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- Therap Adv Gastroenterol
- v.12; 2019
- PMC6764031
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Therap Adv Gastroenterol. 2019; 12: 1756284819877788.
Published online 2019 Sep 25. doi:10.1177/1756284819877788
PMCID: PMC6764031
PMID: 31598134
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Abstract
Background:
Poor habits can worsen gastroesophageal reflux disease (GERD) and reducetreatment efficacy. Few large-scale studies have examined lifestyleinfluences, particularly eating habits, on GERD in China, and researchrelated to eating quickly, hyperphagia, and eating hot foods is quitelimited. The aim of this study was to evaluate the relationship between GERDpathogenesis and lifestyle factors to produce useful information for thedevelopment of a clinical reference guide through a national multicentersurvey in China.
Methods:
Symptom and lifestyle/habit questionnaires included 19 items were designed.The questionnaire results were subjected to correlation analysis relative toGERD symptom onset. A standard proton pump inhibitor (PPI) was advised tocorrect patients with unhealthful lifestyle habits.
Results:
A total of 1518 subjects (832 GERD, 686 non-GERD) enrolled from six Chinesehospitals completed symptom and lifestyle/habit questionnaires. The toplifestyle factors related to GERD were fast eating, eating beyond fullness,and preference for spicy food. Univariate analysis showed that 21 factors,including male gender, a supra-normal body mass index (BMI), smoking,drinking alcohol, fast eating, eating beyond fullness, eating very hotfoods, and drinking soup, among others, were associated with GERD(p < 0.05). Logistic multivariate regressionanalysis revealed the following risk factors for GERD [with odds ratios(ORs)]: fast eating (4.058), eating beyond fullness (2.849), wearing girdlesor corsets (2.187), eating very hot foods (1.811), high BMI (1.805), lyingdown soon after eating (1.544), and smoking (1.521). Adjuvant lifestyleinterventions improved outcomes over medication alone(z = –8.578, p < 0.001 Mann–Whitneyrank sum test).
Conclusions:
Lifestyle interventions can improve medication efficacy in GERD patients.Numerous habits, including fast eating, eating beyond fullness, and eatingvery hot foods, were associated with GERD pathogenesis. The present resultsmay be useful as a reference for preventive education and treatment.
Keywords: dietary habits, gastroesophageal reflux disease (GERD), hyperphagia, life style, therapeutics
Introduction
Gastroesophageal reflux disease (GERD) is characterized by abnormal gastric refluxinto the esophagus at least once a week leading to heartburn and acid regurgitation.1 It is a common disease globally, with increasing prevalence, and,consequently, greater burden on healthcare systems.2,3 The prevalence rates of GERD inWestern countries, where it is most prevalent, have been reported to be 10–20%.4 Meanwhile, recent modernization of living standards, and the accompanyinglifestyle changes and acceleration of the pace of life, have led to an increasingprevalence of symptomatic GERD in China, which reached 3.8% in 2016.5 Because of repeated treatment and prolonged healing, GERD is associated withreduced health-related quality of life,6 substantial costs for patients,7 and increased risk of esophageal adenocarcinoma.8
GERD has been reported to be alleviated, or even cured, with a combination oflifestyle interventions and medication.9 Moreover, poor lifestyle habits can worsen GERD and reduce treatment efficacy.10 A consensus of GERD treatment strategy has yet to be established due to thelack of a unified view of GERD-promoting behavior. For example, opposing effects ofcoffee or caffeine on GERD have been reported,11,12 questions remain about thepotential relationship between esophageal acid exposure and meal times,13,14 as well asabout whether GERD symptoms are related to body mass index (BMI).15,16 Because it isdifficult for patients who lack awareness of what constitutes a high-risk lifestyleto correct unhealthful habits after the emergence of red-flag symptoms beforeirreversible damage has been done, such patients tend to have poor drug treatmentoutcomes.
Lifestyle changes for GERD recommended by the American College of Gastroenterology,in 2013, and the Chinese Medical Association Digestive Diseases Branch, in 2014,include weight loss, head-of-bed elevation, cessation of smoking and frequentalcohol use, avoidance of meals 2–3 h before bedtime, and reduced intake of coffee,chocolate, spices, acidic foods, and high-fat foods. The lifestyle interventionsmentioned in the guide, however, are quite limited.
GERD may progress from reflux esophagitis to Barrett’s esophagus (precancerousesophageal adenocarcinoma lesions), and, ultimately, to esophageal adenocarcinoma, agravely serious outcome of GERD comorbidity with esophageal injury syndrome. In ourprior investigation of 103 patients with esophageal cancer, we found that manypatients with esophageal cancer had habits such as eating quickly, eating until veryfull, and consuming very hot foods, that are not addressed in GERD lifestyleintervention therapy guidance.
Few large-scale studies have examined lifestyle influences on GERD in China, andresearch related to eating quickly, eating beyond fullness, and eating hot foods,particularly, is quite limited. In the present study, we sought to examine which ofthese habits may be responsible for GERD pathogenesis. Toward this aim, we analyzedlifestyle questionnaires from GERD patients from six hospitals in China relative toGERD onset and aggravation.
Materials and methods
Participants
From August 2015 to August 2017, patients with upper gastrointestinal symptomsattending digestive clinics at six hospitals (the Third Xiangya Hospital ofCentral South University, the General Hospital of Chinese People’s LiberationArmy, the People’s Hospital of Wuhan University, the Second Affiliated Hospitalof Nanjing Medical University, the People’s Hospital of Jilin Province, and ArmyGeneral Hospital) were invited to complete a questionnaire. This study wasapproved by the Third Xiangya Hospital Ethics Committee of Central SouthUniversity (approval number 2018-S384). Written informed consent forms wereobtained from all participants before questionnaire disbursem*nt. All of ourGERD group patients’ symptoms were treated with a standard proton pump inhibitor(PPI). All of these patients were advised to correct bad lifestyle habits.
Inclusion criteria
The GERD case group inclusion criteria could be met in two ways: presentationwith typical clinical GERD manifestations (i.e. nausea, acid regurgitation,and heartburn), a total score ⩾12 on the reflux diagnostic questionnaireused for initial GERD diagnosis, and a positive PPI test; orendoscopic/imaging demonstration of esophageal disease, an erosive esophagusinflammation diagnosis, or a Barrett’s esophagus diagnosis. Patients meetingeither one of these two criteria sets were eligible for enrollment.
The control group inclusion criteria sets were as follows: an absence ofGERD-typical symptoms (nausea, acid reflux, heartburn, and substernal pain),a total score <12 on the reflux diagnostic questionnaire used for initialGERD diagnosis; and endoscopic- or imaging-based ruling out of the aforementioned esophageal disease manifestations. To be selected as controls,subjects were required to meet both criteria sets.
Exclusion criteria
The exclusion criteria for the GERD case group were gastrointestinal relatedorganic lesions (including esophageal hiatal hernia); surgery within 1 yearbefore being diagnosed with GERD; diagnosis with diffuse esophageal fistulaor achalasia, and suspected malignancy; inability to complete 2 weeks oftreatment and follow up; major mental illness or communication disorder; andserious comorbidity. The exclusion criteria for the control group werediagnosis with a disease or major mental illness.
Study design
Outpatients completed questionnaires independently. We conducted diagnostic PPItreatments in all enrolled patients. GERD patients were selected according toclinical symptom score, endoscopy findings, and PPI test results. Therelationships between GERD incidence and habits were analyzed.
Questionnaires
The survey included four Simplified Chinese Questionnaires: a demographicquestionnaire (name, gender, age, occupation, height, weight, contactinformation); a reflux disease questionnaire (RDQ) to assess typical GERDsymptoms; a query for gastroscope/imaging findings; and a lifestylequestionnaire.
RDQ structure and scoring
The RDQ was used to collect detailed information about GERD symptoms,including reflux, acid regurgitation, heartburn, and substernal pain in thepast 4 weeks,1 as well as information regarding symptom frequency and severity,classified according to intrinsic scoring criteria.17 Prior studies have demonstrated the utility of the RDQ in GERDdiagnosis.17,18 In the RDQ, frequency of the symptoms of nausea,acid regurgitation, heartburn, and substernal pain were graded as: never = 0points; <1 day/week = 1 point; 1 day/week = 2 points; 2–3 day/week = 3points; 4–5 day/week = 4 points, and 6–7 day/week = 5 points. Severity ofthese symptom categories were graded as follows: not present = 0 points; notobvious/subtle = 1 point; mild (degree of symptoms intermediate between 1point and 3 points) = 2 points; severe enough to sometimes affect daily lifeand requires medication occasionally = 3 points; moderately severe (degreeof symptoms intermediate between 3 points and 5 points); very severe,affecting daily life markedly and requiring medication regularly = 5 points.RDQ frequency and severity subscores each ranged from 0 (none of thesymptoms experienced) to 20 (maximal frequency or severity of all fourcategories), with a maximal combined score of 40 (sum of frequency andseverity scores) and higher scores indicating a more severe presentation.The common RDQ screening GERD cut-off of 12 points was adopted.
Assessment of lifestyle and eating habits
The lifestyle questionnaire included 19 items assessing the following habits:smoking, alcohol drinking, fast eating, eating beyond fullness, lying downsoon after eating, eating shortly before bedtime, difficulty withdefecation, sleep difficulties, feeling stress continually, wearing girdlesor corsets, and consumption of very hot substances, strong teas, and coffee,as well as preferences for drinking soup, spicy foods, high-fat foods,acidic foods, sweets, and hard/solid foods. A regular smoker was defined asa person who smokes ⩾1 cigarette/day, for 6 months continuously orcumulatively, in accordance with World Health Organization (WHO) standards.A drinker was defined as a person with a daily alcohol consumption level of>25 g for men or >15 g for women, for 6 months continuously orcumulatively, in accordance with the recommendations of the Chinese Ministryof Health. Dietary habits were assessed with 11 items (definingclarifications in parentheses): fast eating (<10 min per meal and chewing<10 times per bite); eating beyond fullness (continuing to eat beyond asensation of fullness until unable to eat any more); eating too-hot foods(>60°C); preference for drinking soup; preference for spicy foods;preference for high-fat food (e.g. chocolates, fried foods, animal offal);preference for acidic foods (e.g. citrus fruits and acidic drinks);preference for sweets (e.g. cream, cake, chocolate); preference for hardfoods (e.g. walnuts, peanuts); preference for strong teas (>3 g of tea);and preference for coffee drinking. Lifestyle habits were assessed with thefollowing six items: lying down soon after eating (<30 min); eating justbefore bedtime (within 2 h); difficulty defecating (inability or timeconsuming); sleep difficulties (insufficient sleep sleepwalking, nightterrors, nightmares, etc.); anxiety (e.g. irritability, panic); and wearinggirdles or corsets. Preference was defined as engaging in the habit>3 day/week, continuously or cumulatively for 6 months.
PPI test
Participants received a standard diagnostic oral PPI test in which they tookesomeprazole (20 mg) or lansoprazole (30 mg) enteric-coated tablets twice perday for 2 weeks. No other drugs were taken during the treatment. Subsequently,patients were followed up in an outpatient clinic or telephone appointment, andcompleted the RDQ again. The PPI test was considered positive (supporting a GERDdiagnosis) if the symptom score was reduced by >80% versuspretreatment.
Follow up and efficacy
We performed regular telephone follow up (half-month, 1 month, 3 months, and 6months after commencing treatment). At each follow up, the patients recompletedthe RDQ and were asked about whether they had made favorable lifestyle changes.The half-month follow-up results were used to judge PPI test results. Patientswho followed all recommended habit changes formed the observation subgroup;those who followed some or none of the recommendations formed the lifestylecontrol subgroup. We compared pretreatment versus 6-monthfollow-up RDQ scores. If the total score decreased by >80%, 50–80%, or<50%, the intervention was considered substantially effective, moderatelyeffective, or invalid, respectively. The total effective rate was the sum of theeffective and moderately effective rates.
Statistical analysis
Quantitative data were compared across groups with t-tests. TheWald test was used for univariate analysis. Significant factors from theunivariate analysis were included in a multivariate logistic regression analysis(method: Enter). Odds ratios (ORs) and 95% confidence intervals (CIs) werecalculated by logistic regression. Our sample was derived from thegrade/frequency table data of two-independent samples, so the relationshipbetween outcomes and habit revision was analyzed by variance and theMann–Whitney rank sum test. p < 0.05 was consideredsignificant. SPSS 20.0 were used for the analysis.
Results
Characteristics of study subjects
Enrollment and group designation are summarized in Figure 1. The size, gender ratio, and agecharacteristics of the GERD case group and non-GERD control group are reportedin Table 1. The agesof patients in both groups have a normal distribution.
Study recruitment flowchart.
Of 2113 potential participants, 832 met the GERD case group criteria.Among them, 449 had an RDQ score ⩾12 and a positive PPI test, and 383had a positive esophageal endoscopy. The non-GERD group included 686patients with RDQ scores <12 and negative esophageal endoscopy.Patients with data analysis difficulties due to data loss or incompletedata were excluded.
GERD, gastroesophageal reflux disease; PPI, proton pump inhibitor; RDQ,reflux disease questionnaire.
Table 1.
Baseline demographic characteristics of GERD and non-GERD groups.
| Baseline characteristics | GERD (n = 832) | Non-GERD (n = 686) |
|---|---|---|
| Age, years | ||
| Mean (standard deviation) | 48.51 (13.22) | 47.45 (14.86) |
| Range | 17–86 | 15–84 |
| Gender, n (%) | ||
| Male | 455 (54.69) | 302 (44.02) |
| Female | 377 (45.31) | 384 (55.98) |
GERD, gastroesophageal reflux disease.
GERD-correlated factors
The composition ratio analysis results for GERD-correlated factors are reportedin Table 2. Eatingtoo fast and eating beyond fullness were habits shared by majority of the GERDpatient group. Eating foods hotter than 60°C was also common.
Table 2.
Number and composition ratio of lifestyle habit factors by group.
| Lifestyle factors | GERD | Non-GERD | ||
|---|---|---|---|---|
| n | Composition ratio, % | n | Composition ratio, % | |
| Fast eating | 663 | 79.7 | 244 | 35.6 |
| Eating beyond fullness | 568 | 68.3 | 190 | 27.7 |
| Preference for spicy foods | 509 | 61.2 | 28 | 42.0 |
| Preference for soup | 437 | 52.5 | 312 | 45.5 |
| Preference for sweets | 435 | 52.3 | 270 | 39.4 |
| Chronic stress | 431 | 51.8 | 280 | 40.8 |
| Preference for high-fat foods | 418 | 50.2 | 170 | 24.8 |
| Eating too-hot food | 371 | 44.6 | 148 | 21.6 |
| Sleep difficulty | 334 | 40.1 | 218 | 31.8 |
| Lying down soon after eating | 316 | 38.0 | 144 | 21.0 |
| Preference for hard foods | 294 | 35.3 | 112 | 16.3 |
| Smoking | 289 | 34.7 | 122 | 17.8 |
| Preferring spicy food | 287 | 34.5 | 124 | 18.1 |
| Drinking alcohol | 235 | 28.2 | 98 | 14.3 |
| Drinking strong tea | 232 | 27.9 | 82 | 12.0 |
| Eating just before bedtime | 209 | 25.1 | 132 | 19.2 |
| Difficulty with defecation | 170 | 20.4 | 92 | 13.4 |
| Wearing girdles or corsets | 156 | 18.8 | 40 | 5.8 |
| Drinking coffee | 113 | 13.6 | 36 | 5.2 |
GERD, gastroesophageal reflux disease.
Univariate analysis with Chi-square tests indicated that the demographic factorsof being male and having a BMI >24 (Table 3) as well as 18 lifestyle habits(smoking, drinking, fast eating, eating beyond fullness, eating food too hot,preference for drinking soup, preference for spicy foods, preference forhigh-fat foods, preference for acidic foods, preference for sweets, preferencefor hard foods, preference for strong tea, preference for coffee, lying downsoon after eating, eating just before bedtime, difficulty with defecation, sleepdifficulties, feeling stress continually, and wearing girdles or corsets; Table 4) wereassociated with the presence of GERD symptoms. As reported in Figure 2, logisticregression analysis of risk factors reported being related to GERD in theunivariate analysis implicated the following habits as risk factors (more toless robust): fast eating, eating beyond fullness, wearing girdles or corsets,eating food too hot, BMI above normal, lying down soon after eating, andsmoking.
Table 3.
Univariate analysis of GERD-related demographic risk factors.
| Factor | Number in group | χ2 | p | |
|---|---|---|---|---|
| GERD | Non-GERD | |||
| Gender | 17.11 | <0.001 | ||
| Female | 455 | 302 | ||
| Male | 377 | 384 | ||
| Age | 1.11 | 0.290 | ||
| <60 years (young/middle-aged adult) | 631 | 536 | ||
| ⩾60 years (elderly) | 201 | 150 | ||
| BMI | 35.15 | <0.001 | ||
| ⩽23.9 (normal) | 477 | 494 | ||
| ⩾24 (overweight/obese) | 355 | 192 | ||
Highly significant p values are shown in bold.
GERD, gastroesophageal reflux disease.
Table 4.
Univariate analysis of lifestyle risk factors for GERD.
| Lifestyle factor | Number in group | |||||
|---|---|---|---|---|---|---|
| GERD | Non-GERD | χ2 | p | |||
| No | Yes | No | Yes | |||
| Smoking | 543 | 289 | 564 | 122 | 54.72 | <0.001 |
| Drinking | 597 | 235 | 588 | 98 | 42.79 | <0.001*** |
| Fast eating | 169 | 663 | 442 | 244 | 304.31 | <0.001*** |
| Eating beyond fullness | 264 | 568 | 496 | 190 | 247.57 | <0.001*** |
| Eating too-hot food | 461 | 371 | 538 | 148 | 88.53 | <0.001*** |
| Preference for soup | 395 | 437 | 374 | 312 | 7.46 | 0.006** |
| Preference for spicy food | 322 | 509 | 398 | 288 | 56.79 | <0.001*** |
| Preference for high-fat foods | 412 | 418 | 516 | 170 | 105.19 | <0.001*** |
| Preference for acid food | 544 | 287 | 562 | 124 | 52.38 | <0.001*** |
| Preference for sweets | 396 | 435 | 416 | 270 | 26.31 | <0.001*** |
| Preference for hard food | 537 | 294 | 574 | 112 | 70.43 | <0.001*** |
| Preference for strong tea | 600 | 232 | 604 | 604 | 58.17 | <0.001*** |
| Preference for coffee | 719 | 113 | 650 | 36 | 29.5 | <0.001*** |
| Lying down soon after eating | 516 | 316 | 542 | 144 | 51.39 | <0.001*** |
| Eating just before bedtime | 23 | 209 | 554 | 132 | 7.46 | 0.006** |
| Difficulty defecating | 662 | 170 | 594 | 2 | 12.98 | <0.001*** |
| Sleep difficulties | 498 | 334 | 468 | 218 | 11.37 | 0.001** |
| Feeling stress continually | 401 | 431 | 406 | 280 | 18.23 | <0.001*** |
| Wearing girdles or corsets | 676 | 156 | 646 | 40 | 55.81 | <0.001*** |
Significance levels: *p < 0.05,**p < 0 .01, ***p < 0.001.
GERD, gastroesophageal reflux disease.
Treatment efficacy
Of 832 patients, 699 completed the 6-month follow up, yielding a successfulfollow-up rate of 84.01%; 133 people were lost to follow up, primarily due topersonal factors and contact information changes. All patients with GERD weretreated with standardized drug therapy (PPI test) and guided to correct badhabits. Of the 699 patients in the GERD group who were followed up successfullyfor 6 months, 326 (46.6%) experienced significant efficiency and 332 (44.5%)experienced marginal efficacy, yielding a total effective rate of 658/699(94.1%). The lifestyle observation subgroup (patients who heeded all lifestylerecommendations) included 464 GERD patients, a majority of whom (264/464; 56.9%)had substantial treatment efficacy. Many patients in the observation subgroup(192/464; 41.4%) had moderate treatment efficacy, while relatively few (8/464;1.7%) had invalid treatment outcomes. The fully followed-up lifestyle controlsubgroup (patients who maintained some bad habits), included 235 GERD patients,only about a quarter of whom (62/235; 26.4%) had substantial treatment efficacy.A majority of the control subgroup patients (140/235; 59.6%) had moderatetreatment efficacy, while the remainder (33/235; 14.0%) had invalid treatmentoutcomes. Mann–Whitney rank sum test results indicated that the lifestyleobservation subgroup patients had better relief after 6 months than those in thecontrol subgroup, with both subgroups receiving medication (Mann–WhitneyU = 35276.000, Z = –8.578, p < 0.001).The average ranks of the observation and control subgroups were 308.53 and431.89, respectively.
Discussion
In the present study, we demonstrated that the top lifestyle elements favoring GERDwere fast eating, eating beyond fullness, and preference for spicy food. Logisticmultiple regression analysis implicated fast eating, eating beyond fullness, wearinggirdles or corsets, eating too-hot foods, a BMI >24, lying down soon aftereating, and smoking as contributors to GERD symptoms. Mann–Whitney rank sum testsindicated that medication was more effective for GERD symptom alleviation whencombined with lifestyle interventions, which is consistent with the results ofseveral studies involving lifestyle interventions in GERD. For instance, EivindNess-Jensen’s studies suggested that weight loss and tobacco smoking cessation couldbe great recommendations, and avoiding late evening meals decreased time of supineacid exposure.19 The American College of Gastroenterology (ACG) guideline (2013) alsorecommended weight loss for GERD patients with overweight or recent weight gain.20 Concerning dietary patterns, predominantly Mediterranean (frequentconsumption of composite/traditional dishes, fresh fruit and vegetables, olive oil,and fish) was reported as having a beneficial effect in the occurrence of GERDversus largely non-Mediterranean (frequent consumption of redmeat, fried food, sweets, and junk/fast food).21 However, few studies on dietary habits in the literature including eating,eating beyond fullness and eating too-hot foods, which are subjective indicatorsneeding objective definition and a large number of RCTs. Lower GERD incidence infemales may be relevant to estrogen inactivating inflammatory cells, therebydelaying GERD progression.22 Although GERD incidence has been reported to raise with age,23 GERD prevalence did not differ between our young/middle-aged adults andelderly adults.
GERD appears to have a multifactorial etiology,24 and it has been supposed that poor dietary habits and lifestyle factors mayinduce or aggravate GERD symptoms. The recent growth in GERD among young adult andmiddle-aged Chinese people is thought to have something to do with dietary changes,acceleration in the pace of work expected, and chronic stress. Epidemiologicalstudies have pointed to an association between a high BMI and GERD.25 GERD in overweight people may be relevant to gastric overfilling, which canloosen the lower esophageal sphincter (LES) and cause hiatal hernia.
Our findings that GERD symptoms were interlocked with cigarette smoking, drinking ofalcohol, consumption of spicy, fatty, acidic, sweet, and hard foods are consistentwith physiological studies26–28 showingreduced esophageal pressure, accelerated gastric peristalsis, augmented secretion,delayed mucosal nerve-stimulated gastric emptying, augmented esophageal acidexposure, and aggrandized inflammation in relation to these food habits. Ourdiscoveries of a connection between strong tea drinking and GERD stay in alignmentwith some other studies involving Chinese subjects,29 though others have failed to find drinking of strong tea to be a significantrisk factor for GERD.30 Theophylline, a major component of tea, can ease LES31 and alleviate visceral discomfort.32 The inconsistency of results with respect to tea drinking may be related todifferences in tea type, production/processing, and additives, as well as culturaldifferences related to tea consumption.
Keeping in step with the present study’s insights into the link between coffeedrinking and GERD symptoms, the results of a double-blind crossover study pointed toan association between coffee intake and GERD reflux.33 Conversely, the results of a single-oval twin study suggested that coffee mayreduce the occurrence of GERD.34 A meta-analysis did not confirm a relationship between coffee intake and GERD.35 It is our view that coffee may increase gastric acid secretion by encouraginggastrin excretion, thereby promoting transient LES looseness, which may contributeto the development of GERD by delaying gastric emptying.36
The most striking findings in our research were related to three factors: fasteating, eating beyond fullness, and eating very hot foods. Research on these threefactors is quite limited at present. Regarding the reasons that these behaviors mayinduce or aggravate the onset of GERD, it may be that swallowing large, rough bolisubjected to limited chewing due to fast eating can do damage to the esophagealmucous membranes. Meanwhile, eating too fast also leads to the consumption of verylarge volumes, which can produce gastric pressure while irritating hydrochloric acidin gastric juice production and lessening LES rigidity and gastrointestinalmotility. Because the gastric emptying rate is limited physiologically, mechanicaland physiological factors induce an extended delay in the gastric emptying of alarge food volume and may increase the risk of gastric contents spilling into theesophagus, promoting or aggravating the occurrence of GERD. Moreover, eatingexcessive amounts leads to overfullness, and, in the long term, obesity, whichcombines with multiple risk factors to accelerate disease progression. Very hotfoods can destroy the esophageal mucosal defence directly. Our findings of anassociation between a preference for soup and GERD may reflect the combined effectsof eating quickly and eating very hot food. There is also a danger that people mayadd soup to a meal that was already calorically sufficient, leading to weight gain,which itself favors GERD.
The linkage of GERD with difficulty defecating and wearing tight girdles or corsetsmay be related to abdominal pressure. Refraining from lying down or going to bedshortly after eating and sleeping with the head elevated are key lifestyleinterventions for GERD. The interconnection between sleep duration and GERD appearsto be bidirectional,37 and sleep can lead to esophageal hyperalgesia.38 Hence, GERD patients will be prone to have difficulty falling and stayingasleep if they are suffering from frequent reflux symptoms, and poor sleep canpromote reflux, forming a vicious circle. GERD symptoms have been linked withpsychosocial characteristics, such as obsessive-compulsive, interpersonalsensitivity, and phobias.39
In the treatment, we found that compared with patients without lifestyleinterventions, GERD patients with lifestyle interventions had a significantly higherremission rate of symptoms under the same PPI treatment conditions. In anotherstudy, a prospective population-based cohort study demonstrated that decrease in BMIwas dose-dependence linked to a reduction of gastroesophageal reflux symptoms, butalso an increased chance of losing reflux symptoms with PPI treatment in the generalpopulation (OR 1.98, 95% CI 1.45–2.72 with >3.5 units decrease in BMI and no orless than weekly medication compared with OR 3.96, 95% CI 2.03–7.65 with >3.5units decrease in BMI and at least weekly medication),40 which is consistent with the findings of our research. A HUNT study reportedthat there was only an association between tobacco smoking cessation andgastroesophageal reflux symptoms status among individuals with severe refluxsymptoms (adjusted OR 1.78; 95% CI: 1.07–2.97) of normal BMI (OR 5.67; 95% CI:1.36–23.64) using anti-reflux medication at least weekly rather than otherindividuals with gastroesophageal reflux symptoms,41 suggesting that lifestyle interventions lead to a superposition effect. Drugsmay temporarily inhibit acid reflux, but the effects of bad habits on the diseaseare persistent and serious, so that the accumulation of bad living habits reducesthe efficiency of drug treatment in GERD patients, and even accelerates the progressof the disease, as said ‘A spark can start a prairie fire’. To sum up, theefficiency of treatment can be significantly improved with the combination ofmedication and lifestyle interventions.
In conclusion, risk factors for GERD include fast eating, eating beyond fullness,wearing girdles or corsets, eating too-hot food, a BMI above the normal range, lyingdown soon after eating, and smoking. Lifestyle changes that address these factors,especially fast eating, eating beyond fullness, and eating too-hot food, which arerarely studied or discussed despite being common, may improve GERD management andtreatment outcomes. It is important to gain a holistic impression of symptoms andtheir impact on quality of life because GERD diagnoses may be missed in patients whoare suffering from symptoms in the absence of endoscopic signs of disease.
Acknowledgments
The authors acknowledge Dr. Xiao Shi from the Third Xiangya Hospital, Central SouthUniversity, China for revising the manuscript.
Footnotes
Contributed by
Author contributions: LZY wrote the paper; PY corrected and revised the text; GSW, SYT, GMH, LZQ, andYJ collected and analyzed data; FW designed the research, contributed to surveydesign, and conducted statistical analysis of the data. All authors contributedintellectually to the writing process and approved the final version of themanuscript.
Funding: The author(s) disclosed receipt of the following financial support for theresearch, authorship, and publication of this article: The present study wassupported by the National Key Research and Development Program of China (No.2016YFC1201800), the National Natural Science Foundation of China (No.81670509), and the New Xiangya Talent Projects of the Third Xiangya Hospital ofCentral South University (No. 20180304).
Conflict of interest statement: The author(s) received no financial support for the research, authorship, and/orpublication of this article.
ORCID iD: Ling-Zhi Yuan 
https://orcid.org/0000-0001-5004-494X
Contributor Information
Ling-Zhi Yuan, Department of Gastroenterology, The ThirdXiangya Hospital, Central South University, Changsha, Hunan, China. Hunan Key Laboratory of NonresolvingInflammation and Cancer, Central South University, Changsha, China.
Ping Yi, Department of Gastroenterology, The ThirdXiangya Hospital, Central South University, Changsha, Hunan, China. Hunan Key Laboratory of NonresolvingInflammation and Cancer, Central South University, Changsha, China.
Gang-Shi Wang, Department of Gastroenterology, The GeneralHospital of Chinese People’s Liberation Army, Beijing, China.
Shi-Yun Tan, Department of Gastroenterology, The People’sHospital of Wuhan University, Hubei, China.
Guang-Ming Huang, Department of Gastroenterology, The SecondAffiliated Hospital of Nanjing Medical University, Jiangsu, China.
Ling-Zhi Qi, Department of Gastroenterology, The People’sHospital of Jilin Province, Changchun, China.
Yan Jia, Department of Gastroenterology, Army GeneralHospital, Beijing, China.
Fen Wang, Department of Gastroenterology, The ThirdXiangya Hospital of Central South University, 138 Tongzipo Road, Changsha410013, Hunan, China. Hunan Key Laboratory of NonresolvingInflammation and Cancer, Central South University, Changsha, China.
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