Dietary Advice for Patients With GERD

Joel E. Richter, MD

Disclosures

December 09, 2003

Question

What do you recommend in terms of dietary advice for patients with gastroesophageal reflux disease (GERD)?

Response from Joel E. Richter, MD

Patients and clinicians alike have long been aware of a relationship between reflux symptoms and the timing and consumption of various foods. Foods can aggravate reflux symptoms by a number of mechanisms, including: (1) increased gastric volume producing gastric distention and transient lower esophageal sphincter (LES) relaxation; (2) reduction of LES pressure; and (3) direct irritation of esophageal mucosa.[1] Having said this, I believe there is a tendency to overdo specific food recommendations in patients with GERD. I believe that the most important factors are a reduction in the volume of the evening meal, fasting for several hours before retiring, and, if obese, weight loss through appropriate dieting.

In the upright position, the major stimulus for transient LES relaxation is gastric distention after a meal. This accounts for the increased amount of physiologic reflux after eating, especially following the large evening meal. Thus, a reduction of meal size alone has the potential to be of benefit in the management of GERD. If this meal can be low in fat and high in protein, then this will further augment LES pressure and decrease the amount of acid reflux. Eating a large meal immediately before retiring should be discouraged, as this increases gastric volume, promoting gastroesophageal reflux with associated poor nocturnal acid clearance. I suggest to my patients that they can have a healthy evening meal, but eat or drink nothing but water for 3-4 hours before going to bed.

Physicians have traditionally encouraged weight loss for obese patients with GERD, although this is not fully supported by clinical studies. Recently, a large public health survey from Norway[2] found a strong dose-response association between increasing body mass index (BMI) and reflux symptoms in both sexes, with a significantly strong association in women. The risk of reflux was increased significantly among severely obese (BMI > 35) men (odds ratio [OR], 3.3; 95% confidence interval [CI], 2.4-4.7) and women (OR, 6.3; 95% CI, 4.9-8.0) compared with those with a BMI < 25. The association between BMI and reflux symptoms was stronger among premenopausal women compared with postmenopausal women, although the use of postmenopausal hormonal therapy increased the strength of the association. Of note, a reduction in weight was associated with decreased risk of reflux symptoms. Based on this important study in over 60,000 adult subjects, I think we need to be stronger in our recommendations about weight loss. However, please be practical. I find frequently from my history that patients associate worsening of their reflux symptoms with a critical increase in their weight. Therefore, my goal is to get their weight below this critical point (often only 20-50 pounds) rather than shoot for an ideal body weight.

A variety of foods, especially chocolate, carminatives such as spearmint or peppermint, and fats can decrease LES pressure and sometimes promote reflux.[1] Other foods, such as tomato-based products and spicy foods, provoke heartburn symptoms most likely related to direct irritation to the esophagus, possibly because of the high osmolality of these substances. Many beverages can induce heartburn either as a result of their high titratable acidity or low pH.[3] Whether coffee or tea (either caffeinated or decaffeinated) causes reflux is quite controversial. Finally, alcoholic beverages can promote reflux by decreasing LES pressure, impairing esophageal peristalsis, and promoting acid secretion. These findings apply to both high-proof alcoholic beverages (such as vodka) and low-proof alcoholic beverages (such as beer and white wine). Other patients specifically comment that red wines may aggravate their heartburn.

In regard to specific food products, I think one needs to be careful about cautioning patients to stop all of these potential refluxogenic foods. Rather, I find that most patients have selected out the foods that bother them and tend to avoid them already. I prefer that my patients have a healthy meal, and they can certainly have acidic beverages, coffee, tea, or alcohol if they desire. If food products bring on their symptoms, then they can be avoided. Generally, an over-the-counter H2 blocker can control these symptoms if taken before the meal. I have found this approach much more practical and accepted by patients, while emphasizing the "3 pillars" of dietary therapy: small evening meal, not eating late before retiring, and weight loss if obese.

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