The Effects of Lifestyle Modifications on GERD

Lauren B. Gerson, MD, MSc http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886414/ G&H Based upon the studies conducted thus far, how effective is weight loss for treating gastroesophageal reflux disease? LG There is good evidence that weight loss does improve symptoms due to chronic heartburn based upon analysis of the Nurses Health Study, which was published by Jacobson and colleagues in 2006 in The New England Journal of Medicine. Obesity likely causes heartburn due to many factors, including an increase in intra-abdominal pressure, a greater association of hiatal hernia, and hormonal factors associated with obesity that can further reduce sphincter pressure. The study by Jacobson and colleagues demonstrated that a weight gain of approximately 1015 pounds in a normal-weight woman is associated with an increased risk of frequent heartburn symptoms of approximately 40%. Conversely, losing approximately 1015 pounds decreases the occurrence of frequent heartburn by approximately 40%. Patients who were overweight or obese at baseline had a 23-fold increased risk of frequent gastroesophageal reflux disease (GERD) symptoms. Even in subjects with normal body weight at baseline, however, the risk of heartburn increased with weight gain despite the fact that the body mass index remained in the normal range. G&H Have studies also shown that reducing tobacco and alcohol is effective for treating GERD? LG Tobacco has been thought to decrease sphincter pressure and potentially worsen GERD symptoms. However, three case-control studies examining the effect of tobacco cessation on GERD did not demonstrate any improvement in heartburn symptoms or esophageal pH with tobacco cessation. Thus, there is no evidence to date that cessation of tobacco is effective in the reduction of GERD symptoms. Similarly, it was also suggested in preliminary studies that alcohol may worsen GERD symptoms and esophageal pH. Only one study, a casecontrolled trial of alcoholics compared to control patients, has been conducted in which patients stopped consumption of alcohol and the effect on GERD was measured. This study did not show that stopping alcohol use for more than 6 months improved esophageal pH levels or GERD symptoms. G&H Could you discuss any data on the effect of different types of foods and drinks (eg, coffee and spicy foods) on GERD?

LG A number of studies have explored the effect of coffee and caffeine on GERD but could not demonstrate that sphincter pressure or esophageal pH were affected. There have been no studies in which patients were instructed to eliminate coffee or caffeine and the effect on GERD was studied. In terms of spicy foods, two studies were performed that looked specifically at sphincter pressure and pH effect, but they did not demonstrate any effect. As with coffee and caffeine, there have not been any studies in which patients have been matched to controls and told to eliminate spicy foods from their diet in order to determine the effect on heartburn symptoms. Other foods that have been evaluated include citrus foods and chocolate, and the findings associated with both are similar to those associated with caffeine and spicy foods. Three studies have been conducted with citrus foods, but all were unable to prove that there was an effect on lower esophageal sphincter pressure, and there have not been any studies in which people were told to remove the items from their diet. Although there is some evidence that sphincter pressure may potentially be lowered with chocolate consumption, no studies have been conducted in which heartburn subjects were told to eliminate chocolate from their diet to see if the GERD improved. Mint has also been examined, but there is no evidence to support it one way or the other. People with heartburn are commonly told to avoid carbonated beverages, but there have been no good data suggesting that eliminating carbonated beverages in a persons diet will improve GERD symptoms. On a similar note, the effect of late-evening meals (defined as eating within 3 hours of going to bed) on GERD has been studied. As with all the other foods, there was some preliminary evidence that avoiding late-night eating might improve esophageal pH, but there is not much evidence supporting symptom improvement. Nevertheless, it is common sense to tell patients not to eat immediately before going to bed. G&H Have studies examined the effects of head-of-bed elevation or sleeping positions on GERD? LG Head-of-bed elevation has been shown to be effective in terms of improving pH as well as GERD symptoms. Head-of-bed elevation is effective, particularly for subjects with nocturnal GERD, because of the fact that stomach contents containing acid will more likely reflux into the esophagus while patients are laying flat without the beneficial effect of gravity. Head-of-bed elevation has been associated with significantly fewer and shorter reflux episodes, faster acid clearing, and fewer reflux symptoms. We usually recommend raising the head of the bed not for all GERD patients, but for those who experience nighttime symptoms or symptoms that prevent them from sleeping.

Some preliminary evidence was found that sleeping on the right side at night might worsen pH and sphincter pressure, though it is unclear whether the sphincter is more relaxed in this position. GERD occurs due to increased transient lower esophageal sphincter relaxations in the right position or possibly because the gastroesophageal junction lies above the level of gastric acid in the left lateral position. Total reflux time, average acid clearance, and lower esophageal sphincter relaxations have been reported to be significantly prolonged in patients laying on their right sides compared to the left lateral decubitus position. Laying on the left side has been shown to increase sphincter pressure and esophageal pH, but it is not feasible to advise this positioning for most patients at night. G&H Should GERD patients adhere to all of these lifestyle modifications even if abundant data do not yet exist supporting their effectiveness in improving GERD? LG Of all the lifestyle modifications discussed above, the only two factors demonstrating effectiveness in randomized controlled trials have been weight loss and head-of-bed elevation. Nevertheless, the first-line GERD treatment recommended to most patients includes weight loss, eliminating a list of foods and drinks from a patients diet (including caffeine, spicy foods, citrus, chocolate, mint, and others), and elevating the head of the bed. I have found in my clinical practice that although patients try to adhere to all of these modifications, they often become very frustrated because their GERD may not be improving and their quality of life is affected by the significant dietary changes. Primary care physicians may inform their patients that if they eliminate all of foods listed above, their heartburn will improve. I inform my patients that we currently do not have any evidence that all of these dietary modifications will eliminate GERD symptoms. I strongly encourage patients to lose weight and recommend head-of-bed elevation only if patients are experiencing symptoms at night or after dinner. I usually consider the dietary recommendations on a case-by-case basis, telling patients to look for cause-and-effect relationships between specific foods and GERD symptoms. For example, if they notice that every time they eat spicy foods they have heartburn, they should eliminate spicy foods. However, I no longer recommend eliminating all of these food items to all patients because of the lack of supporting data. G&H Are weight loss and head-of-bed elevation sufficient treatment in some patients with GERD? LG If patients are able to lose weight, this lifestyle modification is very effective and can reduce or eliminate the need for medical therapy. The reality of the situation is that most patients are unable to lose weight. If

required, bariatric surgery is an effective antireflux therapy. Lifestyle modification is usually more effective in patients with mild symptoms. For example, if they have mild heartburn before going to bed at night, then head-of-bed elevation alone may be very effective. Most of the patients I see, however, are experiencing more severe symptoms and are unlikely to benefit from lifestyle modifications alone. G&H If GERD does not resolve with lifestyle modification, at what point should medical therapy come into play? LG Medical therapy should come into play when people are experiencing regular symptoms that affect their quality of life. Patients who report ingestion of a significant number of anti-acid pills daily should be offered prescription medical therapy for superior symptom control. G&H When moving onto medical treatment for GERD, is treatment more effective if patients try to continue the suggested lifestyle modifications as well or are they no longer helpful at that point? LG I do continue to tell patients to lose weight because weight loss will help them either eliminate medications or reduce their therapy. I also continue to recommend head-of-bed elevation for nighttime symptoms. I am not as stringent with food recommendations, as discussed previously, due to the lack of adequate evidence, unless patients claim that the foods exacerbate their symptoms. Further studies are required to determine if food elimination has a significant effect on chronic GERD. Go to:

Suggested Reading
1. Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med. 2006;166:965971. [PubMed] 2. Jacobson BC, Somers SC, Fuchs CS, Kelly CP, Camargo CA., Jr Body-mass index and symptoms of gastroesophageal reflux in women. N Engl J Med. 2006;354:23402348.[PMC free article] [PubMed] 3. Schindlbeck NE, Heinrich C, Dendorfer A, Pace F, Muller-Lissner SA. Influence of smoking and esophageal intubation on esophageal pHmetry. Gastroenterology. 1987;92:19941997.[PubMed] 4. Waring JP, Eastwood TF, Austin JM, Sanowski RA. The immediate effects of cessation of cigarette smoking on gastroesophageal reflux. Am J Gastroenterol. 1989;84:10761078.[PubMed]

5. Grande L, Monforte R, Ros E, Toledo-Pimentel V, Estruch R, et al. High amplitude contractions in the middle third of the oesophagus: a manometric marker of chronic alcoholism? Gut.1996;38:655662. [PMC free article] [PubMed] 6. Kadakia SC, Kikendall JW, Maydonovitch C, Johnson LF. Effect of cigarette smoking on gastroesophageal reflux measured by 24-h ambulatory esophageal pH monitoring. Am J Gastroenterol. 1995;90:17851790. [PubMed] 7. Gerson LB. A little weight gain, how much gastroesophageal reflux disease? Gastroenterology.2006;131:16441646. discussion 1646. [PubMed] 8. Festi D, Scaioli E, Baldi F, Vestito A, Pasqui F, et al. Body weight, lifestyle, dietary habits and gastroesophageal reflux disease. World J Gastroenterol. 2009;15:16901701. [PMC free article][PubMed] 9. Gerson LB, Fass R. A systematic review of the definitions, prevalence, and response to treatment of nocturnal gastroesophageal reflux disease. Clin Gastroenterol Hepatol.2009;7:372378. quiz 367. [PubMed]

Chocolate, wine and spicy foods may be OK for heartburn

BY LOUIS BERGERON Patients have been known to hug Lauren Gerson, MD, so overjoyed are they at hearing her words. What does she say to them? Go ahead and eat chocolate. Indulge your passion for spicy cuisine. Drink red wine. Enjoy coffee when you want it, have that orange juice with breakfast and, what the heck, eat a grapefruit, too. Gerson says that for most heartburn patients, there's insufficient evidence to support the notion that eating these foods will make heartburn worse or that cutting them out will make it go away. Many of Gerson's patients walk into her clinic upset, having been advised elsewhere to severely limit their diets to help reduce their heartburn symptoms. But recent research by Gerson, assistant professor of medicine, indicates there's no evidence to support a need for dietary deprivation, except for the unlucky few whose heartburn is clearly triggered by a particular food. Gerson's advice runs counter to the long-standing recommendations of virtually every professional organization of gastroenterologists, including the American College of Gastroenterology, as well as the

National Institutes of Health. For the past 15-20 years, the standard treatment for heartburn has been to cut out the aforementioned culinary joysalong with fried and fatty foods, all alcoholic and carbonated beverages, tobacco and mint and to stop eating three hours before lying down. In addition, you're advised to keep your weight under control. Those lifestyle changes coupled with antacids and various over-the-counter and prescription medications have been the accepted first line of treatment. But Gerson, a practicing gastroenterologist for seven years and director of Stanford's Esophageal and Small Bowel Disorder Center, said the stream of "very unhappy" patients referred to her clinic by outside doctors caused her to doubt the efficacy of the usual treatment advice. "The patients were on very bland diets and cutting out coffee and wine and everything that they enjoy and basically their heartburn wasn't getting any better," she said. "So I decided that maybe it's time to look and see if these lifestyle measures really work." In the May 8 issue of Archives of Internal Medicine, Gerson and two other physicians at the School of Medicine Tonya Kaltenbach, MD, and Seth Crockett, MDpublished the results of a systematic survey they conducted of more than 2,000 studies published worldwide on heartburn, also known as acid reflux or GERD (gastroesophageal reflux disease), between 1975 and 2004. They found 100 studies looking at lifestyle factors thought to be associated with heartburn. Only 16 of those studies examined how implementing lifestyle changes affect heartburn symptoms, and these studies were the focus of their article. Their conclusion: There is currently no evidence to show that any of the dietary restrictions usually recommended make a difference. They found only two lifestyle changes for which there was evidence of a clear benefit from making a change. First, if you're overweight, then losing some pounds will reduce or even eliminate the amount of heartburn you suffer. Second, raising the head of your bed will cut down on the amount of stomach acid that can enter your esophagus while you sleep. But Gerson noted a conundrum in her counsel. Although there is no evidence that ceasing consumption of the suspect foods will reduce heartburn, some of the studies did show that certain of the foods (such as chocolate and carbonated beverages) can reduce the pressure exerted by the esophageal sphincter, the control valve that

keeps the food you've swallowed and your digestive acids down in your stomach, where they belong. Heartburn is most commonly caused when the esophageal sphincter relaxes more often than it is supposed to, allowing stomach acid to flow up into the esophagus. That causes a burning sensation behind the breastbone or acidic fluid surging up into the mouth. So it might seem logical to think that if a particular food has been shown to cause a loosening of the sphincter, then eliminating that food from your diet would allow the sphincter to tighten up, thus reducing your heartburn. But, no, said Gerson, that doesn't necessarily seem to be the case, because simply eliminating a certain food doesn't fix the main problem of the esophageal sphincter relaxing too readily. Gerson's experiences with her patients back that up. "It's very rare to see a patient who says, 'Oh, I just changed my diet and everything got better,'" she said, "though this might be the case for patients with milder heartburn symptoms who never walk into the doctor's office for advice." The cause of the conundrum lies in the nature of the studies that have been done. They generally looked at whether a particular food decreased the pressure exerted by the sphincter or increased the acidity in the stomach, but not at whether taking that food out of a patient's diet made any difference. For example, Gerson said, "There were 14 studies that examined the effect of coffee on sphincter pressure and acidity in the esophagus, and none of them demonstrated a change after coffee consumption. To date, no one has done a study where they took patients and told them to cut coffee out for several days to see if their sphincter pressures or acid profiles markedly improved." Gerson and her co-authors said that to really sort out how effective, or ineffective, dietary and lifestyle changes are in combating GERD, future research has to be designed to specifically look at the effects of implementing those measures. Most physicians treating a heartburn sufferer will generally put them on a medication, in addition to any lifestyle changes they recommend. These days that's usually a proton pump inhibitor, which reduces the amount of acid secreted in the stomach. Gerson said that for the most part, medication alone is adequate to treat the symptoms of heartburn. "The main reason they probably

have heartburn is that their sphincter muscle is relaxing too much and taking the medicine will decrease the amount of acid that's going into their esophagus," she said. "Since I don't have a lot of evidence that changing their diet dramatically is going to take the heartburn away, it makes more sense just to take the medicine," she added. That said, Gerson allowed that for some patients, a minor change in diet can make sense. "If a patient comes in and states, 'Red wine really gives me terrible heartburn,' then it may be reasonable to say, 'Well, you could avoid it, or you could take a medication before you drink some red wine,'" she said. According to the ACG, more than 60 million Americans experience heartburn at least once a month and estimates are that more than 15 million suffer from it daily. For the great majority of those sufferers, Gerson's recent findings could free them from the bonds of dietary self-denial. She is considering doing studies of her own to learn more about what effects dietary changes actually have or don't haveon heartburn. "It probably wouldn't be that hard to recruit volunteers for a study of chocolate," Gerson noted. "People like to eat chocolate."