Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal conditions, affecting approximately 30% of the Western population. Its definition varies from simply experiencing heartburn that responds to over-the-counter antacids to a more formal and expert-based definition. The Montreal Definition and Classification of Gastroesophageal Reflux Disease consensus statement1 defines GERD as the presence of troublesome symptoms, such as heartburn and regurgitation, resulting from reflux of gastric contents into the esophagus. The most common treatment for management of GERD is a course of acid suppressants, such as proton pump inhibitors (PPI). PPIs are often prescribed long-term, but occasionally are used on an as-needed basis. Another management strategy includes lifestyle modifications, which alone and/or in combination with medical therapy can be efficacious in the management of GERD.
In a Norwegian study by Ness-Jensen and colleagues2 recently published in Clinical Gastroenterology and Hepatology, the authors conducted a systematic review of the literature to assess the exact role of lifestyle interventions for the treatment of GERD. The authors performed a comprehensive literature search limiting studies to systematic reviews, randomized controlled trials, and prospective observational studies published over the past 70 years. They also analyzed three guidelines and technical reviews.
Among the interventions explored, one of the most effective was weight loss. Three randomized controlled trials demonstrated a significant reduction in the prevalence of reflux symptoms with a decrease in body mass index (BMI). These results were also noted in one study of normal weight individuals (BMI 23.5), where a mean BMI decrease of only 1.6 resulted in a significant improvement in reflux symptoms.
The second intervention associated with improvement in reflux symptoms was tobacco cessation. Tobacco is known to reduce lower esophageal sphincter pressure, as well as decrease salivary secretion of bicarbonate, which acts as an acid buffer. In one large population-based study of nearly 30,000 individuals, a 5-time reduction in risk was noted in patients who discontinued smoking.
The third non-medical intervention which improved reflux symptoms was elevation of the head of the bed. In one small cross-over study of 15 GERD patients, elevation with a wedge measuring 10 inches reduced intra-esophageal acid exposure compared to patients who slept in a flat position. There was a statistical difference in the percentage of time that pH was <4 between GERD patients who elevated the head of the bed versus those that did not (15% vs 21%, p<.05). Although not discussed in this systematic review, another small study in 24 GERD patients3 also evaluated the effect of bed head elevation on reflux symptoms. Again, the percent time acid was found in the esophagus improved when sleeping on a 20-cm block for 1 week. Additionally, the majority experienced improvement in sleep.
Somewhat surprisingly, dietary intervention was not significantly associated with reduction of reflux symptoms. Specifically, low calorie diets and drinking carbonated beverages had no effect on reflux symptoms. Rather, late evening meals—within 2 hours of bedtime—did worsen nocturnal reflux, a fact well known by patients and providers. Another small randomized cross-over study demonstrated that using fiber products for only 2 weeks improved the number of days without heartburn.
In summary, the results of this systematic review reinforce and validate strategies that many primary care providers already prescribe to their patients in terms of lifestyle modifications to alleviate symptoms of GERD. These methods are particularly recommended for patients who would rather treat their symptoms the more “natural” way without PPIs. Weight loss is effective in controlling symptoms even in patients with a normal BMI. Loss of a few pounds can help reduce heartburn and regurgitation. Smoking cessation will also improve symptoms, especially in patients with a normal BMI. Avoiding late night meals and, during sleep, elevating the head of the bed several inches may allow for a more restful night without heartburn.
1. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R; Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101:1900-1920; quiz 1943.
2. Ness-Jensen E, Hveem K, El-Serag H, Lagergren J. Lifestyle intervention in gastroesophageal reflux disease. Clin Gastroenterol Hepatol. 2016;14:175-182.
3. Khan BA, Sodhi JS, Zargar SA, et al. Effect of bed head elevation during sleep in symptomatic patients of nocturnal gastroesophageal reflux. J Gastroenterol Hepatol 2012; 27:1078-1082.