Alimentary Pharmacology & Therapeutics
Dysphagia: epidemiology, risk factors and impact on quality of
life a population-based study
G. D. ESLICK*, & N. J. TALLEY,
*School of Public Health, The
University of Sydney, Sydney, NSW,
Australia; Department of Medicine,
The University of Sydney, Nepean
Hospital, Penrith, NSW, Australia;
Department of Internal Medicine,
Mayo Clinic, Jacksonville, FL, USA
Correspondence to:
Dr G. D. Eslick, Program in Molecular
and Genetic Epidemiology, Harvard
School of Public Health, 677
Huntington Ave., Bldg II, 2nd Floor,
Boston, MA 02115, USA.
E-mail: geslick@hsph.harvard.edu
Publication data
Submitted 31 January 2008
First decision 19 February 2008
Resubmitted 20 February 2008
Accepted 25 February 2008
Epub OnlineAccepted 27 February
2008
2008 The Authors
Journal compilation 2008 Blackwell Publishing Ltd
doi:10.1111/j.1365-2036.2008.03664.x
SUMMARY
Background
Data on the population epidemiology of dysphagia are scarce. Little is
known about the prevalence, risk factors and impact on quality of life
of dysphagia in the general community.
Aim
To determine the magnitude and impact of dysphagia in the general
community.
Methods
A random sample of 1000 individuals of Sydney, Australia, were mailed
a validated self-report questionnaire to assess dysphagia. Measured were
dysphagia symptoms, potential mechanisms, risk factors, psychological
disorders, quality of life and demographics.
Results
The response rate of included subjects (n = 926) was 73% (n = 672).
Dysphagia ever was reported by 16% (n = 110). Multiple logistic regres-
sion analysis found that odynophagia was independently associated
with gastro-oesophageal reflux disease (GERD) (OR = 3.41, 95% CI:
1.1610.04). Intermittent dysphagia was independently associated with
GERD (OR = 2.96, 95% CI: 1.764.98) and anxiety (OR = 1.09, 95% CI:
1.011.19). The presence of progressive dysphagia was independently
associated with depression (OR = 1.34, 95% CI: 1.071.67). Progressive
dysphagia was independently associated with reduced general health
(OR = 0.95, 95% CI: 0.900.99), while intermittent dysphagia was asso-
ciated with a reduction in the role physical subscale (OR = 0.98, 95%
CI: 0.970.99).
Conclusions
Dysphagia is remarkably common in the general population. GERD is a
risk factor for dysphagia as well as odynophagia. Intermittent dysphagia
was associated with anxiety, while progressive dysphagia was associated
with depression.
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972 G . D . E S L I C K and N. J. TALLEY
INTRODUCTION
Dysphagia is an important alarm symptom; however,
the epidemiology remains poorly defined. Population-
based studies that determine the prevalence of dys-
phagia are rare; previous studies suggest that the
prevalence of dysphagia is between 16% and 22%.14
A majority of these studies only assessed dysphagia in
older age groups (aged >50 years) and showed varia-
tion in dysphagia prevalence and functional status.14
Previous reports highlight that that dysphagia is more
common in elderly individuals and will be a significant
healthcare issue because of an ageing population.5, 6
There is a dearth of studies assessing the impact that
dysphagia has on quality of life, work productivity and
health care related costs, with the majority of studies
related to individuals with otolaryngological can-
cers.7, 8 Very little exists in terms of studies that have
evaluated the psychological effects of dysphagia on
individuals in the community.911 Currently, there are
no population-based data that assess the epidemiology
of dysphagia among adults aged 18 years and older.
We therefore conducted a study of dysphagia in a
representative adult (18 years) population sample. We
aimed to determine the prevalence, risk factors and
psychological conditions associated with dysphagia in
the community, and to determine the impact of dys-
phagia on quality of life.
PATIENTS AND METHODS
Subjects
This study was approved by the University of Sydney
and the Wentworth Area Health Service (WAHS) Ethics
Committees. A total of 1000 adult subjects (18 years)
were randomly selected from the electoral rolls of all
local government areas included in the region covered
by the WAHS. We have previously published data on
noncardiac chest pain from this population-based
sample.12
Individuals were randomly selected from the Nepean
catchment area. This consists of a population of
307 787 (7.7% of the Sydney population), and is
socio-demographically very similar to the Australian
population according to 2001 Census data, except that
its inhabitants are slightly younger (30 vs. 35 median
years) and it has a slightly higher socioeconomic sta-
tus based on income ($450 vs. $350 median individual
income per week) respectively. Ethnic status was not
obtained, but the majority would be Caucasian, based
on Australian Bureau of Statistics data (http://
www.abs.gov.au). The list of selected subjects com-
prised equal numbers of males (n = 500) and females
(n = 500).
Methods
A letter was sent to all eligible subjects. This letter
outlined the study and requested participation.
Included with the letter was the validated Chest Pain
Questionnaire (CPQ). A reminder letter was sent 3 and
6 weeks after the initial mail-out. At week 6, this
included another questionnaire.12 The survey was
closed at 10 weeks. A prepaid return envelope was
included to allow subjects to return the completed
questionnaire. Subjects who indicated at any point
that they did not wish to participate were not con-
tacted further.
A $1.00 lottery ticket was included with the ques-
tionnaire as a financial incentive to maximize the
response rate. We have shown that financial incentives
improve the initial response rate if they are included
with the questionnaire.1316 A database linking record
numbers to identifying information (e.g. names and
addresses) was stored on an isolated, secured and pass-
word protected computer.
Of the 1000 people in the general community to
whom we sent the questionnaire, 57 (5.7%) had
moved, and were excluded on that basis. Another 17
(1.7%) were excluded due to serious illness, death or
language difficulties, leaving us with a valid sample
receiving the questionnaire of 926 subjects. By the
close of the survey, only 16 subjects (1.6%) had
explicitly refused to participate. The completed ques-
tionnaire was returned by 672 subjects, giving a
response rate of 73%, with 52% being female.
Questionnaire
The validated CPQ was developed to study the epide-
miology of chest pain and related disorders, which
included dysphagia.17 It measures symptoms over the
previous 12-month presurvey period, with individual
items assessing the prevalence, frequency and severity
of dysphagia, possible causes of dysphagia, quality of
life (SF-36) and psychological conditions (anxiety,
depression, neuroticism).
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Definitions
Dysphagia (trouble swallowing). A feeling that food
sticks in your throat or chest.18, 19
Dysphagia frequency (past 12 months) was measured
as: less than once a month, about once a month, about
once a week, several times a week and daily. The
severity of dysphagia (past 12 months) was measured
as: mild can be ignored if I do not think about it;
moderate cannot be ignored, but does not affect my
life style; severe affects my life style; and very
severe markedly affects my life style.
Gastro-oesophageal reflux disease. As defined in the
questionnaire, gastro-oesophageal reflux disease
(GERD) was defined as heartburn and or acid regurgi-
tation occurring at least weekly.
Risk factors measured
Risk factors assessed included cardiovascular factors
(angina, acute myocardial infarction, diabetes mellitus,
high cholesterol, high blood pressure and smoking sta-
tus). Alcohol consumption and body mass index (BMI)
were not assessed. In addition, psychological condi-
tions including anxiety, depression and neuroticism
were evaluated. State anxiety and depression (defined
as current past month) was measured by the vali-
dated Hospital Anxiety and Depression Scale.17 Cases
of anxiety and depression were defined by scores 11.
Neuroticism was measured using the validated 10-item
Eysenck Personality Questionnaire.20 Cases of neuroti-
cism were defined by scores 8.
Quality of life
Quality of life was measured using the validated SF-36.
The SF-36 consists, first, of the physical health
measures which include the four subscales [Physical
Functioning, Role Physical, Bodily Pain and General
Health Perceptions], and secondly, the mental health
measures which include the four subscales [Vitality,
Social Functioning, Role Emotional and Mental Health].
It has been extensively utilized and validated.21
STATISTICAL ANALYSIS
Age-adjusted, gender-specific, and overall age and
gender-adjusted prevalence rates of dysphagia were
2008 The Authors, Aliment Pharmacol Ther 27, 971979
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D Y S P H A G I A A P O P U L A T I O N - B A S E D S T U D Y 973
obtained. All P-values calculated were two-tailed; the
alpha level of significance was set at 0.05. Patient
demographic and clinical characteristics have been
reported as mean and standard deviation or confidence
interval for numeric-scaled features and percentages
for discrete characteristics.
Risk factors for dysphagia were identified using
unconditional logistic regression. Analysis proceeded
in two steps: (i) identification of statistically signifi-
cant and independent risk factors for dysphagia within
logical domains (e.g. all cardiovascular risk factors)
and (ii) identification of statistically significant and
independent risk factors for dysphagia across logical
domains (e.g. risk factors, psychological conditions).
This two-step process provides a complete risk factor
profile for dysphagia.
RESULTS
Dysphagia symptoms
Of all respondents, 110 (16%, 95% CI: 1420%)
reported having ever had dysphagia. The prevalence of
dysphagia showed a relatively normal distribution
peaking in the 40- to 49-year group with a slightly
skewed distribution suggesting a decrease with
increasing age (Figure 1). The severity of dysphagia
was most often reported as mild (65%), followed by
moderate (30%) (Figure 2). The frequency of dysphagia
40
Males
35 Females
30
25
% 20
15
10
5
0
1829 3039 4049 5059 6069 >70
Age (years)
Figure 1. Population prevalence rates of dysphagia by
age and gender.
974 G . D . E S L I C K and N. J. TALLEY

80 Gastrointestinal symptoms
70 Gastrointestinal symptoms assessed included heart-
Males
burn, acid regurgitation and GERD. Among subjects
60 Females
with dysphagia, 58% had experienced heartburn
50 (OR = 2.28, 95% CI: 1.503.48), 67% had experi-
enced acid regurgitation (OR = 2.76, 95% CI: 1.76
% 40
4.32) and 72% had experienced GERD (OR = 2.46,
30 95% CI: 1.573.87), with a frequency of at least once
per month within the previous 12 months. The logistic
20
regression analysis (including gender, age, heartburn,
10 acid regurgitation, GERD) found only GERD
(OR = 4.20, 95% CI: 1.5611.32) was associated with
0
<1/month ~1/month ~1/week >7/week Daily dysphagia. However, the logistic regression analysis
Frequency found that GERD was not independently associated
with solid food or progressive dysphagia (OR = 0.68,
Figure 2. Frequency of dysphagia among subjects in the 95% CI: 0.261.80; OR = 1.14, 95% CI: 0.264.94
population. respectively). However, intermittent dysphagia and
odynophagia were independently associated with
GERD (OR = 2.96, 95% CI: 1.764.98; OR = 3.41, 95%
CI: 1.1610.04 respectively).

70
Other symptoms
60 Males
Females Other symptoms assessed included cough, musculo-
50 skeletal chest pain. Univariately, the significant symp-
toms associated with dysphagia included cough (27%
40 vs. 15%, P = 0.003; OR = 2.05, 95% CI: 1.263.33)
%
30
and musculoskeletal chest pain (23% vs. 14%,
P = 0.02; OR = 1.81, 95% CI: 1.093.01). The logistic
20 regression analysis (including gender, age, cough and
musculoskeletal chest pain) found one independent
10 symptom associated with dysphagia, cough
0
(OR = 1.84, 95% CI: 1.033.27).
Mild Moderate Severe Very severe
Severity Cardiac risk factors

Figure 3. Severity of dysphagia among subjects in the
population.
symptoms were reported as <1 month (65%),
1 month (15%), 1 week (8%), several times a week
(9%) and daily (1%) (Figure 3). Of those with dyspha-
gia, pain on swallowing was reported by 29%, with
4% and 7% having rapidly and slowly become worse
in the past 12 months, respectively. Potential sources
of dysphagia included liquids only (8%), solid foods
only (54%), or both solid foods and liquids (38%).
Other risk factors assessed were chest pain, acute myo-
cardial infarction, angina pectoris, diabetes mellitus
(BSL >8 mmol L), high cholesterol (>5.5 mmol L),
high blood pressure (>140 90 mmHg) and smoking
status (current, past, never). Univariately, the signifi-
cant risk factors associated with dysphagia compared
with nil symptom controls included diabetes mellitus
(19% vs. 6%, P = 0.03; OR = 3.42, 95% CI: 1.318.83)
and high blood pressure (48% vs. 27%, P = 0.002;
OR = 2.50, 95% CI: 1.344.66). The logistic regression
analysis (including gender, age, high blood pressure,
angina, smoking, diabetes mellitus, high cholesterol)
found one independent cardiac risk factor for

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dysphagia, which was high blood pressure (OR = 2.58,

Table 2. Quality of life (SF-36) scores comparing those
95% CI: 1.225.44). with nil dysphagia and dysphagia

Nil dysphagia Dysphagia P-value

Psychological risk factors
The three psychological risk factors considered were SF-36 Physical Functioning (0100)
Mean 82.62 77.87 0.03
anxiety, depression and neuroticism. Amongst those s.d. 22.35 22.57
with dysphagia compared to no dysphagia, the preva- SF-36 Role Physical (0100)
lence of clinical depression was 7% (95% CI: 314%) Mean 80.94 63.42 <0.001
vs. 5% (95% CI: 37%), anxiety 20% (95% CI: 13 s.d. 32.99 39.10
29%) vs. 14% (95% CI: 1117%) and neuroticism 18% SF-36 Pain Index (0100)
Mean 75.94 68.56 0.002
(95% CI: 1227%) vs. 13% (95% CI: 1117%) respec-
s.d. 24.89 24.38
tively. Unadjusted analyses of those with dysphagia SF-36 General Health Perceptions (0100)
compared with no dysphagia found that there was a Mean 72.55 64.38 <0.001
significant difference for anxiety (OR = 1.08, 95% CI: s.d. 20.61 20.64
1.031.13) and depression (OR = 1.06, 95% CI: 1.01 SF-36 Vitality (0100)
1.13) (Table 1). Mean 59.06 53.02 0.007
s.d. 21.16 21.10
The logistic regression analysis (including gender, SF-36 Social Functioning (0100)
age, neuroticism, anxiety and depression) found that Mean 83.31 78.55 0.11
intermittent dysphagia was independently associated s.d. 23.87 24.88
with anxiety (OR = 1.09, 95% CI: 1.011.19), while the SF-36 Role Emotional (0100)
presence of progressive dysphagia was independently Mean 80.78 70.06 0.002
s.d. 32.60 37.28
associated with depression (OR = 1.34, 95% CI: 1.07
SF-36 Mental Health Index (0100)
1.67). Mean 74.56 69.66 0.04
s.d. 17.91 19.12
Impact on quality of life
Comparing the individual subscale scores in those with
no dysphagia and those with dysphagia, there were for the subscales physical functioning, social function-
lower scores in dysphagia, indicating impaired quality ing and mental health index (Tables 24).
of life on the SF-36. The score differences were all >5 The logistic regression analysis (including gender,
points, indicating clinically relevant changes except age and all the QOL subscales) found that only the
subscales role physical (OR = 0.99, 95% CI: 0.98
0.99) and general health (OR = 0.98, 95% CI: 0.97
0.99) were independently associated with dysphagia.
Table 1. Psychological risk factors among those with nil
The model was also adjusted for anxiety and depres-
dysphagia and dysphagia
sion, where only role physical remained significant
Nil dysphagia Dysphagia (OR = 0.99, 95% CI: 0.980.99, P < 0.001) and
(OR = 0.98, 95% CI: 0.980.99, P < 0.001). Moreover,
Neuroticism progressive dysphagia was independently associated
Mean score 3.80 4.36
with reduced general health (OR = 0.95, 95% CI:
s.d. 2.96 3.01
P-value 0.001 0.900.99), while intermittent dysphagia was indepen-
Anxiety dently associated with a reduction in the role physi-
Mean score 5.93 7.27 cal subscale (OR = 0.98, 95% CI: 0.970.99).
s.d. 4.07 4.10
P-value 0.04
Depression DISCUSSION
Mean score 3.86 4.58
s.d. 3.27 3.52 The epidemiology of dysphagia has been largely unex-
P-value 0.08 plored.22 The present population-based study suggests
that dysphagia is common in the general community,

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Table 3. Quality of life (SF-36) scores for dysphagia symptom frequency

P-value P-value Several P-value P-value

<1 month vs. 1 month vs. times 1 week vs. several Several times
<1 month 1 month 1 month 1 week 1 week a week times a week Daily week vs. daily

SF-36 Physical Functioning (0100)

Mean 81.87 67.70 0.03* 82.71 0.14 60.00 0.05 16.67 na
s.d. 20.71 27.30 16.30 29.02 na
SF-36 Role Physical (0100)
Mean 67.07 54.17 0.29 72.22 0.26 52.50 0.30 00.00 na
s.d. 39.27 32.47 38.41 43.22 na
SF-36 Pain Index (0100)
Mean 70.85 65.13 0.34 69.44 0.67 53.90 0.26 31.00 na
s.d. 22.42 21.47 24.34 32.53 na
SF-36 General Health Perceptions (0100)
Mean 65.66 62.55 0.51 66.22 0.64 55.05 0.28 57.00 na
s.d. 20.81 22.44 17.40 24.72 na
SF-36 Vitality (0100)
Mean 54.84 48.33 0.24 60.00 0.16 49.00 0.32 15.00 na
s.d. 21.19 18.28 22.77 24.24 na
SF-36 Social Functioning (0100)
Mean 79.16 73.33 0.39 93.05 0.03* 78.75 0.21 62.50 na
s.d. 24.07 25.38 9.08 30.64 na
SF-36 Role Emotional (0100)
Mean 73.77 64.28 0.37 74.07 0.51 66.67 0.63 66.66 na
s.d. 37.57 38.07 32.39 31.42 na
SF-36 Mental Health Index (0100)
Mean 71.44 65.33 0.24 75.11 0.27 64.00 0.33 72.00 na
s.d. 17.26 21.20 21.05 25.85 na

na, not able to calculate. *P < 0.05.

that high blood pressure appears to be a novel risk
factor, that GERD, anxiety and depression were
independently associated with dysphagia and that
dysphagia has a significant impact on quality of life.
There are five published studies that estimate the
prevalence of dysphagia in the general population.
The first of these studies was published in 1981 and
assessed a sample (n = 2329) of 55-year-old Swedes
reporting that 27% with oesophageal dysfunction and
13% with normal oesophageal function had dysphagia,
with the overall prevalence of dysphagia being
22.3%.3 No assessment in terms of the role of gender
was reported. Ten years later Bloem et al.4 in a study
of elderly individuals (n = 130) aged over 87 years
from the Netherlands observed that 16% had symp-
toms of dysphagia that were not related to age, gender
or mental status. Another Swedish study was con-
ducted on a population of 50- to 79-year olds
(n = 556) and found 1.6% had obstructive symptoms
which remained stable over the age groups and 20.9%
had globus sensation, which increased slightly with
increasing age.1 Talley et al.2 in a study that assessed
functional gastrointestinal symptoms among a popula-
tion aged 3064 years (n = 1021) in the US found that
approximately 6% of individuals reported difficulty in
swallowing >25% of the time. Recently, a Japanese
study of 1313 elderly people living at home aged
65 years and older reported symptoms of dysphagia in
13.8% of the sample.23 We found similar prevalence
rates in this study; the prevalence of dysphagia was
16%; however, we discovered that dysphagia decreases
with increasing age, which is in paradox with previous
studies that have reported that dysphagia increases
with increasing age; however, these studies only
assessed elderly samples or diseases associated with
increasing age [e.g. cerebrovascular accident (CVA),
Parkinsons disease, oesophageal malignancy].
This study found a relationship for GERD, which
was independently associated with dysphagia among
this community sample. Very few community-based

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Table 4. Quality of life (SF-36) P-value <1, P-value, P-value,

scores for dysphagia symptom mild vs. moderate Very severe vs.
severity Mild Moderate moderate Severe vs. severe severe very severe

SF-36 Physical Functioning (0100)

Mean 81.88 72.39 0.03* 60.32 0.30 61.11 0.96
s.d. 18.49 27.23 28.40 33.79
SF-36 Role Physical (0100)
Mean 68.94 59.89 0.27 39.28 0.21 41.67 0.93
s.d. 37.36 38.47 49.70 52.04
SF-36 Pain Index (0100)
Mean 72.60 65.25 0.09 53.00 0.23 42.00 0.62
s.d. 21.75 22.19 28.99 37.47
SF-36 General Health Perceptions (0100)
Mean 66.87 63.87 0.46 58.28 0.50 30.67 0.06
s.d. 17.74 22.77 10.37 32.65
SF-36 Vitality (0100)
Mean 56.73 50.78 0.16 53.57 0.77 15.00 0.03*
s.d. 17.83 23.59 23.57 15.00
SF-36 Social Functioning (0100)
Mean 80.97 80.07 0.84 82.14 0.85 41.67 0.03*
s.d. 21.60 26.53 15.90 36.08
SF-36 Role Emotional (0100)
Mean 71.87 66.67 0.53 90.47 0.11 11.11 <0.001*
s.d. 36.71 35.92 16.26 19.24
SF-36 Mental Health Index (0100)
Mean 72.47 68.50 0.29 74.85 0.43 38.67 0.05
s.d. 15.52 22.06 16.92 34.94

*P < 0.05.

studies have reported similar associations; a study of
1000 residents from Argentina reported that frequent
gastro-oesophageal reflux symptoms were associated
with dysphagia (OR = 2.12, 95% CI: 1.273.54).24
Moreover, oesophageal motility studies have observed
that patients with solid dysphagia (59%) were more
likely to have GERD than those with mixed dysphagia
(29%); however, this study found no such relation-
ship.25 Importantly, we found that GERD is also a risk
factor for odynophagia.
Risk factors associated with dysphagia have not
been adequately assessed in community studies. This
study found a novel risk factor, high blood pressure is
independently associated with dysphagia symptoms
(OR = 2.58, 95% CI: 1.225.44). Dysphagia has previ-
ously been reported as a complication of CVAs;26
however, high blood pressure has not been reported
previously in a population-based sample. The present
finding raises a number of potentially important
issues. First, the association between high blood pres-
sure and dysphagia may not be a causal relationship;
confounders, some of which we have not been able to
address in this study (i.e. BMI, diet, alcohol intake,
NSAID use), may actually be responsible for the
increase in blood pressure.
Studies have reported links between dysphagia and
psychological and emotional disorders.911 Ekberg
et al.11 investigated the psychological and social
impact of dysphagia on a sample of 350 patients, 41%
of patients reported that they experienced panic or
anxiety during mealtimes with 36% avoiding eating
with others because of their dysphagia. This study
found an independent relationship among those with
intermittent dysphagia, which was associated with
anxiety, while progressive dysphagia was associated
with depression, but no specific reason for this finding
was determined. It has been suggested that anxiety
associated with dysphagia typically occurs when eat-
ing and often individuals want to eat by themselves.9
No population-based studies have assessed quality
of life among individuals with dysphagia.9 We found
that progressive dysphagia was independently associ-

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ated with reduced general health, while intermittent
dysphagia was independently associated with a reduc-
tion in the role physical subscale. The subscale role
physical remained significant after adjustment for
anxiety and depression. Furthermore, the severity of
dysphagia was associated with some subscales, physi-
cal functioning with mild to moderate dysphagia,
vitality, social functioning, and role emotional with
severe to very severe dysphagia. Frequency of dyspha-
gia was also linked with the subscales physical func-
tioning for <1 month vs. 1 month, and social
functioning for 1 month vs. 1 week. Statistically, it
appears that the severity of dysphagia has a greater
impact on quality of life compared with the frequency
of dysphagia; it should be noted that this does not
equate to clinical significance as the subscale scores
dropped substantially for both dysphagia severity and
frequency groups.
The main limitations of this study include is that it
did not specifically assess the presence of a globus
sensation (describes the sensation of something in the
throat), a symptom that can sometimes be confused by
individuals as dysphagia and perhaps vice versa;
therefore, there may be some misclassification. On the
other hand, dysphagia was clearly defined in the ques-
tionnaire in simple, nontechnical terms, which should
have reduced any potential bias. In addition, other
limitations include the lack of information on food
impaction and eosinophilic oesophagitis.
In summary, our study has shown that dysphagia is
a common medical problem in the adult community.
GERD is a risk factor for dysphagia as well as odyno-
phagia. The presence of intermittent dysphagia was
associated with anxiety, while progressive dysphagia
was associated with depression. Dysphagia is a signifi-
cant health problem in the community with a substan-
tial impact on the lives of those affected in terms of
physical and mental functioning.
ACKNOWLEDGEMENTS
Declaration of personal interests: None. Declaration of
funding interests: Guy D. Eslick was supported by the
National Health and Medical Research Council
(NHMRC) of Australia, with a Public Health Postgradu-
ate Research Scholarship and by the Gastroenterologi-
cal Society of Australia (GESA), with a Postgraduate
Biomedical Research Scholarship.

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