The association between peptic ulcer disease and physical activity in Wuwei cohort of northwest China: A cross-sectional study

doi:10.21203/rs.3.rs-3798595/v1

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The association between peptic ulcer disease and physical activity in Wuwei cohort of northwest China: A cross-sectional study

https://doi.org/10.21203/rs.3.rs-3798595/v1

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Although the incidence of peptic ulcer disease (PUD) is gradually decreasing, it is still a common upper gastrointestinal disease worldwide. The relationship between PUD and physical activities was evaluated in Wuwei cohort. Ultimately 4612 patients were included. The status of PUD was confirmed by gastroscopy and the metabolic equivalents of task (MET) scores were evaluated through questionnaires. In addition to the overall analysis, stratified regression analysis was performed based on body measurement indice and age. Female participants in moderate level group had a lower prevalence of gastric ulcer (GU) (OR: 0.58, 95% CI: 0.36, 0.93). After further adjusting, the same conclusion could still be reached (model 2 OR: 0.53, 95% CI: 0.28, 0.99). In stratified analysis based on body mass index (BMI) and waist circumference (WC), moderate physical activity was associated with a reduction in the risk of GU among females. In stratified analysis by age, participants with age < 60 in moderate and high level groups had a lower risk of GU. The prevalence of gastric ulcer in female participants with moderate physical activity was lower. In addition, females under 60 in the high level group had a lower risk of PUD.

Peptic ulcer disease

Gastric ulcer

Duodenal ulcer

Physical activity

Peptic ulcer disease (PUD) is a common gastrointestinal disease in the Asia-Pacific region, including China, characterized by ulceration of the stomach or duodenum. While Helicobacter pylori is a recognized risk factor for peptic ulcers, not all individuals infected with H. pylori develop PUD[1–3]. PUD is caused by multiple risk factors, such as H. pylori infection, alcohol consumption, smoking, and others. The incidence of PUD has gradually decreased in recent years due to the use of acid suppressants (proton pump inhibitors and H2 receptor blockers) and a better understanding of its pathology[4–6]. But it also brought huge socioeconomic costs to the country for prevention and treatment.

Moderate physical activity has been shown to have a protective effect against a variety of diseases, including cardiovascular disease and metabolic syndrome[7–12]. However, the association between PUD and physical activity is not well understood. Previous studies have reported conflicting results, with one study suggesting an increased risk of duodenal ulcer with moderate physical work and high occupational activity, while a Danish study found a significantly lower risk of gastric ulcer in individuals with an active lifestyle. Only a few studies have explored the role of physical activity in PUD, and the conclusions have not been consistent[13–15].

In this study, we aimed to evaluate the association between physical activity and PUD using a questionnaire-based approach in the Wuwei cohort, located in the northwest of China.

Data sources

This cross-sectional study was registered at The First Hospital of Lanzhou University: LDYYLL2012001, and informed consent was obtained from all participants.

The participants included in this study were from the Wuwei cohort in Gansu province, northwest China, between 2013 and 2016. Comprehensive questionnaires and laboratory examinations were conducted by professional staff to collect epidemiological data, including lifestyle, occupation, and other characteristics, as well as other characteristics and serological information including hematological traits, lipids and glucose. Besides, upper gastrointestinal tract endoscopy was performed in all subjects to assess the gastrointestinal mucosal status. H. pylori status was determined through 14C-Urea breath tests.[16].

Evaluation of physical activity

Evaluation of Physical Activity: Physical activity was assessed using the short version of the international physical activity questionnaire (IPAQ), which was designed to measure the amount and intensity of physical activity across various domains, including leisure time, domestic and gardening activities, work-related activities, and transportation-related activities. [17, 18]. The IPAQ short-form classified the population into three levels of physical activity: high-intensity, moderate-intensity, and low-intensity, based on the amount, type, frequency, and duration of physical activity each week. All physical activities were categorized into three groups: walking, moderate-intensity, and vigorous-intensity activities, and assigned metabolic equivalents of task scores (MetS) of 3.3, 4.0, and 8.0, respectively.

The total consumption of MetS-min/week was calculated by multiplying the MetS of each physical activity by its duration (in minutes) in a week. Participants who engaged in vigorous-intensity activity on at least 3 days, achieving a minimum total physical activity of 1500 MetS-min/week, or any combination of the three categories of physical activity on at least 7 days, achieving a minimum total physical activity of 3000 MetS-min/week, were classified as engaging in high-intensity physical activity. Those who met at least one of the following criteria were defined as engaging in moderate-intensity physical activity: a) 3 or more days of vigorous-intensity activity for at least 20 minutes per day; b) 5 or more days of moderate-intensity activity and/or walking for at least 30 minutes per day; c) 5 or more days of any combination of walking, moderate-intensity, or vigorous-intensity activities, achieving a minimum total physical activity of 600 MetS-min/week. Participants who did not meet the criteria for moderate-intensity or high-intensity physical activity were classified as engaging in low-intensity physical activity

Assessment of PUD

Trained hospital staff performed esophagogastroduodenoscopy (EGD) on participants who had fasted overnight to confirm the presence of PUD.

Data Analysis

We performed all statistical analyses by Stata version 14.0, (StataCorp, College Station, TX, USA). P < 0.05 was considered the result was statistical significance. The characteristics of the participants were performed with means ± standard deviations (SD) or as medians (interquartile ranges) for continuous variables and proportions (%) for categorical variables. Continuous variables were compared with Student’s t test, and categorical variables were compared with chi-squared analysis. The associations between physical activity with peptic ulcers was assessed by binary logistic regression analysis to calculate odds ratios and 95% confidence intervals(95%CI).

Characteristics of study subjects

Table 1 presents the characteristics of the study subjects. A total of 4612 participants were included, with 1917 (41.6%) being males and 2695 (58.4%) females. The average age of normal participants was 47.4 ± 6.7 years, while that of PUD participants was 50.5 ± 7.6 years. The percentage of PUD subjects in the population was 19.7%. PUD participants were older, had higher BMI and waist circumference (WC), higher blood pressure, higher H. pylori infection rate, higher smoking rate, and lower education level.

Table 1

**Characteristics of the study subjects**.
	Normal (n = 3704)	PUD (n = 908)	P
Age(years)	47.4 ± 6.7	50.5 ± 7.6	< 0.001
Male (%)	1340 36.2%	577 63.5%	< 0.001
Married	3,584 (96.8%)	876 (96.5%)	0.68
Smoking	974 (26.3%)	434 (47.9%)	< 0.001
Drinking	158 (4.3%)	50 (5.5%)	0.11
Education			0.002
Uneducated	544 (14.7%)	125 (13.8%)
Primary school	1,399 (37.8%)	291 (32.0%)
Middle/high school	1,744 (47.1%)	490 (54.0%)
University	17 (0.5%)	2 (0.2%)
Hot food diet	2,312 (62.4%)	527 (58.0%)	0.016
Diet fast	917 (24.8%)	180 (19.8%)	0.002
Systolic BP (mmHg)	120.2 ± 14.2	122.8 ± 14.4	< 0.001
Diastolic BP (mmHg)	76.3 ± 9.8	77.3 ± 9.3	0.007
BMI (kg/m2)	23.6 ± 2.9	23.9 ± 2.9	0.039
WC (cm)	83.7 ± 8.7	85.1 ± 9.1	< 0.001
Physical activity			0.20
Low	512 (13.8%)	134 (14.8%)
Moderate	1,055 (28.5%)	232 (25.6%)
High	2,137 (57.7%)	542 (59.7%)
Helicobacter pylori status (%)	1,755 (47.5%)	621 (68.6%)	< 0.001

Physical activity and PUD

Tables 2 and 3 present the association between physical activity intensity, metabolic equivalent expenditure, and PUD risk for males and females. After adjusting for age, there was no statistically significant difference in PUD incidence between male participants with different levels of physical activity intensity and metabolic equivalent expenditure. However, among female participants, those with moderate physical activity intensity had a 0.58-fold lower incidence of gastric ulcers compared to those with low physical activity intensity (95% CI: 0.36, 0.93). After further adjusting for smoking and drinking status, education level, blood glucose, blood pressure, BMI, WC, and H. pylori status, compared with the reference group (low intensity physical activity), the risk of gastric ulcer was also lower in females with moderate physical activity (model 2 OR: 0.53, 95% CI: 0.28, 0.99).

Table 2

The association between physical activity and peptic ulcer disease in male.
Physical activity	PUD		GU		DU
Physical activity	Model 1	Model 2	Model 1	Model 2	Model 1	Model 2
Low	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)
Moderate	0.97 (0.71–1.33)	1.24 (0.83–1.87)	0.83 (0.58–1.19)	1.10 (0.68–1.78)	1.31 (0.76–2.25)	1.34 (0.72–2.51)
High	1.08 (0.82–1.42)	1.22 (0.84–1.77)	0.87 (0.63–1.19)	0.97 (0.63–1.50)	1.53 (0.95–2.49)	1.54 (0.87–2.72)
MET: metabolic equivalents of task; WC: waist circumference; PUD: peptic ulcer disease; GU: gastric ulcer; DU: duodenal ulcer
Model 1: adjusted age.
Model 2: adjusted for variables in model 1, plus smoking, drinking, hot food diet, diet fast, H. pylori status, blood pressure, BMI, WC.

Table 3

The association between physical activity and peptic ulcer disease in female.
Physical activity	PUD		GU		DU
Physical activity	Model 1	Model 2	Model 1	Model 2	Model 1	Model 2
Low	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)
Moderate	0.95 (0.64–1.40)	0.88 (0.54–1.45)	0.58 (0.36–0.93)	0.53 (0.28–0.99)	1.97 (0.95–4.09)	1.49 (0.66–3.34)
High	1.09 (0.76–1.56)	1.15 (0.72–1.83)	0.84 (0.55–1.26)	0.80 (0.46–1.42)	1.67 (0.82–3.39)	1.54 (0.71–3.36)
MET: metabolic equivalents of task; WC: waist circumference; PUD: peptic ulcer disease; GU: gastric ulcer; DU: duodenal ulcer
Model 1: adjusted age
Model 2: adjusted for variables in Model 1, plus smoking, drinking, hot food diet, diet fast, H. pylori status, blood pressure, BMI, WC

In stratifed analysis by BMI categories, we found that there was no significant change in the risk of PUD based on physical activity intensity and the consumption of MET-min/week among males in different BMI categories. But, moderate physical activity was associated with a decrease in gastric ulcer odds among female individuals with BMI < 24 (model 1 OR: 0.48, 95% CI: 0.26–0.90), and the OR (95% CI) was 0.50 (0.22–1.13) after adjusting more covariates in model 2 (Table 4).

Table 4

The association between physical activity and peptic ulcer disease stratified by BMI in female
Physical activity	PUD		GU		DU
Physical activity	Model 1	Model 2	Model 1	Model 2	Model 1	Model 2
BMI < 24
Low	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)
Moderate	0.91(0.54–1.52)	0.95(0.49–1.84)	0.48(0.26–0.90)	0.50(0.22–1.13)	2.62(0.89–7.67)	2.23(0.63–7.88)
High	1.02(0.63–1.64)	1.18(0.63–2.21)	0.78(0.46–1.32)	0.78(0.37–1.62)	1.89(0.66–5.44)	2.15(0.62–7.45)
BMI ≥ 24
Low	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)
Moderate	0.99(0.54–1.82)	0.85(0.39–1.85)	0.73(0.35–1.53)	0.60(0.21–1.73)	1.45(0.53–3.99)	1.08(0.36–3.18)
High	1.20(0.69–2.11)	1.19(0.58–2.44)	0.96(0.50–1.86)	0.97(0.37–2.53)	1.53(0.59–3.99)	1.25(0.45–3.43)
MET: metabolic equivalents of task; WC: waist circumference; PUD: peptic ulcer disease; GU: gastric ulcer; DU: duodenal ulcer
Model 1: adjusted age
Model 2: adjusted for variables in model 1, plus smoking, drinking, hot food diet, diet fast, H. pylori status, blood pressure, WC

In Tables 5 and 6, we conducted a stratified analysis by WC category. Among females with WC < 85, participants engaged in moderate physical activity had a lower prevalence of gastric ulcers in model 1, with an OR value of 0.35 (0.15–0.79). However, this trend disappeared in model 2. In the WC ≥ 85 category, there were no statistically significant differences in gastric ulcer prevalence between participants engaged in moderate physical activity and the control group in model 1. However, in model 2, participants engaged in moderate physical activity had a lower prevalence of gastric ulcers compared to the low physical activity group (OR: 0.42, 95% CI: 0.19–0.91).

Table 5

The association between physical activity and peptic ulcer disease stratified by WC in male
Physical activity	PUD		GU		DU
Physical activity	Model 1	Model 2	Model 1	Model 2	Model 1	Model 2
WC < 85
Low	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)
Moderate	0.87(0.53–1.43)	1.20 (0.60–2.38)	0.77(0.44–1.34)	0.91(0.42–1.97)	1.27 (0.51–3.21)	1.78(0.54–5.81)
High	1.27(0.84–1.91)	1.51 (0.82–2.79)	1.09(0.69–1.73)	1.13(0.57–2.23)	1.89 (0.86–4.15)	2.58(0.90–7.43)
WC ≥ 85
Low	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)	1.00(1.00–1.00)
Moderate	1.03(0.68–1.56)	1.22 (0.73–2.04)	0.87(0.54–1.41)	1.25(0.67–2.35)	1.26 (0.64–2.47)	1.13(0.54–2.38)
High	0.94(0.64–1.37)	1.03 (0.64–1.66)	0.69(0.45–1.08)	0.84(0.47–1.51)	1.32 (0.72–2.45)	1.19(0.60–2.35)
MET: metabolic equivalents of task; PUD: peptic ulcer disease; GU: gastric ulcer; DU: duodenal ulcer
Model 1: adjusted age
Model 2: adjusted for variables in model 1, plus smoking, drinking, hot food diet, diet fast, H. pylori status, blood pressure, BMI.

Table 6

The association between physical activity and peptic ulcer disease stratified by WC in female.
Physical activity	PUD		GU		DU
Physical activity	Model 1	Model 2	Model 1	Model 2	Model 1	Model 2
WC < 80
Low	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)
Moderate	0.72 (0.36–1.45)	1.61 (0.56–4.67)	0.35 (0.15–0.79)	0.78 (0.25–2.44)	1.10 (0.51–2.37)	0.95 (0.38–2.40)
High	0.94 (0.52–1.72)	1.84 (0.67–5.08)	0.62 (0.33–1.17)	0.92 (0.32–2.65)	1.00 (1.00–1.00)	1.00 (1.00–1.00)
WC ≥ 80
Low	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)
Moderate	1.04 (0.65–1.68)	0.71 (0.40–1.26)	0.75 (0.41–1.37)	0.42 (0.19–0.91)	1.42 (0.67–3.03)	1.03 (0.44–2.41)
High	1.17 (0.74–1.83)	0.94 (0.55–1.62)	1.00 (0.58–1.73)	0.72 (0.36–1.43)	1.22 (0.58–2.54)	1.02 (0.45–2.29)
MET: metabolic equivalents of task; PUD: peptic ulcer disease; GU: gastric ulcer; DU: duodenal ulcer.
Model 1: adjusted age
Model 2: adjusted for variables in model 1, plus smoking, drinking, hot food diet, diet fast, H. pylori status, blood pressure, BMI.

Furthermore, we conducted an analysis on the association between physical activity and PUD risk by age category. For males, there were no statistically significant differences between physical activity and PUD risk in different age categories (Table 7). However, for females, participants engaged in moderate physical activity had a lower risk of gastric ulcers than the control group in the age category < 60 (model 1 OR: 0.24, 95% CI 0.08–0.75; model 2 OR: 0.19, 95% CI 0.04–0.83).

Table 7

The association between physical activity and peptic ulcer disease stratified by age in male.
Physical activity	PUD		GU		DU
Physical activity	Model 1	Model 2	Model 1	Model 2	Model 1	Model 2
Age < 60
Low	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)
Moderate	1.33 (0.60–2.93)	2.45 (0.87–6.93)	1.12 (0.47–2.68)	1.98 (0.61–6.43)	1.82 (0.51–6.49)	3.22 0.63–16.44)
High	1.31 (0.63–2.71)	1.51 (0.58–3.97)	1.04 (0.46–2.33)	0.98 (0.32–2.99)	2.07 (0.64–6.75)	3.64(0.79–16.79)
Age ≥ 60
Low	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)	1.00 (1.00–1.00)
Moderate	0.91 (0.65–1.29)	1.04 (0.66–1.62)	0.78 (0.52–1.16)	0.90 (0.52–1.53)	1.21 (0.66–2.20)	1.00 (0.50-2.00)
High	1.04 (0.77–1.40)	1.09 (0.73–1.63)	0.84 (0.60–1.18)	0.86 (0.53–1.39)	1.43 (0.85–2.43)	1.24 (0.67–2.27)
MET: metabolic equivalents of task; WC: waist circumference; PUD: peptic ulcer disease; GU: gastric ulcer; DU: duodenal ulcer
Model 1: unadjusted model.
Model 2: adjusted for variables in Model 1, plus smoking, drinking, hot food diet, diet fast, H. pylori status, blood pressure, BMI, WC.

We found that moderate physical activity was a protective factor for gastric ulcers in female participants. This study conducted a comprehensive analysis of physical activity and PUD, including stratified analyses based on different anthropometric indices (BMI, WC) and age. Additionally, a short version of the IPAQ questionnaire was used to define physical activity intensity.

Previous studies have often shown that leisure time physical activity is a protective factor for PUD, while physically demanding occupations increase the risk[15, 19, 20]. In the Wuwei Cohort, which mainly consisted of individuals from rural towns in northwest China, we observed a lower prevalence of gastric ulcers in female participants with moderate exercise intensity.

The development of gastric ulcers is a complex pathophysiological process that may be influenced by multiple endogenous and exogenous factors[21]. For endogenous risk factors, physical activity is known to impact mucosal blood flow in the digestive tract and stomach acid secretion[22]. During physical activity, the body activates the sympathetic nervous system, leading to constriction of blood vessels in the abdomen and reduced local circulation in the gastrointestinal mucosa. Excessive exercise can decrease blood flow to the intestinal mucous membranes, potentially damaging their endothelium and promoting ulcer occurrence[23, 24]. Therefore, maintaining moderate physical activity can help reduce the risk of gastrointestinal mucosal damage. Furthermore, gastric acid secretion is closely related to the occurrence and development of peptic ulcers. Previous research has indicated that moderate physical activity may decrease gastric secretions in healthy individuals, thereby protecting the mucosa of the digestive tract[25, 26]. However, the impact of this on populations with pre-existing ulcer lesions has yielded inconsistent results in various studies[27, 28].

For exogenous factors, H. pylori infection is well known to be an important factor in the occurrence of PUD[29]. In recent years, although studies have reported that moderate physical activity can regulate the immune system and increase levels of immunoglobulin A in saliva and gastric juice, which can antagonize H. pylori, excessive physical activity can also reduce immune response, leading to negative effects[30, 31]. Based on the proof of epidemiological research, it is difficult to say that physical activity can regulate H. pylori infection. Mental health is a significant risk factor for various organic and non-organic illnesses[32–36]. The onset of PUD is often associated with mental stress. In a study from Finland, individuals experiencing high levels of mental stress and anxiety were found to have a higher susceptibility to developing ulcers[37]. Furthermore, previous research indicated that people with heightened psychological stress have a greater likelihood of engaging in smoking and alcohol consumption, which could be considered to increase the risk of PUD[14]. Early findings suggest that regular exercise may alleviate mental stress, indicating that physical activity could potentially serve as a preventative measure against ulcers[38–40].

Our study has several advantages. Firstly, all cases of PUD were confirmed through gastroscopy, avoiding bias caused by self-reporting by participants and ensuring accurate diagnosis. Additionally, the relationship between PUD and physical activity in the population of northwest China has not been previously reported. Therefore, our study provides valuable epidemiological evidence for future research in this region. However, there are some limitations to consider. Firstly, the use of nonsteroidal anti-inflammatory drugs, a widely recognized risk factor for PUD, was not clearly accounted for in our study. This could have influenced the results. Secondly, the sample size was relatively small, with only 4612 individuals included, which may limit the generalizability of the findings compared to larger-scale clinical studies. Moreover, as our study was conducted in a single center, the results may not be applicable to other regions.

We found that the impact of physical activity on PUD differed between male and female participants. Moderate physical activity showed a preventive effect against gastric ulcers in female participants, but this effect was not observed in male participants. It is important to note that our estimation of participants' weekly MET-min consumption through self-reported questionnaires may not fully capture the differences in exercise intensity reported by men and women. This categorization method focused on the specific class and duration of physical activity, without considering precise exercise intensity and metabolism. Therefore, our analysis strategy may have been insufficiently comprehensive. Furthermore, hormonal factors may contribute to the observed gender differences. Previous animal experiments have shown that progesterone has a protective effect on the development of gastric and duodenal ulcers, likely through increased activity of gastric mucus and parietal cells, as well as enhanced ulcer healing by improving blood flow to the ulcer edge, rather than directly reducing gastric acid production[41–43]. On the other hand, sexual hormones can directly affect the gut microbiome and immune cells. Estradiol affects the transformation of dendritic cells to produce inflammatory factors and activate B cells. This promotes the generation of an inflammatory environment and changes in intestinal permeability, leading to the migration of gut microbiota to the lamina propria, further promoting the inflammatory process[44, 45]. These factors may collectively lead to gender differences in the association between physical activity and PUD.

Overall, our study suggests that women should maintain moderate intensity exercise to prevent gastric ulcers. Of course, these findings need more clinical research to further validate.

Author Contributions: Conceptualization, Qian Ren and Yongning Zhou; Data curation, Zhaofeng Chen and Yongning Zhou; Formal analysis, Bowen Li and Ya Zheng; Funding acquisition, Qian Ren and Yongning Zhou; Investigation, Qinghong Guo and Rui Ji; Methodology, Bowen Li, Kaipeng Peng and Ya Zheng; Supervision, Yuping Wang and Qian Ren; Writing – original draft, Bowen Li and Kaipeng Peng; Writing – review & editing, Qian Ren.

Funding: This study was funded by Ministry of Science and Technology of the People’s Republic of China (2012GS620101), the Fundamental Research Funds for the Central Universities (lzujbky-2021-ct17), and the Natural Science Foundation of Gansu Province (21JR7RA381).

Institutional Review Board Statement: Not applicable.

Ethics approval and informed Consent Statement: The cohort study was approved by the ethics committee of The First Hospital of Lanzhou University (approval number: LDYYLL2012001). Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this paper.

Data Availability Statement: The datasets generated during and analyzed during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest: The authors declare no conflict of interest.

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No competing interests reported.

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The association between peptic ulcer disease and physical activity in Wuwei cohort of northwest China: A cross-sectional study

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Abstract

Introduction

Materials and Methods

Data sources

Evaluation of physical activity

Assessment of PUD

Data Analysis

Results

Characteristics of study subjects

Physical activity and PUD

Discussion

Declarations

References

Additional Declarations

Status:

Version 1