Association between dinner-to-bed time and gastro-esophageal reflux disease.
ABSTRACT It is generally recommended that patients with gastro-esophageal reflux disease (GERD) refrain from eating within 3 h of going to sleep. In addition to a remarkable lack of supporting clinical evidence, whether GERD patients have shorter dinner-to-bed time is unknown. This study was designed to determine a possible association between dinner-to-bed time and GERD, compared with healthy adults.
In a matched case-control study, we enrolled 147 GERD patients, and age- and sex-matched 294 controls without GERD symptoms such as heartburn and acid regurgitation during the previous year. Dinner-to-bed time, defined as the time intervals until going to bed after finishing eating dinner, was examined by a self-report questionnaire. Logistic regression was used to calculate odds ratio (OR) and 95% confidence intervals (CI) for GERD.
After adjustment for smoking habits, drinking habits, and body mass index, shorter dinner-to-bed time was significantly associated with an increased OR of GERD (p < 0.0001) and the OR for patients whose dinner-to-bed time was less than 3 h was 7.45 (95% CI 3.38-16.4) compared with patients whose dinner-to-bed time was 4 h or more. These observations were consistent in both patients with non-erosive GERD and erosive esophagitis, and there was no significant difference in dinner-to-bed time intervals between non-erosive GERD and erosive esophagitis.
In this matched case-control study, shorter dinner-to-bed time was significantly associated with an increased OR for GERD.
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ABSTRACT: Gastric cancer remains the second cause of cancer-related death worldwide. The aim of this study was to investigate the effects of shorter dinner-to-bed time, post-dinner walk, and obesity on gastric cardia adenocarcinoma (GCA) risk.Annals of Surgical Oncology 05/2014; · 3.94 Impact Factor
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ABSTRACT: Esophageal squamous cell carcinoma (ESCC) remains a significant cause of morbidity and mortality worldwide. The aim of the study was to investigate the effects of shorter dinner-to-bed time and post-dinner walk on ESCC risk. A matched case-control study with 232 ESCC patients and 286 age- and gender-matched healthy controls enrolled was conducted. Conditional logistic regression was used to calculated odds ratio (OR) and 95 % confidence intervals (95 % CI). The adjusted ORs of ESCC for subjects with shorter dinner-to-bed time (<3 h) were 2.84 (95 % CI 1.64-4.29), relative to those with longer dinner-to-bed time (≥4 h). While post-dinner walk was associated with a decreased ESCC risk (adjusted OR 0.64; 95 % CI 0.41-0.89). What's more, when reflux symptom was added into the multivariate models, risk estimate for shorter dinner-to-bed time still remained statistically significant (p = 0.003), and risk estimate for post-dinner walk changed slightly. In the subgroup analysis stratified by post-dinner walk, subjects with shorter dinner-to-bed time experienced similar risk (adjusted ORs 2.71 vs. 2.82). Shorter dinner-to-bed time is a potential risk factor for ESCC and post-dinner walk is a protective factor, providing evidence for the effect of lifestyle factors on ESCC risk.Journal of Cancer Research and Clinical Oncology 02/2014; 140(5). · 2.91 Impact Factor
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ABSTRACT: Nutrition can contribute to the development of gastroesophageal reflux disease (GERD). The relevant studies often provide contradictory results.Przegląd Gastroenterologiczny 01/2014; 9(5):297-301. · 0.38 Impact Factor
American Journal of Gastroenterology
C ?2005 by Am. Coll. of Gastroenterology
Published by Blackwell Publishing
Association Between Dinner-to-Bed Time
and Gastro-Esophageal Reflux Disease
Yasuhiro Fujiwara, M.D., Ph.D., Ai Machida, M.D., Ph.D., Yoko Watanabe, M.D., Ph.D.,
Masatsugu Shiba, M.D., Ph.D., Kazunari Tominaga, M.D., Ph.D., Toshio Watanabe, M.D., Ph.D., Nobuhide
Oshitani, M.D., Ph.D., Kazuhide Higuchi, M.D., Ph.D., and Tetsuo Arakawa, M.D., D.M.Sc., F.A.C.G.
Department of Gastroenterology, Osaka City University, Graduate School of Medicine, Osaka, Japan
OBJECTIVE:It is generally recommended that patients with gastro-esophageal reflux disease (GERD) refrain from
eating within 3 h of going to sleep. In addition to a remarkable lack of supporting clinical evidence,
whether GERD patients have shorter dinner-to-bed time is unknown. This study was designed to
determine a possible association between dinner-to-bed time and GERD, compared with healthy
METHODS: In a matched case-control study, we enrolled 147 GERD patients, and age- and sex-matched 294
controls without GERD symptoms such as heartburn and acid regurgitation during the previous year.
Dinner-to-bed time, defined as the time intervals until going to bed after finishing eating dinner, was
examined by a self-report questionnaire. Logistic regression was used to calculate odds ratio (OR) and
95% confidence intervals (CI) for GERD.
RESULTS:After adjustment for smoking habits, drinking habits, and body mass index, shorter dinner-to-bed
time was significantly associated with an increased OR of GERD (p < 0.0001) and the OR for patients
whose dinner-to-bed time was less than 3 h was 7.45 (95% CI 3.38–16.4) compared with patients
whose dinner-to-bed time was 4 h or more. These observations were consistent in both patients with
nonerosive GERD and erosive esophagitis, and there was no significant difference in dinner-to-bed
time intervals between nonerosive GERD and erosive esophagitis.
CONCLUSION: In this matched case-control study, shorter dinner-to-bed time was significantly associated with an
increased OR for GERD.
(Am J Gastroenterol 2005;100:2633–2636)
Gastro-esophageal reflux disease (GERD) is the most com-
mon gastrointestinal disease and includes nonerosive GERD
prevalence of GERD ranges from 10% to 48% in Western
countries (1) and 6.6% to 9.8 % in Japan (2, 3). Management
of GERD includes lifestyle modification, pharmacological
agents such as proton pump inhibitors, H2-blockers, proki-
netics and antacids, endoluminal techniques, and antireflux
Numerous lifestyle modifications have been advocated to
be important in GERD therapy. They include elevation of the
head of the bed, cessation of smoking, and avoidance of par-
ticular foods and/or alcoholic drinks, which provoke GERD
symptoms (4, 5). These lifestyle changes may be of varying
benefit to achieve satisfactory control of GERD symptoms,
yet, it is important to educate the patients about these in-
terventions because patients can then choose for themselves
how to integrate them into their treatment plan. In the text-
book (6) and the guidelines from the American College of
Gastroenterology (5), it is recommended that the patient re-
frain from eating within 3 h of going to sleep. In addition
to a remarkable lack of clinical data about the efficacy of
lifestyle modifications, whether patients with GERD have
shorter time intervals until going to bed after finishing eating
dinner is unknown. The present study was designed to ex-
amine a possible association between dinner-to-bed time and
GERD by a matched case-control study.
MATERIALS AND METHODS
Between 2002 and 2003, patients with GERD including
nonerosive GERD and erosive esophagitis at our depart-
ment were enrolled. Exclusion criteria were age over 70 yr,
coincidence of Barrett’s esophagus, peptic ulcer disease or
gastric surgery. All patients were examined by esophagogas-
troduodenoscopy and the presence of esophageal mucosal
break was assessed by the Los Angeles classification (7).
Nonerosive GERD was defined as the absence of mucosal
breaks in the esophageal mucosa although GERD symptoms
2634 Fujiwara et al.
such as heartburn and acid regurgitation were present at least
twice weekly. In this study, minimal changes were classified
as nonerosive GERD. For accurate diagnosis of nonerosive
GERD, patients who had received acid-suppressing drugs
weight, smoking habits, drinking habits, and dinner-to-bed
time were examined before treatment. A total of 147 subjects
(86 men and 61 women) completed the study. Their ages
ranged from 23 to 69 yr and the mean age was 54.5 yr. Age-
and sex-matched controls were recruited from healthy sub-
jects who visited Nagahori Clinic for checkup between July
2001 and December 2001. They were employees of several
population in Japan, and Japanese law requires all employers
to conduct annual health screening for all employees. In our
previous study (3), we had asked them the presence (and fre-
quency) or absence of GERD symptoms. We recruited 294
control subjects from 3,363 persons who had never experi-
enced GERD symptoms during the past 1 yr. All patients
and control subjects were asked to fill in a same self-report
questionnaire about dinner-to-bed time as follows: “Usually,
how long is the interval until going to bed after finishing eat-
ing dinner?” The protocol of the study was approved by the
Osaka City University Ethics Committee.
Finally, we collected detailed information on confounding
factors categorized as follows: body mass index (BMI) cal-
culated as body weight divided by the square of body height
in meters (kg/m2), smoking habits (current smokers or non-
smokers), alcohol-drinking habits (current drinkers or non-
compared using the χ2test. Differences in mean values be-
tween GERD and controls were compared using the paired
Student’s t-test. Dinner-to-bed time was divided into three
categories: less than 3 h, 3 h or more but less than 4 h, and 4
h or more. Conditional multiple logistic regression analysis
that accounts for the paired design was used to evaluate the
simultaneous effects of dinner-to-bed time, BMI, smoking
habits and drinking habits. Linear trends in risks were evalu-
ated by indicators for each categorical level of dinner-to-bed
time using the median value for each category. The p val-
ues less than 0.01 were considered to undertake statistically
using the SAS statistical software package (SAS Institute
Inc., Cary, NC, USA).
Among 147 subjects, 38 patients were given a diagnosis of
nonerosive GERD and 109 had erosive esophagitis: 53 grade
Angeles classification. Baseline characteristic of study sub-
jects are shown in Table 1. There was a significantly higher
percentage of smokers among patients with GERD while
Table 1. Baseline Characteristics of Study Subjects
(n = 147)
54.5 ± 10.3
23.6 ± 3.2
3.0 ± 1.6
(n = 294)
54.5 ± 10.3
23.2 ± 3.0
3.5 ± 1.2
Drinking habits (%)
Smoking habits (%)
Values are means ± standard deviation or frequency (%).
GERD patients and control subjects. Dinner-to-bed time in-
tervals in patients with GERD were significantly shorter than
in controls. The crude odds ratio (OR) and the multiple ad-
significantly associated with an increased OR of GERD (p <
0.0001). The OR for patients whose dinner-to-bed time was
less than 3 h was 7.45 (95% CI 3.38–16.4) compared with
Next, we analyzed to further clarify whether associa-
tion between dinner-to-bed time and GERD is consistent in
both subgroups of GERD (nonerosive GERD and erosive
bed time between nonerosive GERD and erosive esophagitis
(3.09 ± 1.43 hr in patients with nonerosive GERD versus
2.96 ± 1.67 hr in patients with erosive esophagitis, p =
0.6586). In a matched case-control study, shorter dinner-
to-bed time was significantly associated with an increased
OR of both nonerosive GERD and erosive esophagitis, and
the OR for patients whose dinner-to-bed time was less than
3 h was 5.86 (95% CI 1.52–22.6) in patients with nonerosive
esophagitis compared with patients with an interval of 4 h or
more in a multiple adjusted model.
Lifestyle factors have not been established as the domi-
nant factor of pathogenesis of GERD because of insufficient
Table 2. Odds Ratio of Gastro-Esophageal Reflux Disease Accord-
ing to Dinner-to-Bed Time Interval
OR (95% CI)
Bed Time (hr) Case Control
OR (95% CI)
1.22 (0.67–2.15) 1.51 (0.70–3.27)
4.30 (2.39–7.76) 7.45 (3.38–16.4)
∗Adjusted for body mass index, drinking habits, and smoking habits.
GERD and Dinner-to-Bed2635
tors (4). The present study is the first report to show a sig-
nificant association between GERD and shorter dinner-to-
bed time intervals. In another study concerning lifestyle and
eat more frequently before going to bed than controls, con-
ease, in association with significant serious nocturnal GERD
It is generally accepted that a full stomach produces gas-
tric distention, resulting in an increase in transient relaxation
of the lower esophageal sphincters, which is associated with
an increase in gastro-esophageal reflux (9). The frequency of
transient lower esophageal sphincter relaxation, however, is
of the association between GERD and shorter dinner-to-bed
time interval are unknown.
to-bed time between GERD patients and control, the preva-
lence of subjects whose dinner-to-bed time was less than 3 h
than in controls (63 of 294, 21.4%), reflecting a significantly
high OR of GERD for patients whose dinner-to-bed time
was less than 3 h. These findings had clinical significance
since they supported the guideline recommendation from the
American College of Gastroenterology. However, there was
a wide range of CI, possibly due to sample size.
Several studies (11–13) have shown clinical differences
between nonerosive GERD and erosive esophagitis. A pre-
vious study by the authors demonstrated that female gender,
low BMI, not smoking, and absence of hiatal hernia were
independently associated with nonerosive GERD compared
with erosive esophagitis (13). Although the present study
showed no difference in dinner-to-bed time between nonero-
sive GERD and erosive esophagitis, exact reasons are un-
known. Moreover, recent studies suggest that patients with
nonerosive GERD are a heterogeneous group with different
etiologies for their symptoms (14, 15). Since a definite clas-
sification and diagnostic criteria of nonerosive GERD have
not yet been established, association between dinner-to-bed
time and subgroups of nonerosive GERD should be clarified
and compare with those of erosive esophagitis in future.
Our study has some potential limitations. First, we ex-
cluded GERD patients aged over 70 yr because the lifestyle
of the elderly usually differs from that of the nonelderly. Sec-
ond, since our cases are patients who visited hospital to seek
medication, they may have had relatively serious problems
about GERD. Third, we chose persons without GERD symp-
toms as control to compare lifestyle of GERD patients with
endoscopic examinations, they might have included patients
with asymptomatic erosive esophagitis. Fourth, recall bias
might exist because of the intrinsic nature of the self-report
questionnaire study. Since we analyzed usual dinner-to-bed
GERD compared with control subjects by a matched case-
nighttime GERD symptoms occur especially when patients
we did not include several other variables such as family
history, use of drugs including nonsteroidal antiinflamma-
tory drugs and lower esophageal sphincter-relaxing drugs,
working hours, and diet intake. Especially, a recent study
demonstrated that high dietary fat intake was associated with
an increased risk of GERD symptoms while high fiber in-
take correlated with a reduced risk of GERD symptoms (16).
These factors should be included in future studies.
In conclusion, the present study is apparently the first to
provide evidence that a shorter dinner-to-bed time interval
is significantly associated with GERD. Since patients with
GERD are frequently led to believe that they should be able
to cure themselves by correction of an inappropriate lifestyle
(4), we should examine whether advising avoiding going to
bed within 3 h after eating dinner would reduce or improve
GERD symptoms, especially nighttime symptoms.
The authors thank Dr. Hideki Nishikawa, Nagahori Clinic,
for help of collection of the control subjects. The authors are
indebted to Prof. Patrick Barron of the International Medical
review of this manuscript. This study was supported, in part,
by a Grant-in-Aid for Scientific Research from the Ministry
of Education, Science and Culture in Japan.
Reprint requests and correspondence: Yasuhiro Fujiwara, M.D.,
Ph.D., Department of Gastroenterology, Osaka City University,
Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka
Received March 16, 2005; accepted August 15, 2005.
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