Diet and Gastroesophageal Reflux Disease: Role in Pathogenesis and Management

Sajiv Sethi; Joel E. Richter


Curr Opin Gastroenterol. 2017;33(2):107-111. 

In This Article

Food Composition

The increasing prevalence of GERD along with its increasing prevalence in the Western world has encouraged examination of food and dietary habits as a potential cause or exacerbating factor in the development of reflux symptoms. Although anecdotal evidence has suggested associations with certain foods (fats, nonvegetarian, fried foods, and beverages) with reflux symptoms, objective evidence based data in this field remain unclear. Recent evidence points to the increasing importance of lifestyle in disease development as well.

Citrus and other acidic foods such as tomatoes are considered to trigger reflux symptoms. A study assessing the physiologic dynamics of ingesting acidic foods noted that acidic liquids took longer to drink, required a higher number of swallows, had a slower duration of ingestion, and contained a smaller volume in each swallow when compared to a neutral bolus.[11] This suggests a possible mechanism for the worsening of reflux symptoms in some patients, with ingestion of acidic foods such as fruits, juices, coffee, and carbonated beverages. The effect of different foods on patient's subjective perception of symptoms often leads patients to self-modify their diet decreasing their consumption of food that exacerbates reflux symptoms. This was seen in a community-based cross-sectional study that evaluated adherence of patients with GERD to dietary guidelines finding that patients avoided some (liquor and citrus foods) but not all foods traditionally attributed to worsen GERD symptoms.[1]

Ingestion of nonvegetarian foods has been noted to worsen GERD symptoms, whereas a diet consisting of greasy foods was independently associated as a risk factor for the development of nonerosive reflux disease.[5] Diets high in fat may be a risk factor for development of Barrett's esophagus, whereas diets rich in fruits and vegetables have a protective effect.[6] It is also important to note the GERD is part of a larger cohort of upper gastrointestinal symptoms which includes dyspepsia as well. The use of canned foods and alcohol has been associated with functional dyspepsia using multivariate analysis. Disease symptoms from canned foods may be because of the individual components such as food additives, food pH, and tin material.[5] High fat meals may decrease lower esophageal sphincter pressure (LESP) compared to a high protein meal of the same caloric value. A higher fat meal content also correlated with increased acid exposure time in patients when compared to a low fat meal. At the same time, it bears mentioning that other randomized trials were unable to replicate differences in LESP, transient LES relaxations, number of reflux episodes, or esophageal exposure to acid dependent on fat content in meals.[11]

Chocolate is often implicated in the worsening of reflux symptoms. Although ingestion of chocolate has been shown to decrease LESP and increase acid exposure time, no studies have assessed the benefit of chocolate abstinence.[12]

Various diet plans have been explored to improve GERD symptoms, especially in patients with other comorbid conditions. For example, in patients with inflammatory bowel disease, an improvement of reflux symptoms after initiation of a gluten free diet was noted.[13] A Mediterranean diet is characterized by a high intake of vegetables, legumes, fruits, whole grains, fish, and olive oil, moderate amounts of alcohol and dairy products, and low amounts of red or processed meat. Its benefit in cardiovascular disease, cancer, and diabetes is extensively documented, including prospective trials.[14] Mone et al.[15] performed a cross-sectional study involving 817 participants and found that following a Mediterranean diet decreased the risk for GERD symptoms. When controlled for eating habits (meal regularity, eating rate, and meal-to-sleep interval), the positive association between GERD and a Mediterranean diet persisted.[15] Examination of individual food items has established foods that may help with disease control as well. A Japanese study found that daily ingestion of the high fiber fruit, Japanese apricot, was associated with decreased symptoms of esophageal dysmotility (belching, early satiety, bloating, and heaviness) without affecting acid type symptoms in patients with GERD.[16]