The impact of inflammatory bowel disease on women’s health: a cross sectional study in India
Article information
Abstract
Background/Aims
The gender-specific impact of inflammatory bowel disease (IBD) on women in low- and middle-income countries remains underexplored. We aimed to assess the effects of IBD on different domains of women’s health.
Methods
A cross-sectional study was conducted in women with IBD at a tertiary care center in North India. Women with IBD were interviewed using a structured questionnaire assessing menstrual, reproductive, sexual, mental, social, and financial health, and healthcare access.
Results
Two hundred and two women (median age, 41 years; ulcerative colitis [n = 155, 76.7%]) were enrolled. Anemia was present in 161 women (79.7%), with a median hemoglobin of 10.5 g/dL. Among menstruating women (n = 138), 69 (50%) had irregular cycles, and 39 (28.3%) experienced IBD exacerbations during menstruation. Sexual dysfunction was reported in 82.5% (n = 137/166). Pregnancy-related concerns were common (n = 120, 59.4%), mainly due to risk of heritability and safety of IBD medication. Ten women (4.9%) attributed pregnancy loss to disease activity. Cervical cancer screening (3.0%) and human papillomavirus vaccination (4.0%) rates were low. The median SICC-IBD (social impact of chronic conditions in IBD) score was 0.6. Forty-three women (21.3%) reported difficulties in finding a partner due to IBD. Limited access to IBD specialists (n = 150, 74.3%) and medications (n = 164, 81.2%) were reported in hometown. Fifty-five women (27.2%) relied on loans to manage treatment expenses.
Conclusions
IBD affects women across physical, reproductive, social, and financial domains. Culturally sensitive, multidisciplinary care models are essential to address these unmet needs.
INTRODUCTION
Inflammatory bowel disease (IBD) is characterized by a complex interplay of genetic, immune, and environmental factors that contribute to its onset, progression, and response to treatment. Epidemiological studies have highlighted sex-based variations in the incidence and prevalence of IBD, clinical manifestations and disease severity [1-3]. The underlying reasons for these gender differences remain incompletely understood but are likely influenced by a combination of genetic, hormonal and psychosocial factors [4-6]. Hormonal fluctuations across various life stages, including puberty, pregnancy, and menopause, influence disease activity and symptom severity [6,7]. Psychosocial challenges, such as mental health concerns, social stigma, and body image issues, add another dimension to the disease burden [8-10]. Additionally, disparities in healthcare access and cultural perceptions of health-seeking behaviors, particularly in low- and middle-income countries (LMICs) where women may encounter barriers to specialized care, contribute to these variations [11,12]. The impact of IBD on women’s health is, therefore, multifaceted, necessitating a comprehensive approach to care.
A nuanced understanding of these gender-specific challenges is crucial to addressing the diverse needs of women to ensure tailored, evidence-based interventions. The present study aims to systematically explore the challenges faced by women living with IBD in LMICs. Guided by the World Health Organization’s holistic definition of health, the present study evaluates the impact of IBD across key domains, including physical, mental, social, environmental, and financial well-being. Additionally, it seeks to identify barriers to care and unmet needs, with the fundamental goal of informing context-specific strategies to enhance the overall health and quality of life of women with IBD.
METHODS
1. Study Design
A cross-sectional, questionnaire-based study with semiquantitative assessments was conducted at a tertiary care institution in northern India from June 2023 to December 2024. Consecutive adult females with an established diagnosis of ulcerative colitis (UC) or Crohn’s disease (CD) were enrolled [13]. Females younger than 18 years of age and those who did not provide informed consent were excluded. The study was approved by the Institutional Ethics Committee of Dayanand Medical College and Hospital (No. DMCH/P/2023/549). Informed consent was obtained from all participants.
2. Data Collection
The lived experiences, challenges, and perspectives of females with IBD, in relation to different domains of health, were captured through a structured questionnaire administered during semi-structured face-to-face interviews. A single investigator (A.B.), trained in the specific interview methodology, conducted all interviews to ensure consistency in data collection and minimize potential interviewer bias.
3. Data Collection Tool
Data were systematically collected using a proforma designed to capture the multidimensional impact of IBD on health, social relationships, financial stability, and environmental factors. The questionnaire included the following sections.
1) Demographics
Basic demographic details were collected. The socioeconomic status was assessed using the Kuppuswamy Socioeconomic Scale, updated for 2023, which categorizes individuals into distinct socioeconomic status classes based on education, occupation, and monthly family income (Supplementary Table 1) [14].
2) Disease Characteristics
Disease characteristics, including type of IBD (UC or CD), disease duration, Montreal classification, disease activity (partial Mayo Score for UC and Harvey Bradshaw Index for CD), extraintestinal manifestations, concomitant therapies, and history of IBD-related surgery, were recorded.
3) Anemia
Hemoglobin levels were measured at recruitment. Anemia was defined as a hemoglobin concentration 11.0 g/dL in pregnant women, and 12.0 g/dL in non-pregnant women [15].
4) Reproductive Health
Data on menstruation, fertility, pregnancy, childbirth, menopause, sexual health, contraceptive access, and reproductive health choices were collected. IBD-related symptoms were assessed in relation to menstruation using a 0–10 visual analog scale (VAS) for severity. Participants provided information on pregnancies, live births, stillbirths, and medical terminations. The survey also addressed difficulties in conception, fertility concerns (rated on a 0–10 VAS), use of assisted reproduction (assisted reproductive technology [ART]/in vitro fertilization [IVF]), contraceptive practices, cervical cancer screening, human papillomavirus (HPV) vaccination, and breastfeeding-related concerns. The Arizona Sexual Experiences Scale (ASEX), a 5-item rating scale assessing sex drive, arousal, vaginal lubrication/penile erection, ability to achieve orgasm, and orgasm satisfaction, was used to assess sexual dysfunction [16].
5) Mental Health
Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). A score >10 was considered indicative of significant anxiety or depressive symptoms [17]. The Perceived Stress Scale (PSS) was employed to assess the degree to which participants perceived life as unpredictable, uncontrollable, and overwhelming over the past month. Perceived stress levels were categorized as follows: 0–13 (low), 14–26 (moderate), and 27–40 (severe) [18].
6) Body Image
Body image was assessed using the standardized Contour Drawing Rating Scale (CDRS) at diagnosis and at the time of survey. The CDRS includes detailed contour illustrations with graduated body sizes, allowing clear comparison of body proportions. Participants also rated their body image satisfaction on a scale of 0 (not satisfied) to 10 (extremely satisfied).
7) Social Health
The social impact of chronic conditions in IBD (SICC-IBD) scale was employed to evaluate the social dimension of health [19]. The SICC-IBD scale evaluates the broader social impact of IBD, including disruptions in family and social relationships, workplace challenges, and changes in educational or career paths. It comprises 8 item pairs, with the first assessing applicability and the second measuring impact on a 0–5 Likert scale (0 not applicable; 5 extreme impact). The final SICC score is a weighted sum of applicable items, with values approaching 1 indicating greater social burden. Participants were queried about concerns related to acceptance or rejection by potential marriage partners or family members. Additional items assessed the impact of diagnosis on attitudes toward marriage and its influence on family planning discussions during courtship or marriage. Feelings of social alienation, perceived lack of support, and deterioration in personal relationships due to the disease were also evaluated.
8) Environmental Health
The questionnaire included items on access to clean toilet facilities at home and in the workplace, as well as travel-related challenges in both private and public transportation. Dietary difficulties were assessed, along with barriers to accessing IBD specialists, availability of specialists in the local area, distance to the nearest IBD care facility, and challenges in obtaining IBD medications.
9) Financial Health
Financial health was assessed by collecting data on average monthly income, costs of IBD-related treatments, and out-of-pocket expenses. Participants were also asked whether they had to take loans, borrow money, or use personal savings to cover IBD-related medical expenses.
4. Outcomes
The outcomes included the characterization and assessment of the burden and impact of IBD across various domains of health.
5. Statistical Analysis
Categorical variables were presented as frequencies and percentages, while continuous variables were summarized using means and standard deviations or medians and interquartile ranges (IQRs), depending on data distribution. The Kolmogorov-Smirnov test was applied to assess the normality of the data distribution. All analyses were conducted using SPSS version 26.0 (IBM Corp., Armonk, NY, USA).
RESULTS
1. Demographics and Disease Characteristics
During the study period, 230 women with IBD were approached, of whom 202 (87.8%) consented to participate (median age, 41 years; IQR, 32.0–48.2 years) and were interviewed. The majority of participants had UC (n=155, 76.7%), with a median duration of IBD of 5 years (IQR, 3–12 years). The baseline characteristics are summarized in Table 1.
Baseline Characteristics (n=202)
2. Anemia
Anemia was present in 162 women (80.2%), with a median hemoglobin level of 10.5 g/dL (IQR, 9.3–11.7 g/dL). Median transferrin saturation and ferritin levels were 13% (IQR, 7%–23%) and 24 ng/mL (IQR, 11–49 ng/mL), respectively. Among those with anemia, iron deficiency anemia was present in 115 women (71.4%). Macrocytic anemia secondary to vitamin B12 deficiency was observed in 7 women (4.3%), while 40 (24.8%) had normocytic normochromic anemia.
3. Physical Health
Among the study participants, 138 women (68.3%) were menstruating. The median age at menarche was 12 years (IQR, 12–14 years). Menstrual cycles were predominantly irregular in 58 women (42.0%) and consistently irregular in 11 (7.9%). Most women (n=72, 52.2%) reported moderate menstrual flow, while 29 (21.0%) reported heavy flow and 10 (7.2%) variable patterns. Fatigue emerged as the most severe symptom on VAS (Fig. 1A).
Impact of IBD on menstrual and sexual health and pregnancy. (A) severity of symptoms during menstruation (median value on VAS), (B) disruption of sexual act due to abdominal/pelvic pain, (C) complications during pregnancy, (D) reasons for apprehension about conception. VAS, visual analog scale; IBD, inflammatory bowel disease.
IBD symptom exacerbation during menstruation was reported by 39 women (28.2%), including 4 (2.9%) who experienced worsening with each cycle; the remaining 99 (71.7%) reported no change. A total of 64 women (31.7%) were postmenopausal or had undergone hysterectomy, with a median age at menopause of 44 years (IQR, 42–45 years).
Of the 202 women surveyed, 165 (81.7%) were sexually active. Among them, 39 (23.6%) reported occasional and 5 (3.0%) frequent difficulties during sexual activity due to IBD-related symptoms. Pelvic pain was the most commonly reported symptom (n=122, 73.5%), followed by abdominal pain (n=93, 56.0%). Pain-related interruption of intercourse was reported frequently by 55 (33.1%) women and occasionally by 59 (35.5%) (Fig. 1B).
Among the 165 participants assessed using the ASEX, 137 participants (83.0%) met the criteria for sexual dysfunction, while 28 (17.0%) participants did not report any dysfunction. Further analysis of ASEX scoring patterns showed that a total score ≥19 was observed in 45 participants (27.1%). Additionally, 82 participants (49.4%) reported a score >5 on at least one item, and 137 (83.0%) participants met the criterion of a score >4 on any three items. Regarding reproductive health counseling, 178 (88.1%) women had never received advice on contraception, only 5 (2.5%) had received guidance on cervical cancer screening, and 8 (4.0%) had received the HPV vaccine.
One hundred and sixty-five women (81.68%) reported a history of pregnancy, with a median age at first pregnancy of 23 years (IQR, 22–25 years). Among these, 35 (21.2%) experienced spontaneous abortion, 19 (11.5%) underwent medical termination for unwanted pregnancy, and 5 (3.0%) reported stillbirth (Fig. 1C). Assisted reproduction (IVF/ART) was used by 2 (0.99%) women, and pregnancy loss was directly attributed to IBD activity in 10 (4.95%) women.
Concerns regarding conception were reported by 120 (59.4%) women. The most common concern was fear of heritability of IBD (n=112, 55.4%), followed by concerns about congenital abnormalities (n=87, 43.1%), pregnancy complications (n=77, 38.1%), adverse effects of medication (n=77, 38.1%), financial constraints (n=28, 13.9%), and lack of support or difficulty in child-rearing (n=18, 8.9%) (Fig. 1D). Concerns during breastfeeding included potential adverse effects of medication on the child (n=65, 32.2%) and transmission of IBD through breastfeeding (n=96, 47.5%).
4. Mental Health
Psychological well-being was assessed using validated scales for stress, depression, and anxiety. On the PSS, 192 (95.0%) women reported moderate stress with scores ranging from 14 to 26, while an additional 9 (4.5%) women reported high stress, defined as a score of ≥ 27. Depressive symptoms were evaluated using the HADS. Of the participants, 90 (44.6%) women scored between 11 and 15, and 62 (30.7%) women scored between 16 and 21 on the depression subscale - both score ranges indicative of clinically relevant depressive symptoms. Similarly, the anxiety subscale of the HADS revealed that 77 (38.1%) women scored between 11 and 15, and 65 (32.2%) women scored between 16 and 21, indicating moderate to severe symptoms of anxiety in over 70% of participants (70.3%).
5. Body Image
Body image was assessed using the CDRS, a visual tool that captures perceived body shape by having participants select from standardized body silhouettes ranging from lean to obese. At the time of diagnosis, the most frequently selected body image was silhouette “C” (n=60, 29.7%), which typically represents a normal or mildly lean body type. At the time of assessment, the most commonly selected silhouette shifted to “D” (n=63, 31.2%), indicating a perceived increase in body size or a change in self-perception over the disease course or during treatment. In addition to silhouette selection, participants rated their satisfaction with their current body image using a 0–10 VAS, where 0 indicated complete dissatisfaction and 10 indicated complete satisfaction. The median satisfaction score was 5.00 (IQR 4.00–6.00), reflecting ambivalence regarding body image.
6. Social Health
Among 202 women surveyed, 43 (21.3%) reported difficulty in finding a partner, and 42 (20.8%) experienced direct rejections due to their IBD diagnosis. Additionally, 54 (26.7%) felt that IBD negatively influenced their perspective on marriage. Of the respondents, 84 (41.6%) felt unaccepted within their families, while 134 of 175 (76.6%) married women reported lack of acceptance from their in-laws. Feelings of non-acceptance were also reported in the workplace by 21 of 35 (60.0%) women, and in the broader social circle by 117 of 202 (57.9%) women (Fig. 2A). The SICC-IBD score was used to assess the psychosocial burden of IBD across personal, interpersonal, and occupational domains. The median SICC-IBD score was 0.6 (IQR, 0.4–0.6), indicating a moderate to high level of perceived social impact among the participants. The majority of women (n=90, 44.5%) scored within the 0.41–0.60 range, while 60 (29.7%) women scored between 0.21–0.40 (Fig. 2B). Relationship breakups were reported by 94 women (46.5%), and interpersonal difficulties with partners, family members, friends, or colleagues were reported by 106 women (52.5%). Functional limitations were also highly prevalent. Nearly all respondents (n=198, 98.0%) reported some degree of difficulty performing physical activities of daily living. The occupational consequences of IBD were significant. Forty-three (21.3%) women reported loss of employment, while 51 (25.2%) felt that their earning potential was negatively affected. Thirty-five (17.3%) participants had to change jobs due to the disease, and a similar number expressed ongoing concerns about job security. Educational pursuits were also affected, with 43 (21.3%) women reporting that their academic progression was adversely impacted by IBD (Fig. 2C).
mpact of IBD on social domain of health (A) self-perceived perception of acceptance in society, (B) the distribution of social impact of chronic conditions in IBD (SICC-IBD) scores, and (C) number of patients responding in affirmation to different questions in the SICC-IBD score. IBD, inflammatory bowel disease.
7. Environmental Health
At home, 195 women (96.5%) reported access to clean toilet facilities. However, only 23 of 35 (65.7%) employed women had uninterrupted access to clean toilets at the workplace. Access during travel was more limited, with 144 (71.3%) women reporting difficulty in finding clean facilities. Following an IBD diagnosis, 145 (71.8%) women experienced difficulty in making dietary changes. Common challenges included the need to cook separately from family meals (n=145, 71.8%), excessive dietary restrictions (n=128, 63.4%), conflicting advice from friends/family (n=58, 28.7%) and increased cost of meals (n=58, 28.7%) (Fig. 3A). A total of 150 (74.3%) women lacked access to an IBD specialist in their hometown and had to travel to another city for consultation. An additional 20 women (9.9%) had local access but chose to consult elsewhere to maintain privacy. Prolonged travel was common, with 161 (79.7%) women reporting travel times exceeding 4 hours (Fig. 3B). Access to medications was also a challenge, with 164 (81.2%) women experiencing varying degrees of difficulty in procuring IBD drugs locally (Fig. 3C).
The environmental impacts of IBD (A) major challenges faced while making changes to the diet, post-IBD diagnosis, (B) access to IBD medicines in hometown, (C) travel time from home to IBD care facility. IBD, inflammatory bowel disease.
8. Financial Health
Of the cohort, 35 (17.3%) women were employed. Among them, the median monthly income was Indian Rupee (INR) 27,500 (USD 316; IQR, INR 19,500 [USD 224]–INR 52,500 [USD 603]), while the median income for the entire cohort was INR 7,400 (USD 85). The median monthly expenditure on medications was INR 7,500 [USD 86.00; IQR, INR 6,500 [USD 74]–INR 9,000 [USD 103]). Most women (n=187, 92.6%) reported that the cost of therapy was covered by their spouse or family. Financial difficulties in affording IBD medications were reported by 73 (36.1%) women, and 55 (27.2%) frequently relied on loans to manage expenses.
9. Effect of Disease Type and Disease Activity
A subgroup analysis was conducted to compare the differential impact in women with UC and CD. Women with UC were younger, both in age at enrolment and at the time of diagnosis, and exhibited significantly higher median scores on the PSS. When stratified by disease activity, active UC was associated with higher mean PSS scores and elevated anxiety levels, with a greater proportion of patients reporting HADS anxiety scores >10. Among patients with CD, active disease was significantly associated with higher rates of anemia, symptom exacerbation during menstruation, lower pregnancy rates, and increased median scores for both anxiety and depression on the HADS (Table 2).
Impact of Disease Type and Disease Activity on Key Domains of Health
DISCUSSION
We evaluated the impact of IBD across different domains of health on women in a LMIC (Fig. 4). The median age of the study cohort was 41 years, consistent with the global trends of IBD peaking in early-to-middle adulthood [20]. This age group commonly faces challenges in managing disease alongside professional, caregiving, and personal health responsibilities. The cohort’s median of 3 siblings and birth order of 2 reflects familial structures typical of LMICs where extended families often provide emotional and logistical support in management of chronic diseases [21,22].
The multifaceted impact of IBD on women’s health. ASEX, Arizona Sexual Experiences Scale; HPV, human papillomavirus; IBD, inflammatory bowel disease; INR, Indian Rupee; SICC-IBD, social impact of chronic conditions in IBD.
About one-third of women in this cohort reported worsening of IBD symptoms during menstruation, consistent with previous reports of exacerbated gastrointestinal and systemic symptoms during menses [23,24]. These symptom flares have significant clinical and societal implications, including increased absenteeism, reduced productivity, and heightened physical and psychological distress, highlighting the need for workplace accommodations such as flexible or remote work during menstruation.
The relationship between IBD and menopausal age is understudied in India and other LMICs. The median age of menopause in our cohort was 44 years, which is lower than the average reported in both national and international data. Indian studies have documented a mean age at menopause of approximately 46.2 to 46.6 years, significantly earlier than that of women in many Western countries, where the average age is around 50 to 51 years [25-27]. Sociocultural, family planning, and socioeconomic factors likely contribute to this difference [28,29]. Earlier menopause prolongs the postmenopausal period, increasing the risk of cardiovascular disease, osteoporosis, and hormone-related cancers in affected women.
Sexual dysfunction is prevalent among women with IBD, with reported rates ranging from 50% to 90%, significantly exceeding those observed in the general population [30-32]. Integrating sexual health discussions into routine clinical care is vital and can be made feasible through context-appropriate strategies. Brief, validated screening tools such as the ASEX can be incorporated into routine assessments, and healthcare providers can be trained in empathetic, culturally sensitive communication. Opportunistic screening during chronic disease consultations, task-shifting to trained nurses or counsellors, and ensuring privacy in clinical settings can facilitate this disclosure [33]. Educational materials and mHealth tools may further support awareness and engagement.
Significant concerns were noted regarding heritability, congenital abnormalities, pregnancy complications, and the impact of medications on fetal development. Genetic predisposition to IBD also contributes to anxiety about transmission to offspring. Prior studies have identified lack of desire for parenthood and perceived support for child-rearing as key factors influencing voluntary childlessness, which are critical considerations in preconception counselling [34].
In our cohort, only 2.47% women reported having ever received guidance on cervical cancer screening, and 3.96% had received the HPV vaccine, indicating significant gaps in preventive health practices. These figures are consistent with low broader national trends in India, where overall HPV vaccination coverage among eligible women has been estimated at < 2% [35]. Cervical cancer screening rates are similarly low across the country. Two studies report a national average prevalence of screening for cervical cancer to be 1.9% with marked interstate variation, from as low as 0.2% in West Bengal and Assam to 10.1% in Tamil Nadu [36,37]. The extremely low uptake of both HPV vaccination and cervical cancer screening observed in our study reinforces the urgent need for targeted educational and preventive strategies, particularly among women with chronic diseases like IBD, who may face additional barriers to accessing routine gynecologic care. Pregnancy complications in this study included spontaneous abortions, stillbirths, and terminations due to active IBD. The stillbirth rate in India, based on the National Family Health Survey, is 9.7 per 1000 births, while the UK reports a rate of 0.4% [38,39]. In the current IBD cohort, stillbirth incidence was twice that of the general Indian population and five times higher than rates in developed countries. This elevated risk in women with IBD exacerbates the existing stillbirth burden in LMICs, posing significant public health challenges by increasing demands for specialized maternal-fetal care, enhanced prenatal monitoring, and optimized disease management.
Significant social and emotional challenges related to marriage and family planning were reported, highlighting stigma and misconceptions associated with IBD. Perceived rejection was most prominent from in-laws, followed by workplace and social environments. Elevated SICC-IBD scores, along with high rates of relationship difficulties, job loss, and disruptions to daily life and education, further call attention to the impact of IBD on women’s social and professional functioning.
The women in current cohort also faced unique and amplified challenges related to toilet accessibility. Implementing the IBD passport, a disease card with priority access to toilets, in LMICs is especially crucial for women, to ensure dignity, security, and equitable access to facilities, ultimately improving their participation in professional and social life [40].
Access to specialized IBD care remains a significant challenge, with only 26% of women having an IBD specialist locally. Many women were required to travel long distances for care, which, combined with societal and caregiving responsibilities, hinders regular follow-up. These barriers negatively affect reproductive health, pregnancy outcomes, and overall well-being. High costs of treatment underline the need for improved insurance coverage, subsidized care, and policy interventions including financial counselling and patient assistance programs to reduce the economic burden of IBD management, especially in areas where majority of the women are unemployed.
The strengths of the study include a large, age-diverse sample and a comprehensive, focused questionnaire covering multiple health domains. Data collection consistency was ensured by using a single interviewer. Importantly, this is the first study from a LMIC to examine the unique challenges faced by women with IBD, distinct from those in developed settings. The limitations include its single-center design, lack of endoscopic disease activity scores at baseline, use of some non-validated, region-specific sections in the questionnaire, and a cross-sectional cohort without longitudinal follow-up or a control group, restricting generalizability and direct comparison to women without IBD. Nonetheless, the study provides valuable insights into the health impact on women with IBD, aiming to inform evidence-based policies and tailored healthcare interventions.
In conclusion, this study highlights the complex impact of IBD on women in LMICs, emphasizing the need for gender-sensitive, comprehensive care. An integrated model combining effective IBD management with reproductive health services and psychosocial support is essential. Achieving healthcare equity for women with IBD must be recognized as a fundamental right, necessitating sustained clinical and policy-level action.
Notes
Funding Source
The authors received no financial support for the research, authorship, and/or publication of this article.
Conflict of Interest
Dubinsky MC has received consultancy fees from AbbVie, Arena, BMS, Eli Lilly, Janssen, Pfizer, Prometheus Biosciences and Takeda. Sebastian S has received consulting fees from Celltrion, BMS Takeda, AbbVie, Merck, Ferring, Pharmacocosmos, Warner Chilcott, Janssen, Falk Pharma, Biohit, TriGenix, Celgene, Lilly, and Tillots Pharma; has received payment or honoraria for lectures from AbbVie, Takeda, Celltrion, Pfizer, Biogen, AbbVie, Janssen, Merck, Warner Chilcott, Falk Pharma, Janssen, and Lilly. Sood A received honorarium for speaker events from Pfizer India and Takeda India. Sood A is also a member of the Editorial Board but was not involved in the peer review process or in any decision regarding this manuscript. The remaining authors disclose no conflicts.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Author Contributions
Conceptualization: Bhardwaj A, Singh A, Sood A. Data curation: Bhardwaj A, Singh D. Data interpretation: Bhardwaj A, Singh A, Sood A. Formal analysis: Bhardwaj A, Singh A, Sharma R, Sood A. Methodology: Bhardwaj A, Singh A, Kumar P, Midha V, Sood A. Project administration: Bhardwaj A, Singh A, Sood A. Resources: Bhardwaj A, Singh A, Sharma R, Bhardwaj G, Joshi L, Sood A. Supervision: Kumar P, Midha V, Sood A. Validation: Bhardwaj A, Singh A, Bhardwaj G, Joshi L, Sood A. Visualization: Bhardwaj A, Singh A, Sharma R, Bhardwaj G, Joshi L, Mahajan R, Dubinsky MC, Sebastian S, Midha V, Sood A. Writing – original draft: Bhardwaj A, Singh A, Sood A. Writing – review & editing: all authors. Approval of final manuscript: all authors.
Additional Contributions
The authors acknowledge the contribution from Ms. Riaz Bhardwaj (Freelance Economic Consultant, Private Sector) in creating the illustrations and graphics for the manuscript.
Supplementary Material
Supplementary materials are available at the Intestinal Research website (https://www.irjournal.org).
Supplementary Table 1.
Kuppuswamy Scale (Updated for 2023)