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01.12.2013 | Research article | Ausgabe 1/2013 Open Access

BMC Gastroenterology 1/2013

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

Zeitschrift:
BMC Gastroenterology > Ausgabe 1/2013
Autoren:
Seon Hee Lim, Jin-Won Kwon, Nayoung Kim, Gwang Ha Kim, Jung Mook Kang, Min Jung Park, Jeong Yoon Yim, Heung Up Kim, Gwang Ho Baik, Geom Seog Seo, Jeong Eun Shin, Young-Eun Joo, Joo Sung Kim, Hyun Chae Jung
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1471-230X-13-104) contains supplementary material, which is available to authorized users.
Seon Hee Lim, Jin-Won Kwon contributed equally to this work.

Competing interests

All authors declare that they have no conflict of interest.

Authors’ contributions

SHL carried out the acquisition of data, analysis and interpretation of data, and drafting of the manuscript; JK carried out statistical analysis, interpretation of data, and drafting of the manuscript; NK carried out study concept and design, critical revision of the manuscript for important intellectual content and study supervision as a corresponder; GHK participated in acquisition of the data of southeastern part of Korea; JMK participated in design of the study and acquisition of data; MJP participated in acquisition of data; JYY participated in acquisition of data and study concept; HUK participated in acquisition of the data of southernmost part of Korea; GHB participated in acquisition of the data of northeastern part of Korea; GSS participated in acquisition of the data of western part of Korea; JES participated in acquisition of the data of middle upcountry of Korea; YEJ participated in acquisition of the data of southwestern part of Korea ;JSK participated in technical or material support and study supervision ;HCJ participated in study supervision and provided general support. All authors read and approved the final manuscript.
Abbreviations
GC
Gastric cancer
GI
Gastrointestinal
H. pylori
Helicobacter pylori
TG
Triglyceride
TC
Total cholesterol.

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).
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/m 2)
<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/m 2)
<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.
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.

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.

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).

Competing interests

All authors declare that they have no conflict of interest.

Authors’ contributions

SHL carried out the acquisition of data, analysis and interpretation of data, and drafting of the manuscript; JK carried out statistical analysis, interpretation of data, and drafting of the manuscript; NK carried out study concept and design, critical revision of the manuscript for important intellectual content and study supervision as a corresponder; GHK participated in acquisition of the data of southeastern part of Korea; JMK participated in design of the study and acquisition of data; MJP participated in acquisition of data; JYY participated in acquisition of data and study concept; HUK participated in acquisition of the data of southernmost part of Korea; GHB participated in acquisition of the data of northeastern part of Korea; GSS participated in acquisition of the data of western part of Korea; JES participated in acquisition of the data of middle upcountry of Korea; YEJ participated in acquisition of the data of southwestern part of Korea ;JSK participated in technical or material support and study supervision ;HCJ participated in study supervision and provided general support. All authors read and approved the final manuscript.
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