Constantly repeating yourself? Don’t let reflux disease give you the run around

Gastro-Oesophageal Reflux Disease (GORD) is one of the most common digestive disorders worldwide - and it's on the rise. The number of people living with GORD has increased by 18.1% in the last 30 years, prompting the question, why? ^{(1 - see references below)} Current speculation suggests that the increased availability of high fat foods and the rising rates of obesity play a part.

So, lets talk diet, what should and shouldn’t we be eating and what can we do to prevent acid reflux episodes.

What is acid reflux?

The terms acid reflux, heartburn and gastro-oesophageal reflux are often used interchangeably; in reality, they all have different meanings.

As acid reflux refers to the occasional, rather than persistent, regurgitation of stomach contents, we’ll be directing our focus towards the management of GORD in this article.

Symptoms

The typical symptoms of GORD are:

• Heartburn
• Regurgitation
• Non-burning Chest Pain

The following symptoms can occur when the upper parts of the wind-pipe and throat are exposed to stomach contents:

• Hoarse-voice
• Cough
• Sore throat

These are often referred to as signs of “silent reflux” because many of those affected do not experience any of the classic symptoms of heartburn or regurgitation ⁽³⁾.

Is it dangerous?

Most improve with lifestyle changes and medication, however if you have any of the following red-flag symptoms you should consult a GP:

• Difficulty swallowing
• Unintentional weight loss
• Black poo or vomiting blood
• Persistent vomiting
• Chest pain associated with exercise (not food)

What causes acid reflux?

The movement of food and air between the throat and stomach is regulated by a muscle barrier. It temporarily relaxes when we swallow, to allow food down, but normally tightens up to stop food and acid leaking back up into the throat. Whilst the exact causes of GORD remain unclear, those affected often have more muscle relaxations or a weaker muscle barrier. This means there are more opportunities for stomach contents to move up into the throat. For others, GORD may occur due to an increase in stomach acid production.

The diet and lifestyle factors outlined below are associated with GORD because of their impact on the muscle barrier and/or the production of acid.

• Weight

Weight alone can predict the risk of GORD. On a global scale, GORD is least common among those that are underweight and most common among those that are obese ⁽⁴⁾. This is because carrying additional fat around the abdomen increases stomach pressure, weaking the muscle barrier and allowing acid to be regurgitated.

Losing weight can be helpful.  81% report a reduction in symptoms after losing 10% of their body weight. It is not however a guaranteed solution, with some continuing to report symptoms despite losing 10kg or more ⁽⁵⁾. Despite conflicting evidence, national guidelines recognise the potential benefits of weight loss and advocate it for those that are overweight or obese wishing to manage symptoms.

• Smoking

Cigarette smoking reduces muscle barrier pressure and increases the time taken to clear acid from the throat. Not surprising, GORD is more common among current smokers than ex-smokers and non-smokers ⁽⁴⁾. The likelihood of developing GORD increases with the number of cigarettes smoked a day and the number of years spent smoking ⁽⁶⁾.

The effects on acid reflux are not long-lasting, with around 44% of those that quit reporting adequate symptom relief at one year compared to 18% of those that did not quit ⁽⁷⁾. Not all studies have come to the same conclusion; perhaps because the beneficial effects are countered by weight gain, which is common with smoking cessation.

• Diet

Whilst diet is often thought to be central in the development and management of GORD, the evidence is less convincing. The common triggers are outlined below.

• Fatty Food

Those with GORD tend to have higher daily intakes of fat, but is this relevant? High fat meals increase the frequency of reflux symptoms, whilst low fat meal do not. However, it is high calorie meals which cause stomach contents to be regurgitated. So whilst reducing intakes of fat may help symptoms, distributing calories evenly throughout the day is most important in minimising acid regurgitation ⁽⁸⁾.

• Spicy Foods

Spicy foods trigger heartburn in 88% of those with GORD ⁽⁹⁾. Perhaps because chilli peppers contain capsaicin; an irritant that causes a burning sensation upon contact. Almost all participants with GORD reported chest pain and heartburn when exposed directly to capsaicin ⁽¹⁰⁾. Interestingly, repeated exposure decreased symptoms, suggesting that eating spicy foods regularly improves tolerance ⁽¹¹⁾.  

• Fermentable Carbohydrates

Fermentable carbohydrates – widely known as FODMAPs – are found in a variety of fruits, vegetables, pulses, cereals and dairy products. They cannot be digested in the small bowel and so ferment in the large bowel. Trials have shown that fermentable carbohydrates, particularly those found in onion and garlic, induce relaxation of the muscle barrier, giving rise to more frequent reflux episodes.

The low FODMAP diet – designed to lower the intake of fermentable carbohydrate – reduces symptoms of both heartburn (68%) and acid regurgitation (61%) within the first eight weeks. Unfortunately, these benefits are not sustained once foods are reintroduced ⁽¹²⁾.

• Coffee

Both caffeinated and decaffeinated coffee exacerbate symptoms of GORD, whilst neither caffeinated nor decaffeinated tea do. This would suggest that there is a component in coffee (other than caffeine) that triggers symptoms. Whilst opting for decaffeinated alternatives alone may not improve symptoms, drinking coffee with meals – rather than during fasted periods – may help to prevent reflux episodes ⁽¹³⁾.

• Fizzy Drinks

High intakes of fizzy drinks have consistently been shown to worsen reflux symptoms. All fizzy drinks (including decaffeinated options and fizzy water) have been found to weaken the muscle barrier and therefore give rise to increased opportunity for acid regurgitation ⁽¹⁴⁾.

• Citrus Drinks

Intakes of citrus foods tend to be lower than average among those with severe and frequent GORD. It is unknown whether this is an intentional avoidance due to their effect on symptoms. Citrus foods are thought to be troublesome due to their acidity, although symptoms occur even when the acidity is neutralized ⁽¹⁴⁾.

• Alcoholic Drinks

Most researchers have concluded that alcohol, particularly in large quantities, increases the risk of reflux. However, GORD is no more common among moderate and heavy drinkers than light drinkers or those that do not drink ⁽⁴⁾. Perhaps it is the choice of drink which is of importance; beer and wine (red and white) increase stomach acid production, but spirits do not ⁽¹⁵⁾. Whilst the avoidance of alcohol may not improve symptoms or reduce acid exposure, swapping to spirits may be a better choice for those wishing to drink alcohol.

Are there foods which are good for acid reflux?

• Ginger

Ginger has been shown to speed up stomach emptying. This suggests it can reduce pressure on the muscle barrier and minimise the risk of acid regurgitation. It remains unclear as to whether this helps to manage GORD in practice and if so, the dose needed ⁽¹⁸⁾.

• Fibre

Those with GORD have habitually low intakes of fibre (around 6g a day). A study published in 2018 found that increasing fibre intake, in the form of three psyllium husk sachets a day, resulted in complete symptom resolution in 60% of those with reflux disease. More research is needed to support these findings ⁽¹⁹⁾.

• Stress

Stress alters our perception of symptoms, with reflux being regarded as more severe when under pressure ⁽¹⁶⁾. Using breathing exercises (30 minutes a day) can reduce acid exposure and the need for acid suppressing medication. Whilst acupuncture is more effective than doubling the dose of acid suppressing medication, making these psychological therapies particularly useful for that do not respond to medication ⁽¹⁷⁾. Please ask your GP what psychological therapies are available in your local area. Alternatively, self-help apps designed to manage stress are free to download via the NHS apps library.

How do I treat acid reflux?

To summarise the information above, the following may help to manage symptoms of GORD:

• Lose weight (if overweight or obese)
• Quit smoking
• Eat “little and often”
• Limit intake of fizzy drinks
• Manage stress

As much of the evidence remains limited and conflicting, the blanket exclusion of the common trigger foods outlined above is not recommended. It is advisable to take an individual approach; removing suspected trigger foods from the diet for a short period, before reintroducing to determine tolerance.

Remember: the lifestyle changes made must be sustained for the beneficial effects to last. 

Can a dietitian help with reflux disease?

A dietitian is a registered healthcare professional qualified to provide dietary advice for a range of clinical conditions, including reflux disease. They are trained to translate the most up-to-date scientific evidence into practical advice.

Your dietitian will ask about your history, including past medical history, medication history and relevant investigations and/or surgical procedures, as well as your current dietary and lifestyle habits. Using this information, they will create a care plan specific to you to aid in the management of your reflux. This may involve removing any suspected trigger foods from the diet for a short period of time.

If you think it would be beneficial to see a dietitian, please ask your GP to refer you to your local NHS Nutrition and Dietetics Service. Alternatively, if you would prefer to seek help privately, check out the British Dietetic Association Freelance Dietitians webpage to find a dietitian in your area.

Somerset NHS Foundation Trust have prepared a patient-friendly webinar on reflux disease and the dietary, lifestyle and medical interventions designed to manage it. 

• Medication

Proton Pump Inhibitor (PPI) medication, which reduces stomach acid production, is often prescribed as an initial course of treatment for those with GORD. If symptoms do not improve with this, another drug which reduces stomach acid production known as Histamine 2 Receptor Antagonist (H₂RA) medication, may be offered (20).

Antacid medication (such as Gaviscon, Pepto-bismol and Rennie) available over-the-counter may be taken during reflux episodes to neutralise acid and provide immediate relief.  

• Surgery

There is a surgical procedure – known as laparoscopic fundoplication – for those with confirmed GORD that either do not tolerate acid suppression medication or do not wish to take it long-term (20). It aims to recreate the muscle barrier at the base of the throat by wrapping the stomach around the lower part of the throat. This tighter barrier helps to prevent the upward movement of stomach contents.  

References

1. GBD 2017 Gastro-oesophageal Reflux Disease Collaborators. [2020]. ‘The global, regional and national burden of gastro-oesophageal reflux disease in 195 countries and territories, 1990 – 2017: a systematic analysis for the Global Burden of Disease Study 2017.’ Lancet Gastroenterol Hepatol. 5 (1) 561 – 581
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5. Singh, M., Lee. J., Gupta, N., Gaddam, S., Smith, BK., Wani, SB., Sullivan, DK., Rastogi, A., Bansal, A., Donnelly, JE. And Sharma, P. [2013]. ‘Weight loss can lead to resolution of gastroesophageal reflux disease symptoms: a prospective intervention trial.’ Obesity. 21 (2) 284 – 290
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9. Kaltenbach, T., Crockett, S. and Gerson, LB. [2006]. ‘Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach.’ Archives of Internal Medicine. 166 (9)965–971
10. Herrera-Lopez, JA., Mejia-Rivas, MA, Vargas-Vorackova, F. and Valdovinos-Diaz MA. [2010]. ‘Capsaicin induction of esophageal symptoms in different phenotypes of gastroesophageal reflux disease.’ Rev Gastroenterol Mex. 75 (4) 396-404.
11. Yi CH, Lei WY, Hung JS, Liu TT, Chen CL, Pace F. [2016]. ‘Influence of capsaicin infusion on secondary peristalsis in patients with gastroesophageal reflux disease.’ World J Gastroenterol. 22(45) 10045 -10052.
12. Seamark, L., Barclay, Y., Marchant, C., Williams, M. and Hickson, M. [2021]. ‘Long‐term symptom severity in people with irritable bowel syndrome following dietetic treatment in primary care: A service evaluation.’ J Hum Nutr Diet. Available at: https://doi.org/10.1111/jhn.12860
13. Boekema, PJ., Samsom, M. and Smout, AJ. [1999]. ‘Effect of coffee on gastro-oesophageal reflux in patients with reflux disease and healthy controls.’ Eur J Gastroenterol Hepatol. 11 (11) p. 1271 – 1276
14. Kubo, A., Block, G., Quesenberry, CP., Buffler, P. and Corley, DA. [2014]. ‘Dietary guideline adherence for gastroesophageal reflux disease.’ BMC Gastroenterology. 14 (144)
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16. Bradley, LA. Richter, JE., Pulliam, TJ., Haile, JM., Scarinci, IC., Schan, CA., Dalton, CB. And Salley, AN. [1993]. ‘The relationship between stress and symptoms of gastroesphageal reflux: the influence of psychological factors.’ Am J Gastroenterol. 88 (1) 11 – 19
17. Dossett, ML., Cohen, EM. and Cohen J. [2017]. ‘Integrative Medicine for Gastrointestinal Disease.’ Prim Care. 44 (2) 265 - 280.
18. Bodagh, MN., Maleki, I. and Hekmatdoost, A. [2018]. ‘Ginger in gastrointestinal disorders: A systematic review of clinical trials.’ Crit Rev Food Sci Nutr. 7 (1) 96 - 108
19. Morozov, S., Isakov, V. and Konovalova, M. [2018]. ‘Fibre-enriched diet helps to control symptoms and improves oesphageal motility in patients with non-erosive gastroesophageal reflux disease.’ World J Gastroenterol. 24 (21) p. 2291 – 2299
20. NICE. [2019]. ‘Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management.’ Available at: https://www.nice.org.uk/guidance/CG184/chapter/1-Recommendations#laparoscopic-fundoplication [Accessed 29 July 2021]