Adherence to an anti-reflux lifestyle may prevent many symptoms of gastrointestinal reflux disorder (GERD) in women, data from Nurses’ Health Study II suggest. And the decreased risk was evident even in regular users of acid suppressants such as proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs).
“Possible explanations include decreases in lower esophageal sphincter tone, increases in gastroesophageal pressure gradients, and mechanical factors, including hiatal hernia,” wrote Andrew T. Chan, MD, MPH, of Massachusetts General Hospital in Boston, and colleagues.
In addition, they said in a research letter in JAMA Internal Medicine, the results support the importance of lifestyle modification in managing GERD.
The team explained that the overall Nurses’ Health Study II is an ongoing nationwide prospective cohort study established in 1989 with 116,671 female participants who returned biennial health questionnaires with information on smoking, body mass index (BMI), physical activity, medication use, and history of diabetes, along with a “validated, semiquantitative” food frequency questionnaire every 4 years.
The cohort for the new analysis included 42,955 women ages 42 to 62 (mean 52.0, standard deviation 4.7). Over a period stretching from the return of the initial questionnaire in 2007 to a final follow-up in 2017, representing 392,215 person-years of follow-up, a total of 9,291 incident cases of GERD symptoms were identified.
The investigators used an anti-reflux lifestyle score (range 0-5) consisting of five variables:
- Normal weight, defined as BMI of 18.5 to less than 25.0
- Never smoking
- Moderate-to-vigorous physical activity for at least 30 minutes a day
- No more than two cups of coffee, tea, or soda daily
- Eating a prudent diet
Participants were considered to have GERD symptoms if they reported acid reflux or heartburn at least weekly, as in previous research by the same team. The estimated proportion of cases of GERD symptoms preventable by all five factors in the anti-reflux lifestyle score was 37% (95% CI 28-46, top 40% of dietary pattern score).
Compared with women who did not adhere to anti-reflux lifestyle factors, the multivariable hazard ratio (HR) for GERD symptoms was 0.50 (95% CI 0.42-0.59) in those with five anti-reflux lifestyle factors, the investigators reported.
Furthermore, each lifestyle factor was independently associated with GERD symptoms. The individual mutually adjusted multivariable HRs for non-adherence to each factor ranged from 0.94 (95% CI 0.90-0.99, population-attributable risk 3%) for smoking to 0.69 (95% CI 0.66-0.72, population-attributable risk 19%) for BMI.
“The diet associated with less reflux symptoms is generally in keeping with what we consider to be a healthy diet — that is, low in concentrated sweets, red meat, and refined grains,” Chan told MedPage Today. “This should be a fairly straightforward diet for people to follow, especially in view of the other potential health benefits.”
He noted that the study focused on coffee, tea, and soda: “We did not examine specifically carbonated mineral water, but we think that coffee, tea, and soda may increase the risk of GERD because of their effect on the tone of the lower esophageal sphincter or the acidity of stomach contents,” Chan explained.
His group previously reported that these three drinks were associated with a heightened risk of GERD symptoms.
The authors noted that they also considered the possibility that PPI and/or H2RA initiation during follow-up might have influenced the results. In analyses of the use of these agents to indicate the presence of GERD symptoms, participants with the five favorable lifestyle factors had a multivariable-adjusted HR of 0.47 (95% CI 0.41-0.54) for GERD manifestations compared with those with no anti-reflux lifestyle factors.
In an analysis of 3,625 women who reported regular use of PPIs and/or H2RAs and were free of GERD symptoms at baseline, those with the five factors had a multivariable-adjusted HR of 0.32 (95% CI 0.18-0.57) for GERD symptoms compared with PPI and/or H2RA users with none of the anti-reflux lifestyle factors.
Asked for her perspective, Anne Peery, MD, MSCR, of the University of North Carolina at Chapel Hill, who was not involved with the study, said that modern research has established that being healthy in some ways is associated with being healthy in other ways. “Dr. Chan’s study adds to this considerable literature, and few would question that it is good to be a thin, physically active nonsmoker who eats a healthy diet. It appears that this model lifestyle also results in less reflux,” she said.
“Most physicians care for patients who are unable to lose weight or quit smoking despite remarkable efforts on their part. When using language like ‘lifestyle’ and ‘adherence,’ both of which make assumptions about agency, we have to be careful that we don’t leave our patients feeling abandoned, judged, and ashamed,” Perry said.
Also asked for her opinion, Christine Y. Lee, MD, of the Cleveland Clinic, and also not involved with the research, said the recommendations will be helpful for doctors counseling patients in clinical practice: “GERD affects nearly 30% of the U.S. population and is likely to rise in the future. I would also be interested to know about the role or influence of chronic pain medications and narcotics in GERD symptoms.”
Lee said she typically recommends an overall prudent diet that avoids high-protein and keto-type diets as these tend to cause constipation and abdominal bloating, which can exacerbate GERD symptoms.
Limitations to the study, Chan and co-authors said, included that the GERD symptoms were self-reported; that the population-attributable risk estimate used was population-specific and assumed a causal relationship; and that the participants were primarily white women, the population group most commonly affected by GERD, especially in the 30-to-60 age category.
This study was supported by grants from the National Institutes of Health and a Stuart and Suzanne Steele Massachusetts General Hospital Research Scholar Award.
Chan reported financial relationships with Bayer, Pfizer, and Boehringer Ingelheim; a co-author reported financial relationships with AstraZeneca, Gelesis, Takeda, Shire, Arena Pharmaceuticals, and Boston Pharmaceuticals.
Peery and Lee disclosed no competing interests related to their comments.