Are Lifestyle Measures Effective in Patients with Gastroesophageal Reflux Disease? An Evidence-Based Approach
June 15, 2006 3 minutes read
Are Lifestyle Measures Effective in Patients with Gastroesophageal Reflux Disease? An Evidence-Based Approach
By Malcolm Robinson, MD, FACP, FACG, Emeritus Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City. Dr. Robinson serves as a consultant for TAP, Pfizer, Janssen, Eisai, J&J-Merck, and Procter & Gamble, is on the speaker's bureau of Janssen, Eli Lilly, Solvay, TAP, and Aventis, and does research for Forest Labs, Wyeth-Ayerst, AstraZeneca, and Centocor.
Synopsis: Other than weight loss and head of bed elevation, this study found little justification for most of the lifestyle modifications ordinarily recommended for GERD management.
Source: Sharara AI, et al. A randomized double-blind placebo-controlled trial of rifaximin in patients with abdominal bloating and flatulence. Am J Gastroenterol. 2006;101:326-333.
Gastroesophageal reflux disease (GERD) is very common, and the American College of Gastroenterology recommends lifestyle changes as important components of GERD management including elevation of the head of the bed (HOB); decreased fat, chocolate, peppermint, and coffee; cessation of smoking and alcohol; and avoiding recumbency for 3 hours postprandially. The authors performed a systematic review of English-language literature to assess objective data on the effects of lifestyle modifications on GERD; 2,039 studies were screened, and only 100 were found to be relevant. Although smoking does seem to adversely affect GERD physiology, cessation of smoking has not been demonstrated to improve GERD symptoms. Similarly, although alcohol has been shown to have deleterious effects on various parts of GERD pathophysiology and to worsen symptoms, alcohol abstinence is not demonstrably helpful for symptoms.
There was general consensus that obesity and GERD are strongly correlated, and weight loss has been variably effective in leading to diminution of GERD symptoms. Citrus products cause apparent esophageal discomfort, probably not due to their acidity. No study has shown effects of citrus avoidance on GERD. There are very equivocal data on carbonated beverages, coffee and caffeine, spicy foods, mint, and chocolate. All have been implicated in worsening symptoms, but withdrawal trials of these agents haven't been done. Although quite good (classical) studies have shown that fat will provoke reflux, a recent review of this subject failed to recommend any modification of fat in GERD patients. Almost all physicians would agree that large late meals are a bad idea for GERD sufferers, but these authors found some conflicting data including a study by Orr and Harnish (Aliment Pharmacol Ther. 1998;12:1033-1038) suggesting that there was no difference between an earlier and a later meal. HOB elevation also has been studied with some conflict in results, but these authors concluded that sufficient data exist to continue this recommendation. Although data are sound for less reflux in the left lateral decubitus position, the authors thought that recommending this would not be 'practical.'
Commentary
As an author who is cited in the bibliography of this article and as a long-time GERD investigator, I find many of Dr. Gerson's group's conclusions surprising and potentially misleading. In an era of proton pump inhibitors, studies of lifestyle modifications are unlikely to be done. This was also largely true in the histamine H2-receptor antagonist era. It seems to me that the large numbers of studies affirming physiologic worsening of GERD with the provocations outlined in the article cannot be ignored despite an absence of controlled trials of lifestyle measures for specific amelioration of disease symptoms.
Untold numbers of patients have clearly delineated their increased GERD-type symptoms following coffee, spicy foods, high fat meals, alcohol, onions, tomatoes, and citrus products. Similar numbers have been certain that their symptoms improved when such provocations were eliminated. "Blinded" intraesophageal infusions of coffee and orange juice and spicy tomato drinks have been shown to provoke clear-cut GERD symptoms. The study of late vs early meals by Orr and Harnish specifically excluded patients with esophagitis, and the meal that they selected may have been insufficiently provocative. GERD is a complicated illness characterized by very large variations in presentation and undoubtedly in pathophysiology. Patients with hypersensitive esophageal mucosa (a large proportion of the total patient population) may respond quite differently than patients with extensive mucosal injury (less common) or those with Barrett's esophagus (often relatively insensitive to acid and other provocations).
All in all, I believe that wise clinicians will continue to follow the ACG Guidelines for lifestyle modification since they have seemingly been very helpful to large numbers of patients over the years. They are also inexpensive and harmless. Until clear-cut data refuting these guidelines are forthcoming, I for one do not believe that the absence of clear clinical end points is the same as the negation of utility of specific interventions.
Other than weight loss and head of bed elevation, this study found little justification for most of the lifestyle modifications ordinarily recommended for GERD management.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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