Perspectives in clinical gastroenterology and hepatology
Lifestyle Intervention in Gastroesophageal Reflux Disease

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Background & Aims

Gastroesophageal reflux disease (GERD) affects up to 30% of adults in Western populations and is increasing in prevalence. GERD is associated with lifestyle factors, particularly obesity and tobacco smoking, which also threatens the patient’s general health. GERD carries the risk of several adverse outcomes and there is widespread use of potent acid-inhibitors, which are associated with long-term adverse effects. The aim of this systematic review was to assess the role of lifestyle intervention in the treatment of GERD.

Methods

Literature searches were performed in PubMed (from 1946), EMBASE (from 1980), and the Cochrane Library (no start date) to October 1, 2014. Meta-analyses, systematic reviews, randomized clinical trials (RCTs), and prospective observational studies were included.

Results

Weight loss was followed by decreased time with esophageal acid exposure in 2 RCTs (from 5.6% to 3.7% and from 8.0% to 5.5%), and reduced reflux symptoms in prospective observational studies. Tobacco smoking cessation reduced reflux symptoms in normal-weight individuals in a large prospective cohort study (odds ratio, 5.67). In RCTs, late evening meals increased time with supine acid exposure compared with early meals (5.2% point change), and head-of-the-bed elevation decreased time with supine acid exposure compared with a flat position (from 21% to 15%).

Conclusions

Weight loss and tobacco smoking cessation should be recommended to GERD patients who are obese and smoke, respectively. Avoiding late evening meals and head-of-the-bed elevation is effective in nocturnal GERD.

Section snippets

Methods

Systematic literature searches on lifestyle interventions for patients with GERD were performed in MEDLINE using PubMed from 1946 and EMBASE using OvidSP from 1980 to October 1, 2014. In addition, the Cochrane Library was searched (last search was performed on October 1, 2014). The searches included the thesaurus terms (MeSH in MEDLINE and EMTREE in EMBASE): “gastroesophageal reflux,” “heartburn,” “peptic esophagitis” (EMBASE)/”esophagitis, peptic” (MEDLINE) and “non-erosive reflux disease”

Literature Searches

Literature searches on lifestyle intervention identified 15 original studies that met the inclusion criteria (Table 1 and Supplementary Table 1). In addition, 1 previous systematic review on lifestyle intervention and 1 previous systematic review on conservative and surgical treatment for obesity in GERD were identified.32, 33 No relevant Cochrane reviews were identified. Three management guidelines were assessed: the Canadian Association of Gastroenterology consensus (2005),24 the American

Discussion

RCTs have shown reduced reflux symptoms and esophageal acid exposure with weight loss,37, 38, 39, 40 findings supported by well-designed observational studies showing a dose-dependent decreased presence of reflux symptoms after weight reduction. A large prospective observational study showed reduced reflux symptoms with tobacco smoking cessation in normal-weight individuals.47 RCTs also showed that early evening meals48 and head-of-the-bed elevation51 decreased the esophageal acid exposure

Conclusions

Recent evidence supports lifestyle intervention in the treatment of GERD. These include weight loss, tobacco smoking cessation, avoiding late evening meals, and head-of-the-bed elevation. Meanwhile, the awareness of adverse effects of medical treatment has increased, questioning long-term and continuous PPI therapy, at least in mild GERD.

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    This article has an accompanying continuing medical education activity on page e19. Learning Objective–Upon completion of this activity, successful learners should be able to identify lifestyle interventions with documented effect on gastroesophageal reflux disease.

    Conflicts of interest The authors disclose no conflicts.

    Funding Supported by the Norwegian and Swedish Research Councils (E.N.-J.); by National Institutes of Health grant K24 DK04-107 and the Houston VA Health Services Research and Development Center of Excellence (HFP90-020) (H.E.-S.); and by grants from the Swedish Research Council (J.L.).

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