Are Lifestyle Measures Effective in Patients With Gastroesophageal Reflux Disease?
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REVIEW ARTICLE
Are Lifestyle Measures Effective in Patients
With Gastroesophageal Reflux Disease?
An Evidence-Based Approach
Tonya Kaltenbach, MD; Seth Crockett, MD; Lauren B. Gerson, MD, MSc
L
ifestyle modifications are first-line therapy for patients with gastroesophageal reflux dis-
ease (GERD). We applied an evidence-based approach to determine the efficacy of life-
style measures for GERD management. We used PubMed and Ovid to perform a search
of the literature published between 1975 and 2004 using the key words heartburn, GERD,
smoking, alcohol, obesity, weight loss, caffeine or coffee, citrus, chocolate, spicy food, head of bed eleva-
tion, and late-evening meal. Each study was reviewed by 2 reviewers who assigned one of the follow-
ing ratings: evidence A, randomized clinical trials; evidence B, cohort or case-control studies; evi-
dence C, case reports or flawed clinical trials; evidence D, investigator experience; or evidence E,
insufficient information. We screened 2039 studies and identified 100 that were relevant. Only 16
clinical trials examined the impact on GERD (by change in symptoms, esophageal pH variables, or
lower esophageal sphincter pressure) of the lifestyle measure. Although there was physiologic evi-
dence that exposure to tobacco, alcohol, chocolate, and high-fat meals decreases lower esophageal
sphincter pressure, there was no published evidence of the efficacy of dietary measures. Neither to-
bacco nor alcohol cessation was associated with improvement in esophageal pH profiles or symp-
toms (evidence B). Head of bed elevation and left lateral decubitus position improved the overall
time that the esophageal pH was less than 4.0 (evidence B). Weight loss improved pH profiles and
symptoms (evidence B). Weight loss and head of bed elevation are effective lifestyle interventions
for GERD. There is no evidence supporting an improvement in GERD measures after cessation of
tobacco, alcohol, or other dietary interventions. Arch Intern Med. 2006;166:965-971
Gastroesophageal reflux disease (GERD) a dysfunction in the body’s antireflux de-
is characterized by symptoms of subster- fense system. Accordingly, the American
nal burning or acid regurgitation pro- College of Gastroenterology recom-
duced by the abnormal reflux of gastric mends the use of lifestyle changes, includ-
contents into the esophagus.1 According ing elevation of the head of the bed (HOB);
to US population surveys, 44% of all decreased fat, chocolate, alcohol, pepper-
Americans experience heartburn at least mint, and coffee intake; cessation of smok-
once per month, 14% at least once per ing; and avoiding recumbency for 3 hours
week, and up to 7% daily.2,3 The major postprandially, in addition to antireflux
mechanism for GERD is transient relax- medical treatment.1 However, the evidence
ation of the lower esophageal sphincter
(LES).4 Recommendations for lifestyle CME course available at
modifications are based on the presump-
tion that certain foods, body position, to- www.archinternmed.com
bacco, alcohol, and obesity contribute to to support such lifestyle modification
Author Affiliations: Division of Gastroenterology and Hepatology (Drs Kaltenbach recommendations has not been well
and Gerson) and Department of Medicine (Dr Crockett), Stanford University substantiated. The purpose of this study
School of Medicine, Stanford, Calif. is to apply an evidence-based approach to
(REPRINTED) ARCH INTERN MED/ VOL 166, MAY 8, 2006 WWW.ARCHINTERNMED.COM
965
©2006 American Medical Association. All rights reserved.increasing reflux symptoms, with
Table 1. Evidence Levels an odds ratio (OR) for reflux of 1.7
(95% confidence interval [CI], 1.4-
Evidence A Evidence B Evidence C Evidence D Evidence E 2.0; P⬍.001) in daily smokers with
One or more Cohort or case-control Case reports, Expert or Insufficient a greater than 20-year tobacco use
well-designed trials, flawed clinical investigator evidence or history compared with those who
randomized controlled nonrandomized or trials, opinion trials with
clinical trials with uncontrolled clinical population significantly
smoked daily for less than 1 year.
consistent evidence trials studies conflicting data Cigarette smoking has been shown
to prolong acid clearance and
decrease baseline LES pressure
(LESP),96,97 with an abrupt decline in
Table 2. Summary of Physiologic Evidence* LESP at the start of smoking that re-
turns to normal within minutes of
Trials, Lowered Worsened Worsened completion of the cigarette.98 Abrupt
Factor No. LESP pH Symptoms References increases in intra-abdominal pres-
Tobacco 12 B B B 6-17 sure, such as with coughing or deep
Alcohol 16 No effect (B) B B 3,6,9,10,16-27 inspiration, have been associated with
Obesity 24 E E E 28-51 reflux symptoms in smokers.11 Stud-
Coffee and caffeine 14 E E No effect (C) 10,16,17,52-62 ies12-14 that examined acid perfusion
Chocolate 2 B B E 63,64 (using the Bernstein test) or esoph-
Spicy foods 2 E E C 3,65
Citrus 3 No effect (B) E C 52,66,67
ageal pH have reported conflicting as-
Carbonated beverages 2 B E C 68,69 sociations; for example, despite hav-
Fatty foods 9 D B E 70-78 ing more “reflux episodes,” smokers
Mint 1 D E E 79 (compared with nonsmokers) do not
Recumbent position 1 E B B 80 show increased esophageal acid ex-
RLD position 3 B B E 81-83 posure time.15
Late-evening meal 3 E No effect (B) E 84-86
No improvement was shown in
Abbreviations: LESP, lower esophageal sphincter pressure; RLD, right lateral decubitus.
3 case-control studies (evidence B)
*See Table 1 for a summary of evidence A through E. that evaluated the effect of tobacco
cessation on GERD outcomes. One
study15 compared a cohort of 30
the literature to determine which study, evidence-based ratings of A healthy volunteers (15 smokers and
lifestyle measures are most likely to through E were assigned. A consensus 15 nonsmokers) with 10 smokers
benefit patients with GERD. was obtained through a second review with GERD and found that smokers
if there was a difference of opinion on had more reflux episodes than non-
initial review.
METHODS smokers but that 24-hour smoking
cessation did not reduce the total time
RESULTS that the esophageal pH was less than
We performed a systematic review of the
English-language literature relating to 4.0. Another study87 showed that
human subjects published between 1975 Of 2039 trials screened for rel- 1-day cessation of smoking de-
and 2004 using PubMed and Ovid to ob- evancy, 100 were included in this creased the number of daily reflux
tain data pertaining to the effects of life- analysis. Only 16 trials examined the episodes but did not significantly
style modifications on GERD. We in- impact of lifestyle changes on GERD affect total esophageal acid expo-
cluded the following key words in the variables. The subsections that fol- sure. On the contrary, Kadakia et al,88
search: lifestyle modification, heartburn, low describe the physiologic evi- after their evaluation of smokers with
GERD, reflux, smoking, alcohol, obesity, dence of lifestyle interventions on GERD who abstained from smok-
weight loss, caffeine or coffee, citrus, choco-
GERD measures (Table 2), fol- ing for 48 hours, concluded that
late, mint, carbonated beverages, spicy
food, fatty foods, head of bed elevation, and lowed by the available evidence on smoking significantly increased dis-
late-evening meal. cessation of the lifestyle measure and tal esophageal acid exposure. Al-
To be included in the study, trials had the impact on GERD variables though tobacco use has been associ-
to contain a lifestyle intervention and out- (Table 3). ated with an adverse effect on the
comes of GERD measures, including LES, the evidence to date does not
heartburn symptoms, ambulatory esoph- SMOKING support an improvement in GERD
ageal pH monitoring, and esophageal after cessation of tobacco use.
manometric variables. Studies of the Cigarette smoking has been associ-
physiologic effects of lifestyle interven- ated with symptomatic GERD. Ques- ALCOHOL
tions only are included as introductory
tionnaires have reported higher rates
evidence for each lifestyle intervention.
We applied an evidence-based ap- of reflux symptoms in tobacco smok- Alcohol consumption may precipi-
proach to the literature using a stan- ers compared with nonsmokers.6-9 tate GERD by increasing acid secre-
dard scoring system (Table 1).5 After Multivariate analysis from a case- tion through gastrin stimulation, re-
2 of us (either T.K. and L.B.G. or S.C. control study10 showed that dura- ducing LESP, increasing spontaneous
and L.B.G.) independently reviewed each tion of smoking was associated with LES relaxations, and impairing
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©2006 American Medical Association. All rights reserved.esophageal motility and gastric emp-
tying.18 Modest alcohol intake has Table 3. Summary of Lifestyle Intervention or Cessation Trials*
been shown to induce reflux symp-
toms and decrease esophageal pH in Trials, Improved
Factor No. Raised LESP Improved pH Symptoms References
healthy individuals without GERD
symptoms19-21 despite normal over- Tobacco 3 E No effect (B) No effect (B) 15,87,88
Alcohol 1 No effect (B) No effect (B) NA 27
all 24-hour pH measurements. 22
Weight loss 5 E B B 89-93
Randomized and cross-sectional Coffee and caffeine 0 E E E NA
studies16,23-26 have suggested an in- Chocolate 0 E E E NA
creased prevalence of symptomatic Spicy foods 0 E E E NA
reflux in alcohol users. Wang et al16 Citrus 0 E E E NA
reported reflux symptoms in 43% of Carbonated beverages 0 E E E NA
heavy (ⱖ210 g/wk) alcohol users Fatty foods 0 E E E NA
Mint 0 E E E NA
compared with 16% of nondrinkers Elevation of the HOB 3 E A B 80,94,95
(OR, 2.85; 95% CI, 1.67-4.49; LLD position 3 B B E 81-83
P⬍.01); however, large American9 Late-evening meal 2 E B E 84,85
and multinational17 cross-sectional
studies have not shown similar as- Abbreviations: HOB, head of the bed; LESP, lower esophageal sphincter pressure; LLD, left lateral
sociations. decubitus; NA, not applicable.
*See Table 1 for a summary of evidence A through E.
In a case-control study27 (evi-
dence B) that examined GERD out-
comes in symptomatic alcoholic pa- et al31 reported an adjusted OR of 1.82 P⬍.05) and postprandial reflux epi-
tients compared with matched (95% CI, 1.33-2.5) for overweight pa- sodes (49.0 vs 32.1; P⬍.05) in pa-
groups (without alcohol consump- tients with weekly heartburn symp- tients with a mean weight loss of 12.4
tion) of controls, patients with toms compared with 1.5 (95% CI, kg in 13 weeks. However, in an-
GERD, and patients with nut- 1.13-1.99) for individuals of aver- other study90 that randomized 20
cracker esophagus, most alcoholic age weight. Cross-sectional stud- obese patients with reflux esophagi-
patients demonstrated LES hyper- ies34-38 have similarly reported higher tis to either a 430-kcal/d diet or an
tension, high-amplitude esopha- weekly reflux symptoms in obese pa- unrestricted diet, there was no sig-
geal contractions, or nonperistaltic tients. Another study39 showed that nificant difference in reflux symp-
esophageal contractions that im- for every increment of body mass in- toms between controls and patients
proved after prolonged (⬎6 months) dex of 5, the risk of GERD increased with a 10% body weight loss after 6
alcohol abstinence but were not ac- by 1.2. In a multivariate logistic re- months. Therefore, although weight
companied by improvements in gression model,32 women with a body loss seems to have a promising effect
esophageal pH. Therefore, al- mass index greater than 35 were on pH measures and symptoms, fur-
though esophageal motility abnor- shown to have an increased risk of ther randomized controlled studies
malities were shown to improve af- GERD (OR, 6.3; 95% CI, 2.4-4.7) are warranted to determine its exact
ter the cessation of alcohol use, there compared with men with a similar effect on GERD outcomes.
is insufficient evidence to support body mass index (OR, 3.3; 95% CI,
the direct effect of alcohol absti- 2.4-4.7; P⬍.001). Although some CITRUS FRUITS AND JUICES
nence on pH or GERD symptoms. studies40-45 have reported a link be-
tween obesity and GERD by demon- Citrus fruits are often cited as pre-
OBESITY strating abnormal pH and manomet- cipitants of heartburn symptoms. In
ric measures, other studies46-51 have a questionnaire of approximately
Obesity has been speculated to cause refuted such an association. 400 patients with GERD, 72% of re-
GERD symptoms because of mul- Bariatric surgery has been asso- spondents reported increased heart-
tiple factors, including increased ciated with improved GERD vari- burn with ingestion of either or-
(1) gastroesophageal sphincter gra- ables.105-112 Given that the surgical ange or grapefruit juice.66 However,
dient,99 (2) incidence of hiatal her- procedure has inherent antireflux Price et al 5 2 found that acid-
nia,100-102 (3) intra-abdominal pres- properties, it is difficult to directly sensitive patients (positive Bern-
sure,103 and (4) output of bile and assess the effect of weight loss on stein test results) were sensitive to
pancreatic enzymes.104 Although GERD. Five studies89-93 have evalu- intraesophageal infusion of orange
some studies 2 8 have shown in- ated the independent effect of weight juice, even when the orange juice
creased GERD in morbidly obese in- loss on GERD variables. Fraser- was adjusted to a pH of 7, suggest-
dividuals, other studies29,30 did not Moodie et al89 showed a significant ing that acidity is not the only fac-
demonstrate similar findings. Sev- correlation between weight loss and tor determining the citrus effect on
eral population-based studies31-33 have esophageal pH (OR, 0.55; P⬍.001) GERD. Cranley et al 6 7 demon-
found a significant relationship be- in an uncontrolled study of 34 obese strated that patients with GERD did
tween increasing body mass index patients with GERD. Mathus- not change their LESP when chal-
(calculated as weight in kilograms di- Vliegen et al91-93 demonstrated a simi- lenged with orange juice infusion;
vided by the square of height in me- lar correlation with a decreased up- this was in contrast to controls who
ters) and GERD symptoms. Murray right pH less than 4 (8.0% vs 5.5%; showed increased LESP. No stud-
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967
©2006 American Medical Association. All rights reserved.ies, to our knowledge, have as- is insufficient evidence to support lowed by an intraesophageal infusion
sessed the effect of avoidance of cit- the routine recommendation that pa- of hydrochloric acid. There were no
rus on GERD. tients with GERD avoid such bev- significant differences in acid sen-
erages. sitivity symptoms with respect to the
CARBONATED BEVERAGES fat infusion.70 Two studies71,72 re-
CHOCOLATE ported significantly shorter onset to
Studies have postulated that carbon- heartburn symptoms or reflux epi-
ated beverages cause GERD.113 In Chocolate is frequently implicated sodes with acid infusion regardless
one study,68 carbonated soft drink as a provoker of GERD. There are of whether patients were receiving
consumption was found to be a pre- limited data that chocolate may affect intraduodenal infusions of a lipid so-
dictor of GERD symptoms in a mul- esophageal pH and LES profiles. One lution or isotonic sodium chloride.
tivariate analysis. Another small early uncontrolled study63 found that Fat infusions have not been shown
study69 of healthy individuals found ingestion of 120 mL of chocolate to affect LESP or the rate of tran-
equivalent decreases in LESP with syrup by 9 controls caused LESP to sient LES relaxations.72
ingestion of carbonated water, caf- significantly decrease compared with Nebel and Castell73 evaluated the
feinated cola, or caffeine-free cola baseline measurements (P⬍.01). In LES response to ingestion of fat and
compared with water ingestion. No 7 patients with typical GERD symp- protein meals with equivalent ca-
cessation trials have been pub- toms, Murphy and Castell64 found loric value in healthy individuals and
lished to date, to our knowledge. greater acid exposure time after found that fatty meals decreased LES
chocolate ingestion compared with pressure significantly compared with
COFFEE AND CAFFEINE ingestion of a test drink of equiva- protein meals, which increased
lent osmolality and caloric value LESP. Becker et al74 studied esoph-
Despite the fact that intraesopha- (P = .04). No studies have ad- ageal acid exposure after high- and
geal infusion of coffee in patients dressed the effect of chocolate ab- low-fat meals and found that the fat
with acid sensitivity has been shown stinence on GERD symptoms. content was not significantly asso-
to cause heartburn,52 2 large epide- ciated with esophageal pH abnor-
miologic studies16,17 found no asso- SPICY FOODS malities. In a study75 of 20 healthy
ciation between coffee drinking and individuals in the supine position,
GERD. A recent survey10 in Nor- Although patients frequently cite those who consumed high-fat meals
way described a negative associa- spicy foods as an inciting agent in had significantly increased acid ex-
tion between coffee drinking and heartburn episodes, little data have posure compared with the low-fat
GERD incidence. Although some been published regarding the ef- group, but this study also found that
studies 5 3 , 5 4 have described in- fects of spicy food consumption on acid exposure increased in patients
creased LESP with regular and de- LESP or esophageal pH. Nebel et al3 who ingested a greater volume.
caffeinated coffees, another trial55 conducted a survey of patients with Other randomized trials have found
showed no effect of coffee on the GERD symptoms and found that no difference comparing high- and
number of reflux episodes, total re- 88% listed spicy foods as a precipi- low-fat meals with respect to LESP,
flux time, or LESP in patients with tant of heartburn. One study65 found transient LES relaxations,76 num-
GERD or controls. There is conflict- that in patients with GERD vs con- ber of reflux episodes, or esopha-
ing evidence regarding how differ- trols, onion intake increased the geal exposure to acid.77 There is con-
ent coffee preparations, roasting number of reflux episodes (P⬍.01) flicting evidence regarding whether
methods, and processing methods and the esophageal acid exposure caloric content of foods is more im-
affect GERD variables.56-59 Decaf- time (P⬍.05). The results of this portant than fat content.76,78
feinated compared with caffeinated study have not been confirmed by Based on the previously men-
coffee ingestion was associated with other larger trials. Many patients tioned trials, there is limited evi-
significantly less acid exposure time who believe that spicy foods exac- dence to suggest that the fat content
in some studies.60 Salmon et al61 erbate their GERD symptoms may of meals affects GERD outcomes. In
noted that patients had lower post- abstain from these foods although we fact, a recent review114 on this sub-
prandial LESP regardless of whether found no published trials that stud- ject concluded that present evi-
they were exposed to coffee, sug- ied the effect of abstinence on change dence does not support any recom-
gesting that the association be- in GERD symptoms. mendations for patients with GERD
tween coffee and GERD may be con- to limit fat in their diets.
founded by the fact that people FATTY FOODS
frequently drink coffee after meals. MINT
Another study62 reported that cof- It has been postulated that fat in-
fee decreased LESP in healthy indi- creases not only reflux but also the Peppermint and spearmint are plant
viduals and in patients with reflux sensitivity of the esophagus to acid extracts that are commonly used in
esophagitis when fasting or follow- exposure. In a randomized clinical foods and flavorings of toothpaste,
ing a standard test meal. Given the trial,70 8 patients with GERD and 11 mouthwash, and candy. Mint is
conflicting reported data, the rela- controls received either an intragas- commonly thought to relax the LES,
tionship between caffeine or coffee tric infusion of isotonic sodium chlo- and thus it is commonly recom-
and GERD remains unclear. There ride or a 20% lipid solution fol- mended that patients with GERD
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968
©2006 American Medical Association. All rights reserved.avoid ingesting mint.115 We found showed that compared with pa- to support an association between
only 1 study examining the effect of tients who slept flat, patients who lifestyle and dietary behaviors and
mint ingestion on GERD. Bulat et al79 slept with an elevated HOB (using GERD,113,117 such interventions con-
conducted a randomized double- 28-cm blocks) had significantly tinue to be recommended as first-
blind placebo-controlled trial in fewer reflux episodes, shorter re- line therapy.1,118 Gastroesophageal
which the LES tone of healthy vol- flux episodes, faster acid clearing, reflux disease is a chronic disease
unteers was measured in response to and fewer reflux symptoms. Hamil- that affects health-related quality of
spearmint, and they found no dif- ton et al94 conducted a randomized life.119 The results of this evidence-
ference in symptoms, sphincter pres- clinical trial comparing sleeping on based approach suggest that al-
sure, or reflux episodes with inges- a wedge, sleep with HOB elevation, though there is physiologic evi-
tion of spearmint. There were no and sleeping in the horizontal posi- dence that smoking, alcohol,
studies published on the effect of ces- tion and found that sleeping on a chocolate, or fatty or citrus food in-
sation of mint intake on GERD wedge was associated with signifi- take may adversely affect symp-
symptoms. cantly less esophageal acid expo- toms or esophageal pH, there is little
sure compared with sleeping in the evidence that cessation of these
LATE-EVENING MEAL horizontal position. Sleeping with agents will improve GERD vari-
HOB elevation also showed im- ables. Elevations in the HOB, left lat-
Postprandial reflux is common in pa- proved acid exposure, but this dif- eral decubitus positioning, and
tients with GERD.116 Two studies that ference was not statistically signifi- weight loss have been associated
evaluated the effect of the timing of cant. 9 4 In another randomized with improvement in GERD vari-
the evening meal on 24-hour intra- controlled trial95 of HOB elevation ables in case-control studies. Larger
gastric acidity in healthy volunteers for 2 weeks in patients with reflux prospective controlled trials are war-
showed different effects on noctur- symptoms treated with proton pump ranted to conclusively recommend
nal pH. A study84 of early (6 PM) vs inhibitors and cisapride, HOB eleva- dietary and lifestyle modifications in
late (9 PM) dinner demonstrated tion was not associated with a dif- the treatment of GERD.
lower intragastric pH (median pH, ference in symptoms or antacid use.
1.39 vs 1.67; P⬍.001) in the later The HOB elevation, therefore, seems Accepted for Publication: Novem-
meal setting, but only between mid- to be an effective measure to im- ber 7, 2005.
night and 7 AM. The second study85 prove the symptoms and physi- Correspondence: Lauren B. Ger-
in 10 healthy patients showed that ologic variables in some patients son, MD, MSc, Division of Gastro-
nocturnal and 24-hour integrated in- with GERD. enterology and Hepatology, Stan-
tragastric acidity were unaffected by ford University Medical Center,
changes in the timing of the evening RIGHT LATERAL Room A149, Stanford, CA 94305-
meal. In the only study in patients DECUBITUS POSITION 5202 (lgerson@stanford.edu).
with GERD that examined the effect Author Contributions: Dr Gerson
of late-evening meals, Orr and Har- Several studies have shown that re- had full access to all the data in the
nish86 measured esophageal pH and flux is increased in patients in the study and takes responsibility for the
symptoms in 20 patients during right lateral decubitus position. The integrity of the data and the accu-
a late-evening meal on one night reason for this phenomenon is not racy of the data analysis.
and a meal before 7 PM on another completely clear, but it may be re- Financial Disclosure: None.
night. There was no difference be- lated to increased transient LES re- Funding/Support: This study was
tween the 2 nights in terms of acid laxations in the right position, or supported by a Research Scholar
exposure, number of reflux epi- possibly that the gastroesophageal Award from the American Gastroen-
sodes, and mean reflux episode du- junction lies above the level of gas- terological Association (Dr Gerson).
ration.86 The evidence to routinely tric acid in the left lateral posi- Role of the Sponsor: The Ameri-
recommend avoidance of late- tion.113 Specifically, total reflux time, can Gastroenterological Associa-
evening meals in patients with GERD average acid clearance, and LES re- tion was not involved in the design
remains incomplete. laxations are significantly pro- of the study; in the collection, analy-
longed in patients lying on their right sis, and interpretation of the data; or
RECUMBENT POSITION AND side compared with the left lateral in the preparation, review, or ap-
HOB ELEVATION decubitus position.81-83 Despite evi- proval of the manuscript.
dence that the right lateral decubi-
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