Salt intake and smoking play major roles in GERD

Heartburn experts praised a Norwegian study but add that there is not yet enough evidence to eliminate dietary restrictions on alcohol, coffee and tea consumption.

By Victoria Stagg Elliott — Posted Dec. 13, 2004

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The usual bits of advice -- that gastroesophageal reflux disease patients give up on alcohol, coffee and tea -- may not actually be words of wisdom, according to a study published in this month's Gut.

Scandinavian researchers analyzed data from two extensive public health surveys of thousands of people in Norway. They found that smoking, long considered a culprit in causing GERD, increased the risk of the disease by 70%. The use of table salt, which has never been implicated in this condition, also increased the risk by 70%.

Alcohol, coffee and tea intake did not appear to make a difference. Dietary fiber and regular exercise seemed to be protective.

"The present study indicates an important role for exogenous exposures in the form of lifestyle-related factors in the etiology of GERD," wrote the authors.

Heartburn experts widely praised the study for taking a closer look at the eating, drinking and other activities that may play a role in the disease's development and for suggesting a research path that might lead to prevention strategies.

"This study brings up the under-appreciated point that lifestyle-related factors may bring on the very common symptoms of heartburn," said A. Mark Fendrick, MD, a member of the medical advisory board of the National Heartburn Alliance and professor of internal medicine and health management and policy at the University of Michigan Medical School. "And maybe we can try to prevent the disease process from starting."

Primary care physicians appreciated the paper because it adds weight to the argument that their patients, particularly if they have reflux, should quit smoking, reduce their salt intake, eat fiber and exercise.

"The conclusions for this article really kind of go along with what we need to be promoting in primary care anyway," said Joel Heidelbaugh, MD, clinical assistant professor in the Dept. of Family Medicine at the University of Michigan and a co-author of his institution's GERD management guidelines.

Continuing questions

Experts said, however, that while these were intriguing data, it would be premature to advise GERD patients, many of whom may have cut out or reduced coffee, tea and alcohol intake, to now return to their old ways.

"This is going to raise new questions" said Dr. Heidelbaugh. "But one study is not going to change everybody's mind."

Meanwhile, critics suggested that some of the conclusions may not be that generalizable to the United States, and that, although the belief that alcohol, tea and coffee play a role in GERD is not backed by much science, it is supported by experience.

"I would love to see this survey duplicated here or across several nations," said Edward Zurad, MD, a family physician from Tunkhannock, Pa. "In our American population, both from a pragmatic and anecdotal standpoint, we believe that there is a causal connection."

Some experts also questioned the conclusions.

They said this population-based case control study supported the idea that there was an association between these lifestyle factors and GERD, but not whether one caused the other. This study also relied on patient self-reporting of symptoms rather than a physician-confirmed diagnosis.

"These are important associations, but they don't necessarily tell us about risk because there may be other confounders that they didn't consider," said Charlene Prather, MD, a gastroenterologist and associate professor of medicine at Saint Louis University School of Medicine.

Experts also suggested that salt or fiber intake could be indicators of other players in the condition such as the amount of fat in a diet.

"Dietary fiber may just be a surrogate marker for a lower-fat diet, and we do know that higher fat increases your risk for reflux disease," said Dr. Prather. "Also, perhaps people who salt their food are people who eat higher-fat food?"

This study adds to the growing body of literature about lifestyle factors that may lead to the development of the disease, but physicians working with GERD patients concede there is still little evidence that changing these factors can make a difference once symptoms occur.

Also, by the time patients approach physicians with questions about reflux, they have usually tried lifestyle changes and over-the-counter remedies and are looking for something more advanced.

"Most of our patients when they come to us really want to go to sophisticated pharmacologic approach in addition to a review of lifestyle changes," said Dr. Zurad.

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When life leads to reflux

Objective: Determine which lifestyle habits are associated with the development of gastroesophageal reflux disease.

Participants: More than 3,000 people with GERD symptoms and more than 40,000 without who participated in two large public health surveys in Nord-Trondelag, Norway.

Methods: Using a case control design, the data were analyzed to develop odds ratios linking GERD with smoking and exercise as well as with the consumption of alcohol, coffee, tea, table salt and fiber.

Results: People who smoked for more than 20 years or always used extra table salt were 70% more likely to have reflux symptoms. No association was found between reflux and coffee, tea or alcohol. Eating bread high in dietary fiber and regular exercise appeared to be protective.

Conclusions: Smoking and excess salt intake are risk factors for GERD. A diet high in fiber and regular exercise may be protective. Alcohol, coffee and tea, which have long been viewed as aggravators of this condition, may not play a role.

Source: Gut, December

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External links

"Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux," abstract, Gut, December (link)

National Heartburn Alliance (link)

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