevalence of reflux
oesophagitis should use a standardized definition, e.g.
the Los Angeles classification,86 and the denominator
population should be clearly described.
The presence of hiatus hernia is closely correlated with
GERD. The use of the prevalence of hiatus hernia,
usually detected at upper endoscopy, as a surrogate
marker for the prevalence of GERD is subject to the same
problems as stated above for reflux oesophagitis.
Additionally, the reliability of endoscopic diagnosis of
hiatus hernia has never been established. The criteria
for diagnosis may not be standardized and are not even
stated in some publications. At the individual level, the
 SYSTEMATIC REVIEW: GEOGRAPHICAL AND ETHNIC DIFFERENCES IN GERD
presence and size of hiatus hernia may vary according
to the phase of respiration, the degree of air insufflation,
and whether or not the patient is straining or swallow-
ing. Barium studies have generally been supplanted by
endoscopy in the diagnosis of dyspepsia, but the
radiological diagnosis of hiatus hernia is also poorly
standardized and the technique variable.
Barrett’s oesophagus
Classical long-segment Barrett’s oesophagus results
from GERD, and it can therefore be used as a surrogate
marker for severe GERD in different populations and at
different times. While columnar-lined oesophagus can
be diagnosed at endoscopy, histological confirmation of
intestinal metaplasia is not always obtained, the
number of biopsies taken is not standardized. These
factors have to be taken into consideration in using
Barrett’s oesophagus as an index of GERD frequency.
Abnormal lower oesophageal acid exposure
Abnormal lower oesophageal acid exposure, determined
at ambulatory lower oesophageal pH monitoring, is
presently the only method of diagnosing non-erosive
GERD. However, the availability of this investigation
tends to be limited, and it has not been used for
assessing the frequency of GERD in a given population.
Possible reasons for a low frequency of GERD in the east
Simplistically, GERD arises from reflux of excessive acid
across an incompetent gastro-oesophageal sphincter,
with or without a hiatus hernia. Gastric acid output is
known to be lower among Chinese subjects compared
with Caucasian individuals,88 although these studies
pre-date the discovery of Helicobacter pylori and the
results could have been influenced by the frequency and
pattern of H. pylori infection. In most cases of H. pylori
infection there is predominant antral inflammation with
little atrophy, resulting in either no change in gastric
secretion or an increase.89 However, in some individ-
uals with a propensity to gastric cancer and proximal
gastric ulcers, H. pylori infection leads to an atrophic
pan-gastritis resulting in reduced acid secretion.89 The
latter could be the predominant pattern in the Far East,
where there is a high incidence of gastric cancer. In a
western series, corpus gastritis was also shown to be
negatively associated with reflux oesophagitis.90 A low

2004 Blackwell Publishing Ltd, Aliment Pharmacol Ther 20, 705–717
713
acid secretion would be associated with a reduced
prevalence of GERD, as is generally observed in the Far
East. It is interesting that while in general the preval-
ence of H. pylori infection is lower among with GERD
compared to those without, Far Eastern patients with
GERD had a lower prevalence of H. pylori infection
compared to western patients with GERD.91 This is
despite the prevalence of H. pylori infection being higher
in the Far East compared with the west.
Another possible reason for a lower prevalence of
GERD and hiatus hernia in the Far East compared with
the west is a lower body mass index in oriental
individuals. Body mass index is positively associated
with both hiatus hernia and reflux oesophagitis.
However, this is unlikely to be a major factor, since a
multivariate analysis in a mixed population of Chinese
and English patients showed that race is far more
important than body mass index for both hiatus hernia
and reflux oesophagitis.78 In this study, being English
rather than Chinese gave ORs of 4.04 for oesophagitis
and 3.07 for hiatus hernia, compared with 1.11 and
1.08 respectively for a high body mass index.78
Differences in the consumption of dietary fat and the
use of alcohol and tobacco may also be relevant.
The decline worldwide in the prevalence of H. pylori
infection in recent decades92 would be expected to
increase gastric acid secretion, and hence increase the
frequency of GERD in the Far East. Even among
individuals without H. pylori infection, gastric acid
output among Japanese increased in recent years
presumably because of nutritional factors.93 Socio-
economic changes currently occurring in many coun-
tries in the Far East may increase the prevalence of
GERD. Dietary and lifestyle habits previously associated
with western cultures are increasingly being adopted
while body mass indices are increasing.94
There are indications that the frequency of GERD is
indeed increasing. The community prevalence of reflux
symptoms in Singapore in 1994 was 1.6% compared
with 10.6% 5 years later (P ¼ 0.051).95 The frequency
of endoscopic oesophagitis in Singapore increased from
4.4% in 1992 to 7.3% in 1998 (P < 0.001).96 A study
of 23 870 upper endoscopies in a single Japanese centre
showed that the prevalence of reflux oesophagitis
increased from 0.76% in 1975–77, 1.67% in 1985–
85 to 2.31% in 1995–97.97 In Malaysia, the prevalence
of reflux oesophagitis among patients undergoing
upper endoscopy in a single medical centre increased
from 2.5% in 1997–98 to 7.5% in 2000–01
714 J. Y. KANG
(P < 0.001).36, 38, 39 While such longitudinal, single
centre studies are subject to bias through increasing
awareness and interest in the condition, these findings
seem consistent across three different countries.
As in the Far East, the prevalence of H. pylori infection
is high in sub-Sahara Africa. However, peptic ulcer
disease is uncommon in this population, the so-called
‘African Enigma’.98 It is uncertain why hiatus hernia is
also uncommon in this population, but dietary factors
and body mass index may be a possibility.
Studies on migrants provide clues regarding the
relative importance of genetic and environmental
influences in disease causation. When disease frequency
among migrants is different from that in the host
population, reduction of the difference with time is
expected if there is a significant environmental influence
to the condition. For GERD, environmental and genetic
factors seem equally important.99 It is of interest that
heartburn is more prevalent among Asians in Eng-
land16 compared with white people whereas the reverse
is true for Barrett’s oesophagus.41 Barrett’s oesophagus
probably develops after many years of GERD, and time
trends in the relative prevalence rates of reflux
oesophagitis and Barrett’s oesophagus in second and
subsequent generation migrants will provide further
insights into the aetiology of GERD.
CONCLUSIONS
Although data currently available in the literature
regarding the frequency of GERD can be difficult to
interpret and are not always consistent or comparable,
the overall impression does suggest the existence of
genuine geographical and ethnic differences.
Limited data on the frequency of GERD symptoms and
endoscopic oesophagitis and hiatus hernia, however
defined, in different community across the world show
higher prevalence rates in western countries compared
with the Far East. Among oriental countries, GERD may
be more common in Japan compared with Hong Kong,
Singapore and Korea, and its prevalence may be
increasing. A small number of studies suggest that
GERD is relatively frequent in the Middle East, although
a comparison of Turkish and ethnically Dutch patients
in Holland showed a lower prevalence of reflux
oesophagitis in Turkish individuals compared with the
ethnically Dutch.
Among western countries, USA, Canada, Britain and
Scandinavian countries seem to have higher frequencies

2004 Blackwell Publishing Ltd, Aliment Pharmacol Ther 20, 705–717
of GERD symptoms compared with southern European
countries such as Spain and Italy. The only large
western study reporting a low prevalence of oesopha-
gitis was from Italy. While more data are required, there
may be a north–south gradient for the frequency of
GERD in Europe.
Hiatus hernia, as diagnosed by barium studies, seems
extremely uncommon in sub-Sahara Africa. Scanty
data relating to the prevalence of oesophagitis and
Barrett’s oesophagus also suggest a low prevalence
among black Africans.
Within individual countries, ethnic differences in the
prevalence of GERD symptoms, reflux oesophagitis and
Barrett’s oesophagus have been described. A single
endoscopist studying consecutive series of dyspeptic
patients from Singapore and England reported a signi-
ficant difference in the prevalence of endoscopic
oesophagitis, hiatus hernia and Barrett’s oesophagus.78
In conclusion, a systematic review of the literature to
evaluate geographical and ethnic differences in the
prevalence of GERD has revealed a number of problems
in the way data have been presented, which hamper
interpretation and comparison across studies. However,
the overall impression is that of a higher prevalence of
GERD in western countries compared with the Far East
and sub-Sahara Africa. Data regarding the prevalence of
GERD in the Indian subcontinent, Middle East, Africa
and South America are particularly scarce, and studies
from these regions would be particularly helpful.
ACKNOWLEDGEMENT
No external funding was received for this study.
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