Ninety-Six Hour Wireless Esophageal pH Study in Patients with GERD Shows that Restrictive Diet Reduces Esophageal Acid Exposure

The Efficacy of Dietary Interventions in Patients with Gastroesophageal Reflux Disease: A Systematic Review and Meta-Analysis of Intervention Studies

BACKGROUND

International guidelines recommend dietary interventions as one of the most important treatments for patients with gastroesophageal reflux disease (GERD). Evidence to confirm the efficacy of these treatment modalities is lacking. The present study aims to evaluate the efficacy of dietary interventions on GERD-related outcomes evaluated in intervention studies on GERD patients.

METHODS

A systematic review and meta-analysis was performed according to PRISMA. The PubMed/MEDLINE, Web of Sciences, and Scopus databases were utilized for the literature search. Two independent researchers searched for relevant publications published up until June 2023. Intervention studies evaluating the efficacy of dietary interventions in patients with GERD were included.

RESULTS

A total of 577 articles were identified during the initial literature search. After reviewing, 21 studies with 16 different types of dietary interventions were included in the analysis. The interventions were divided into low-carbohydrate diets (3 studies), high-fat diets (2 studies), speed of eating studies (3 studies), low-FODMAP diets (2 studies), and other interventions (12 studies). A meta-analysis could be performed for low-carbohydrate diets and speed of eating interventions. Low-carbohydrate diets resulted in a significant reduction in esophageal acid exposure time (mean difference = -2.834%, 95% confidence interval (CI): -4.554 to -1.114), while a slow speed of eating did not lead to a lower percentage of reflux events compared to fast eating (risk ratio = 1.044, 95% CI: 0.543-2.004). Most other interventions showed positive effects in only a single study.

CONCLUSION

Low-carbohydrate diets showed a significant improvement in GERD-related outcomes, while a slow eating speed did not result in a reduction in reflux events. The overall evidence regarding dietary interventions in GERD remains scarce. High-quality, long-term RCTs are still required to confirm the effects of dietary interventions in GERD patients.

The Impact of Intermittent Fasting on Patients With Suspected Gastroesophageal Reflux Disease

GOAL

The aim was to investigate the short-term impact of time restricted feeding on patients with suspected gastroesophageal reflux disease (GERD).

BACKGROUND

Lifestyle modifications are often suggested, but the role of diet in GERD is unclear. Intermittent fasting is popular in the media and has demonstrated potential benefits with weight loss and inflammatory conditions as well as alterations in gastrointestinal hormones.

STUDY

Patients who were referred for 96-hour ambulatory wireless pH monitoring off proton pump inhibitor to investigate GERD symptoms were screened for eligibility. Patients were instructed to maintain their baseline diet for the first 2 days of pH monitoring and switch to an intermittent fasting regimen (16 consecutive hour fast and 8 h eating window) for the second 2 days. Objective measures of reflux and GERD symptom severity were collected and analyzed.

RESULTS

A total of 25 participants were analyzed. 9/25 (36%) fully adhered to the intermittent fasting regimen, with 21/25 (84%) demonstrating at least partial compliance. Mean acid exposure time on fasting days was 3.5% versus 4.3% on nonfasting days. Intermittent fasting was associated with a 0.64 reduction in acid exposure time (95% CI: -2.32, 1.05). There was a reduction in GERD symptom scores of heartburn and regurgitation during periods of intermittent fasting (14.3 vs. 9.9; difference of -4.46, 95% CI: -7.6,-1.32).

CONCLUSIONS

Initial adherence to time restricted eating may be difficult for patients. There is weak statistical evidence to suggest that intermittent fasting mildly reduces acid exposure. Our data show that short-term intermittent fasting improves symptoms of both regurgitation and heartburn.

Dietary factors involved in GERD management

Gastroesophageal reflux disease (GERD) is extremely common, and even modest weight gain has been associated with higher symptom burden as well as objective evidence of reflux on endoscopy and physiological measurement. Certain trigger foods, especially citrus, coffee, chocolate, fried food, spicy food and red sauces are frequently reported to worsen reflux symptoms, although hard evidence linking these items to objective GERD is lacking. There is better evidence that large meal volume and high calorie content can increase esophageal reflux burden. Conversely, sleeping with the head end of the bed raised, avoiding lying down close to meals, sleeping on the left side and weight loss can improve reflux symptoms and objective reflux evidence, especially when the esophagogastric junction 'reflux barrier' is compromised (e.g., in the presence of a hiatus hernia). Consequently, attention to diet and weight loss are both important elements of management of GERD, and need to be incorporated into management plans.

Value of 96-hour ambulatory esophageal pH monitoring in the assessment of patients with refractory acid reflux symptoms and their response to anti-reflux diet

Ambulatory esophageal pH monitoring is a diagnostic tool in patients with heartburn and regurgitation. The aim of this study is to evaluate 96-hour esophageal pH monitoring in patients with gastroesophageal reflux disease (GERD), at baseline and under diet that impedes GER. We hypothesized that diet would potentially reduce pathologic acid exposure time (AET). Retrospective series of 88 patients with GERD undergoing wireless 96-hour pH monitoring. Two-day (48 hours) tandem periods, one on liberal, followed by another on restricted diet assessed esophageal AET. Primary end point was >30% reduction in AET while on anti-GER diet. Of the 88 patients, 16 were excluded because of probe migration. Endoscopy and biopsies assessed erosive esophagitis (EE) and Barrett's esophagus (BE), or normal esophagus. Abnormal AET (% pH < 4.0 ≥ 6) further defined nonerosive reflux disease (NERD), whereas normal AET (% pH < 4.0 < 6) with normal endoscopy defined patients as functional heartburn (FH). There were 6 patients with EE (n = 5) and BE (n = 1), 23 with NERD and 43 with FH. Anti-GER diet led to >30% reduction in AET in EE and NERD patients, but not in those with FH. Most patients (n = 43/72; 60%) had FH and could have avoided acid suppression. Furthermore, (14/23; 61%) of patients with NERD completely normalized AET with diet, potentially negating acid suppression. Ninety-six-hour esophageal pH distinguishes GERD patients from those with FH. Fifty percent of EE/BE patients and 61% of those with NERD completely normalize AET with diet. If pathologic AET occurs despite diet, acid suppression is indicated.

[Conservative Therapy of Reflux Disease and its Limits]

Gastrooesophageal reflux disease (GORD) is common. Proton pump inhibitors (PPI) are regarded as first line therapy for all clinical manifestations. However, their efficacy is inadequate for at least 30% of patients and they are occasionally poorly tolerated. Moreover, some patients would prefer an alternative therapy. Alginate cause mechanical reflux inhibition by forming a gelatinous layer in the so-called acid pocket, an acid reservoir that forms on the surface of the chyme in the gastric corpus immediately after food intake. They may be used an alternative to treat the symptoms of uncomplicated GORD and as an add-on to PPIs if these do not improve symptoms adequately. If the reflux symptoms persist or if reflux oesophagitis does not heal, differentiated diagnostic testing must be performed, using endoscopy and functional analysis. Extraoesophageal manifestations of GORD include cough, compulsive clearing of the throat, problems with the voice and globus sensation. These often do not respond to antireflux therapy. Recent data indicate that these are complex hypersensitivity syndromes and that reflux is only one of several possible triggers.