Primary Care Corner with Geoffrey Modest MD: Lifestyle Changes and GERD

By Dr. Geoffrey Modest

Gastroesophageal reflux disease (GERD) is a remarkably common problem in patients presenting to primary care clinicians. Although there are an array of lifestyle interventions that have been suggested, there are somewhat limited data on their efficacy. A recent systematic review assessed the literature (see Clinical Gastroenterology and Hepatology 2016;14:175).

Details:

• Background:
  • ​Prevalence of GERD in western populations is 30%; incidence is 5/1000 person-years
  • GERD is associated with decreased quality-of-life and work productivity, and increased risk of esophageal carcinoma (for guidelines on Barretts esophagus management, see blog: https://stg-blogs.bmj.com/bmjebmspotlight/2016/01/21/primary-care-corner-with-geoffrey-modest-md-barretts-esophagus-guidelines/ )
  • Reflux is associated with a variety of factors leading to relaxation of the lower esophageal sphincter (LES), including coffee, alcohol, chocolate, peppermint, citrus, perhaps carbonated drinks, and spicy foods), as well as obesity and cigarette smoking

• Results:
  • Weight loss: a variety of studies:
    • Large prospective population-based cohort studies (Nurses’ Health Study and Nord-Trondelag health studies) have found that, comparing those whose weight remained stable, those with decreasing BMI had decreased reflux symptoms, in a dose-dependent fashion, with a 2-fold increased likelihood of disappearance of reflux symptoms off medications
    • A largish RCT found that those patients who lost weight had decreased prevalence of GERD symptoms
    • ​Three very small studies showed weight loss was associated with improvement or normalization of esophageal pH levels, though one small study did not find this
  • Smoking cessation:
    • The Nord-Trondelag health study of 29,610 participants found a decrease in severe reflux symptoms in normal-weight people on medications who stopped smoking, with an OR of 5.67 (1.36-23.64), vs those who continued smoking. Overweight or obese people did not derive this benefit, which the study authors thought might be related to the possibility that weight was such a strong predictor of GERD symptoms that it overwhelmed smoking’s attributable risk
  • ​Other dietary interventions: no evidence that carbonated beverages promote GERD; a small RCT (30 patients) found that an early meal (6 hours prior to bed) led to less pH-verified supine reflux vs a late meal (2 hours before bed); and another small study (30 patients) found that patients on fiber vs placebo had fewer days of and less severe symptoms of heartburn
  • Head-of-bed elevation: a small cross-over RCT of 15 GERD patients found that elevating the head of the bed by a 10-inch wedge led to less time the esophageal pH was <4.

So, a few points:

• The best data for lifestyle changes are from the large observational studies, which of course do not confirm causation (i.e., did those who lost weight also adapt other healthier lifestyle changes which might have been the cause of the decreased symptoms?)
• In terms of RCTs, the most compelling data showing improvement of GERD symptoms is for weight reduction in overweight/obese patients.
• Despite some prior analyses and recommendations, it does seem that smoking cessation is useful for GERD symptom reduction, especially in non-overweight people (adding to the list of reasons to stop smoking…)
• There are not adequate study data on other dietary interventions, though probably a high fiber diet and not eating late meals are reasonable. Though not rigorously studied, it certainly makes sense to listen to the patient: if they think spicy foods, or other items cause more symptoms, it seems prudent to reinforce that such a dietary change may be appropriate to try if not already done.
• Raising the head of the bed does have some minimal data of support (though I must mention one of my patients from long ago who warned me that he tried this, but he slipped down uncomfortably to the bottom of the bed because he used silk bedsheets…)
• Other recommendations may also be appropriate, in part for their other benefits (even though not so clear for GERD, for which they are untested), such as decreasing alcohol consumption (which does in fact lower LES pressure), avoiding tight-fitting corsets (which could increase the intraabdominal pressures, putting stress on the LES gradient), and for similar reasons, promoting abdominal breathing
• So, as always, I think lifestyle changes are really important (and, of course, not just for GERD symptoms). I do find it distressing that formal recommendations from specialty societies are so grounded in the evidence-based model that they minimize potentially important recommendations for lack of data. So, for example, the 2013 recommendations of the American College of Gastroenterology (see http://gi.org/guideline/diagnosis-and-managemen-of-gastroesophageal-reflux-disease/ ) has 13 treatment recommendations: one suggesting weight loss if overweight or recent weight gain, one suggesting head-of-bed elevation and avoidance of meals 2-3 hours before bed, and another unequivocally dismissing the utility of routine food elimination (including alcohol but not smoking, which is not even mentioned). And almost all of their recommendations (7 of 13) are about PPIs, 1 mentions H2-blockers, and 2 dismiss all other medical therapies (see https://stg-blogs.bmj.com/bmjebmspotlight/category/gi-dyspepsia/ for several blogs questioning the overuse of PPIs).​ [It turns out that drug companies do not often sponsor studies on non-drug based lifestyle interventions….]. So, because either not-great or no studies were done (e.g., There are no studies looking at cessation of chocolate, caffeine, spicy foods, citrus, or carbonated beverages and their effect on GERD), the guidelines state that these interventions should not be recommended generally, only if the patient has already tried them and they work….. Personally, I do continue to recommend trying the broad array of lifestyle changes, including those without any data/not recommended in the above guidelines (e.g. around caffeine, tobacco, alcohol, spicy foods, and, yes, even chocolate), at least for the patient to experiment to see if these help.