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Gastroesophageal reflux symptoms among Italian university students: Epidemiology and dietary correlates using automatically recorded transactions

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Background: Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorders worldwide, with relevant impact on the quality of life and health care costs.The aim of our study is to assess the prevalence of GERD based on self-reported symptoms among university students in central Italy. The secondary aim is to evaluate lifestyle correlates, particularly eating habits, in GERD students using automatically recorded transactions through cashiers at university canteen. Methods: A web-survey was created and launched through an app, ad-hoc developed for an interactive exchange of information with students, including anthropometric data and lifestyle habits. Moreover, the web-survey allowed users a self-diagnosis of GERD through a simple questionnaire. As regard eating habits, detailed collection of meals consumed, including number and type of dishes, were automatically recorded through cashiers at the university canteen equipped with an automatic registration system. Results: We collected 3012 questionnaires. A total of 792 students (26.2% of the respondents) reported typical GERD symptoms occurring at least weekly. Female sex was more prevalent than male sex. In the set of students with GERD, the percentage of smokers was higher, and our results showed that when BMI tends to higher values the percentage of students with GERD tends to increase. When evaluating correlates with diet, we found, among all users, a lower frequency of legumes choice in GERD students and, among frequent users, a lower frequency of choice of pasta and rice in GERD students. Discussion: The results of our study are in line with the values reported in the literature. Nowadays, GERD is a common problem in our communities, and can potentially lead to serious medical complications; the economic burden involved in the diagnostic and therapeutic management of the disease has a relevant impact on healthcare costs. Conclusions: To our knowledge, this is the first study evaluating the prevalence of typical GERD-related symptoms in a young population of University students in Italy. Considering the young age of enrolled subjects, our prevalence rate, relatively high compared to the usual estimates, could represent a further negative factor for the future economic sustainability of the healthcare system.
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Martinucci et al. BMC Gastroenterology (2018) 18:116
https://doi.org/10.1186/s12876-018-0832-9
RESEARCH ARTICLE Open Access
Gastroesophageal reflux symptoms
among Italian university students:
epidemiology and dietary correlates using
automatically recorded transactions
Irene Martinucci1* , Michela Natilli2,1, Valentina Lorenzoni4, Luca Pappalardo5,2 , Anna Monreale2,
Giuseppe Turchetti4, Dino Pedreschi2, Santino Marchi6, Roberto Barale3and Nicola de Bortoli6
Abstract
Background: Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorders
worldwide, with relevant impact on the quality of life and health care costs.The aim of our study is to assess the
prevalence of GERD based on self-reported symptoms among university students in central Italy. The secondary aim is
to evaluate lifestyle correlates, particularly eating habits, in GERD students using automatically recorded transactions
through cashiers at university canteen.
Methods: A web-survey was created and launched through an app, ad-hoc developed for an interactive exchange of
information with students, including anthropometric data and lifestyle habits. Moreover, the web-survey allowed
users a self-diagnosis of GERD through a simple questionnaire. As regard eating habits, detailed collection of meals
consumed, including number and type of dishes, were automatically recorded through cashiers at the university
canteen equipped with an automatic registration system.
Results: We collected 3012 questionnaires. A total of 792 students (26.2% of the respondents) reported typical GERD
symptoms occurring at least weekly. Female sex was more prevalent than male sex. In the set of students with GERD,
the percentage of smokers was higher, and our results showed that when BMI tends to higher values the percentage
of students with GERD tends to increase. When evaluating correlates with diet, we found, among all users, a lower
frequency of legumes choice in GERD students and, among frequent users, a lower frequency of choice of pasta and
rice in GERD students.
Discussion: The results of our study are in line with the values reported in the literature. Nowadays, GERD is a common
problem in our communities, and can potentially lead to serious medical complications; the economic burden
involved in the diagnostic and therapeutic management of the disease has a relevant impact on healthcare costs.
Conclusions: To our knowledge, this is the first study evaluating the prevalence of typical GERD–related symptoms
in a young population of University students in Italy. Considering the young age of enrolled subjects, our prevalence
rate, relatively high compared to the usual estimates, could represent a further negative factor for the future
economic sustainability of the healthcare system.
Keywords: Gastroesophageal reflux disease, GERD, Heartburn, Regurgitation, Diet, Prevalence, University students
*Correspondence: martinucci.irene@gmail.com
1Division of Gastroenterology–Versilia Hospital, Lido di Camaiore–Lucca, Italy
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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Martinucci et al. BMC Gastroenterology (2018) 18:116 Page 2 of 10
Background
Gastroesophageal reflux disease (GERD) is a chronic con-
dition which develops when the reflux of gastric contents
into the esophagus causes troublesome symptoms and/or
complications [1,2]. It is well known that a wide and vary-
ing range of symptoms is associated with GERD. The two
most typical symptoms are heartburn and regurgitation;
however, patients may complain also other symptoms
including chest pain, as well as extra esophageal manifes-
tations such as chronic cough, asthma, and laryngitis [1].
GERD is one of the most common gastrointestinal dis-
orders worldwide, with relevant impact on the quality of
life and health care costs [3]. According to population–
based studies, when defined as at least weekly heartburn
and/or regurgitation, prevalence estimates generally range
from 10 to 30% in Western populations, and only East Asia
shows estimates consistently lower than 10% [4]. In addi-
tion, it is worth noting that evidence suggests an increase
in disease prevalence since 1995 [47].
The etiology of GERD is largely unknown, and its
pathogenesis is multifactorial in nature, mainly involving
dysfunctions of the esophagogastric junction, ineffective
esophageal acid and bolus clearance, increased intra-
gastric pressure, and esophageal hypersensitivity [8,9].
Moreover, the main established risk factors of GERD are
heredity, obesity and tobacco smoking. Thus, according
to a recent systematic review and current guidelines, the
first step in GERD management consists of lifestyle inter-
ventions, such as weight loss, tobacco smoking cessation,
avoiding late evening meals and head–of–the–bed eleva-
tion [1013]. Along the same line, dietary modifications
have also been proposed as first–line therapy for patients
with GERD [14]. However, few and heterogeneous ran-
domized clinical trials and observational studies have
shown inconsistent or conflicting results about the puta-
tive role of specific dietary items in development of reflux
symptoms [10,15,16]. In this context, the effect of the
overall dietary pattern of a population on the risk of GERD
has been scarcely evaluated. Recently, a cross–sectional
study by Mone et al.[17] highlighted a beneficial effect of
a Mediterranean diet in the occurrence of GERD.
Based on the above considerations, the aim of our
study is to assess the prevalence of GERD based on self–
reported symptoms among university students in central
Italy. The secondary aim is to evaluate lifestyle corre-
lates, particularly eating habits, in GERD students using
data from a web survey and transactions automatically
recorded through cashiers at university canteen.
Methods
This work is part of a larger study aiming at studying
the nutritional habits of University of Pisa students and
the relation between these habits and gastrointestinal dis-
orders. The project consists of several phases covering
innovative aspects in terms of research and application of
the results.
Design and study population
In order to evaluate the correlation between eating habits
and gastrointestinal disturbances, a web–survey was cre-
ated and launched through an app, ad hoc developed for
an interactive exchange of information with students. Par-
ticipants were recruited among students of University of
Pisa and participation to the survey was voluntary. To
ensure adequate widespread of the project among the tar-
get population, information was diffused through various
means: the web portal of University of Pisa, the email
contactlistofUniversityofPisaandbrochuresintothe
canteen area. The students were informed that they would
have been notified on the results of their questionnaire
and that a number of dietary recommendations suitable
for any detected disorder would have been available. Stu-
dents can access the survey only through the university’s
personal credentials and all individuals who agreed to par-
ticipate gave an informed consent through the web–app.
The survey was built (in Java) on Liferay Community
Edition, a Content Management System (CMS) that can
create the succession of questions and possible answers
with images and scores.
The survey included both qualitative and quantitative
questions devoted to the collection of anthropometric
data and lifestyle habits of the student (i.e., height, weight,
smoking, coffee consumption), as well as possible gas-
trointestinal symptoms.
Data sources and data collection
To reach the project’s goals, three different sources of
data were used and merged to obtain the database for the
analysis:
i. data from the University administrative archive;
ii. data collected with a web–app that allows users a
self–diagnosis for the gastrointestinal disturbances
through a simple questionnaire;
iii. data on meals consumption provided by the regional
company that manages the University canteen.
The University archive, used to identify the overall stu-
dents enrolled in the academic year 2016–17, provides
demographic and academic career data for all students
enrolled.
For those students participating into the web–survey
and/or using the university canteen additional informa-
tion was added as detailed below.
The web questionnaire comprises specific sections
to investigate the presence of gastrointestinal disor-
ders, with particular reference to GERD, and a general
section devoted to the collection of demographic and
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Martinucci et al. BMC Gastroenterology (2018) 18:116 Page 3 of 10
anthropometric data (weight and height), daily coffee con-
sumption and the current smoking behavior.
Since one of the main attributes involved in the study is
the Body Mass Index (BMI), we calculated it as the weight
in kilograms divided by the square of the height in meters
(kg/m2), and, accordingly with WHO definition the class
where defined as show in Table 1. Questions on how many
cups of coffee were consumed by students and a question
in which we ask whether the student is a smoker or a non-
smoker were included.
Questions related to the assessment of the GERD were
formulated on the basis of a simplified version of a val-
idated questionnaire, the GERDq questionnaire, limiting
the questions only to typical reflux symptoms. [1,1820].
In the questionnaire, heartburn was defined as a burn-
ing sensation or pain behind the breast bone in the chest,
and regurgitation was defined as the perception of back-
flow of gastric content coming into the throat or mouth.
In particular, the frequency and the intensity of typical
GERD-related symptoms were evaluated with a Likert
scale and a visual analog scale (VAS).
The survey was launched on October 2016 and it is still
online. The data used for the present work cover a period
of 200 days, from the 21st of October 2016 to the 10th of
May 2017.
The “Azienda Regionale per il Diritto allo Studio Univer-
sitario” (DSU), a public corporation operating throughout
the Region in order to offer food services to students as
well as accommodation, grants or scholarships to the most
deserving ones, administered the three University can-
teens students. Thanks to the personal magnetic cards
used to access the canteen, the DSU owns a dedicated
database collecting, for each transaction (i.e. a meal),
information about date and hours, type of meal, student
ID and price applied. Number and type of dishes are
also automatically recorded for meals consumed in one
of the canteens equipped with an automatic system for
the detailed collection of meals consumed. That source of
data was used in the present analysis to extract records
about meal consumption for those students accessing the
canteen and participating into the web survey.
Table 1 The International Classification of adult underweight,
overweight and obesity according to BMI
Classification kg/m2
Underweight <18.50
Normal range 18.50 24.99
Overweight 25.00 29.99
Obesity class I 30.00 34.99
Obesity class II 35.00 39.99
Extreme obesity 40.00
Statistical analysis
A Heckman–type selection model [21]wasusedtoassess
the presence of selection bias in the sample of students
answering the survey, to determine whether the GERD
prevalence estimated among University students could
be obtained directly from the observed data, or whether
there is need of a correction for selection bias. Sample
selection occurs when the data at hand are not a ran-
dom sample from the population of interest. To deal with
that, Heckman—type selection models have been widely
used in economics and social science to evaluate whether
the mechanism determining the participation (selection)
into a survey is independent of the presence of the out-
come of interest. The selection model typically consists
in a bivariate regression comprising a selection equation,
which describes survey participation, and an outcome
equation, predicting the outcome of interest. The two
equations are linked through a correlation parameter, ρ,
representing the covariance between the outcome and the
participation conditional on observed covariates. A statis-
tically significant value of ρimplies a relation between the
process of participation into the study and the outcome,
thus providing evidence about the presence of selection
bias and hence the need to correct estimates coming from
the observed data. A negative estimate of ρmeans that
subjects in which the outcome is present are less prone to
participate, vice versa in case of a positive value.
A bivariate probit Heckman–type selection model was
used in the present analysis. Age and gender were used as
covariates in the selection equation, while, to comply with
exclusion restriction, only gender was used as covariate in
the outcome equation.
Different statistical analysis were performed: descriptive
statistics on the data collected, a study of the GERD preva-
lence and lifestyle correlates with both a monovariate and
a multivariate approach (logistic regression). The inde-
pendent variables used in the model are: Gender (Female),
a dummy variable that is equal to 1 when the student is a
female; Smoking habit (Smoker): dummy variable that is
equal to 1 when the student is a smoker; Number of coffee,
continuous variable; BMI Underweight, dummy variable;
BMI Overweight, dummy variable; BMI Obesity1,dummy
variable.
Eating habits of students were analysed and compared
based on food items automatically recorded from cashiers’
transactions at University canteens. All food was grouped
into 12 specific groups on the basis of the main dish and
thetypeofcooking:pastaandrice,soups,legumes,veg-
etablesandsalad,potatoes,meat,seafood,fruits,sweets,
fried food, sandwiches and pizza, pies and omelette.
The frequency of different food groups consumption was
described in terms of the number of times the specific
group is selected over the total number of accesses and
reported as percentage. The latter analysis was performed
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Martinucci et al. BMC Gastroenterology (2018) 18:116 Page 4 of 10
on all users and also on the subgroups of frequent users.
Frequent users were defines as those students accessing
the canteens at least 20 times in the year on the basis of the
75th percentile of the distribution of the number of yearly
accesses.
Continuous variables were described in terms of median
[25 75th percentile] and Mann-Whitney U test was
used to perform comparisons between groups. Categor-
ical variables are presented as number of subjects and
percentage and Fisher or χ2tests were used to compare
the distribution of variables between groups.
All analyses were performed using Python, STATA a nd
SPSS.
Results
During the 200 days the survey was online, 3012 question-
naires were collected, about 6.3% of the students enrolled
in the University of Pisa. In Table 2the details of the
respondents.
62.4% of the respondents (n=1,884) were females and
the remaining 37.6% (1,136) were males. The median age
of respondents was 23 years (with a standard deviation of
3.6 years and an interquartile range of 5 years). Table 3
shows the distribution of respondents by gender and Body
Mass Index (BMI): while the “Normal Weight” is the mode
of the distribution, we observe that males have a tendency
toward overweight, while females have a tendency toward
Table 2 Descriptive characteristics of the respondents to the
web-questionnaire
n%
Gender
Male 1136 37.6
Female 1884 62.4
BMI class
Underweight 300 9.9
Normalweight 2268 75.1
Overweight 366 12.1
Class I obesity 65 2.2
Class II obesity 15 0.5
Extreme obesity 6 0.2
Age by gender
FM
Median 24.0 24.0
Mean 26.7 25.9
Q1 22.0 22.0
Q3 27.0 27.0
IQR 5.0 5.0
Table 3 Respondent to the web-questionnaire by gender, BMI
and coffee consumption
F M Female (%) Male (%)
BMI class
Underweight 256 44 13.6 3.9
Normal weight 1422 846 75.5 74.5
Overweight 163 203 8.7 17.9
Class I obesity 33 32 1.8 2.8
Class II obesity 5 10 0.3 0.9
Extreme obesity 5 1 0.3 0.1
Number of coffee consumed
None 439 301 23.3 26.5
1–2 966 539 51.3 47.4
3–4 437 256 23.2 22.5
5 + 42 40 2.2 3.5
Smoking habits
Yes 370 226 19.6 19.9
No 1514 910 80.4 80.1
*P-value <0.05 for comparison between males and females distribution of the
variables
The original numerical variable “number of coffee” was categorized for descriptive
purposes
underweight (statistically significant differences, with P-
value <0.00001).
Regarding coffee consumption, there is a statistically
significant difference in the coffee consumption (see
Tabl e 3), with a higher number of coffees per day for
the female population (P-value=0.023). Furthermore we
observe that for both males and females almost 20% of
the students are smokers, with no statistically significant
differences among gender.
GERD prevalence and lifestyle correlates
Based on the available evidence and the bivariate probit
Heckman–type selection model specification, estimate of
ρwas not significantly different from zero (Table 4). This
means that the hypothesis of the absence of selection bias
could not be rejected, accordingly prevalence estimates
and correlates were derived directly from the observed
data.
Tabl e 5shows the distribution of students’ character-
istics and lifestyle habits according to the presence of
GERD. 792 students out of 3020 respondents (26.2%)
reported typical GERD symptoms occurring at least
weekly. In particular, heartburn and regurgitation were
reported by 47 and 53% of the students, respectively. As
reported in Fig. 1, most reflux symptoms which were
experienced only once a week were very mild in severity,
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Martinucci et al. BMC Gastroenterology (2018) 18:116 Page 5 of 10
Table 4 Estimates from the Heckman–type selection model
Coef. Std. Err. P-value 95% CI
Outcome model: Presence of GERD
Gender 0.255 0.051 <0.001 (-0.354;-0.156)
(cons) 1.302 0.448 0.004 (-2.180;-0.424)
Selection model: Survey Participation
Gender 0.222 0.018 <0.001 (-0.257;-0.187)
Age 0.012 0.002 <0.001 (-0.015;-0.009)
(cons) 0.878 0.047 <0.001 (-0.971;-0.786)
ρ0.582 0.316 (-0.263;0.922)
and the severity increases with the increase of the weekly
frequency of the symptoms.
Female students are more affected by the symptoms,
28.2% versus 22.9%, with this difference statistically signif-
icant (P-value=0.0014).
Furthermore, a cross tabulation between GERD and
BMI was performed. In Table 5the distribution of the two
variables.
Since the number of students in Class II obesity and
Extreme obesity are low they were merged in one cat-
egory to have a more precise idea of this distribution.
As expected, overweight and obese were more frequent
among GERD (P-value =0.030). On the other side, in
the set of students with GERD, the percentage of smokers
is higher than the percentage of students without GERD
(P-value <0.001), and also coffee consumption play an
Table 5 Prevalence of GERD by BMI class, Smoking habits and
number of coffee consumed
No GERD GERD
n%n%
BMI class
Underweight 216 9.7 84 10.6
Normal weight 1694 76.0 574 72.5
Overweight 265 11.9 101 12.8
Class I obesity 42 1.9 23 2.9
Class II obesity or more 11 0.5 10 1.3
Smoking habit
Non smoker 1827 82.0 597 75.3
Smoker 401 18.0 195 24.7
Number of coffee consumed
None 556 25.0 184 23.2
1–2 1131 50.8 374 47.2
3–4 483 21.7 210 26.5
5 or more 58 2.6 24 3.0
*P-value <0.05 for comparison in GERD prevalence among groups
important role in the prevalence of GERD (P-value =
0.036).
Same results can be drawn looking at the odds ratios
(Table 6) of these correlates: smoking habits and over-
weight/obesity have a positive impact on the GERD preva-
lence. Being a female student also seems to be related to
GERD prevalence. These conclusions are based on uni-
variate analysis, but for having a more informative results
a multivariate logistic regression analysis was performed
on the data with the aim of explaining the relationship
between the dependent binary variable (GERD) and all
possible independent variables together.
AsshowninTable6, the variables Gender(F),
Smoker(Yes) and BMI Class Obesity (aggregation of the
3 different levels of obesity) are highly statistically sig-
nificant: smokers are more likely to experience GERD
symptoms, such as female students. The students in the
Obesity class have an odd ratio greater than one, which
means that Obesity can be considered a determinant of
GERD symptoms. The coffee consumption seems to have
a positive impact on GERD presence.
Dietary pattern in GERD
Overall, 32.5% (980) of all respondents accessed at least
once of the University canteen in the academic year
2016–17, and about 13.1% (395) were frequent users. The
prevalence of GERD among the subgroup of respondents
accessing the canteen was 25.9%, not statistically differ-
ent from the value in the overall group of respondents
(p=0.882). Characteristics and lifestyle of overall users are
reported in Additional file 1:TableS1.
When evaluating food choices, among all users a lower
frequency of legumes choice was observed in GERD stu-
dents (P-value =0.002) while, when considering frequent
users we find a significant (P-value=0.034) lower fre-
quency of choice of pasta and rice in GERD students (see
Tabl e 7).
No differences among students with and without GERD
were found also when distinguishing male and female, or
by distinguishing students by BMI category (i.e., normal
weight and overweight/obese) (see Additional file 1:Table
S3-S5).
Discussion
This is the first study evaluating the prevalence of typ-
ical GERD-related symptoms in a young population of
University students in Italy. Our data show a prevalence
rate of weekly symptoms in 26.2% of the total respon-
dents. In a previous population-based study performed in
Italy, 700 employers in Pavia answered a physician inter-
view about typical GERD-related symptoms. The results
showed a prevalence of heartburn and regurgitation of
7.7 and 6.6%, respectively [22]. On the other hand, in
European population-based studies,the range of GERD
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Martinucci et al. BMC Gastroenterology (2018) 18:116 Page 6 of 10
Fig. 1 Intensity of heartburn and regurgitation symptoms by their frequency
prevalence estimates (defined as at least weekly heartburn
and/or regurgitation) was 8.8%–25.9% [5]. Since system-
atic reviews suggested that the prevalence of GERD is
increasing [4,5], the results of our study are in line
with the values reported in the literature. Nowadays,
GERD is a common problem in our communities, and
can potentially lead to serious medical complications (i.e.
Barrett’s esophagus, esophageal adenocarcinoma); more-
over,the economic burden involved in the diagnostic and
therapeutic management of the disease has a relevant
impact on healthcare costs. In this context, considering
the young age of enrolled subjects, our prevalence rate,
relatively high compared to the usual estimates, could rep-
resent a further negative factor for the future economic
sustainability of the healthcare system.
While to analyze GERD risk factors it was not the pri-
mary goal of this article, it is worth noting that female
sex was more prevalent than male sex. Moreover, in the
set of students with GERD the percentage of smokers
was higher. However, current evidence of associations
of GERD with sex or smoking habits are conflict-
ing and inconclusive. On the other hand, evidence
shows incontrovertibly a strong association between over-
weight/obesity and occurrence of GERD symptoms and
its complications, both analyzing data with a monovariate
approach or a multivariate approach,so that the global ris-
ing prevalence of GERD seems to be related to the rapidly
increasing prevalence of obesity, which has occurred in
the last few decades [2327]. Moreover, much evidence
indicates the effectiveness of weight reduction on symp-
tom relief, at least in GERD patients who are overweight
or obese [2830]. In line with these assumptions, our
results show that when BMI tends to higher values the
percentage of students with GERD tends to increase.
Our study has several limitations. First of all, the obser-
vational nature of the study and the groups included
Table 6 Odds ratio and confidence interval for lifestyle correlates with monovariate and multivariate analysis
Monovariate Multivariate
Conf. Interval Conf. Interval
Oddsratio [ 0.025 0.975] Sig. OddsRatio [ 0.025 0.975] Sig.
Gender(F) 1.45 1.19 1.77 0.00 1.52 1.24 1.87 0.00
Smoker(Yes) 1.71 1.35 2.17 0.00 1.6 1.25 2.05 0.00
Number of coffee 1.1 1.03 1.18 0.01 1.04 0.97 1.12 0.25
BMI Underweight 1 0.72 1.39 0.99 0.97 0.69 1.37 0.88
BMI Overweight 1.17 0.89 1.55 0.27 1.26 0.94 1.69 0.12
BMI Obesity 2.04 1.19 3.49 0.009 1.97 1.14 3.43 0.02
Intercept 0.23 0.000
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Table 7 Frequency (as percentage) of food group choice overall and by presence of GERD, among all users and the subgroup of
frequent users
All users
Overall (n=980) No GERD (n=726) GERD (n=254)
Sweets 0 [0-10.1] 0 [0-10.4] 0 [0-10]
Fruits 40 [10.1-73.3] 40.4[11.1-72.6] 40[8.2-75]
Vegetables and salad 36.8 [14.3-59] 36.9 [15.5-60] 36.2[10.3-57.3]
Soups 0 [0-6.5] 0 [0-6.3] 0 [0-7.1]
Seafood 0 [0-6.3] 0 [0-6.3] 0 [0-6.8]
Legumes0 [0-8.2] 1.1 [0-9] 0 [0-6.1]
Sandwiches and pizza 8.3 [0-27.7] 7.1 [0-26.7] 10 [0-33.3]
Meat 27.3[1-50] 27.8 [3.6-50] 25 [0-47.7]
Fried foods 20 [0-36.8] 20 [0-36.4] 28.9[0-37.7]
Pies and omelette 3.9 [0-11.8] 4.4 [0-11.8] 2.3 [0-12.1]
Pasta and rice 64.3 [33.3-90.6] 65.8 [33.3-89.9] 55.7 [30.1-93.6]
Potatoes 14 [0-25] 14.3 [0-25] 13.2 [0-25]
Frequent users
Overall (n=395) No GERD (n=304) GERD (n=91)
Sweets 5.15[1.01-12.5] 5.4[0.9-12.5] 4.8[1.5-12.5]
Fruits 44.3[22.1-70.0] 44.4[21.8-70] 40.4[22.8-67.7]
Vegetables and salad 37.3[24.5-53.2] 37.7[26.2-54.7] 35.7[17.8-50]
Soups 3.1[0-10] 3.1[0-10.1] 2.9[0-9.7]
Seafood 3.6[0-8.3] 3.6[0.8-8.3] 2.7[0-8.3]
Legumes 4.3[1.2-7.9] 4.4[1.46-8.3] 3.4[0-6.8]
Sandwiches and pizza 14.0[5.7-27.9] 13.6[5.4-26.8] 17.9[8.4-32.6]
Meat 30.7[17.2-43.0] 31.5[17.3-43.0] 29.7[17.1-44.1]
Fried foods 28.4[17.4-39.3] 28.57[17.7-39.1] 27.3[16.7-40]
Pies and omelette 7.5[4.05-12.5] 7.3[4.2-12.0] 7.7[3.5-14.1]
Pasta and rice62.5[40.2-80] 65.5[40.9-81.1] 54.8[35.2-75.7]
Potatoes 17.1[11.5-24.3] 17.2[12.0-24.5] 17.1[11.3-23.8]
*P-value <0.05 for comparison between groups
in the analyses that are represented by students using
the canteen and those participating into the survey thus
precluding the generalizability of results. The aforemen-
tioned limitations were considered when performing sta-
tistical analyses and while results from the Heckman–
type selection model suggested no presence of selec-
tion bias, caution is needed in interpreting results from
that model. As only few variables were available for the
inclusion as covariates, the model adapted could fail in
explaining the mechanism underling survey participa-
tion.Itiswellknownthat[31] the choice of selection
variables can impact model estimates, thus despite sig-
nificance of the variables used in the present analysis,
poor fitting of the model suggested that other variables
than those collected in the present study may impact
on the survey participation. In particular, psychological
factors, as attitudes toward the compliance with survey
study and sensitivity to the theme investigated, proba-
bly play a key role in determining survey participation
and should be addressed in future studies. Anyway, to
support findings from the present study, hypothesizing
that possible differences and attitudes among students
could be reflected in the type of studies they attended,
verification of the presence of selection bias was also
performed in the subgroups of students using the Uni-
versity canteen for which other variables were available.
Including also University Department as covariate in
the selection model did not improve fitting and results
remained invariant, still indicating no presence of selec-
tion bias (data not shown). Moreover, prevalence estimate
obtained from our analysis is coherent with available
evidence.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Martinucci et al. BMC Gastroenterology (2018) 18:116 Page 8 of 10
The second limitation of this study is related to the
intrinsic difficulty of identifying which patients actually
suffer from GERD. Indeed, it is well known that patients
with GERD may present with atypical symptoms, such
as cough, asthma, laryngitis, in the absence of typical
esophageal symptoms, and other patients with GERD
experience no symptoms at all [1,32]. As a consequence,
our estimates will include some students who have typ-
ical GERD symptoms generated by mechanisms other
than reflux (i.e., functional heartburn), as well as will not
include students whose symptoms are sporadic or absent.
However, such limitation represents a common problem
for all population-based studies aimed at investigating
GERD prevalence through questionnaires [5]. Indeed, our
prevalence estimate is coherent with available evidence.
In this context, it must be underlined that we used a sim-
plified version of the GERDq questionnaire to assess the
presence of GERD, limiting the questions only to typical
reflux symptoms.
The third limitation of our study is that this is an obser-
vational study in a very selected group of people (i.e.,
students eating at the canteen) whose results cannot be
directly applied to the general population.
According to our secondary aim, we explored the pos-
sible association between different dietary patterns and
GERD to assess the effects of diet on disease risk. In this
regard, it is worth noting that a strength of this article is
that food items are automatically recorded from cashiers’
transactions at University canteen. Thus, these data are
not affected by the well-known problem of memory effect
[33], or by the bias due to the tendency in survey respon-
dents to answer questions in a way that will be viewed
favourably by others, the “social desirability” bias [34]. Of
note, when evaluating food choices, among all users a
lower frequency of legumes choice was observed in GERD
students. However, this data was not confirmed when
considering food choices among frequent users. On the
other hand, when considering frequent users we found
a significant lower frequency of choice of pasta and rice
in GERD students. On the basis of the available litera-
ture and of the known pathophysiological mechanisms of
GERD, it is not currently possible to speculate on why this
low frequency of consumption and how this can affect the
symptoms[3540]. For example, some studies have shown
that consumption of a high-fat diet was associated with
GERD, but several other studies reported conflicting data.
El-Serag et al. have demonstrated that fruits, vegetables,
and high-fiber diets are inversely associated with GERD
[35], whereas Zheng et al. found that none of these items
was associated with the risk of GERD symptoms [39]. Fur-
thermore, high-fat foods and chocolate are empirically
indicated as foods able to reduce lower esophageal sphinc-
ter pressure or to prolong gastric emptying. Recently, an
interesting study by Keshteli et al. [41] found that higher
dietary glycaemic index and glycaemic load may be risk
factors for uninvestigated heartburn and uninvestigated
chronic dyspepsia in men, as well as normal-weight sub-
jects, but not in women and overweight individuals. Thus,
consuming a low-glycaemic index diet might be beneficial
in normal-weight patients with uninvestigated heartburn.
Obviously, these findings warrant evaluation in prospec-
tive studies to establish the potential role of carbohydrate
quality in the management of GERD. However, there
have been no cessation trials evaluating the impact on
GERD outcomes. However, our findings show an inter-
esting aspect to be kept in careful consideration and to
be reassessed, continuing to acquire objective data on the
choice of food over time. Overall, our results showed no
differences among students with and without GERD when
distinguishing male and female, or by aggregating stu-
dents by BMI category. A major concern of this analysis
is that the dietary intake information provided by DSU
might be not reflective of participant’s habitual dietary
intake. Indeed, we do not have a complete mapping of
what each student eats every day, outside the Univer-
sity canteen. However, this study might be considered as
pilot study to properly assess the possible influence of dif-
ferent dietary patterns on gastrointestinal diseases based
on real and objective data about eating habits. Moreover,
as regards GERD, according to current available litera-
ture, the effectiveness of dietary recommendations has
not been shown, and, thus, recommendations are to have
a generally healthy diet and to avoid food items that, in the
experience of the patient, trigger symptoms [23].
Conclusion
To our knowledge, this is the first study evaluating the
prevalence of typical GERD-related symptoms in a young
population of University students in Italy.Our data show a
prevalence rate of weekly symptoms of 26.2%. Consider-
ing the young age of enrolled subjects, our prevalence rate,
relatively high compared to the usual estimates, could rep-
resent a further negative factor for the future economic
sustainability of the healthcare system.
When assessing the effects of diet on disease risk, we
found, among all users, a lower frequency of legumes
choice in GERD students and, among frequent users, a
lower frequency of choice of pasta and rice in GERD stu-
dents. Since food items are automatically recorded from
cashiers’ transactions at University canteen, this study
might be considered as pilot study to properly assess the
possible influence of different dietary patterns on gas-
trointestinal diseases based on real and objective data
about eating habits.
Endnote
1The 3 levels of obesity were aggregated due to the
reduced number of observations
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Martinucci et al. BMC Gastroenterology (2018) 18:116 Page 9 of 10
Additional file
Additional file 1:Supplementary tables. (TEX 11 kb)
Abbreviations
BMI: Body mass index; CMS: Content management system; DSU: Azienda
Regionale per il Diritto allo Studio Universitario; GERD: Gastroesophageal reflux
disease; IQR: Inter quartile range
Acknowledgements
The author wishes to thank Beltos S.r.l. for providing expertise and support in
the development of the web-survey and the staff from "Azienda Regionale per
il Diritto allo Studio Universitario Toscana" for providing data and support for
data linkage as part of the RASUPEA consortium. We also thank the staff from
the University of Pisa for providing data and support for data linkage. Finally
the authors are grateful to all the students who participated in the study.
Funding
The work was part of RASUPEA project: “Le mense Universitarie: ricerca sulle
abitudini alimentari dei giovani e d’educazione e prevenzione alimentare". The
project was supported by a grant of the PRAF 2012-2015 REGIONE TOSCANA
program of the Tuscany Region.
Availability of data and materials
Availability of data is restricted to researchers from the academic institution
member of the RASUPEA consortium.
Authors’ contributions
RB, IM and NdB contributed to the conception and design of the study; MN
contributed to the creation, development and management of the final
database for data storage and the statistical analysis of data from the survey;
VL performed statistical analysis for the assessment of selection bias and
description of eating habits; IM, MN, VL co-wrote the manuscript; LP, NdB, GT,
AM, DP and SM critically reviewed the manuscript and provided support in
interpreting data. All authors read and approved the final version of the
manuscript.
Ethics approval and consent to participate
Not applicable. The local ethics committee of the University and Azienda
Ospedaliera Pisana ruled that no formal ethics approval was required in this
particular case.
A written informed consent was obtained from all participants before entering
the study through the web-app.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1Division of Gastroenterology–Versilia Hospital, Lido di Camaiore–Lucca, Italy.
2Department of Computer Science–University of Pisa, Pisa, Italy. 3Department
of Biology–University of Pisa, Pisa, Italy. 4Institute of Management, Scuola
Superiore Sant’Anna of Pisa, Pisa, Italy. 5Institute of Information Science and
Technologies ISTI - Italian National Research Council (CNR), Pisa, Italy. 6Division
of Gastroenterology, Department of Translational Research and New
Technologies in Medicine and Surgery–University of Pisa, Pisa, Italy.
Received: 3 January 2018 Accepted: 22 June 2018
References
1. Vakil N, Van Zanten SV, Kahrilas P, Dent J, Jones R. The montreal
definition and classification of gastroesophageal reflux disease: a global
evidence-based consensus. Am J Gastroenterol. 2006;101(8):1900.
2. Savarino E, Bredenoord AJ, Fox M, Pandolfino JE, Roman S, Gyawali CP,
et al. Expert consensus document: Advances in the physiological
assessment and diagnosis of gerd. Nat Rev Gastroenterol Hepatol.
2017;14(11):665.
3. Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, Bulsiewicz WJ,
Gangarosa LM, Thiny MT, Stizenberg K, Morgan DR, et al. Burden of
gastrointestinal disease in the united states: 2012 update.
Gastroenterology. 2012;143(5):1179–87.
4. El-Serag HB. Time trends of gastroesophageal reflux disease: a systematic
review. Clin Gastroenterol Hepatol. 2007;5(1):17–26.
5. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the
epidemiology of gastro-oesophageal reflux disease: a systematic review.
Gut. 2014;63(6):871–80. BMJ Publishing Group. https://doi.org/10.1136/
gutjnl-2012- 304269,https://gut.bmj.com/content/63/6/871.
6. Ness-Jensen E, Lindam A, Lagergren J, Hveem K. Changes in prevalence,
incidence and spontaneous loss of gastro-oesophageal reflux symptoms:
a prospective population-based cohort study, the hunt study. Gut.
2012;61:2011.
7. Savarino E, de Bortoli N, De Cassan C, Della Coletta M, Bartolo O,
Furnari M, Ottonello A, Marabotto E, Bodini G, Savarino V. The natural
history of gastro-esophageal reflux disease: a comprehensive review. Dis
Esophagus. 2017;30(2):1–9.
8. Castell DO, Murray J, Tutuian R, Orlando R, Arnold R. Review article: the
pathophysiology of gastro-oesophageal reflux disease- oesophageal
manifestations. Aliment Pharmacol Ther. 2004;20(s9):14–25.
9. Bortoli N, Ottonello A, Zerbib F, Sifrim D, Gyawali CP, Savarino E.
Between gerd and nerd: the relevance of weakly acidic reflux. Ann N Y
Acad Sci. 2016;1380(1):218–29.
10. Ness-Jensen E, Hveem K, El-Serag H, Lagergren J. Lifestyle intervention
in gastroesophageal reflux disease. Clin Gastroenterol Hepatol.
2016;14(2):175–82.
11. Kahrilas PJ, Shaheen NJ, Vaezi MF. American gastroenterological
association medical position statement on the management of
gastroesophageal reflux disease. Gastroenterology. 2008;135(4):1383–91.
12. Kahrilas PJ, Shaheen NJ, Vaezi MF. American gastroenterological
association institute technical review on the management of
gastroesophageal reflux disease. Gastroenterology. 2008;135(4):
1392–413.
13. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and
management of gastroesophageal reflux disease. Am J Gastroenterol.
2013;108(3):308.
14. DeVault KR, Castell DO. Updated guidelines for the diagnosis and
treatment of gastroesophageal reflux disease. Am J Gastroenterol.
2005;100(1):190.
15. Martinucci I, de Bortoli N, Savarino E, Nacci A, Romeo SO, Bellini M,
Savarino V, Fattori B, Marchi S. Optimal treatment of laryngopharyngeal
reflux disease. Ther Adv Chron Dis. 2013;4(6):287–301.
16. Festi D, Scaioli E, Baldi F, Vestito A, Pasqui F, Di Biase AR, Colecchia A.
Body weight, lifestyle, dietary habits and gastroesophageal reflux disease.
World J Gastroenterol WJG. 2009;15(14):1690.
17. Mone I, Kraja B, Bregu A, Duraj V, Sadiku E, Hyska J, Burazeri G.
Adherence to a predominantly mediterranean diet decreases the risk of
gastroesophageal reflux disease: a cross-sectional study in a south
eastern european population. Dis Esophagus. 2016;29(7):794–800.
18. Bortoli N, Martinucci I, Savarino E, Bellini M, Bredenoord A, Franchi R,
Bertani L, Furnari M, Savarino V, Blandizzi C, et al. Proton pump inhibitor
responders who are not confirmed as gerd patients with impedance and
ph monitoring: who are they?. Neurogastroenterol Motil. 2014;26(1):
28–35.
19. Jones R, Junghard O, Dent J, Vakil N, Halling K, Wernersson B, Lind T.
Development of the gerdq, a tool for the diagnosis and management of
gastro-oesophageal reflux disease in primary care. Aliment Pharmacol
Ther. 2009;30(10):1030–8.
20. Jonasson C, Wernersson B, Hoff D, Hatlebakk J. Validation of the gerdq
questionnaire for the diagnosis of gastro-oesophageal reflux disease.
Aliment Pharmacol Ther. 2013;37(5):564–72.
21. Heckman J. Sample selection bias as a specification error. Econometrica.
1979;47(1):153–61.
22. Valle C, Broglia F, Pistorio A, Tinelli C, Perego M. Prevalence and impact
of symptoms suggestive of gastroesophageal reflux disease. Dig Dis Sci.
1999;44(9):1848–52.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Martinucci et al. BMC Gastroenterology (2018) 18:116 Page 10 of 10
23. Bredenoord AJ, Pandolfino JE, Smout AJ. Gastro-oesophageal reflux
disease. Lancet. 2013;381(9881):1933–42.
24. Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Obesity and
estrogen as risk factors for gastroesophageal reflux symptoms. Jama.
2003;290(1):66–72.
25. Ayazi S, Hagen JA, Chan LS, DeMeester SR, Lin MW, Ayazi A, Leers JM,
Oezcelik A, Banki F, Lipham JC, et al. Obesity and gastroesophageal
reflux: quantifying the association between body mass index, esophageal
acid exposure, and lower esophageal sphincter status in a large series of
patients with reflux symptoms. J Gastrointest Surg. 2009;13(8):1440–7.
26. Lagergren J. Influence of obesity on the risk of esophageal disorders. Nat
Rev Gastroenterol Hepatol. 2011;8(6):340–7.
27. Nocon M, Labenz J, Jaspersen D, Meyer-Sabellek W, Stolte M, Lind T,
Malfertheiner P, Willich SN. Association of body mass index with
heartburn, regurgitation and esophagitis: results of the progression of
gastroesophageal reflux disease study. J Gastroenterol Hepatol.
2007;22(11):1728–31.
28. Bortoli N, Guidi G, Martinucci I, Savarino E, Imam H, Bertani L, Russo S,
Franchi R, Macchia L, Furnari M, et al. Voluntary and controlled weight
loss can reduce symptoms and proton pump inhibitor use and dosage in
patients with gastroesophageal reflux disease: a comparative study. Dis
Esophagus. 2016;29(2):197–204.
29. Singh M, Lee J, Gupta N, Gaddam S, Smith BK, Wani SB, Sullivan DK,
Rastogi A, Bansal A, Donnelly JE, et al. Weight loss can lead to resolution
of gastroesophageal reflux disease symptoms: a prospective intervention
trial. Obesity. 2013;21(2):284–90.
30. Jacobson BC, Somers SC, Fuchs CS, Kelly CP, Camargo Jr CA. Body-mass
index and symptoms of gastroesophageal reflux in women. N Engl J Med.
2006;354(22):2340–8.
31. Cuddeback G, Wilson E, Orme JG, Combs-Orme T. Detecting and
statistically correcting sample selection bias. J Soc Serv Res. 2004;30(3):
19–33.
32. Carlsson R, Dent J, Watts R, Riley S, Sheikh R, Hatlebakk J, Haug K,
de Groot G, van Oudvorst A, Dalväg A, et al. Gastro-oesophageal reflux
disease in primary care: an international study of different treatment
strategies with omeprazole. Eur J Gastroenterol Hepatol. 1998;10(2):
119–24.
33. Sudman S, Bradburn NM. Effects of time and memory factors on
response in surveys. J Am Stat Assoc. 1973;68(344):805–15.
34. Phillips DL, Clancy KJ. Some effects of “social desirability” in survey
studies. Am J Sociol. 1972;77(5):921–40.
35. El-Serag H, Satia J, Rabeneck L. Dietary intake and the risk of
gastro-oesophageal reflux disease: a cross sectional study in volunteers.
Gut. 2005;54(1):11–17.
36. Shapiro M, Green C, Bautista J, Dekel R, RISNER-ADLER S, Whitacre R,
Graver E, Fass R. Assessment of dietary nutrients that influence
perception of intra-oesophageal acid reflux events in patients with
gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2007;25(1):
93–101.
37. Meyer J, Lembo A, Elashoff J, Fass R, Mayer E. Duodenal fat intensifies
the perception of heartburn. Gut. 2001;49(5):624–8.
38. Colombo P, Mangano M, Bianchi P, Penagini R. Effect of calories and fat
on postprandial gastro-oesophageal reflux. Scand J Gastroenterol.
2002;37(1):3–5.
39. Zheng Z, Nordenstedt H, Pedersen NL, Lagergren J, Ye W. Lifestyle
factors and risk for symptomatic gastroesophageal reflux in monozygotic
twins. Gastroenterology. 2007;132(1):87–95.
40. Nandurkar S, Locke Gr, Fett S, Zinsmeister AR, Cameron A, Talley N.
Relationship between body mass index, diet, exercise and
gastro-oesophageal reflux symptoms in a community. Aliment
Pharmacol Ther. 2004;20(5):497–505.
41. Keshteli A, Haghighatdoost F, Azadbakht L, Daghaghzadeh H,
Feinle-Bisset C, Afshar H, Feizi A, Esmaillzadeh A, Adibi P. Dietary
glycaemic index and glycaemic load and upper gastrointestinal disorders:
results from the sepahan study. J Hum Nutr Diet. 2017;30(6):714–23.
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... Some dietary components including high-fat and high-carbohydrate foods, tomato products [12], chocolate [13], alcohol [14], coffee or tea [15,16] citrus fruits [13], spicy foods [17], acidic and fried foods [13,18] and mint [19] have been reported to be potentially associated with GERD. This is while previous investigations have led to con icting results when exploring the association between diet and GERD [20][21][22]. Keshteli et al. proposed that the intake of fruits and vegetables which are high in ber, antioxidant vitamins are negatively associated with the odds of GERD in adults [23], that were consistent with other previous studies [24,25]. However, Zheng et al. could not show the same results and stated perhaps factors including genetic, BMI, smoking and physical activity can play a role in incidence of GERD [26]. ...
... The MedDiet is recognized by high consumption of components that has protective effects on GERD and low consumption of components related to increased risk of this disease [21]. Few studies have investigated the relationship between the intake of MedDiet components such as fruits and vegetable [23], legumes [20] and GERD. Keshteli et al [23] in a cross-sectional study reported that subjects with highest intake of fruits had 25% lower chance for developing GERD compared to those in the rst tertile intake; however, the intake of vegetables was not associated with GERD in crude and multivariable-adjusted models [34]. ...
Preprint
Background : Gastroesophageal reflux disease (GERD) is one of common esophageal diseases in adolescents. Recent evidence has shown that dietary patterns might be associated with GERD risk. The aim of this study was to assess the association between a Mediterranean style diet (MedDiet) and GERD in a large sample of adolescents living in central Iran. Methods : This cross-sectional study conducted on 5141 adolescents aged between 13-14 years. Dietary intake assessed by using a food frequency method. The GERD diagnosed using a six-item questionnaire, which askes about its symptoms including heartburn, sense of reflux, poor sleep, medication use, nausea and epigastric pain. A binary logistic regression used to evaluate the relationship between the MedDiet score and GERD and its associated symptoms. Results : The analyses revealed that after adjustment for all possible confounding variables, the adolescents in the highest adherence to the MedDiet score had lower odds of GERD [odds ratio (OR)= 0.53; 95% CI 0.35-0.80, P trend = 0.005)], sense of reflux (OR= 0.45; 95 % CI 0.26-0.77, P trend = 0.01) and poor sleep (OR= 0.54; 95% CI 0.31-0.96, P trend = 0.02) compared with those in the lowest adherence. This association remained significant after adjustment for confounding factors including of age, sex, watching TV and computer and BMI. No significant link found between MedDiet and other GERD symptoms. Conclusion : The present study reported an inverse association between adherence to a Mediterranean style diet and GERD among Iranian adolescents. Adherence to MedDiet may be an important strategy in preventing GERD in adolescents.
... GERD has also extra-esophageal symptoms like chronic cough, asthma, and sometimes tissue lesions [3]. GERD has unknown causes, it is mostly caused by multifactorial pathogenesis like esophagogastric junction dysfunction, hypersensitivity of the esophagus, impaired esophageal bolus transit, and high intragastric pressure [4]. There are risk factors that increase the chance of getting GERD like age, obesity, lifestyle, taking non-steroidal anti-inflammatory drugs (NSAIDs), and smoking [5]. ...
... GERD is usually treated by proton pump inhibitors (PPIs) and lifestyle modification [6,7,8]. Depending on a recent systematic review for GERD management, one of the most important management is lifestyle modification like decreasing weight, smoking cessation, and avoid heavy meals at night [4]. If GERD is left without treatment, it will lead to dangerous complications like Barrett's esophagus then esophagus cancer [1,5]. ...
Article
Full-text available
Background Gastroesophageal reflux disease (GERD) is a common upper gastrointestinal disorder characterized by heartburn and acid regurgitation. A higher incidence is found in Arab countries. Untreated GERD has a negative impact on individuals that interfere with daily activities and impaired quality of life. This study aims to estimate the prevalence of GERD and associated risk factors in the Eastern region, Saudi Arabia. Material & Methodology A descriptive cross-sectional study was carried out among 1517 healthy participants from the Eastern province of Saudi Arabia from May to August 2021. The sample was randomly collected through a structured self-administered questionnaire. The questionnaire was composed of questions related to sociodemographic and lifestyle characteristics as risk factors for GERD. The existence of GERD was assessed by using GERD Questionnaire (GerdQ) for diagnosing GERD, when the score is 8 or more. Results A total of 1517 participants were included in the study: 58.8% male, 41.2% female; 9% of whom were pregnant. The age of participants ranged from 18 to 58 with a mean age of 27.5 ± 11.4 years old. The existence of GERD was 20.6% among the total participants, in which their GerdQ scores were 3-7 (68.9%), 8-10 (22.1%), and 8-11 (8.5%). The higher risk groups of having GERD were pregnant women, smoker, being male, regular usage of analgesia, soft drinks, and having a family history of GERD. Conclusion This study showed the prevalence of GERD among the general population of the Eastern region, Saudi Arabia was 20.6%. Several sociodemographic and lifestyle characteristics were associated with the disease. Further studies are needed to explore the role of psychological factors in developing GERD.
... Many studies have focused on the association between GERD and established risk factors, such as age, gender, body mass index (BMI) (Martinucci, 2018), obesity (Lagergren, 2001), tobacco smoking (Ness-Jensen, 2014) and physical activity (Djarv et al, 2012). ...
Article
Full-text available
The aim of this study is to assess dietary and lifestyle factors associated with GERD (Gastroesophageal reflux disease) through a survey conducted on population of Delhi and Noida, Uttar Pradesh from age group-15 to 45 years and above. GERD is related to many irregular dietary and lifestyle habits (such as a habit of midnight snacking, skipping breakfast, large gap between meals, eating quickly, eating very spicy foods, eating junk food frequently high fatty food and eating beyond fullness). An interval of less than three hours between dinner and bedtime, disturbed sleeping pattern was positively related to GERD, while proper physical exercise was negatively correlated with GERD. Smoking, alcohol consumption and mental state (poor mental state) were positively correlated with GERD. In conclusion, many dietary and lifestyle factors affect the onset of GERD and these factors differ among sex, age groups and job types. Unhealthy lifestyles are closely related to high incidence of suspected GERD. These findings need to be further confirmed in subsequent studies.
... GERD consists of troublesome symptoms or mucosal damage resulting from retrograde movement of the gastric content through an incompetent esophagogastric junction (EGJ) [1]. The prevalence of GERD based on symptom perception in individual cross-sectional surveys varies from 2.5% to more than 25% [3][4][5][6][7], depending on the criteria used to define their presence and frequency, and the geographical location of the study, with lower rates in Asia compared to Western countries [8,9]. ...
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The clinical diagnosis of gastro-esophageal reflux disease (GERD) is based on the presence of typical esophageal troublesome symptoms. In clinical practice, heartburn relief following a proton pump inhibitor (PPI) trial or endoscopy can confirm a diagnosis of GERD. In cases of diagnostic uncertainty or before anti-reflux interventions, combined impedance-pH monitoring (MII-pH) provides a comprehensive assessment of both physical and chemical properties of the refluxate, allowing to achieve a conclusive diagnosis of GERD. Recently, the Lyon Consensus proposed the use of mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave index (PSPW-I) as novel MII-pH metrics to support the diagnosis of GERD. The calculation of MNBI and PSPW-I currently needs to be performed manually, but artificial intelligence systems for the automated analysis of MII-pH tracings are being developed. Several studies demonstrated the increased diagnostic yield MNBI and PSPW-I for the categorization of patients with GERD at both on- and off-PPI MII-pH monitoring. Accordingly, we performed a narrative review on the clinical use and diagnostic yield of MNBI and PSPW-I when the diagnosis of GERD is uncertain. Based on currently available evidence, we strongly support the evaluation of PSPW-I and MNBI as part of the standard assessment of MII-pH tracings for the evaluation of GERD, especially in patients with endoscopy-negative heartburn.
... The authors found significant differences in frequency of the disorder according to sex, smoking habits, and BMI. GERD-related symptoms were more common among females, smokers, and those with higher BMI values [18][19][20]. ...
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Abstract Background/Aim Population-based studies on the prevalence of GERD-related symptoms are still missing in Eastern Europe, therefore, we aimed to obtain such data in South-East Hungarian subjects. Methods A total of 2,002 apparently healthy blood donor volunteers were consecutively enrolled and completed detailed questionnaires related to general factors, demographic data, socioeconomical factors, and the presence and frequency of typical and atypical GERD-related symptoms. Results Among 2,002 study participants, 56.5% were completely asymptomatic. The prevalence of typical GERD symptoms appearing at least monthly or weekly was 16.5% and 6.8%, respectively. Two-thirds (209/330) of the patients experienced at least monthly occurring typical GERD symptoms and also had associated atypical symptoms and this was even more pronounced when comparing subgroups with higher symptom frequencies. Significant correlations were found between monthly GERD-related complaints and height, body mass index (BMI), coffee consumption, and smoking. Positive family history was another significant factor in all the symptom-frequency categories. GERD-related symptom frequency showed a linear association with sex (R2 = 0.75, P = 0.0049). Typical and atypical GERD symptoms were significantly more common in those with chronic diseases than those without. Heartburn was observed in 12.5% and 4.4% (P<0.05) and acid regurgitation was seen in 6.9% and 1.8% (P<0.05), respectively. Conclusion The prevalence of GERD-related symptoms in South Hungary was significantly lower than that in Western countries and was closer to Eastern values. The presence of mild, non-exclusionary chronic diseases significantly increased the prevalence of GERD-related symptoms, as well as positive family history of GERD, height, BMI, coffee consumption, and smoking.
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Background: Beverage-drinking behavior could be a potential risk factor for gastroesophageal reflux disease (GERD) in young populations. However, GERD prevalence in this population has not been investigated, and beverage consumption's association with GERD remains inconclusive. This study aimed to evaluate the prevalence and beverage-related risk factors of GERD among Chinese college freshmen and in youth around the world. Methods: A cross-sectional survey was conducted in Chinese college freshmen in September 2019 using random cluster sampling method. Participants completed questionnaires on demographic information, food intake frequency, and GER symptoms. Multivariate logistic regression models were applied to assess the association between beverages and GERD. Studies were retrieved from multiple databases for systemic review. The prevalence of GERD in young populations and beverage-related risk factors were pooled using random-effect models. Key results: Based on the 3345 individuals who completed the questionnaires, GERD prevalence in Chinese college freshmen is 5.1%. Multivariate analysis showed students who drink green tea daily, and those who drink coffee regularly were more likely to develop GERD compared with those who never drink tea or coffee. The pooled prevalence of GERD in young populations is 18.0%, and frequent alcohol consumption is positively associated with GERD in general population. Conclusions and inferences: The prevalence of GERD in Chinese college freshmen is significantly lower than that in worldwide youth populations. Alcohol, green tea, and coffee consumption could be potential risk factors for GERD. Future large-scale epidemiological studies are warranted for reliable identification of beverage-related risk factors for GERD in young populations.
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Purpose Recently, there has been increased emphasis in the dysphagia literature on what constitutes the “normal” swallow, including rates of aspiration and penetration in healthy persons across the age ranges. Since a majority of the normed-based studies utilized videofluoroscopy and were conducted in a tightly controlled environment, there is a need to increase the ecological validity of this body of research and investigate the swallow during functional, day-to-day activities. The aim of this study is to track the incidence of swallowing difficulty in young, healthy adults over an extended period to determine the frequency of aspiration-related events and under what environmental circumstances these events occurred. Method Sixty-nine young, healthy women (aged 18–39 years) participated in the study and recorded data for 95 consecutive days. Participants installed a web-based application on their cell phones and were asked to access the app and answer three simple questions immediately following any adverse swallowing events. These data were used to determine the frequency of aspiration-related events and their relationship to environmental circumstance. Results Fifty-three of the 69 participants (76.8%) reported coughing or choking, 43 (62.3%) reported clearing their throat, 19 (27.5%) reported a globus sensation, and 14 (20.2%) reported difficulty initiating a swallow. The environmental circumstances most commonly associated with aspiration-related events were talking, being distracted, and using an electronic device. Conclusion Results suggest that young, healthy adults experience aspiration-related events at a high frequency and that these events typically occur during activities that require dual attention.
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Introduction The gastro‐oesophageal reflux disease (GERD) is a public health issue for its prevalence and association with low life quality and substantial costs. Since most of Italian data refer to over a decade ago, the aim was to provide an updated estimate of GERD symptoms prevalence. Knowledge about appropriate nutrition and behaviours in presence of GERD was assessed. Predictors for symptoms presence and knowledge were explored. Methods This study was an online cross‐sectional survey that investigated socio‐demographics, knowledge about nutrition/behaviours in case of GERD (Knowledge Score KS: percentage of right answers), nutrition/lifestyle attitudes. The questionnaire included the GerdQ to assess symptoms (presence if score ≥8). Adults resident in Italy were enrolled between June and August 2019 through convenience sampling on the major social networks (sample size = 559). Descriptive analyses were run. Multivariable regressions were performed to explore predictors of symptoms presence and KS. Results The 27.7% had GERD symptoms. Among them, 33.8% never received GERD information by their general practitioner (GP). Body mass index (P = .036), secondary education (P = .040) were associated with higher symptoms risk. Weekly exercise was associated with lower risk (P < .001). Median KS was 92% (IQR = 12). Sleeping on the left side, chocolate, citrus fruit, mint reported the lowest right answers percentages. None/basic education was negatively associated with KS (P < .001), being female (P = .004) and in a relationship (P = .012) positively. Conclusions A high prevalence was reported, consistently with the worldwide increasing trend. Despite overall knowledge was high, specific gaps were found. GPs should improve communication and awareness campaigns targeted to less known aspects must be planned.
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GERD is a common condition worldwide. Key mechanisms of disease include abnormal oesophagogastric junction structure and function, and impaired oesophageal clearance. A therapeutic trial of acid-suppressive PPI therapy is often the initial management, with endoscopy performed in the setting of alarm symptoms and to exclude other conditions. If symptoms persist and endoscopy does not reveal evidence of GERD, oesophageal function tests are performed, including oesophageal manometry and ambulatory reflux monitoring. However, reflux episodes can be physiological, and some findings on endoscopy and manometry can be encountered in asymptomatic individuals without GERD symptoms. The diagnosis of GERD on the basis of functional oesophageal testing has been previously reported, but no updated expert recommendations on indications and the interpretation of oesophageal function testing in GERD has been made since the Porto consensus over a decade ago. In this Consensus Statement, we aim to describe modern oesophageal physiological tests and their analysis with an emphasis on establishing indications and consensus on interpretation parameters of oesophageal function testing for the evaluation of GERD in clinical practice. This document reflects the collective conclusions of the international GERD working group, incorporating existing data with expert consensus opinion.
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Gastroesophageal reflux disease (GERD) is a common disorder of the upper gastrointestinal tract which is typically characterized by heartburn and acid regurgitation. These symptoms are widespread in the community and range from 2.5% to more than 25%. Economic analyses showed an increase in direct and indirect costs related to the diagnosis, treatment and surveillance of GERD and its complications. The aim of this review is to provide current information regarding the natural history of GERD, taking into account the evolution of its definition and the worldwide gradual change of its epidemiology. Present knowledge shows that there are two main forms of GERD, that is erosive reflux disease (ERD) and non-erosive reflux disease (NERD) and the latter comprises the majority of patients (up to 70%). The major complication of GERD is the development of Barrett esophagus, which is considered as a pre-cancerous lesion. Although data from medical literature on the natural history of this disease are limited and mainly retrospective, they seem to indicate that both NERD and mild esophagitis tend to remain as such with time and the progression from NERD to ERD, from mild to severe ERD and from ERD to Barrett's esophagus may occur in a small proportion of patients, ranging from 0 to 30%, 10 to 22% and 1 to 13% of cases, respectively. It is necessary to stress that these data are strongly influenced by the use of powerful antisecretory drugs (PPIs). Further studies are needed to better elucidate this matter and overcome the present limitations represented by the lack of large prospective longitudinal investigations, absence of homogeneous definitions of the various forms of GERD, influence of different treatments, clear exclusion of patients with functional disorders of the esophagus.
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Background: Little is known about the effects of carbohydrate, particularly any association between dietary glycaemic index or glycaemic load and uninvestigated heartburn or uninvestigated chronic dyspepsia in the community. The present study aimed to determine associations between dietary glycaemic index or glycaemic load and uninvestigated heartburn or uninvestigated chronic dyspepsia. Methods: This cross-sectional study was conducted in 2987 adults. Dietary glycaemic index and glycaemic load were estimated using a validated food-frequency questionnaire. Uninvestigated heartburn and uninvestigated chronic dyspepsia were determined using a modified and validated version of the Rome III questionnaire. Results: After controlling for various confounders, high glycaemic load was associated with an increased risk of uninvestigated heartburn [odds ration (OR) = 1.75; 95% confidence interval CI = 1.03, 2.97; P = 0.04] and uninvestigated chronic dyspepsia (OR = 2.14; 95% CI: 1.04, 4.37; P = 0.04) in men but not in women. In normal-weight individuals, high glycaemic index was related to an increased risk of uninvestigated heartburn (OR = 1.52; 95% CI: 1.07, 2.15; P = 0.02) and high glycaemic load to an increased risk of uninvestigated chronic dyspepsia (OR=1.78; 95% CI: 1.05, 3.01; P = 0.03). No significant associations were observed in subjects with excess body weight. Conclusions: Our data suggest that there are body mass index- and sex-specific associations between dietary carbohydrate quality with uninvestigated heartburn and uninvestigated chronic dyspepsia.
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Nonerosive reflux disease (NERD) is a common condition and the most frequent phenotype of gastroesophageal reflux disease (GERD). NERD is extremely heterogeneous and includes patients with negative endoscopy but abnormal esophageal acid exposure and/or positive reflux-symptom association analysis (hypersensitive esophagus). This segregation is only possible owing to the use of impedance-pH monitoring. Indeed, weakly acidic reflux represents one of the most common causes of refractory symptoms in patients evaluated off antisecretory therapy and, more importantly, during antisecretory drug treatment. Patients with heartburn who do not have any type of reflux underlying their symptoms (functional heartburn) must be excluded from the category of GERD. The drawbacks of impedance-pH are mainly due to the day-to-day variability of the test and the fact that the accuracy of the symptom-reflux correlation scores is often far from perfect. Some histopathological characteristics, such as dilated intercellular spaces, can be helpful in distinguishing patients with NERD through esophageal biopsies. Patients with NERD in whom acid is the main pathogenetic factor respond successfully to proton pump inhibitor therapy, while those with hypersensitive esophagus to weakly acidic reflux could be treated with reflux inhibitors or surgery, although further controlled studies are required.
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The American Journal of Gastroenterology is published by Nature Publishing Group (NPG) on behalf of the American College of Gastroenterology (ACG). Ranked the #1 clinical journal covering gastroenterology and hepatology*, The American Journal of Gastroenterology (AJG) provides practical and professional support for clinicians dealing with the gastroenterological disorders seen most often in patients. Published with practicing clinicians in mind, the journal aims to be easily accessible, organizing its content by topic, both online and in print. www.amjgastro.com, *2007 Journal Citation Report (Thomson Reuters, 2008)
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Our aim was to assess the association of a Mediterranean diet and gastroesophageal reflux disease among adult men and women in Albania, a former communist country in South Eastern Europe with a predominantly Muslim population. A cross-sectional study was conducted in 2012, which included a population-based sample of 817 individuals (≥18 years) residing in Tirana, the Albanian capital (333 men; overall mean age: 50.2 ± 18.7 years; overall response rate: 82%). Assessment of gastroesophageal reflux disease was based on Montreal definition. Participants were interviewed about their dietary patterns, which in the analysis was dichotomized into: predominantly Mediterranean (frequent consumption of composite/traditional dishes, fresh fruit and vegetables, olive oil, and fish) versus largely non-Mediterranean (frequent consumption of red meat, fried food, sweets, and junk/fast food). Logistic regression was used to assess the association of gastroesophageal reflux disease with the dietary patterns. Irrespective of demographic and socioeconomic characteristics and lifestyle factors including eating habits (meal regularity, eating rate, and meal-to-sleep interval), employment of a non-Mediterranean diet was positively related to gastroesophageal reflux disease risk (fully adjusted odds ratio = 2.3, 95% confidence interval = 1.2-4.5). Our findings point to a beneficial effect of a Mediterranean diet in the occurrence of gastroesophageal reflux disease in transitional Albania. Findings from this study should be confirmed and expanded further in prospective studies in Albania and in other Mediterranean countries. © 2015 International Society for Diseases of the Esophagus.
Article
Objective: To update the findings of the 2005 systematic review of population-based studies assessing the epidemiology of gastro-oesophageal reflux disease (GERD). Design: PubMed and Embase were screened for new references using the original search strings. Studies were required to be population-based, to include ≥ 200 individuals, to have response rates ≥ 50% and recall periods <12 months. GERD was defined as heartburn and/or regurgitation on at least 1 day a week, or according to the Montreal definition, or diagnosed by a clinician. Temporal and geographic trends in disease prevalence were examined using a Poisson regression model. Results: 16 studies of GERD epidemiology published since the original review were found to be suitable for inclusion (15 reporting prevalence and one reporting incidence), and were added to the 13 prevalence and two incidence studies found previously. The range of GERD prevalence estimates was 18.1%-27.8% in North America, 8.8%-25.9% in Europe, 2.5%-7.8% in East Asia, 8.7%-33.1% in the Middle East, 11.6% in Australia and 23.0% in South America. Incidence per 1000 person-years was approximately 5 in the overall UK and US populations, and 0.84 in paediatric patients aged 1-17 years in the UK. Evidence suggests an increase in GERD prevalence since 1995 (p<0.0001), particularly in North America and East Asia. Conclusions: GERD is prevalent worldwide, and disease burden may be increasing. Prevalence estimates show considerable geographic variation, but only East Asia shows estimates consistently lower than 10%.
Article
While lifestyle modifications are currently used as first-line treatment for subjects with gastroesophageal reflux disease (GERD), the pathogenetic role of lifestyle factors and consequently, the efficacy of lifestyle measures is controversial. Our aim was to systematically review the pathogenetic link between overweight/obesity, dietary habits, physical activity and GERD, and the beneficial effect of specific recommended changes, by means of the available literature from the 1999 to the present. Obesity, in particular, abdominal obesity, plays a key role in determining GERD symptoms and complications through mechanical and metabolic effects. Controlled weight loss (by diet or surgery) is effective in improving GERD symptoms. No definitive data exist regarding the role of diet and, in particular, of specific foods or drinks, in influencing GERD clinical manifestations. Moderate physical activity seems to be beneficial for GERD, while vigorous activity may be dangerous in predisposed individuals. In conclusion, being obese/overweight and GERD-specific symptoms and endoscopic features are related, and weight loss significantly improves GERD clinical-endoscopic manifestations. The role of dietary behavior, mainly in terms of specific dietary components, remains controversial. Mild routine physical activity in association with diet modifications, i.e. a diet rich in fiber and low in fat, is advisable in preventing reflux symptoms.
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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 general health. GERD carries 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. 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. Weight loss was followed by decreased time with esophageal acid exposure in two RCTs (from 5.6% to 3.7% and from 8.0% to 5.5%, respectively), 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 to early meals (5.2% points change), and head of the bed elevation decreased time with supine acid exposure compared to a flat position (from 21% to 15%). 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. Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.
Article
A wide variety of pieces of evidence has suggested that obesity is associated with a significant increase in the risk for gastroesophageal reflux disease (GERD) symptoms and its complications. The aim of this study was to evaluate the effect of weight loss on reflux symptoms in overweight/obese patients with proven GERD. We enrolled overweight/obese patients with typical GERD symptoms and erosive esophagitis. At baseline, patients underwent detailed reflux symptoms evaluation and anthropometric assessment, and were divided into two treatment groups: group A received proton pump inhibitor (PPI) and a personalized hypocaloric diet and aerobic exercise; and group B received PPI and a 'standard of care diet'. The dietetic treatment was considered effective if at least 10% of weight loss was achieved within 6 months. All patients were evaluated in terms of anthropometric data, GERD symptoms, and PPI use. In group A, mean body mass index (BMI) decreased from 30.3 ± 4.1 to 25.7 ± 3.1 (P < 0.05), and mean weight decreased from 82.1 ± 16.9 kg to 69.9 ± 14.4 kg (P < 0.05). In group B, there was no change in BMI and weight. Symptom perception decreased (P < 0.05) in both groups during PPI therapy, but a higher improvement was recorded in group A. In group A, PPI therapy was completely discontinued in 27/50 of the patients, and halved in 16/50. Only 7/50 continued the same PPI dosage. In group B, 22/51 halved the therapy and 29/51 maintained full dosage of therapy, but none was able to discontinue PPI due to a symptom recurrence. Overall, weight loss of at least 10% is recommended in all patients with GERD in order to boost the effect of PPI on reflux symptom relief and to reduce chronic medication use. © 2014 International Society for Diseases of the Esophagus.