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Spicy food gerd: Foods Inducing Typical Gastroesophageal Reflux Disease Symptoms in Korea

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Foods Inducing Typical Gastroesophageal Reflux Disease Symptoms in Korea

J Neurogastroenterol Motil. 2017 Jul; 23(3): 363–369.

Department of Gastroenterology, Korea University Guro Hospital, Seoul,
Korea

*Correspondence: Young-Tae Bak, MD, Department of Gastroenterology, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea, Tel: +82-2-2626-1778, Fax: +82-504-366-6381, E-mail: rk.ca.aerok@tykabrd

Received 2016 Jul 28; Revised 2016 Oct 17; Accepted 2016 Nov 13.

Copyright © 2017 The Korean Society of Neurogastroenterology and MotilityThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background/Aims

Several specific foods are known to precipitate gastroesophageal reflux disease (GERD) symptoms and GERD patients are usually advised to avoid such foods. However, foods consumed daily are quite variable according to regions, cultures, etc. This study was done to elucidate the food items which induce typical GERD symptoms in Korean patients.

Methods

One hundred and twenty-six Korean patients with weekly typical GERD symptoms were asked to mark all food items that induced typical GERD symptoms from a list containing 152 typical foods consumed daily in Korea. All patients underwent upper gastrointestinal endoscopy followed by 24-hour ambulatory esophageal pH monitoring. The definition of “GERD” was if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.

Results

One hundred and twenty-six cases (51 GERD and 75 possible GERD) were enrolled. In 19 (37.3%) of 51 GERD cases and in 17 (22.7%) of 75 possible GERD cases, foods inducing typical GERD symptoms were identified. In the GERD group (n = 19), frequent symptom-inducers were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki. In the possible GERD group (n = 17), frequent symptom-inducers were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizza, topokki, rice cakes, champon noodles, and hotdogs.

Conclusions

In one-third of GERD patients, foods inducing typical symptoms were identified. Hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki were the foods frequently inducing typical symptoms in Korea. The list of foods frequently inducing typical GERD symptoms needs to be modified based on their own local experiences.

Keywords: Food, Gastroesophageal reflux, Korea, Symptom assessment

Introduction

Gastroesophageal reflux disease (GERD) is characterized by abnormal reflux of the gastric contents into the esophagus.1 In most patients with GERD, reflux of gastric juice commonly causes heartburn and regurgitation.2 Barrett’s esophagus, which is a premalignant lesion for esophageal adenocarcinoma, is considered one of the most important complications of GERD. 3

These troublesome symptoms and complications are the main drivers for GERD patients to seek medical attention. The conditions, such as male gender, a presence of a hiatal hernia, history of Helicobacter pylori eradication, current alcohol intake, and abdominal obesity, are known as risk factors for GERD.4,5 Dietary factors traditionally have been thought to induce or worsen GERD. GERD symptoms are commonly reported postprandially, suggesting that some specific diet components are more likely to induce symptoms.4 With the introduction of 24-hour pH monitoring, it has been objectively shown that postprandial reflux is important in reflux symptom profiles.6,7 However, there have been few attempts to measure the effect of specific food stuffs that might provoke or increase gastroesophageal reflux. Although several studies have reported that high-fat foods, spicy foods, chocolate, mint, and citrus fruits are closely related to GERD symptoms,810 the daily consumed foods are quite variable according to race, geographic specificity, diet habit, and culture. The conflicting conditions may cause differences in food-induced GERD symptoms between Asian and Western populations. Therefore, dietary recommendations should be based on local experiences. According to a recent Korean study, dietary categories aggravating typical or atypical GERD symptoms in possible GERD cases were noodles, fatty meals, caffeinated drinks, spicy foods, alcohol, breads, carbonated drinks, and sweets.11

This study was performed to investigate food items that are frequently consumed daily and may be responsible for inducing typical GERD symptoms in confirmed GERD patients in their daily lives in Korea.

Materials and Methods

One hundred and twenty-six consecutive subjects who visited our Digestive Disease Center between February 2009 and September 2014 due to at least weekly typical GERD symptoms (heartburn or regurgitation) for at least 3 months were recruited into this prospective study. Subjects were excluded if they had other significant gastrointestinal diseases (for example, active peptic ulcer disease, infectious conditions of the intestine and gastric malignancy), a history of gastrectomy or severe health problems. Exclusion criteria also included any use of NSAIDs, oral steroids or aspirin, use of proton pump inhibitors or histamine h3 receptor antagonists over the preceding 3 months, and current pregnancy. All subjects provided written informed consent prior to the investigation.

All patients underwent upper gastrointestinal endoscopy to assess the presence and extent of esophageal mucosal breaks. Thereafter, 24-hour ambulatory esophageal pH monitoring was carried out. Patients with GERD symptoms were divided into 2 groups according to the results of endoscopy and pH monitoring; “GERD” if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.

The patients were asked during their first visit whether they experienced their typical GERD symptoms induced by any specific food intake for the preceding 3 months. Then they marked all food items which induced their typical GERD symptoms from a food list containing 152 foods usually consumed daily by Koreans. The food list was made including all individually collected daily food consumption lists from more than 20 hospital staffs and patients. Considering the possibility of omission of any foods, if the patients could not find any symptom-inducing foods of their own from the list, they were instructed to add such foods freely to the list. In addition, they crossed out all food items that they had not consumed for the preceding 3 months from the list.

Symptom-inducing foods were categorized into 2 groups: “frequent symptom-inducers” if they induced symptom(s) in half or more occasions of consumption, and “occasional symptom-inducers” if they induced symptom(s) in less than half occasions of consumption. When any food induced typical GERD symptoms in half or more patients of the group, it was regarded as a meaningful culprit food.

All statistical analyses were conducted using the SPSS statistical software (version 20.0; IBM Corp, Armonk, NY, USA). P-values less than 0.05 were considered statistically significant. The data with continuous variables were expressed as mean ± standard deviation. The estimated internal consistency of the food list questionnaire was assessed through Cronbach’s alpha coefficients.

Written informed consent was obtained from all participants. This study received approval from the institutional review board of Korea University Guro Hospital.

Results

A total of 126 patients completed the study. Among these subjects, the age of 51 GERD patients ranged from 27 to 72 years, and the 75 possible GERD patients were aged 17 to 79 years. In 19 (37.3%) out of the 51 GERD cases and in 17 (22.7%) out of the 75 possible GERD cases, foods inducing typical GERD symptoms were identified (). The Cronbach’s alpha value of the overall questionnaire was 0.77 (95% confidence interval 0.75 – 0.78) among the 152 food items and, therefore, it was acceptable for internal consistency.

Enrolled cases. GERD, gastroesophageal reflux disease.

shows clinical characteristics of the 4 subgroups according to the presence of mucosal breaks and/or pathologic refluxes and symptom-inducing foods. There were no differences in age, gender, height, weight, and body mass index (BMI) between patients with and without symptom-inducing foods in both GERD and possible GERD groups, except a female predominance in the possible GERD group with symptom-inducing foods. Among the patients without symptom-inducing foods, the BMI in GERD patients was significantly greater than that in possible GERD patients (24.9 ± 4.6 vs 22.5 ± 3.7, P = 0.007).

Table 1

Baseline Characteristics According to Status of Gastroesophageal Reflux Disease and Symptom-inducing Foods

GERDP-valuePossible GERDP-value


Food (+)
(n = 19)
Food (−)
(n = 32)
Food (+)
(n = 17)
Food (−)
(n = 58)
Age (mean ± SD)55. 5 ± 9.852.7 ± 11.50.35850.8 ± 13.152.5 ± 14.10.670
Gender (M/F)7/1212/200.9631/1620/380.021
Height (mean ± SD, cm)160.0 ± 10.2161. 5 ± 7.90.554159.3 ± 6.7161.2 ± 8.20.182
Weight (mean ± SD, kg)62.3 ± 11.465.1 ± 13.40.45458.5 ± 7.859.5 ± 13.00.375
BMI (mean ± SD)24.3 ± 3.224. 9 ± 4.60.60923.1 ± 2.122.5 ± 3.70.809

In the GERD group, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki (stir-fried rice cakes). Foods that frequently or occasionally induced GERD symptoms in half or more patients included biscuits, breads, hand-pulled dough soups, hamburgers, doughnuts, spicy noodles with vegetables and seafoods (champon), noodles with stir-fried bean paste (jajangmyeon), alcohols, carbonated beverages, pizzas, mandarins, plain noodles, oranges, and milk ().

Table 2

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms and Percentage of Patients in Gastroesophageal Reflux Disease Cases

GERD patients (n = 19)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews63. 2Hot spicy stews84.2
Rice cakes63.2Ramen noodles84.2
Ramen noodles57.9Fried foods75.0
Fried foods50.0Rice cakes73.7
Topokki50. 0Biscuits64.3
Breads63.2
Hand-pulled dough soups60.0
Topokki56.3
Hamburgers56. 3
Doughnuts55.6
Champon55.6
Jajangmyeon55.6
Alcohols54. 5
Fanta beverages54.5
Pizzas53.3
Mandarins52.6
Plain noodles52. 6
Oranges50.0
Milk50.0

In the possible GERD group, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizzas, topokki, rice cakes, champon, and hotdogs. Moreover, cola, oranges, alcohols, hamburgers, jajangmyeon, hand-pulled dough soups, dumplings, red beans, green tea, and rice cake soups were added to the list of foods that frequently or occasionally induced GERD symptoms in half or more patients ().

Table 3

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms and Percentage of the Patients in Possible Gastroesophageal Reflux Disease Cases

Possible GERD patients (n = 17)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews76. 9Fried foods88.9
Fried foods66.7Hot spicy stews84.6
Doughnuts66.7Topokki81.8
Breads62.5Breads81.3
Ramen noodles57. 1Pizzas77.8
Coffee57.1Rice cakes73.3
Pizzas55.6Coffee71.4
Topokki54.5Doughnuts66.7
Rice cakes53. 3Ramen noodles64.3
Champon50.0Hotdogs62.5
Hotdogs50.0Cola60.0
Oranges58.3
Champon57. 1
Alcohols57.1
Hamburgers57.1
Jajangmyeon55.6
Hand-pulled dough soup53. 8
Dumplings50.0
Red beans50.0
Green tea50.0
Rice cake soups50. 0

In all confirmed or possible GERD cases, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, rice cakes, ramen noodles, fried foods, breads, and topokki. Foods that frequently or occasionally induced GERD symptoms in half or more patients additionally included pizzas, doughnuts, coffee, hand-pulled dough soups, champon, hamburgers, alcohols, jajangmyeon, oranges, biscuits, cola, and plain noodles ().

Table 4

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms, and Percentage of Patients with Gastroesophageal Reflux Disease and Possible Gastroesophageal Reflux Disease Cases

GERD or possible GERD patients (n = 36)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews68. 8Hot spicy stews84.4
Rice cakes58.8Fried foods80.0
Ramen noodles57.6Ramen noodles75.8
Fried foods56.0Rice cakes73.5
Breads54. 3Breads71.4
Topokki51.9Topokki66.7
Pizzas62.5
Doughnuts59.1
Coffee58. 1
Hand-pulled dough soups57.1
Champon56.3
Hamburgers56.0
Alcohols55. 6
Jajangmyeon54.8
Oranges53.1
Biscuits51.9
Cola51. 9
Plain noodles50.0

Discussion

It is commonly accepted that meals can trigger symptoms in GERD patients, but accurate and objective data are limited. Most of the recommendations on changes in dietary habits are not strongly supported by objective measurements. The relationship between foods and GERD in the Korean population still remains unclear. The results of our study show that hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki are frequently inducing typical GERD symptoms in Korean GERD patients.

Although some studies reported that some nutrients and foods are related to the presence of GERD symptoms in Western patients,10,12 there are no well-organized data regarding foods associated with GERD symptoms in Asian patients. In Europe and the United States, some investigators have shown that dietary fat, cholesterol, saturated fatty acid, dietary fiber, and other nutrients are associated with GERD.10,12 They believe that both improved socioeconomic status and the westernized pattern of diet consumption may be associated with the increasing prevalence of GERD in Asians.13 However, the currently available data do not support a strong relationship between GERD and dietary factors in Asians including Koreans. Taken together, our findings support a recommendation for Korean patients with GERD and possible GERD to avoid specific foods because GERD symptoms appear more frequently after consumption of the common symptom-inducing foods. This study also systematically evaluated the role of daily consumed Korean traditional foods as well as westernized foods in GERD symptom generation.

Supporting data exist regarding some specific meals in relation to GERD symptoms. The role of fat in symptom generation has been demonstrated in several studies. 6,1416 In some clinical studies, it was shown that esophageal pH monitoring provides direct evidence on the association between dietary fat and acid reflux, and that high-fat meal decreases the lower esophageal sphincter pressure, increases the rate of transient lower esophageal sphincter relaxation, and delays the gastric emptying,5 which may lead to a greater incidence of reflux.14,15 Spicy foods attributable to direct irritation of already inflamed lower esophageal mucosa may exacerbate heartburn.17 Red pepper, which contains the neurotoxin capsaicin, has been shown to delay gastric emptying,18,19 and it can possibly provoke reflux. Some previous studies have found that an increase in salt consumption was associated with GERD, which was attributed to the inhibited gastric motor activity and delayed gastric emptying after high salt intake.20,21 It was also found that a low-carbohydrate diet reduces distal esophageal acid exposure in 24-hour pH testing and improves GERD symptoms. 22 In a study, ingestion of lactose resulted in an increased number of transient lower esophageal sphincter relaxations, increased reflux episodes, higher esophageal acid exposure, and more severe GERD symptoms in healthy volunteers.23 Similarly, our results also revealed a relationship between the above mentioned tastes or nutrients and GERD symptoms. Many GERD patients are more likely to experience a perceived reflux event when they eat some fatty, spicy, salty foods, and meals with high carbohydrate content. Ramen noodles, hot spicy stews, and topokki are typically spicy and salty Korean traditional foods. Rice cake and bread contain high carbohydrate nutrients. These are the foods to which Koreans have easy access and they are frequently used for main meal replacement.

Conflicting data exist regarding the roles of specific meals in relation to GERD symptoms. In several studies investigating the effect of diet on gastroesophageal reflux, the results have not been consistent. 2426 Certain eating habits, such as eating quickly and irregularly, eating big meals, eating between meals, or eating directly before sleeping, individualized acid hypersensitivity and psychological stress may contribute to the appearance of symptoms.11,27,28 As shown in our study, females were predominant among possible GERD patients with food related symptoms. It may be that females have a tendency to have a sensitive esophagus or to relate to psychological stress.

This is the first study that systematically and prospectively evaluated the role of 152 variable diets with frequency in symptom generation among patients with GERD and possible GERD by permitting multiple choices and using a comprehensive diet tool. In addition, many possible GERD patients, who are commonly encountered in one-third to one-half of the Korean population with GERD symptoms, were enrolled.29 Hence, this study can reflect the actual aspects of the racial, geographic, and cultural specificities in Korean patients with GERD symptoms. Interestingly, most symptom-inducing foods are Korean traditional foods which have been consumed since a long time ago. The recent increase in GERD prevalence in Korea cannot be fully explained by the change to westernized foods. Finally, although a high BMI is a well-known independent risk factor for esophageal erosions, it did not affect esophageal inflammation particularly in patients with food-induced symptoms in our study. This finding is in contrast with patients without food-related symptoms.

This study could be used as a reference for the development and validation of diet recommendations for GERD patients that are applicable to Korean patients. A recent cross-sectional study demonstrated that GERD patients consumed symptom-inducing foods more frequently than in asymptomatic individuals. This suggested that dietary modification could be effective in reducing and managing GERD symptoms.30 Based on our study, a dietary education program for GERD patients could be developed using figures of foods which are familiar to the patients and are encountered daily. It could help physicians and patients to gain an insight into the symptoms possibly related to foods and reinsure avoidance of these foods. Regardless of the emergence of potent medicines (such as improved proton pump inhibitors, transient lower esophageal sphincter relaxation reducers, mucosal protectants, and esophageal-specific pain modulators),31 correctable diet modifications should be emphasized. Avoiding such foods may be important for maintaining patients in a symptom-free state which was attained with medications, although it may not be helpful to induce healing of GERD. Dietary advice such as avoidance of symptom-inducing foods may not be very difficult to follow and can reduce unnecessary medical costs.

Our study has some limitations. First, although we used a rather short time window of 3 months, the recall bias and residual confounding factors (eating habits, lifestyle, and genetic risk factors) might have influenced the results. Second, this study has a limitation stemming from its small sample size. The reason why we could not recruit more cases was that we included only new patients with typical GERD symptoms while excluding users of NSAIDs, oral steroids or aspirin, users of proton pump inhibitors or histamine h3 receptor antagonists over the preceding 3 months, and we included only those who underwent both upper gastrointestinal endoscopy and 24-hour ambulatory pH monitoring. Further researches with a larger scale multicenter national study seem to warrant better clarification of the relationship between foods and GERD symptoms in Korea.

In conclusion, hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki are most common foods that induce typical GERD symptoms in Korean GERD patients. The list of food items that produce typical GERD symptoms in patients from Asian countries needs to be revised substantially from the Western literature based on their own local experiences.

Footnotes

Conflicts of interest: None.

Author contributions: Jung Wan Choe: data analysis, data interpretation, and writing the manuscript; Young-Tae Bak: data acquisition, data analysis, data interpretation, and drafting the manuscript; and Moon Kyung Joo, Hyo Jung Kim, Beom Jae Lee, Ji Hoon Kim, Jong Eun Yeon, Jong-Jae Park, Jae Seon Kim, and Kwan Soo Byun: data acquisition and critical revision of the manuscript.

Financial support: None.

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;101:1900–1920. doi: 10.1111/j.1572-0241.2006.00630.x. [PubMed] [CrossRef] [Google Scholar]2. Kao SS, Chen WC, Hsu PI, et al. The frequencies of gastroesophageal and extragastroesophageal symptoms in patients with mild erosive esophagitis, severe erosive esophagitis, and barrett’s esophagus in Taiwan. Gastroenterol Res Pract. 2013;2013:480325. doi: 10.1155/2013/480325. [PMC free article] [PubMed] [CrossRef] [Google Scholar]3. Falk GW. Gastroesophageal reflux disease and Barrett’s esophagus. Endoscopy. 2001;33:109–118. doi: 10.1055/s-2001-11669. [PubMed] [CrossRef] [Google Scholar]4. Dore MP, Maragkoudakis E, Fraley K, et al. Diet, lifestyle and gender in gastro-esophageal reflux disease. Dig Dis Sci. 2008;53:2027–2032. doi: 10. 1007/s10620-007-0108-7. [PubMed] [CrossRef] [Google Scholar]5. Kulig M, Nocon M, Vieth M, et al. Risk factors of gastroesophageal reflux disease: methodology and first epidemiological results of the ProGERD study. J Clin Epidemiol. 2004;57:580–589. doi: 10.1016/j.jclinepi.2003.10.010. [PubMed] [CrossRef] [Google Scholar]6. Shapiro M, Green C, Bautista JM, et al. Assessment of dietary nutrients that influence perception of intra-oesophageal acid reflux events in patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2007;25:93–101. doi: 10.1111/j.1365-2036.2006.03170.x. [PubMed] [CrossRef] [Google Scholar]7. Ravi K, Francis DL, See JA, Geno DM, Katzka DA. The effects of a weakly acidic meal on gastric buffering and postprandial gastro-oesophageal reflux. Aliment Pharmacol Ther. 2011;34:568–575. doi: 10.1111/j.1365-2036.2011.04761.x. [PubMed] [CrossRef] [Google Scholar]8. Schönfeld J, Evans DF. [Fat, spices and gastro-oesophageal reflux]. Z Gastroenterol. 2007;45:171–175. doi: 10.1055/s-2006-927271. [German] [PubMed] [CrossRef] [Google Scholar]9. Vemulapalli R. Diet and lifestyle modifications in the management of gastroesophageal reflux disease. Nutr Clin Pract. 2008;23:293–298. doi: 10.1177/0884533608318106. [PubMed] [CrossRef] [Google Scholar]10. Wu P, Zhao XH, Ai ZS, et al. Dietary intake and risk for reflux esophagitis: a case-control study. Gastroenterol Res Pract. 2013;2013:691026. doi: 10.1155/2013/691026. [PMC free article] [PubMed] [CrossRef] [Google Scholar]11. Song JH, Chung SJ, Lee JH, et al. Relationship between gastroesophageal reflux symptoms and dietary factors in Korea. J Neurogastroenterol Motil. 2011;17:54–60. doi: 10.5056/jnm.2011.17.1.54. [PMC free article] [PubMed] [CrossRef] [Google Scholar]12. Festi D, Scaioli E, Baldi F, et al. Body weight, lifestyle, dietary habits and gastroesophageal reflux disease. World J Gastroenterol. 2009;15:1690–1701. doi: 10.3748/wjg.15.1690. [PMC free article] [PubMed] [CrossRef] [Google Scholar]13. Wu JC. Gastroesophageal reflux disease: an Asian perspective. J Gastroenterol Hepatol. 2008;23:1785–1793. doi: 10.1111/j.1440-1746.2008.05684.x. [PubMed] [CrossRef] [Google Scholar]14. Iwakiri K, Kobayashi M, Kotoyori M, Yamada H, Sugiura T, Nakagawa Y. Relationship between postprandial esophageal acid exposure and meal volume and fat content. Dig Dis Sci. 1996;41:926–930. doi: 10.1007/BF02091532. [PubMed] [CrossRef] [Google Scholar]15. Holloway RH, Lyrenas E, Ireland A, Dent J. Effect of intraduodenal fat on lower oesophageal sphincter function and gastro-oesophageal reflux. Gut. 1997;40:449–453. doi: 10.1136/gut.40.4.449. [PMC free article] [PubMed] [CrossRef] [Google Scholar]17. Milke P, Diaz A, Valdovinos MA, Moran S. Gastroesophageal reflux in healthy subjects induced by two different species of chilli (Capsicum annum) Dig Dis. 2006;24:184–188. doi: 10.1159/000090323. [PubMed] [CrossRef] [Google Scholar]18. Park HJ, Na SK, Lee SI, Kang JK, Park IS. The effect of red pepper and capsaicin on gastric emptying in human volunteers. Gastroenterology. 1998;114:A818. [Google Scholar]19. Horowitz M, Wishart J, Maddox A, Russo A. The effect of chilli on gastrointestinal transit. J Gastroenterol Hepatol. 1992;7:52–56. doi: 10.1111/j.1440-1746.1992.tb00935.x. [PubMed] [CrossRef] [Google Scholar]20. Tanaka T, Mizumoto A, Muramatsu S, et al. Postprandial normal saline intake delays gastric emptying of solids in conscious dogs: partial involvement of CCK in its mechanism. Dig Dis Sci. 1999;44:1516–1524. doi: 10.1023/A:1026642422375. [PubMed] [CrossRef] [Google Scholar]21. Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux. Gut. 2004;53:1730–1735. doi: 10.1136/gut.2004.043265. [PMC free article] [PubMed] [CrossRef] [Google Scholar]22. Austin GL, Thiny MT, Westman EC, Yancy WS, Jr, Shaheen NJ. A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms. Dig Dis Sci. 2006;51:1307–1312. doi: 10.1007/s10620-005-9027-7. [PubMed] [CrossRef] [Google Scholar]23. Piche T, Zerbib F, Varannes SB, et al. Modulation by colonic fermentation of LES function in humans. Am J Physiol Gastrointest Liver Physiol. 2000;278:G578–G584. [PubMed] [Google Scholar]24. Zheng Z, Nordenstedt H, Pedersen NL, Lagergren J, Ye W. Lifestyle factors and risk for symptomatic gastroesophageal reflux in monozygotic twins. Gastroenterology. 2007;132:87–95. doi: 10.1053/j.gastro.2006.11.019. [PMC free article] [PubMed] [CrossRef] [Google Scholar]25. Nandurkar S, Locke Gr, 3rd, Fett S, Zinsmeister AR, Cameron AJ, Talley NJ. Relationship between body mass index, diet, exercise and gastro-oesophageal reflux symptoms in a community. Aliment Pharmacol Ther. 2004;20:497–505. doi: 10.1111/j.1365-2036.2004.02156.x. [PubMed] [CrossRef] [Google Scholar]26. Ruhl CE, Everhart JE. Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization: the NHANES I epidemiologic followup study. First national health and nutrition ezamination survey. Ann Epidemiol. 1999;9:424–435. doi: 10.1016/S1047-2797(99)00020-4. [PubMed] [CrossRef] [Google Scholar]27. Yang JH, Kang HS, Lee SY, et al. Recurrence of gastroesophageal reflux disease correlated with a short dinner-to-bedtime interval. J Gastroenterol Hepatol. 2014;29:730–735. doi: 10.1111/jgh.12455. [PubMed] [CrossRef] [Google Scholar]28. Matsuki N, Fujita T, Watanabe N, et al. Lifestyle factors associated with gastroesophageal reflux disease in the Japanese population. J Gastroenterol. 2013;48:340–349. doi: 10.1007/s00535-012-0649-1. [PubMed] [CrossRef] [Google Scholar]29. Kim N, Lee SW, Cho SI, et al. The prevalence of and risk factors for erosive oesophagitis and non-erosive reflux disease: a nationwide multicentre prospective study in Korea. Aliment Pharmacol Ther. 2008;27:173–185. doi: 10.1111/j.1365-2036.2007.03561.x. [PubMed] [CrossRef] [Google Scholar]30. Kubo A, Block G, Quesenberry CP, Buffler P, Corley DA. Dietary guideline adherence for gastroesophageal reflux disease. BMC Gastroenterol. 2014;14:144. doi: 10.1186/1471-230X-14-144. [PMC free article] [PubMed] [CrossRef] [Google Scholar]31. Maradey-Romero C, Fass R. New and future drug development for gastroesophageal reflux disease. J Neurogastroenterol Motil. 2014;20:6–16. doi: 10.5056/jnm.2014.20.1.6. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

Foods Inducing Typical Gastroesophageal Reflux Disease Symptoms in Korea

J Neurogastroenterol Motil. 2017 Jul; 23(3): 363–369.

Department of Gastroenterology, Korea University Guro Hospital, Seoul,
Korea

*Correspondence: Young-Tae Bak, MD, Department of Gastroenterology, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea, Tel: +82-2-2626-1778, Fax: +82-504-366-6381, E-mail: rk.ca.aerok@tykabrd

Received 2016 Jul 28; Revised 2016 Oct 17; Accepted 2016 Nov 13.

Copyright © 2017 The Korean Society of Neurogastroenterology and MotilityThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background/Aims

Several specific foods are known to precipitate gastroesophageal reflux disease (GERD) symptoms and GERD patients are usually advised to avoid such foods. However, foods consumed daily are quite variable according to regions, cultures, etc. This study was done to elucidate the food items which induce typical GERD symptoms in Korean patients.

Methods

One hundred and twenty-six Korean patients with weekly typical GERD symptoms were asked to mark all food items that induced typical GERD symptoms from a list containing 152 typical foods consumed daily in Korea. All patients underwent upper gastrointestinal endoscopy followed by 24-hour ambulatory esophageal pH monitoring. The definition of “GERD” was if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.

Results

One hundred and twenty-six cases (51 GERD and 75 possible GERD) were enrolled. In 19 (37.3%) of 51 GERD cases and in 17 (22.7%) of 75 possible GERD cases, foods inducing typical GERD symptoms were identified. In the GERD group (n = 19), frequent symptom-inducers were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki. In the possible GERD group (n = 17), frequent symptom-inducers were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizza, topokki, rice cakes, champon noodles, and hotdogs.

Conclusions

In one-third of GERD patients, foods inducing typical symptoms were identified. Hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki were the foods frequently inducing typical symptoms in Korea. The list of foods frequently inducing typical GERD symptoms needs to be modified based on their own local experiences.

Keywords: Food, Gastroesophageal reflux, Korea, Symptom assessment

Introduction

Gastroesophageal reflux disease (GERD) is characterized by abnormal reflux of the gastric contents into the esophagus. 1 In most patients with GERD, reflux of gastric juice commonly causes heartburn and regurgitation.2 Barrett’s esophagus, which is a premalignant lesion for esophageal adenocarcinoma, is considered one of the most important complications of GERD.3

These troublesome symptoms and complications are the main drivers for GERD patients to seek medical attention. The conditions, such as male gender, a presence of a hiatal hernia, history of Helicobacter pylori eradication, current alcohol intake, and abdominal obesity, are known as risk factors for GERD.4,5 Dietary factors traditionally have been thought to induce or worsen GERD. GERD symptoms are commonly reported postprandially, suggesting that some specific diet components are more likely to induce symptoms.4 With the introduction of 24-hour pH monitoring, it has been objectively shown that postprandial reflux is important in reflux symptom profiles.6,7 However, there have been few attempts to measure the effect of specific food stuffs that might provoke or increase gastroesophageal reflux. Although several studies have reported that high-fat foods, spicy foods, chocolate, mint, and citrus fruits are closely related to GERD symptoms,810 the daily consumed foods are quite variable according to race, geographic specificity, diet habit, and culture. The conflicting conditions may cause differences in food-induced GERD symptoms between Asian and Western populations. Therefore, dietary recommendations should be based on local experiences. According to a recent Korean study, dietary categories aggravating typical or atypical GERD symptoms in possible GERD cases were noodles, fatty meals, caffeinated drinks, spicy foods, alcohol, breads, carbonated drinks, and sweets.11

This study was performed to investigate food items that are frequently consumed daily and may be responsible for inducing typical GERD symptoms in confirmed GERD patients in their daily lives in Korea.

Materials and Methods

One hundred and twenty-six consecutive subjects who visited our Digestive Disease Center between February 2009 and September 2014 due to at least weekly typical GERD symptoms (heartburn or regurgitation) for at least 3 months were recruited into this prospective study. Subjects were excluded if they had other significant gastrointestinal diseases (for example, active peptic ulcer disease, infectious conditions of the intestine and gastric malignancy), a history of gastrectomy or severe health problems. Exclusion criteria also included any use of NSAIDs, oral steroids or aspirin, use of proton pump inhibitors or histamine h3 receptor antagonists over the preceding 3 months, and current pregnancy. All subjects provided written informed consent prior to the investigation.

All patients underwent upper gastrointestinal endoscopy to assess the presence and extent of esophageal mucosal breaks. Thereafter, 24-hour ambulatory esophageal pH monitoring was carried out. Patients with GERD symptoms were divided into 2 groups according to the results of endoscopy and pH monitoring; “GERD” if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.

The patients were asked during their first visit whether they experienced their typical GERD symptoms induced by any specific food intake for the preceding 3 months. Then they marked all food items which induced their typical GERD symptoms from a food list containing 152 foods usually consumed daily by Koreans. The food list was made including all individually collected daily food consumption lists from more than 20 hospital staffs and patients. Considering the possibility of omission of any foods, if the patients could not find any symptom-inducing foods of their own from the list, they were instructed to add such foods freely to the list. In addition, they crossed out all food items that they had not consumed for the preceding 3 months from the list.

Symptom-inducing foods were categorized into 2 groups: “frequent symptom-inducers” if they induced symptom(s) in half or more occasions of consumption, and “occasional symptom-inducers” if they induced symptom(s) in less than half occasions of consumption. When any food induced typical GERD symptoms in half or more patients of the group, it was regarded as a meaningful culprit food.

All statistical analyses were conducted using the SPSS statistical software (version 20. 0; IBM Corp, Armonk, NY, USA). P-values less than 0.05 were considered statistically significant. The data with continuous variables were expressed as mean ± standard deviation. The estimated internal consistency of the food list questionnaire was assessed through Cronbach’s alpha coefficients.

Written informed consent was obtained from all participants. This study received approval from the institutional review board of Korea University Guro Hospital.

Results

A total of 126 patients completed the study. Among these subjects, the age of 51 GERD patients ranged from 27 to 72 years, and the 75 possible GERD patients were aged 17 to 79 years. In 19 (37.3%) out of the 51 GERD cases and in 17 (22.7%) out of the 75 possible GERD cases, foods inducing typical GERD symptoms were identified (). The Cronbach’s alpha value of the overall questionnaire was 0.77 (95% confidence interval 0.75 – 0.78) among the 152 food items and, therefore, it was acceptable for internal consistency.

Enrolled cases. GERD, gastroesophageal reflux disease.

shows clinical characteristics of the 4 subgroups according to the presence of mucosal breaks and/or pathologic refluxes and symptom-inducing foods. There were no differences in age, gender, height, weight, and body mass index (BMI) between patients with and without symptom-inducing foods in both GERD and possible GERD groups, except a female predominance in the possible GERD group with symptom-inducing foods. Among the patients without symptom-inducing foods, the BMI in GERD patients was significantly greater than that in possible GERD patients (24.9 ± 4.6 vs 22.5 ± 3.7, P = 0.007).

Table 1

Baseline Characteristics According to Status of Gastroesophageal Reflux Disease and Symptom-inducing Foods

GERDP-valuePossible GERDP-value


Food (+)
(n = 19)
Food (−)
(n = 32)
Food (+)
(n = 17)
Food (−)
(n = 58)
Age (mean ± SD)55. 5 ± 9.852.7 ± 11.50.35850.8 ± 13.152.5 ± 14.10.670
Gender (M/F)7/1212/200.9631/1620/380.021
Height (mean ± SD, cm)160.0 ± 10.2161. 5 ± 7.90.554159.3 ± 6.7161.2 ± 8.20.182
Weight (mean ± SD, kg)62.3 ± 11.465.1 ± 13.40.45458.5 ± 7.859.5 ± 13.00.375
BMI (mean ± SD)24.3 ± 3.224. 9 ± 4.60.60923.1 ± 2.122.5 ± 3.70.809

In the GERD group, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki (stir-fried rice cakes). Foods that frequently or occasionally induced GERD symptoms in half or more patients included biscuits, breads, hand-pulled dough soups, hamburgers, doughnuts, spicy noodles with vegetables and seafoods (champon), noodles with stir-fried bean paste (jajangmyeon), alcohols, carbonated beverages, pizzas, mandarins, plain noodles, oranges, and milk ().

Table 2

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms and Percentage of Patients in Gastroesophageal Reflux Disease Cases

GERD patients (n = 19)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews63. 2Hot spicy stews84.2
Rice cakes63.2Ramen noodles84.2
Ramen noodles57.9Fried foods75.0
Fried foods50.0Rice cakes73.7
Topokki50. 0Biscuits64.3
Breads63.2
Hand-pulled dough soups60.0
Topokki56.3
Hamburgers56. 3
Doughnuts55.6
Champon55.6
Jajangmyeon55.6
Alcohols54. 5
Fanta beverages54.5
Pizzas53.3
Mandarins52.6
Plain noodles52. 6
Oranges50.0
Milk50.0

In the possible GERD group, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizzas, topokki, rice cakes, champon, and hotdogs. Moreover, cola, oranges, alcohols, hamburgers, jajangmyeon, hand-pulled dough soups, dumplings, red beans, green tea, and rice cake soups were added to the list of foods that frequently or occasionally induced GERD symptoms in half or more patients ().

Table 3

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms and Percentage of the Patients in Possible Gastroesophageal Reflux Disease Cases

Possible GERD patients (n = 17)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews76. 9Fried foods88.9
Fried foods66.7Hot spicy stews84.6
Doughnuts66.7Topokki81.8
Breads62.5Breads81.3
Ramen noodles57. 1Pizzas77.8
Coffee57.1Rice cakes73.3
Pizzas55.6Coffee71.4
Topokki54.5Doughnuts66.7
Rice cakes53. 3Ramen noodles64.3
Champon50.0Hotdogs62.5
Hotdogs50.0Cola60.0
Oranges58.3
Champon57. 1
Alcohols57.1
Hamburgers57.1
Jajangmyeon55.6
Hand-pulled dough soup53. 8
Dumplings50.0
Red beans50.0
Green tea50.0
Rice cake soups50. 0

In all confirmed or possible GERD cases, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, rice cakes, ramen noodles, fried foods, breads, and topokki. Foods that frequently or occasionally induced GERD symptoms in half or more patients additionally included pizzas, doughnuts, coffee, hand-pulled dough soups, champon, hamburgers, alcohols, jajangmyeon, oranges, biscuits, cola, and plain noodles ().

Table 4

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms, and Percentage of Patients with Gastroesophageal Reflux Disease and Possible Gastroesophageal Reflux Disease Cases

GERD or possible GERD patients (n = 36)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews68. 8Hot spicy stews84.4
Rice cakes58.8Fried foods80.0
Ramen noodles57.6Ramen noodles75.8
Fried foods56.0Rice cakes73.5
Breads54. 3Breads71.4
Topokki51.9Topokki66.7
Pizzas62.5
Doughnuts59.1
Coffee58. 1
Hand-pulled dough soups57.1
Champon56.3
Hamburgers56.0
Alcohols55. 6
Jajangmyeon54.8
Oranges53.1
Biscuits51.9
Cola51. 9
Plain noodles50.0

Discussion

It is commonly accepted that meals can trigger symptoms in GERD patients, but accurate and objective data are limited. Most of the recommendations on changes in dietary habits are not strongly supported by objective measurements. The relationship between foods and GERD in the Korean population still remains unclear. The results of our study show that hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki are frequently inducing typical GERD symptoms in Korean GERD patients.

Although some studies reported that some nutrients and foods are related to the presence of GERD symptoms in Western patients,10,12 there are no well-organized data regarding foods associated with GERD symptoms in Asian patients. In Europe and the United States, some investigators have shown that dietary fat, cholesterol, saturated fatty acid, dietary fiber, and other nutrients are associated with GERD.10,12 They believe that both improved socioeconomic status and the westernized pattern of diet consumption may be associated with the increasing prevalence of GERD in Asians.13 However, the currently available data do not support a strong relationship between GERD and dietary factors in Asians including Koreans. Taken together, our findings support a recommendation for Korean patients with GERD and possible GERD to avoid specific foods because GERD symptoms appear more frequently after consumption of the common symptom-inducing foods. This study also systematically evaluated the role of daily consumed Korean traditional foods as well as westernized foods in GERD symptom generation.

Supporting data exist regarding some specific meals in relation to GERD symptoms. The role of fat in symptom generation has been demonstrated in several studies.6,1416 In some clinical studies, it was shown that esophageal pH monitoring provides direct evidence on the association between dietary fat and acid reflux, and that high-fat meal decreases the lower esophageal sphincter pressure, increases the rate of transient lower esophageal sphincter relaxation, and delays the gastric emptying,5 which may lead to a greater incidence of reflux.14,15 Spicy foods attributable to direct irritation of already inflamed lower esophageal mucosa may exacerbate heartburn.17 Red pepper, which contains the neurotoxin capsaicin, has been shown to delay gastric emptying,18,19 and it can possibly provoke reflux. Some previous studies have found that an increase in salt consumption was associated with GERD, which was attributed to the inhibited gastric motor activity and delayed gastric emptying after high salt intake.20,21 It was also found that a low-carbohydrate diet reduces distal esophageal acid exposure in 24-hour pH testing and improves GERD symptoms.22 In a study, ingestion of lactose resulted in an increased number of transient lower esophageal sphincter relaxations, increased reflux episodes, higher esophageal acid exposure, and more severe GERD symptoms in healthy volunteers.23 Similarly, our results also revealed a relationship between the above mentioned tastes or nutrients and GERD symptoms. Many GERD patients are more likely to experience a perceived reflux event when they eat some fatty, spicy, salty foods, and meals with high carbohydrate content. Ramen noodles, hot spicy stews, and topokki are typically spicy and salty Korean traditional foods. Rice cake and bread contain high carbohydrate nutrients. These are the foods to which Koreans have easy access and they are frequently used for main meal replacement.

Conflicting data exist regarding the roles of specific meals in relation to GERD symptoms. In several studies investigating the effect of diet on gastroesophageal reflux, the results have not been consistent.2426 Certain eating habits, such as eating quickly and irregularly, eating big meals, eating between meals, or eating directly before sleeping, individualized acid hypersensitivity and psychological stress may contribute to the appearance of symptoms.11,27,28 As shown in our study, females were predominant among possible GERD patients with food related symptoms. It may be that females have a tendency to have a sensitive esophagus or to relate to psychological stress.

This is the first study that systematically and prospectively evaluated the role of 152 variable diets with frequency in symptom generation among patients with GERD and possible GERD by permitting multiple choices and using a comprehensive diet tool. In addition, many possible GERD patients, who are commonly encountered in one-third to one-half of the Korean population with GERD symptoms, were enrolled.29 Hence, this study can reflect the actual aspects of the racial, geographic, and cultural specificities in Korean patients with GERD symptoms. Interestingly, most symptom-inducing foods are Korean traditional foods which have been consumed since a long time ago. The recent increase in GERD prevalence in Korea cannot be fully explained by the change to westernized foods. Finally, although a high BMI is a well-known independent risk factor for esophageal erosions, it did not affect esophageal inflammation particularly in patients with food-induced symptoms in our study. This finding is in contrast with patients without food-related symptoms.

This study could be used as a reference for the development and validation of diet recommendations for GERD patients that are applicable to Korean patients. A recent cross-sectional study demonstrated that GERD patients consumed symptom-inducing foods more frequently than in asymptomatic individuals. This suggested that dietary modification could be effective in reducing and managing GERD symptoms.30 Based on our study, a dietary education program for GERD patients could be developed using figures of foods which are familiar to the patients and are encountered daily. It could help physicians and patients to gain an insight into the symptoms possibly related to foods and reinsure avoidance of these foods. Regardless of the emergence of potent medicines (such as improved proton pump inhibitors, transient lower esophageal sphincter relaxation reducers, mucosal protectants, and esophageal-specific pain modulators),31 correctable diet modifications should be emphasized. Avoiding such foods may be important for maintaining patients in a symptom-free state which was attained with medications, although it may not be helpful to induce healing of GERD. Dietary advice such as avoidance of symptom-inducing foods may not be very difficult to follow and can reduce unnecessary medical costs.

Our study has some limitations. First, although we used a rather short time window of 3 months, the recall bias and residual confounding factors (eating habits, lifestyle, and genetic risk factors) might have influenced the results. Second, this study has a limitation stemming from its small sample size. The reason why we could not recruit more cases was that we included only new patients with typical GERD symptoms while excluding users of NSAIDs, oral steroids or aspirin, users of proton pump inhibitors or histamine h3 receptor antagonists over the preceding 3 months, and we included only those who underwent both upper gastrointestinal endoscopy and 24-hour ambulatory pH monitoring. Further researches with a larger scale multicenter national study seem to warrant better clarification of the relationship between foods and GERD symptoms in Korea.

In conclusion, hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki are most common foods that induce typical GERD symptoms in Korean GERD patients. The list of food items that produce typical GERD symptoms in patients from Asian countries needs to be revised substantially from the Western literature based on their own local experiences.

Footnotes

Conflicts of interest: None.

Author contributions: Jung Wan Choe: data analysis, data interpretation, and writing the manuscript; Young-Tae Bak: data acquisition, data analysis, data interpretation, and drafting the manuscript; and Moon Kyung Joo, Hyo Jung Kim, Beom Jae Lee, Ji Hoon Kim, Jong Eun Yeon, Jong-Jae Park, Jae Seon Kim, and Kwan Soo Byun: data acquisition and critical revision of the manuscript.

Financial support: None.

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;101:1900–1920. doi: 10.1111/j.1572-0241.2006.00630.x. [PubMed] [CrossRef] [Google Scholar]2. Kao SS, Chen WC, Hsu PI, et al. The frequencies of gastroesophageal and extragastroesophageal symptoms in patients with mild erosive esophagitis, severe erosive esophagitis, and barrett’s esophagus in Taiwan. Gastroenterol Res Pract. 2013;2013:480325. doi: 10.1155/2013/480325. [PMC free article] [PubMed] [CrossRef] [Google Scholar]3. Falk GW. Gastroesophageal reflux disease and Barrett’s esophagus. Endoscopy. 2001;33:109–118. doi: 10.1055/s-2001-11669. [PubMed] [CrossRef] [Google Scholar]4. Dore MP, Maragkoudakis E, Fraley K, et al. Diet, lifestyle and gender in gastro-esophageal reflux disease. Dig Dis Sci. 2008;53:2027–2032. doi: 10.1007/s10620-007-0108-7. [PubMed] [CrossRef] [Google Scholar]5. Kulig M, Nocon M, Vieth M, et al. Risk factors of gastroesophageal reflux disease: methodology and first epidemiological results of the ProGERD study. J Clin Epidemiol. 2004;57:580–589. doi: 10.1016/j.jclinepi.2003.10.010. [PubMed] [CrossRef] [Google Scholar]6. Shapiro M, Green C, Bautista JM, et al. Assessment of dietary nutrients that influence perception of intra-oesophageal acid reflux events in patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2007;25:93–101. doi: 10.1111/j.1365-2036.2006.03170.x. [PubMed] [CrossRef] [Google Scholar]7. Ravi K, Francis DL, See JA, Geno DM, Katzka DA. The effects of a weakly acidic meal on gastric buffering and postprandial gastro-oesophageal reflux. Aliment Pharmacol Ther. 2011;34:568–575. doi: 10.1111/j.1365-2036.2011.04761.x. [PubMed] [CrossRef] [Google Scholar]8. Schönfeld J, Evans DF. [Fat, spices and gastro-oesophageal reflux]. Z Gastroenterol. 2007;45:171–175. doi: 10.1055/s-2006-927271. [German] [PubMed] [CrossRef] [Google Scholar]9. Vemulapalli R. Diet and lifestyle modifications in the management of gastroesophageal reflux disease. Nutr Clin Pract. 2008;23:293–298. doi: 10.1177/0884533608318106. [PubMed] [CrossRef] [Google Scholar]10. Wu P, Zhao XH, Ai ZS, et al. Dietary intake and risk for reflux esophagitis: a case-control study. Gastroenterol Res Pract. 2013;2013:691026. doi: 10.1155/2013/691026. [PMC free article] [PubMed] [CrossRef] [Google Scholar]11. Song JH, Chung SJ, Lee JH, et al. Relationship between gastroesophageal reflux symptoms and dietary factors in Korea. J Neurogastroenterol Motil. 2011;17:54–60. doi: 10.5056/jnm.2011.17.1.54. [PMC free article] [PubMed] [CrossRef] [Google Scholar]12. Festi D, Scaioli E, Baldi F, et al. Body weight, lifestyle, dietary habits and gastroesophageal reflux disease. World J Gastroenterol. 2009;15:1690–1701. doi: 10.3748/wjg.15.1690. [PMC free article] [PubMed] [CrossRef] [Google Scholar]13. Wu JC. Gastroesophageal reflux disease: an Asian perspective. J Gastroenterol Hepatol. 2008;23:1785–1793. doi: 10.1111/j.1440-1746.2008.05684.x. [PubMed] [CrossRef] [Google Scholar]14. Iwakiri K, Kobayashi M, Kotoyori M, Yamada H, Sugiura T, Nakagawa Y. Relationship between postprandial esophageal acid exposure and meal volume and fat content. Dig Dis Sci. 1996;41:926–930. doi: 10.1007/BF02091532. [PubMed] [CrossRef] [Google Scholar]15. Holloway RH, Lyrenas E, Ireland A, Dent J. Effect of intraduodenal fat on lower oesophageal sphincter function and gastro-oesophageal reflux. Gut. 1997;40:449–453. doi: 10.1136/gut.40.4.449. [PMC free article] [PubMed] [CrossRef] [Google Scholar]17. Milke P, Diaz A, Valdovinos MA, Moran S. Gastroesophageal reflux in healthy subjects induced by two different species of chilli (Capsicum annum) Dig Dis. 2006;24:184–188. doi: 10.1159/000090323. [PubMed] [CrossRef] [Google Scholar]18. Park HJ, Na SK, Lee SI, Kang JK, Park IS. The effect of red pepper and capsaicin on gastric emptying in human volunteers. Gastroenterology. 1998;114:A818. [Google Scholar]19. Horowitz M, Wishart J, Maddox A, Russo A. The effect of chilli on gastrointestinal transit. J Gastroenterol Hepatol. 1992;7:52–56. doi: 10.1111/j.1440-1746.1992.tb00935.x. [PubMed] [CrossRef] [Google Scholar]20. Tanaka T, Mizumoto A, Muramatsu S, et al. Postprandial normal saline intake delays gastric emptying of solids in conscious dogs: partial involvement of CCK in its mechanism. Dig Dis Sci. 1999;44:1516–1524. doi: 10.1023/A:1026642422375. [PubMed] [CrossRef] [Google Scholar]21. Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux. Gut. 2004;53:1730–1735. doi: 10.1136/gut.2004.043265. [PMC free article] [PubMed] [CrossRef] [Google Scholar]22. Austin GL, Thiny MT, Westman EC, Yancy WS, Jr, Shaheen NJ. A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms. Dig Dis Sci. 2006;51:1307–1312. doi: 10.1007/s10620-005-9027-7. [PubMed] [CrossRef] [Google Scholar]23. Piche T, Zerbib F, Varannes SB, et al. Modulation by colonic fermentation of LES function in humans. Am J Physiol Gastrointest Liver Physiol. 2000;278:G578–G584. [PubMed] [Google Scholar]24. Zheng Z, Nordenstedt H, Pedersen NL, Lagergren J, Ye W. Lifestyle factors and risk for symptomatic gastroesophageal reflux in monozygotic twins. Gastroenterology. 2007;132:87–95. doi: 10.1053/j.gastro.2006.11.019. [PMC free article] [PubMed] [CrossRef] [Google Scholar]25. Nandurkar S, Locke Gr, 3rd, Fett S, Zinsmeister AR, Cameron AJ, Talley NJ. Relationship between body mass index, diet, exercise and gastro-oesophageal reflux symptoms in a community. Aliment Pharmacol Ther. 2004;20:497–505. doi: 10.1111/j.1365-2036.2004.02156.x. [PubMed] [CrossRef] [Google Scholar]26. Ruhl CE, Everhart JE. Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization: the NHANES I epidemiologic followup study. First national health and nutrition ezamination survey. Ann Epidemiol. 1999;9:424–435. doi: 10.1016/S1047-2797(99)00020-4. [PubMed] [CrossRef] [Google Scholar]27. Yang JH, Kang HS, Lee SY, et al. Recurrence of gastroesophageal reflux disease correlated with a short dinner-to-bedtime interval. J Gastroenterol Hepatol. 2014;29:730–735. doi: 10.1111/jgh.12455. [PubMed] [CrossRef] [Google Scholar]28. Matsuki N, Fujita T, Watanabe N, et al. Lifestyle factors associated with gastroesophageal reflux disease in the Japanese population. J Gastroenterol. 2013;48:340–349. doi: 10.1007/s00535-012-0649-1. [PubMed] [CrossRef] [Google Scholar]29. Kim N, Lee SW, Cho SI, et al. The prevalence of and risk factors for erosive oesophagitis and non-erosive reflux disease: a nationwide multicentre prospective study in Korea. Aliment Pharmacol Ther. 2008;27:173–185. doi: 10.1111/j.1365-2036.2007.03561.x. [PubMed] [CrossRef] [Google Scholar]30. Kubo A, Block G, Quesenberry CP, Buffler P, Corley DA. Dietary guideline adherence for gastroesophageal reflux disease. BMC Gastroenterol. 2014;14:144. doi: 10.1186/1471-230X-14-144. [PMC free article] [PubMed] [CrossRef] [Google Scholar]31. Maradey-Romero C, Fass R. New and future drug development for gastroesophageal reflux disease. J Neurogastroenterol Motil. 2014;20:6–16. doi: 10.5056/jnm.2014.20.1.6. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

Foods Inducing Typical Gastroesophageal Reflux Disease Symptoms in Korea

J Neurogastroenterol Motil. 2017 Jul; 23(3): 363–369.

Department of Gastroenterology, Korea University Guro Hospital, Seoul,
Korea

*Correspondence: Young-Tae Bak, MD, Department of Gastroenterology, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea, Tel: +82-2-2626-1778, Fax: +82-504-366-6381, E-mail: rk.ca.aerok@tykabrd

Received 2016 Jul 28; Revised 2016 Oct 17; Accepted 2016 Nov 13.

Copyright © 2017 The Korean Society of Neurogastroenterology and MotilityThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background/Aims

Several specific foods are known to precipitate gastroesophageal reflux disease (GERD) symptoms and GERD patients are usually advised to avoid such foods. However, foods consumed daily are quite variable according to regions, cultures, etc. This study was done to elucidate the food items which induce typical GERD symptoms in Korean patients.

Methods

One hundred and twenty-six Korean patients with weekly typical GERD symptoms were asked to mark all food items that induced typical GERD symptoms from a list containing 152 typical foods consumed daily in Korea. All patients underwent upper gastrointestinal endoscopy followed by 24-hour ambulatory esophageal pH monitoring. The definition of “GERD” was if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.

Results

One hundred and twenty-six cases (51 GERD and 75 possible GERD) were enrolled. In 19 (37.3%) of 51 GERD cases and in 17 (22.7%) of 75 possible GERD cases, foods inducing typical GERD symptoms were identified. In the GERD group (n = 19), frequent symptom-inducers were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki. In the possible GERD group (n = 17), frequent symptom-inducers were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizza, topokki, rice cakes, champon noodles, and hotdogs.

Conclusions

In one-third of GERD patients, foods inducing typical symptoms were identified. Hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki were the foods frequently inducing typical symptoms in Korea. The list of foods frequently inducing typical GERD symptoms needs to be modified based on their own local experiences.

Keywords: Food, Gastroesophageal reflux, Korea, Symptom assessment

Introduction

Gastroesophageal reflux disease (GERD) is characterized by abnormal reflux of the gastric contents into the esophagus.1 In most patients with GERD, reflux of gastric juice commonly causes heartburn and regurgitation.2 Barrett’s esophagus, which is a premalignant lesion for esophageal adenocarcinoma, is considered one of the most important complications of GERD.3

These troublesome symptoms and complications are the main drivers for GERD patients to seek medical attention. The conditions, such as male gender, a presence of a hiatal hernia, history of Helicobacter pylori eradication, current alcohol intake, and abdominal obesity, are known as risk factors for GERD.4,5 Dietary factors traditionally have been thought to induce or worsen GERD. GERD symptoms are commonly reported postprandially, suggesting that some specific diet components are more likely to induce symptoms.4 With the introduction of 24-hour pH monitoring, it has been objectively shown that postprandial reflux is important in reflux symptom profiles.6,7 However, there have been few attempts to measure the effect of specific food stuffs that might provoke or increase gastroesophageal reflux. Although several studies have reported that high-fat foods, spicy foods, chocolate, mint, and citrus fruits are closely related to GERD symptoms,810 the daily consumed foods are quite variable according to race, geographic specificity, diet habit, and culture. The conflicting conditions may cause differences in food-induced GERD symptoms between Asian and Western populations. Therefore, dietary recommendations should be based on local experiences. According to a recent Korean study, dietary categories aggravating typical or atypical GERD symptoms in possible GERD cases were noodles, fatty meals, caffeinated drinks, spicy foods, alcohol, breads, carbonated drinks, and sweets.11

This study was performed to investigate food items that are frequently consumed daily and may be responsible for inducing typical GERD symptoms in confirmed GERD patients in their daily lives in Korea.

Materials and Methods

One hundred and twenty-six consecutive subjects who visited our Digestive Disease Center between February 2009 and September 2014 due to at least weekly typical GERD symptoms (heartburn or regurgitation) for at least 3 months were recruited into this prospective study. Subjects were excluded if they had other significant gastrointestinal diseases (for example, active peptic ulcer disease, infectious conditions of the intestine and gastric malignancy), a history of gastrectomy or severe health problems. Exclusion criteria also included any use of NSAIDs, oral steroids or aspirin, use of proton pump inhibitors or histamine h3 receptor antagonists over the preceding 3 months, and current pregnancy. All subjects provided written informed consent prior to the investigation.

All patients underwent upper gastrointestinal endoscopy to assess the presence and extent of esophageal mucosal breaks. Thereafter, 24-hour ambulatory esophageal pH monitoring was carried out. Patients with GERD symptoms were divided into 2 groups according to the results of endoscopy and pH monitoring; “GERD” if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.

The patients were asked during their first visit whether they experienced their typical GERD symptoms induced by any specific food intake for the preceding 3 months. Then they marked all food items which induced their typical GERD symptoms from a food list containing 152 foods usually consumed daily by Koreans. The food list was made including all individually collected daily food consumption lists from more than 20 hospital staffs and patients. Considering the possibility of omission of any foods, if the patients could not find any symptom-inducing foods of their own from the list, they were instructed to add such foods freely to the list. In addition, they crossed out all food items that they had not consumed for the preceding 3 months from the list.

Symptom-inducing foods were categorized into 2 groups: “frequent symptom-inducers” if they induced symptom(s) in half or more occasions of consumption, and “occasional symptom-inducers” if they induced symptom(s) in less than half occasions of consumption. When any food induced typical GERD symptoms in half or more patients of the group, it was regarded as a meaningful culprit food.

All statistical analyses were conducted using the SPSS statistical software (version 20.0; IBM Corp, Armonk, NY, USA). P-values less than 0.05 were considered statistically significant. The data with continuous variables were expressed as mean ± standard deviation. The estimated internal consistency of the food list questionnaire was assessed through Cronbach’s alpha coefficients.

Written informed consent was obtained from all participants. This study received approval from the institutional review board of Korea University Guro Hospital.

Results

A total of 126 patients completed the study. Among these subjects, the age of 51 GERD patients ranged from 27 to 72 years, and the 75 possible GERD patients were aged 17 to 79 years. In 19 (37.3%) out of the 51 GERD cases and in 17 (22.7%) out of the 75 possible GERD cases, foods inducing typical GERD symptoms were identified (). The Cronbach’s alpha value of the overall questionnaire was 0.77 (95% confidence interval 0.75 – 0.78) among the 152 food items and, therefore, it was acceptable for internal consistency.

Enrolled cases. GERD, gastroesophageal reflux disease.

shows clinical characteristics of the 4 subgroups according to the presence of mucosal breaks and/or pathologic refluxes and symptom-inducing foods. There were no differences in age, gender, height, weight, and body mass index (BMI) between patients with and without symptom-inducing foods in both GERD and possible GERD groups, except a female predominance in the possible GERD group with symptom-inducing foods. Among the patients without symptom-inducing foods, the BMI in GERD patients was significantly greater than that in possible GERD patients (24.9 ± 4.6 vs 22.5 ± 3.7, P = 0.007).

Table 1

Baseline Characteristics According to Status of Gastroesophageal Reflux Disease and Symptom-inducing Foods

GERDP-valuePossible GERDP-value


Food (+)
(n = 19)
Food (−)
(n = 32)
Food (+)
(n = 17)
Food (−)
(n = 58)
Age (mean ± SD)55.5 ± 9.852.7 ± 11.50.35850.8 ± 13.152.5 ± 14.10.670
Gender (M/F)7/1212/200.9631/1620/380.021
Height (mean ± SD, cm)160.0 ± 10.2161.5 ± 7.90.554159.3 ± 6.7161.2 ± 8.20.182
Weight (mean ± SD, kg)62.3 ± 11.465.1 ± 13.40.45458.5 ± 7.859.5 ± 13.00.375
BMI (mean ± SD)24.3 ± 3.224.9 ± 4.60.60923.1 ± 2.122.5 ± 3.70.809

In the GERD group, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki (stir-fried rice cakes). Foods that frequently or occasionally induced GERD symptoms in half or more patients included biscuits, breads, hand-pulled dough soups, hamburgers, doughnuts, spicy noodles with vegetables and seafoods (champon), noodles with stir-fried bean paste (jajangmyeon), alcohols, carbonated beverages, pizzas, mandarins, plain noodles, oranges, and milk ().

Table 2

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms and Percentage of Patients in Gastroesophageal Reflux Disease Cases

GERD patients (n = 19)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews63.2Hot spicy stews84.2
Rice cakes63.2Ramen noodles84.2
Ramen noodles57.9Fried foods75.0
Fried foods50.0Rice cakes73.7
Topokki50.0Biscuits64.3
Breads63.2
Hand-pulled dough soups60.0
Topokki56.3
Hamburgers56.3
Doughnuts55.6
Champon55.6
Jajangmyeon55.6
Alcohols54.5
Fanta beverages54.5
Pizzas53.3
Mandarins52.6
Plain noodles52.6
Oranges50.0
Milk50.0

In the possible GERD group, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizzas, topokki, rice cakes, champon, and hotdogs. Moreover, cola, oranges, alcohols, hamburgers, jajangmyeon, hand-pulled dough soups, dumplings, red beans, green tea, and rice cake soups were added to the list of foods that frequently or occasionally induced GERD symptoms in half or more patients ().

Table 3

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms and Percentage of the Patients in Possible Gastroesophageal Reflux Disease Cases

Possible GERD patients (n = 17)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews76.9Fried foods88.9
Fried foods66.7Hot spicy stews84.6
Doughnuts66.7Topokki81.8
Breads62.5Breads81.3
Ramen noodles57.1Pizzas77.8
Coffee57.1Rice cakes73.3
Pizzas55.6Coffee71.4
Topokki54.5Doughnuts66.7
Rice cakes53.3Ramen noodles64.3
Champon50.0Hotdogs62.5
Hotdogs50.0Cola60.0
Oranges58.3
Champon57.1
Alcohols57.1
Hamburgers57.1
Jajangmyeon55.6
Hand-pulled dough soup53.8
Dumplings50.0
Red beans50.0
Green tea50.0
Rice cake soups50.0

In all confirmed or possible GERD cases, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, rice cakes, ramen noodles, fried foods, breads, and topokki. Foods that frequently or occasionally induced GERD symptoms in half or more patients additionally included pizzas, doughnuts, coffee, hand-pulled dough soups, champon, hamburgers, alcohols, jajangmyeon, oranges, biscuits, cola, and plain noodles ().

Table 4

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms, and Percentage of Patients with Gastroesophageal Reflux Disease and Possible Gastroesophageal Reflux Disease Cases

GERD or possible GERD patients (n = 36)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews68.8Hot spicy stews84.4
Rice cakes58.8Fried foods80.0
Ramen noodles57.6Ramen noodles75.8
Fried foods56.0Rice cakes73.5
Breads54.3Breads71.4
Topokki51.9Topokki66.7
Pizzas62.5
Doughnuts59.1
Coffee58.1
Hand-pulled dough soups57.1
Champon56.3
Hamburgers56.0
Alcohols55.6
Jajangmyeon54.8
Oranges53.1
Biscuits51.9
Cola51.9
Plain noodles50.0

Discussion

It is commonly accepted that meals can trigger symptoms in GERD patients, but accurate and objective data are limited. Most of the recommendations on changes in dietary habits are not strongly supported by objective measurements. The relationship between foods and GERD in the Korean population still remains unclear. The results of our study show that hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki are frequently inducing typical GERD symptoms in Korean GERD patients.

Although some studies reported that some nutrients and foods are related to the presence of GERD symptoms in Western patients,10,12 there are no well-organized data regarding foods associated with GERD symptoms in Asian patients. In Europe and the United States, some investigators have shown that dietary fat, cholesterol, saturated fatty acid, dietary fiber, and other nutrients are associated with GERD.10,12 They believe that both improved socioeconomic status and the westernized pattern of diet consumption may be associated with the increasing prevalence of GERD in Asians.13 However, the currently available data do not support a strong relationship between GERD and dietary factors in Asians including Koreans. Taken together, our findings support a recommendation for Korean patients with GERD and possible GERD to avoid specific foods because GERD symptoms appear more frequently after consumption of the common symptom-inducing foods. This study also systematically evaluated the role of daily consumed Korean traditional foods as well as westernized foods in GERD symptom generation.

Supporting data exist regarding some specific meals in relation to GERD symptoms. The role of fat in symptom generation has been demonstrated in several studies.6,1416 In some clinical studies, it was shown that esophageal pH monitoring provides direct evidence on the association between dietary fat and acid reflux, and that high-fat meal decreases the lower esophageal sphincter pressure, increases the rate of transient lower esophageal sphincter relaxation, and delays the gastric emptying,5 which may lead to a greater incidence of reflux.14,15 Spicy foods attributable to direct irritation of already inflamed lower esophageal mucosa may exacerbate heartburn.17 Red pepper, which contains the neurotoxin capsaicin, has been shown to delay gastric emptying,18,19 and it can possibly provoke reflux. Some previous studies have found that an increase in salt consumption was associated with GERD, which was attributed to the inhibited gastric motor activity and delayed gastric emptying after high salt intake.20,21 It was also found that a low-carbohydrate diet reduces distal esophageal acid exposure in 24-hour pH testing and improves GERD symptoms.22 In a study, ingestion of lactose resulted in an increased number of transient lower esophageal sphincter relaxations, increased reflux episodes, higher esophageal acid exposure, and more severe GERD symptoms in healthy volunteers.23 Similarly, our results also revealed a relationship between the above mentioned tastes or nutrients and GERD symptoms. Many GERD patients are more likely to experience a perceived reflux event when they eat some fatty, spicy, salty foods, and meals with high carbohydrate content. Ramen noodles, hot spicy stews, and topokki are typically spicy and salty Korean traditional foods. Rice cake and bread contain high carbohydrate nutrients. These are the foods to which Koreans have easy access and they are frequently used for main meal replacement.

Conflicting data exist regarding the roles of specific meals in relation to GERD symptoms. In several studies investigating the effect of diet on gastroesophageal reflux, the results have not been consistent.2426 Certain eating habits, such as eating quickly and irregularly, eating big meals, eating between meals, or eating directly before sleeping, individualized acid hypersensitivity and psychological stress may contribute to the appearance of symptoms.11,27,28 As shown in our study, females were predominant among possible GERD patients with food related symptoms. It may be that females have a tendency to have a sensitive esophagus or to relate to psychological stress.

This is the first study that systematically and prospectively evaluated the role of 152 variable diets with frequency in symptom generation among patients with GERD and possible GERD by permitting multiple choices and using a comprehensive diet tool. In addition, many possible GERD patients, who are commonly encountered in one-third to one-half of the Korean population with GERD symptoms, were enrolled.29 Hence, this study can reflect the actual aspects of the racial, geographic, and cultural specificities in Korean patients with GERD symptoms. Interestingly, most symptom-inducing foods are Korean traditional foods which have been consumed since a long time ago. The recent increase in GERD prevalence in Korea cannot be fully explained by the change to westernized foods. Finally, although a high BMI is a well-known independent risk factor for esophageal erosions, it did not affect esophageal inflammation particularly in patients with food-induced symptoms in our study. This finding is in contrast with patients without food-related symptoms.

This study could be used as a reference for the development and validation of diet recommendations for GERD patients that are applicable to Korean patients. A recent cross-sectional study demonstrated that GERD patients consumed symptom-inducing foods more frequently than in asymptomatic individuals. This suggested that dietary modification could be effective in reducing and managing GERD symptoms.30 Based on our study, a dietary education program for GERD patients could be developed using figures of foods which are familiar to the patients and are encountered daily. It could help physicians and patients to gain an insight into the symptoms possibly related to foods and reinsure avoidance of these foods. Regardless of the emergence of potent medicines (such as improved proton pump inhibitors, transient lower esophageal sphincter relaxation reducers, mucosal protectants, and esophageal-specific pain modulators),31 correctable diet modifications should be emphasized. Avoiding such foods may be important for maintaining patients in a symptom-free state which was attained with medications, although it may not be helpful to induce healing of GERD. Dietary advice such as avoidance of symptom-inducing foods may not be very difficult to follow and can reduce unnecessary medical costs.

Our study has some limitations. First, although we used a rather short time window of 3 months, the recall bias and residual confounding factors (eating habits, lifestyle, and genetic risk factors) might have influenced the results. Second, this study has a limitation stemming from its small sample size. The reason why we could not recruit more cases was that we included only new patients with typical GERD symptoms while excluding users of NSAIDs, oral steroids or aspirin, users of proton pump inhibitors or histamine h3 receptor antagonists over the preceding 3 months, and we included only those who underwent both upper gastrointestinal endoscopy and 24-hour ambulatory pH monitoring. Further researches with a larger scale multicenter national study seem to warrant better clarification of the relationship between foods and GERD symptoms in Korea.

In conclusion, hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki are most common foods that induce typical GERD symptoms in Korean GERD patients. The list of food items that produce typical GERD symptoms in patients from Asian countries needs to be revised substantially from the Western literature based on their own local experiences.

Footnotes

Conflicts of interest: None.

Author contributions: Jung Wan Choe: data analysis, data interpretation, and writing the manuscript; Young-Tae Bak: data acquisition, data analysis, data interpretation, and drafting the manuscript; and Moon Kyung Joo, Hyo Jung Kim, Beom Jae Lee, Ji Hoon Kim, Jong Eun Yeon, Jong-Jae Park, Jae Seon Kim, and Kwan Soo Byun: data acquisition and critical revision of the manuscript.

Financial support: None.

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;101:1900–1920. doi: 10.1111/j.1572-0241.2006.00630.x. [PubMed] [CrossRef] [Google Scholar]2. Kao SS, Chen WC, Hsu PI, et al. The frequencies of gastroesophageal and extragastroesophageal symptoms in patients with mild erosive esophagitis, severe erosive esophagitis, and barrett’s esophagus in Taiwan. Gastroenterol Res Pract. 2013;2013:480325. doi: 10.1155/2013/480325. [PMC free article] [PubMed] [CrossRef] [Google Scholar]3. Falk GW. Gastroesophageal reflux disease and Barrett’s esophagus. Endoscopy. 2001;33:109–118. doi: 10.1055/s-2001-11669. [PubMed] [CrossRef] [Google Scholar]4. Dore MP, Maragkoudakis E, Fraley K, et al. Diet, lifestyle and gender in gastro-esophageal reflux disease. Dig Dis Sci. 2008;53:2027–2032. doi: 10.1007/s10620-007-0108-7. [PubMed] [CrossRef] [Google Scholar]5. Kulig M, Nocon M, Vieth M, et al. Risk factors of gastroesophageal reflux disease: methodology and first epidemiological results of the ProGERD study. J Clin Epidemiol. 2004;57:580–589. doi: 10.1016/j.jclinepi.2003.10.010. [PubMed] [CrossRef] [Google Scholar]6. Shapiro M, Green C, Bautista JM, et al. Assessment of dietary nutrients that influence perception of intra-oesophageal acid reflux events in patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2007;25:93–101. doi: 10.1111/j.1365-2036.2006.03170.x. [PubMed] [CrossRef] [Google Scholar]7. Ravi K, Francis DL, See JA, Geno DM, Katzka DA. The effects of a weakly acidic meal on gastric buffering and postprandial gastro-oesophageal reflux. Aliment Pharmacol Ther. 2011;34:568–575. doi: 10.1111/j.1365-2036.2011.04761.x. [PubMed] [CrossRef] [Google Scholar]8. Schönfeld J, Evans DF. [Fat, spices and gastro-oesophageal reflux]. Z Gastroenterol. 2007;45:171–175. doi: 10.1055/s-2006-927271. [German] [PubMed] [CrossRef] [Google Scholar]9. Vemulapalli R. Diet and lifestyle modifications in the management of gastroesophageal reflux disease. Nutr Clin Pract. 2008;23:293–298. doi: 10.1177/0884533608318106. [PubMed] [CrossRef] [Google Scholar]10. Wu P, Zhao XH, Ai ZS, et al. Dietary intake and risk for reflux esophagitis: a case-control study. Gastroenterol Res Pract. 2013;2013:691026. doi: 10.1155/2013/691026. [PMC free article] [PubMed] [CrossRef] [Google Scholar]11. Song JH, Chung SJ, Lee JH, et al. Relationship between gastroesophageal reflux symptoms and dietary factors in Korea. J Neurogastroenterol Motil. 2011;17:54–60. doi: 10.5056/jnm.2011.17.1.54. [PMC free article] [PubMed] [CrossRef] [Google Scholar]12. Festi D, Scaioli E, Baldi F, et al. Body weight, lifestyle, dietary habits and gastroesophageal reflux disease. World J Gastroenterol. 2009;15:1690–1701. doi: 10.3748/wjg.15.1690. [PMC free article] [PubMed] [CrossRef] [Google Scholar]13. Wu JC. Gastroesophageal reflux disease: an Asian perspective. J Gastroenterol Hepatol. 2008;23:1785–1793. doi: 10.1111/j.1440-1746.2008.05684.x. [PubMed] [CrossRef] [Google Scholar]14. Iwakiri K, Kobayashi M, Kotoyori M, Yamada H, Sugiura T, Nakagawa Y. Relationship between postprandial esophageal acid exposure and meal volume and fat content. Dig Dis Sci. 1996;41:926–930. doi: 10.1007/BF02091532. [PubMed] [CrossRef] [Google Scholar]15. Holloway RH, Lyrenas E, Ireland A, Dent J. Effect of intraduodenal fat on lower oesophageal sphincter function and gastro-oesophageal reflux. Gut. 1997;40:449–453. doi: 10.1136/gut.40.4.449. [PMC free article] [PubMed] [CrossRef] [Google Scholar]17. Milke P, Diaz A, Valdovinos MA, Moran S. Gastroesophageal reflux in healthy subjects induced by two different species of chilli (Capsicum annum) Dig Dis. 2006;24:184–188. doi: 10.1159/000090323. [PubMed] [CrossRef] [Google Scholar]18. Park HJ, Na SK, Lee SI, Kang JK, Park IS. The effect of red pepper and capsaicin on gastric emptying in human volunteers. Gastroenterology. 1998;114:A818. [Google Scholar]19. Horowitz M, Wishart J, Maddox A, Russo A. The effect of chilli on gastrointestinal transit. J Gastroenterol Hepatol. 1992;7:52–56. doi: 10.1111/j.1440-1746.1992.tb00935.x. [PubMed] [CrossRef] [Google Scholar]20. Tanaka T, Mizumoto A, Muramatsu S, et al. Postprandial normal saline intake delays gastric emptying of solids in conscious dogs: partial involvement of CCK in its mechanism. Dig Dis Sci. 1999;44:1516–1524. doi: 10.1023/A:1026642422375. [PubMed] [CrossRef] [Google Scholar]21. Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux. Gut. 2004;53:1730–1735. doi: 10.1136/gut.2004.043265. [PMC free article] [PubMed] [CrossRef] [Google Scholar]22. Austin GL, Thiny MT, Westman EC, Yancy WS, Jr, Shaheen NJ. A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms. Dig Dis Sci. 2006;51:1307–1312. doi: 10.1007/s10620-005-9027-7. [PubMed] [CrossRef] [Google Scholar]23. Piche T, Zerbib F, Varannes SB, et al. Modulation by colonic fermentation of LES function in humans. Am J Physiol Gastrointest Liver Physiol. 2000;278:G578–G584. [PubMed] [Google Scholar]24. Zheng Z, Nordenstedt H, Pedersen NL, Lagergren J, Ye W. Lifestyle factors and risk for symptomatic gastroesophageal reflux in monozygotic twins. Gastroenterology. 2007;132:87–95. doi: 10.1053/j.gastro.2006.11.019. [PMC free article] [PubMed] [CrossRef] [Google Scholar]25. Nandurkar S, Locke Gr, 3rd, Fett S, Zinsmeister AR, Cameron AJ, Talley NJ. Relationship between body mass index, diet, exercise and gastro-oesophageal reflux symptoms in a community. Aliment Pharmacol Ther. 2004;20:497–505. doi: 10.1111/j.1365-2036.2004.02156.x. [PubMed] [CrossRef] [Google Scholar]26. Ruhl CE, Everhart JE. Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization: the NHANES I epidemiologic followup study. First national health and nutrition ezamination survey. Ann Epidemiol. 1999;9:424–435. doi: 10.1016/S1047-2797(99)00020-4. [PubMed] [CrossRef] [Google Scholar]27. Yang JH, Kang HS, Lee SY, et al. Recurrence of gastroesophageal reflux disease correlated with a short dinner-to-bedtime interval. J Gastroenterol Hepatol. 2014;29:730–735. doi: 10.1111/jgh.12455. [PubMed] [CrossRef] [Google Scholar]28. Matsuki N, Fujita T, Watanabe N, et al. Lifestyle factors associated with gastroesophageal reflux disease in the Japanese population. J Gastroenterol. 2013;48:340–349. doi: 10.1007/s00535-012-0649-1. [PubMed] [CrossRef] [Google Scholar]29. Kim N, Lee SW, Cho SI, et al. The prevalence of and risk factors for erosive oesophagitis and non-erosive reflux disease: a nationwide multicentre prospective study in Korea. Aliment Pharmacol Ther. 2008;27:173–185. doi: 10.1111/j.1365-2036.2007.03561.x. [PubMed] [CrossRef] [Google Scholar]30. Kubo A, Block G, Quesenberry CP, Buffler P, Corley DA. Dietary guideline adherence for gastroesophageal reflux disease. BMC Gastroenterol. 2014;14:144. doi: 10.1186/1471-230X-14-144. [PMC free article] [PubMed] [CrossRef] [Google Scholar]31. Maradey-Romero C, Fass R. New and future drug development for gastroesophageal reflux disease. J Neurogastroenterol Motil. 2014;20:6–16. doi: 10.5056/jnm.2014.20.1.6. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

Foods Inducing Typical Gastroesophageal Reflux Disease Symptoms in Korea

J Neurogastroenterol Motil. 2017 Jul; 23(3): 363–369.

Department of Gastroenterology, Korea University Guro Hospital, Seoul,
Korea

*Correspondence: Young-Tae Bak, MD, Department of Gastroenterology, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea, Tel: +82-2-2626-1778, Fax: +82-504-366-6381, E-mail: rk.ca.aerok@tykabrd

Received 2016 Jul 28; Revised 2016 Oct 17; Accepted 2016 Nov 13.

Copyright © 2017 The Korean Society of Neurogastroenterology and MotilityThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background/Aims

Several specific foods are known to precipitate gastroesophageal reflux disease (GERD) symptoms and GERD patients are usually advised to avoid such foods. However, foods consumed daily are quite variable according to regions, cultures, etc. This study was done to elucidate the food items which induce typical GERD symptoms in Korean patients.

Methods

One hundred and twenty-six Korean patients with weekly typical GERD symptoms were asked to mark all food items that induced typical GERD symptoms from a list containing 152 typical foods consumed daily in Korea. All patients underwent upper gastrointestinal endoscopy followed by 24-hour ambulatory esophageal pH monitoring. The definition of “GERD” was if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.

Results

One hundred and twenty-six cases (51 GERD and 75 possible GERD) were enrolled. In 19 (37.3%) of 51 GERD cases and in 17 (22.7%) of 75 possible GERD cases, foods inducing typical GERD symptoms were identified. In the GERD group (n = 19), frequent symptom-inducers were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki. In the possible GERD group (n = 17), frequent symptom-inducers were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizza, topokki, rice cakes, champon noodles, and hotdogs.

Conclusions

In one-third of GERD patients, foods inducing typical symptoms were identified. Hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki were the foods frequently inducing typical symptoms in Korea. The list of foods frequently inducing typical GERD symptoms needs to be modified based on their own local experiences.

Keywords: Food, Gastroesophageal reflux, Korea, Symptom assessment

Introduction

Gastroesophageal reflux disease (GERD) is characterized by abnormal reflux of the gastric contents into the esophagus.1 In most patients with GERD, reflux of gastric juice commonly causes heartburn and regurgitation.2 Barrett’s esophagus, which is a premalignant lesion for esophageal adenocarcinoma, is considered one of the most important complications of GERD.3

These troublesome symptoms and complications are the main drivers for GERD patients to seek medical attention. The conditions, such as male gender, a presence of a hiatal hernia, history of Helicobacter pylori eradication, current alcohol intake, and abdominal obesity, are known as risk factors for GERD.4,5 Dietary factors traditionally have been thought to induce or worsen GERD. GERD symptoms are commonly reported postprandially, suggesting that some specific diet components are more likely to induce symptoms.4 With the introduction of 24-hour pH monitoring, it has been objectively shown that postprandial reflux is important in reflux symptom profiles.6,7 However, there have been few attempts to measure the effect of specific food stuffs that might provoke or increase gastroesophageal reflux. Although several studies have reported that high-fat foods, spicy foods, chocolate, mint, and citrus fruits are closely related to GERD symptoms,810 the daily consumed foods are quite variable according to race, geographic specificity, diet habit, and culture. The conflicting conditions may cause differences in food-induced GERD symptoms between Asian and Western populations. Therefore, dietary recommendations should be based on local experiences. According to a recent Korean study, dietary categories aggravating typical or atypical GERD symptoms in possible GERD cases were noodles, fatty meals, caffeinated drinks, spicy foods, alcohol, breads, carbonated drinks, and sweets.11

This study was performed to investigate food items that are frequently consumed daily and may be responsible for inducing typical GERD symptoms in confirmed GERD patients in their daily lives in Korea.

Materials and Methods

One hundred and twenty-six consecutive subjects who visited our Digestive Disease Center between February 2009 and September 2014 due to at least weekly typical GERD symptoms (heartburn or regurgitation) for at least 3 months were recruited into this prospective study. Subjects were excluded if they had other significant gastrointestinal diseases (for example, active peptic ulcer disease, infectious conditions of the intestine and gastric malignancy), a history of gastrectomy or severe health problems. Exclusion criteria also included any use of NSAIDs, oral steroids or aspirin, use of proton pump inhibitors or histamine h3 receptor antagonists over the preceding 3 months, and current pregnancy. All subjects provided written informed consent prior to the investigation.

All patients underwent upper gastrointestinal endoscopy to assess the presence and extent of esophageal mucosal breaks. Thereafter, 24-hour ambulatory esophageal pH monitoring was carried out. Patients with GERD symptoms were divided into 2 groups according to the results of endoscopy and pH monitoring; “GERD” if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.

The patients were asked during their first visit whether they experienced their typical GERD symptoms induced by any specific food intake for the preceding 3 months. Then they marked all food items which induced their typical GERD symptoms from a food list containing 152 foods usually consumed daily by Koreans. The food list was made including all individually collected daily food consumption lists from more than 20 hospital staffs and patients. Considering the possibility of omission of any foods, if the patients could not find any symptom-inducing foods of their own from the list, they were instructed to add such foods freely to the list. In addition, they crossed out all food items that they had not consumed for the preceding 3 months from the list.

Symptom-inducing foods were categorized into 2 groups: “frequent symptom-inducers” if they induced symptom(s) in half or more occasions of consumption, and “occasional symptom-inducers” if they induced symptom(s) in less than half occasions of consumption. When any food induced typical GERD symptoms in half or more patients of the group, it was regarded as a meaningful culprit food.

All statistical analyses were conducted using the SPSS statistical software (version 20.0; IBM Corp, Armonk, NY, USA). P-values less than 0.05 were considered statistically significant. The data with continuous variables were expressed as mean ± standard deviation. The estimated internal consistency of the food list questionnaire was assessed through Cronbach’s alpha coefficients.

Written informed consent was obtained from all participants. This study received approval from the institutional review board of Korea University Guro Hospital.

Results

A total of 126 patients completed the study. Among these subjects, the age of 51 GERD patients ranged from 27 to 72 years, and the 75 possible GERD patients were aged 17 to 79 years. In 19 (37.3%) out of the 51 GERD cases and in 17 (22.7%) out of the 75 possible GERD cases, foods inducing typical GERD symptoms were identified (). The Cronbach’s alpha value of the overall questionnaire was 0.77 (95% confidence interval 0.75 – 0.78) among the 152 food items and, therefore, it was acceptable for internal consistency.

Enrolled cases. GERD, gastroesophageal reflux disease.

shows clinical characteristics of the 4 subgroups according to the presence of mucosal breaks and/or pathologic refluxes and symptom-inducing foods. There were no differences in age, gender, height, weight, and body mass index (BMI) between patients with and without symptom-inducing foods in both GERD and possible GERD groups, except a female predominance in the possible GERD group with symptom-inducing foods. Among the patients without symptom-inducing foods, the BMI in GERD patients was significantly greater than that in possible GERD patients (24.9 ± 4.6 vs 22.5 ± 3.7, P = 0.007).

Table 1

Baseline Characteristics According to Status of Gastroesophageal Reflux Disease and Symptom-inducing Foods

GERDP-valuePossible GERDP-value


Food (+)
(n = 19)
Food (−)
(n = 32)
Food (+)
(n = 17)
Food (−)
(n = 58)
Age (mean ± SD)55.5 ± 9.852.7 ± 11.50.35850.8 ± 13.152.5 ± 14.10.670
Gender (M/F)7/1212/200.9631/1620/380.021
Height (mean ± SD, cm)160.0 ± 10.2161.5 ± 7.90.554159.3 ± 6.7161.2 ± 8.20.182
Weight (mean ± SD, kg)62.3 ± 11.465.1 ± 13.40.45458.5 ± 7.859.5 ± 13.00.375
BMI (mean ± SD)24.3 ± 3.224.9 ± 4.60.60923.1 ± 2.122.5 ± 3.70.809

In the GERD group, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki (stir-fried rice cakes). Foods that frequently or occasionally induced GERD symptoms in half or more patients included biscuits, breads, hand-pulled dough soups, hamburgers, doughnuts, spicy noodles with vegetables and seafoods (champon), noodles with stir-fried bean paste (jajangmyeon), alcohols, carbonated beverages, pizzas, mandarins, plain noodles, oranges, and milk ().

Table 2

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms and Percentage of Patients in Gastroesophageal Reflux Disease Cases

GERD patients (n = 19)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews63.2Hot spicy stews84.2
Rice cakes63.2Ramen noodles84.2
Ramen noodles57.9Fried foods75.0
Fried foods50.0Rice cakes73.7
Topokki50.0Biscuits64.3
Breads63.2
Hand-pulled dough soups60.0
Topokki56.3
Hamburgers56.3
Doughnuts55.6
Champon55.6
Jajangmyeon55.6
Alcohols54.5
Fanta beverages54.5
Pizzas53.3
Mandarins52.6
Plain noodles52.6
Oranges50.0
Milk50.0

In the possible GERD group, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizzas, topokki, rice cakes, champon, and hotdogs. Moreover, cola, oranges, alcohols, hamburgers, jajangmyeon, hand-pulled dough soups, dumplings, red beans, green tea, and rice cake soups were added to the list of foods that frequently or occasionally induced GERD symptoms in half or more patients ().

Table 3

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms and Percentage of the Patients in Possible Gastroesophageal Reflux Disease Cases

Possible GERD patients (n = 17)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews76.9Fried foods88.9
Fried foods66.7Hot spicy stews84.6
Doughnuts66.7Topokki81.8
Breads62.5Breads81.3
Ramen noodles57.1Pizzas77.8
Coffee57.1Rice cakes73.3
Pizzas55.6Coffee71.4
Topokki54.5Doughnuts66.7
Rice cakes53.3Ramen noodles64.3
Champon50.0Hotdogs62.5
Hotdogs50.0Cola60.0
Oranges58.3
Champon57.1
Alcohols57.1
Hamburgers57.1
Jajangmyeon55.6
Hand-pulled dough soup53.8
Dumplings50.0
Red beans50.0
Green tea50.0
Rice cake soups50.0

In all confirmed or possible GERD cases, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, rice cakes, ramen noodles, fried foods, breads, and topokki. Foods that frequently or occasionally induced GERD symptoms in half or more patients additionally included pizzas, doughnuts, coffee, hand-pulled dough soups, champon, hamburgers, alcohols, jajangmyeon, oranges, biscuits, cola, and plain noodles ().

Table 4

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms, and Percentage of Patients with Gastroesophageal Reflux Disease and Possible Gastroesophageal Reflux Disease Cases

GERD or possible GERD patients (n = 36)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews68.8Hot spicy stews84.4
Rice cakes58.8Fried foods80.0
Ramen noodles57.6Ramen noodles75.8
Fried foods56.0Rice cakes73.5
Breads54.3Breads71.4
Topokki51.9Topokki66.7
Pizzas62.5
Doughnuts59.1
Coffee58.1
Hand-pulled dough soups57.1
Champon56.3
Hamburgers56.0
Alcohols55.6
Jajangmyeon54.8
Oranges53.1
Biscuits51.9
Cola51.9
Plain noodles50.0

Discussion

It is commonly accepted that meals can trigger symptoms in GERD patients, but accurate and objective data are limited. Most of the recommendations on changes in dietary habits are not strongly supported by objective measurements. The relationship between foods and GERD in the Korean population still remains unclear. The results of our study show that hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki are frequently inducing typical GERD symptoms in Korean GERD patients.

Although some studies reported that some nutrients and foods are related to the presence of GERD symptoms in Western patients,10,12 there are no well-organized data regarding foods associated with GERD symptoms in Asian patients. In Europe and the United States, some investigators have shown that dietary fat, cholesterol, saturated fatty acid, dietary fiber, and other nutrients are associated with GERD.10,12 They believe that both improved socioeconomic status and the westernized pattern of diet consumption may be associated with the increasing prevalence of GERD in Asians.13 However, the currently available data do not support a strong relationship between GERD and dietary factors in Asians including Koreans. Taken together, our findings support a recommendation for Korean patients with GERD and possible GERD to avoid specific foods because GERD symptoms appear more frequently after consumption of the common symptom-inducing foods. This study also systematically evaluated the role of daily consumed Korean traditional foods as well as westernized foods in GERD symptom generation.

Supporting data exist regarding some specific meals in relation to GERD symptoms. The role of fat in symptom generation has been demonstrated in several studies.6,1416 In some clinical studies, it was shown that esophageal pH monitoring provides direct evidence on the association between dietary fat and acid reflux, and that high-fat meal decreases the lower esophageal sphincter pressure, increases the rate of transient lower esophageal sphincter relaxation, and delays the gastric emptying,5 which may lead to a greater incidence of reflux.14,15 Spicy foods attributable to direct irritation of already inflamed lower esophageal mucosa may exacerbate heartburn.17 Red pepper, which contains the neurotoxin capsaicin, has been shown to delay gastric emptying,18,19 and it can possibly provoke reflux. Some previous studies have found that an increase in salt consumption was associated with GERD, which was attributed to the inhibited gastric motor activity and delayed gastric emptying after high salt intake.20,21 It was also found that a low-carbohydrate diet reduces distal esophageal acid exposure in 24-hour pH testing and improves GERD symptoms.22 In a study, ingestion of lactose resulted in an increased number of transient lower esophageal sphincter relaxations, increased reflux episodes, higher esophageal acid exposure, and more severe GERD symptoms in healthy volunteers.23 Similarly, our results also revealed a relationship between the above mentioned tastes or nutrients and GERD symptoms. Many GERD patients are more likely to experience a perceived reflux event when they eat some fatty, spicy, salty foods, and meals with high carbohydrate content. Ramen noodles, hot spicy stews, and topokki are typically spicy and salty Korean traditional foods. Rice cake and bread contain high carbohydrate nutrients. These are the foods to which Koreans have easy access and they are frequently used for main meal replacement.

Conflicting data exist regarding the roles of specific meals in relation to GERD symptoms. In several studies investigating the effect of diet on gastroesophageal reflux, the results have not been consistent.2426 Certain eating habits, such as eating quickly and irregularly, eating big meals, eating between meals, or eating directly before sleeping, individualized acid hypersensitivity and psychological stress may contribute to the appearance of symptoms.11,27,28 As shown in our study, females were predominant among possible GERD patients with food related symptoms. It may be that females have a tendency to have a sensitive esophagus or to relate to psychological stress.

This is the first study that systematically and prospectively evaluated the role of 152 variable diets with frequency in symptom generation among patients with GERD and possible GERD by permitting multiple choices and using a comprehensive diet tool. In addition, many possible GERD patients, who are commonly encountered in one-third to one-half of the Korean population with GERD symptoms, were enrolled.29 Hence, this study can reflect the actual aspects of the racial, geographic, and cultural specificities in Korean patients with GERD symptoms. Interestingly, most symptom-inducing foods are Korean traditional foods which have been consumed since a long time ago. The recent increase in GERD prevalence in Korea cannot be fully explained by the change to westernized foods. Finally, although a high BMI is a well-known independent risk factor for esophageal erosions, it did not affect esophageal inflammation particularly in patients with food-induced symptoms in our study. This finding is in contrast with patients without food-related symptoms.

This study could be used as a reference for the development and validation of diet recommendations for GERD patients that are applicable to Korean patients. A recent cross-sectional study demonstrated that GERD patients consumed symptom-inducing foods more frequently than in asymptomatic individuals. This suggested that dietary modification could be effective in reducing and managing GERD symptoms.30 Based on our study, a dietary education program for GERD patients could be developed using figures of foods which are familiar to the patients and are encountered daily. It could help physicians and patients to gain an insight into the symptoms possibly related to foods and reinsure avoidance of these foods. Regardless of the emergence of potent medicines (such as improved proton pump inhibitors, transient lower esophageal sphincter relaxation reducers, mucosal protectants, and esophageal-specific pain modulators),31 correctable diet modifications should be emphasized. Avoiding such foods may be important for maintaining patients in a symptom-free state which was attained with medications, although it may not be helpful to induce healing of GERD. Dietary advice such as avoidance of symptom-inducing foods may not be very difficult to follow and can reduce unnecessary medical costs.

Our study has some limitations. First, although we used a rather short time window of 3 months, the recall bias and residual confounding factors (eating habits, lifestyle, and genetic risk factors) might have influenced the results. Second, this study has a limitation stemming from its small sample size. The reason why we could not recruit more cases was that we included only new patients with typical GERD symptoms while excluding users of NSAIDs, oral steroids or aspirin, users of proton pump inhibitors or histamine h3 receptor antagonists over the preceding 3 months, and we included only those who underwent both upper gastrointestinal endoscopy and 24-hour ambulatory pH monitoring. Further researches with a larger scale multicenter national study seem to warrant better clarification of the relationship between foods and GERD symptoms in Korea.

In conclusion, hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki are most common foods that induce typical GERD symptoms in Korean GERD patients. The list of food items that produce typical GERD symptoms in patients from Asian countries needs to be revised substantially from the Western literature based on their own local experiences.

Footnotes

Conflicts of interest: None.

Author contributions: Jung Wan Choe: data analysis, data interpretation, and writing the manuscript; Young-Tae Bak: data acquisition, data analysis, data interpretation, and drafting the manuscript; and Moon Kyung Joo, Hyo Jung Kim, Beom Jae Lee, Ji Hoon Kim, Jong Eun Yeon, Jong-Jae Park, Jae Seon Kim, and Kwan Soo Byun: data acquisition and critical revision of the manuscript.

Financial support: None.

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;101:1900–1920. doi: 10.1111/j.1572-0241.2006.00630.x. [PubMed] [CrossRef] [Google Scholar]2. Kao SS, Chen WC, Hsu PI, et al. The frequencies of gastroesophageal and extragastroesophageal symptoms in patients with mild erosive esophagitis, severe erosive esophagitis, and barrett’s esophagus in Taiwan. Gastroenterol Res Pract. 2013;2013:480325. doi: 10.1155/2013/480325. [PMC free article] [PubMed] [CrossRef] [Google Scholar]3. Falk GW. Gastroesophageal reflux disease and Barrett’s esophagus. Endoscopy. 2001;33:109–118. doi: 10.1055/s-2001-11669. [PubMed] [CrossRef] [Google Scholar]4. Dore MP, Maragkoudakis E, Fraley K, et al. Diet, lifestyle and gender in gastro-esophageal reflux disease. Dig Dis Sci. 2008;53:2027–2032. doi: 10.1007/s10620-007-0108-7. [PubMed] [CrossRef] [Google Scholar]5. Kulig M, Nocon M, Vieth M, et al. Risk factors of gastroesophageal reflux disease: methodology and first epidemiological results of the ProGERD study. J Clin Epidemiol. 2004;57:580–589. doi: 10.1016/j.jclinepi.2003.10.010. [PubMed] [CrossRef] [Google Scholar]6. Shapiro M, Green C, Bautista JM, et al. Assessment of dietary nutrients that influence perception of intra-oesophageal acid reflux events in patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2007;25:93–101. doi: 10.1111/j.1365-2036.2006.03170.x. [PubMed] [CrossRef] [Google Scholar]7. Ravi K, Francis DL, See JA, Geno DM, Katzka DA. The effects of a weakly acidic meal on gastric buffering and postprandial gastro-oesophageal reflux. Aliment Pharmacol Ther. 2011;34:568–575. doi: 10.1111/j.1365-2036.2011.04761.x. [PubMed] [CrossRef] [Google Scholar]8. Schönfeld J, Evans DF. [Fat, spices and gastro-oesophageal reflux]. Z Gastroenterol. 2007;45:171–175. doi: 10.1055/s-2006-927271. [German] [PubMed] [CrossRef] [Google Scholar]9. Vemulapalli R. Diet and lifestyle modifications in the management of gastroesophageal reflux disease. Nutr Clin Pract. 2008;23:293–298. doi: 10.1177/0884533608318106. [PubMed] [CrossRef] [Google Scholar]10. Wu P, Zhao XH, Ai ZS, et al. Dietary intake and risk for reflux esophagitis: a case-control study. Gastroenterol Res Pract. 2013;2013:691026. doi: 10.1155/2013/691026. [PMC free article] [PubMed] [CrossRef] [Google Scholar]11. Song JH, Chung SJ, Lee JH, et al. Relationship between gastroesophageal reflux symptoms and dietary factors in Korea. J Neurogastroenterol Motil. 2011;17:54–60. doi: 10.5056/jnm.2011.17.1.54. [PMC free article] [PubMed] [CrossRef] [Google Scholar]12. Festi D, Scaioli E, Baldi F, et al. Body weight, lifestyle, dietary habits and gastroesophageal reflux disease. World J Gastroenterol. 2009;15:1690–1701. doi: 10.3748/wjg.15.1690. [PMC free article] [PubMed] [CrossRef] [Google Scholar]13. Wu JC. Gastroesophageal reflux disease: an Asian perspective. J Gastroenterol Hepatol. 2008;23:1785–1793. doi: 10.1111/j.1440-1746.2008.05684.x. [PubMed] [CrossRef] [Google Scholar]14. Iwakiri K, Kobayashi M, Kotoyori M, Yamada H, Sugiura T, Nakagawa Y. Relationship between postprandial esophageal acid exposure and meal volume and fat content. Dig Dis Sci. 1996;41:926–930. doi: 10.1007/BF02091532. [PubMed] [CrossRef] [Google Scholar]15. Holloway RH, Lyrenas E, Ireland A, Dent J. Effect of intraduodenal fat on lower oesophageal sphincter function and gastro-oesophageal reflux. Gut. 1997;40:449–453. doi: 10.1136/gut.40.4.449. [PMC free article] [PubMed] [CrossRef] [Google Scholar]17. Milke P, Diaz A, Valdovinos MA, Moran S. Gastroesophageal reflux in healthy subjects induced by two different species of chilli (Capsicum annum) Dig Dis. 2006;24:184–188. doi: 10.1159/000090323. [PubMed] [CrossRef] [Google Scholar]18. Park HJ, Na SK, Lee SI, Kang JK, Park IS. The effect of red pepper and capsaicin on gastric emptying in human volunteers. Gastroenterology. 1998;114:A818. [Google Scholar]19. Horowitz M, Wishart J, Maddox A, Russo A. The effect of chilli on gastrointestinal transit. J Gastroenterol Hepatol. 1992;7:52–56. doi: 10.1111/j.1440-1746.1992.tb00935.x. [PubMed] [CrossRef] [Google Scholar]20. Tanaka T, Mizumoto A, Muramatsu S, et al. Postprandial normal saline intake delays gastric emptying of solids in conscious dogs: partial involvement of CCK in its mechanism. Dig Dis Sci. 1999;44:1516–1524. doi: 10.1023/A:1026642422375. [PubMed] [CrossRef] [Google Scholar]21. Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux. Gut. 2004;53:1730–1735. doi: 10.1136/gut.2004.043265. [PMC free article] [PubMed] [CrossRef] [Google Scholar]22. Austin GL, Thiny MT, Westman EC, Yancy WS, Jr, Shaheen NJ. A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms. Dig Dis Sci. 2006;51:1307–1312. doi: 10.1007/s10620-005-9027-7. [PubMed] [CrossRef] [Google Scholar]23. Piche T, Zerbib F, Varannes SB, et al. Modulation by colonic fermentation of LES function in humans. Am J Physiol Gastrointest Liver Physiol. 2000;278:G578–G584. [PubMed] [Google Scholar]24. Zheng Z, Nordenstedt H, Pedersen NL, Lagergren J, Ye W. Lifestyle factors and risk for symptomatic gastroesophageal reflux in monozygotic twins. Gastroenterology. 2007;132:87–95. doi: 10.1053/j.gastro.2006.11.019. [PMC free article] [PubMed] [CrossRef] [Google Scholar]25. Nandurkar S, Locke Gr, 3rd, Fett S, Zinsmeister AR, Cameron AJ, Talley NJ. Relationship between body mass index, diet, exercise and gastro-oesophageal reflux symptoms in a community. Aliment Pharmacol Ther. 2004;20:497–505. doi: 10.1111/j.1365-2036.2004.02156.x. [PubMed] [CrossRef] [Google Scholar]26. Ruhl CE, Everhart JE. Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization: the NHANES I epidemiologic followup study. First national health and nutrition ezamination survey. Ann Epidemiol. 1999;9:424–435. doi: 10.1016/S1047-2797(99)00020-4. [PubMed] [CrossRef] [Google Scholar]27. Yang JH, Kang HS, Lee SY, et al. Recurrence of gastroesophageal reflux disease correlated with a short dinner-to-bedtime interval. J Gastroenterol Hepatol. 2014;29:730–735. doi: 10.1111/jgh.12455. [PubMed] [CrossRef] [Google Scholar]28. Matsuki N, Fujita T, Watanabe N, et al. Lifestyle factors associated with gastroesophageal reflux disease in the Japanese population. J Gastroenterol. 2013;48:340–349. doi: 10.1007/s00535-012-0649-1. [PubMed] [CrossRef] [Google Scholar]29. Kim N, Lee SW, Cho SI, et al. The prevalence of and risk factors for erosive oesophagitis and non-erosive reflux disease: a nationwide multicentre prospective study in Korea. Aliment Pharmacol Ther. 2008;27:173–185. doi: 10.1111/j.1365-2036.2007.03561.x. [PubMed] [CrossRef] [Google Scholar]30. Kubo A, Block G, Quesenberry CP, Buffler P, Corley DA. Dietary guideline adherence for gastroesophageal reflux disease. BMC Gastroenterol. 2014;14:144. doi: 10.1186/1471-230X-14-144. [PMC free article] [PubMed] [CrossRef] [Google Scholar]31. Maradey-Romero C, Fass R. New and future drug development for gastroesophageal reflux disease. J Neurogastroenterol Motil. 2014;20:6–16. doi: 10.5056/jnm.2014.20.1.6. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

Foods Inducing Typical Gastroesophageal Reflux Disease Symptoms in Korea

J Neurogastroenterol Motil. 2017 Jul; 23(3): 363–369.

Department of Gastroenterology, Korea University Guro Hospital, Seoul,
Korea

*Correspondence: Young-Tae Bak, MD, Department of Gastroenterology, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea, Tel: +82-2-2626-1778, Fax: +82-504-366-6381, E-mail: rk.ca.aerok@tykabrd

Received 2016 Jul 28; Revised 2016 Oct 17; Accepted 2016 Nov 13.

Copyright © 2017 The Korean Society of Neurogastroenterology and MotilityThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background/Aims

Several specific foods are known to precipitate gastroesophageal reflux disease (GERD) symptoms and GERD patients are usually advised to avoid such foods. However, foods consumed daily are quite variable according to regions, cultures, etc. This study was done to elucidate the food items which induce typical GERD symptoms in Korean patients.

Methods

One hundred and twenty-six Korean patients with weekly typical GERD symptoms were asked to mark all food items that induced typical GERD symptoms from a list containing 152 typical foods consumed daily in Korea. All patients underwent upper gastrointestinal endoscopy followed by 24-hour ambulatory esophageal pH monitoring. The definition of “GERD” was if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.

Results

One hundred and twenty-six cases (51 GERD and 75 possible GERD) were enrolled. In 19 (37.3%) of 51 GERD cases and in 17 (22.7%) of 75 possible GERD cases, foods inducing typical GERD symptoms were identified. In the GERD group (n = 19), frequent symptom-inducers were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki. In the possible GERD group (n = 17), frequent symptom-inducers were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizza, topokki, rice cakes, champon noodles, and hotdogs.

Conclusions

In one-third of GERD patients, foods inducing typical symptoms were identified. Hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki were the foods frequently inducing typical symptoms in Korea. The list of foods frequently inducing typical GERD symptoms needs to be modified based on their own local experiences.

Keywords: Food, Gastroesophageal reflux, Korea, Symptom assessment

Introduction

Gastroesophageal reflux disease (GERD) is characterized by abnormal reflux of the gastric contents into the esophagus.1 In most patients with GERD, reflux of gastric juice commonly causes heartburn and regurgitation.2 Barrett’s esophagus, which is a premalignant lesion for esophageal adenocarcinoma, is considered one of the most important complications of GERD.3

These troublesome symptoms and complications are the main drivers for GERD patients to seek medical attention. The conditions, such as male gender, a presence of a hiatal hernia, history of Helicobacter pylori eradication, current alcohol intake, and abdominal obesity, are known as risk factors for GERD.4,5 Dietary factors traditionally have been thought to induce or worsen GERD. GERD symptoms are commonly reported postprandially, suggesting that some specific diet components are more likely to induce symptoms.4 With the introduction of 24-hour pH monitoring, it has been objectively shown that postprandial reflux is important in reflux symptom profiles.6,7 However, there have been few attempts to measure the effect of specific food stuffs that might provoke or increase gastroesophageal reflux. Although several studies have reported that high-fat foods, spicy foods, chocolate, mint, and citrus fruits are closely related to GERD symptoms,810 the daily consumed foods are quite variable according to race, geographic specificity, diet habit, and culture. The conflicting conditions may cause differences in food-induced GERD symptoms between Asian and Western populations. Therefore, dietary recommendations should be based on local experiences. According to a recent Korean study, dietary categories aggravating typical or atypical GERD symptoms in possible GERD cases were noodles, fatty meals, caffeinated drinks, spicy foods, alcohol, breads, carbonated drinks, and sweets.11

This study was performed to investigate food items that are frequently consumed daily and may be responsible for inducing typical GERD symptoms in confirmed GERD patients in their daily lives in Korea.

Materials and Methods

One hundred and twenty-six consecutive subjects who visited our Digestive Disease Center between February 2009 and September 2014 due to at least weekly typical GERD symptoms (heartburn or regurgitation) for at least 3 months were recruited into this prospective study. Subjects were excluded if they had other significant gastrointestinal diseases (for example, active peptic ulcer disease, infectious conditions of the intestine and gastric malignancy), a history of gastrectomy or severe health problems. Exclusion criteria also included any use of NSAIDs, oral steroids or aspirin, use of proton pump inhibitors or histamine h3 receptor antagonists over the preceding 3 months, and current pregnancy. All subjects provided written informed consent prior to the investigation.

All patients underwent upper gastrointestinal endoscopy to assess the presence and extent of esophageal mucosal breaks. Thereafter, 24-hour ambulatory esophageal pH monitoring was carried out. Patients with GERD symptoms were divided into 2 groups according to the results of endoscopy and pH monitoring; “GERD” if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.

The patients were asked during their first visit whether they experienced their typical GERD symptoms induced by any specific food intake for the preceding 3 months. Then they marked all food items which induced their typical GERD symptoms from a food list containing 152 foods usually consumed daily by Koreans. The food list was made including all individually collected daily food consumption lists from more than 20 hospital staffs and patients. Considering the possibility of omission of any foods, if the patients could not find any symptom-inducing foods of their own from the list, they were instructed to add such foods freely to the list. In addition, they crossed out all food items that they had not consumed for the preceding 3 months from the list.

Symptom-inducing foods were categorized into 2 groups: “frequent symptom-inducers” if they induced symptom(s) in half or more occasions of consumption, and “occasional symptom-inducers” if they induced symptom(s) in less than half occasions of consumption. When any food induced typical GERD symptoms in half or more patients of the group, it was regarded as a meaningful culprit food.

All statistical analyses were conducted using the SPSS statistical software (version 20.0; IBM Corp, Armonk, NY, USA). P-values less than 0.05 were considered statistically significant. The data with continuous variables were expressed as mean ± standard deviation. The estimated internal consistency of the food list questionnaire was assessed through Cronbach’s alpha coefficients.

Written informed consent was obtained from all participants. This study received approval from the institutional review board of Korea University Guro Hospital.

Results

A total of 126 patients completed the study. Among these subjects, the age of 51 GERD patients ranged from 27 to 72 years, and the 75 possible GERD patients were aged 17 to 79 years. In 19 (37.3%) out of the 51 GERD cases and in 17 (22.7%) out of the 75 possible GERD cases, foods inducing typical GERD symptoms were identified (). The Cronbach’s alpha value of the overall questionnaire was 0.77 (95% confidence interval 0.75 – 0.78) among the 152 food items and, therefore, it was acceptable for internal consistency.

Enrolled cases. GERD, gastroesophageal reflux disease.

shows clinical characteristics of the 4 subgroups according to the presence of mucosal breaks and/or pathologic refluxes and symptom-inducing foods. There were no differences in age, gender, height, weight, and body mass index (BMI) between patients with and without symptom-inducing foods in both GERD and possible GERD groups, except a female predominance in the possible GERD group with symptom-inducing foods. Among the patients without symptom-inducing foods, the BMI in GERD patients was significantly greater than that in possible GERD patients (24.9 ± 4.6 vs 22.5 ± 3.7, P = 0.007).

Table 1

Baseline Characteristics According to Status of Gastroesophageal Reflux Disease and Symptom-inducing Foods

GERDP-valuePossible GERDP-value


Food (+)
(n = 19)
Food (−)
(n = 32)
Food (+)
(n = 17)
Food (−)
(n = 58)
Age (mean ± SD)55.5 ± 9.852.7 ± 11.50.35850.8 ± 13.152.5 ± 14.10.670
Gender (M/F)7/1212/200.9631/1620/380.021
Height (mean ± SD, cm)160.0 ± 10.2161.5 ± 7.90.554159.3 ± 6.7161.2 ± 8.20.182
Weight (mean ± SD, kg)62.3 ± 11.465.1 ± 13.40.45458.5 ± 7.859.5 ± 13.00.375
BMI (mean ± SD)24.3 ± 3.224.9 ± 4.60.60923.1 ± 2.122.5 ± 3.70.809

In the GERD group, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki (stir-fried rice cakes). Foods that frequently or occasionally induced GERD symptoms in half or more patients included biscuits, breads, hand-pulled dough soups, hamburgers, doughnuts, spicy noodles with vegetables and seafoods (champon), noodles with stir-fried bean paste (jajangmyeon), alcohols, carbonated beverages, pizzas, mandarins, plain noodles, oranges, and milk ().

Table 2

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms and Percentage of Patients in Gastroesophageal Reflux Disease Cases

GERD patients (n = 19)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews63.2Hot spicy stews84.2
Rice cakes63.2Ramen noodles84.2
Ramen noodles57.9Fried foods75.0
Fried foods50.0Rice cakes73.7
Topokki50.0Biscuits64.3
Breads63.2
Hand-pulled dough soups60.0
Topokki56.3
Hamburgers56.3
Doughnuts55.6
Champon55.6
Jajangmyeon55.6
Alcohols54.5
Fanta beverages54.5
Pizzas53.3
Mandarins52.6
Plain noodles52.6
Oranges50.0
Milk50.0

In the possible GERD group, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizzas, topokki, rice cakes, champon, and hotdogs. Moreover, cola, oranges, alcohols, hamburgers, jajangmyeon, hand-pulled dough soups, dumplings, red beans, green tea, and rice cake soups were added to the list of foods that frequently or occasionally induced GERD symptoms in half or more patients ().

Table 3

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms and Percentage of the Patients in Possible Gastroesophageal Reflux Disease Cases

Possible GERD patients (n = 17)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews76.9Fried foods88.9
Fried foods66.7Hot spicy stews84.6
Doughnuts66.7Topokki81.8
Breads62.5Breads81.3
Ramen noodles57.1Pizzas77.8
Coffee57.1Rice cakes73.3
Pizzas55.6Coffee71.4
Topokki54.5Doughnuts66.7
Rice cakes53.3Ramen noodles64.3
Champon50.0Hotdogs62.5
Hotdogs50.0Cola60.0
Oranges58.3
Champon57.1
Alcohols57.1
Hamburgers57.1
Jajangmyeon55.6
Hand-pulled dough soup53.8
Dumplings50.0
Red beans50.0
Green tea50.0
Rice cake soups50.0

In all confirmed or possible GERD cases, foods that frequently induced typical GERD symptoms in half or more patients were hot spicy stews, rice cakes, ramen noodles, fried foods, breads, and topokki. Foods that frequently or occasionally induced GERD symptoms in half or more patients additionally included pizzas, doughnuts, coffee, hand-pulled dough soups, champon, hamburgers, alcohols, jajangmyeon, oranges, biscuits, cola, and plain noodles ().

Table 4

List of Food Items That Frequently or Occasionally Induced Typical Gastroesophageal Reflux Disease Symptoms, and Percentage of Patients with Gastroesophageal Reflux Disease and Possible Gastroesophageal Reflux Disease Cases

GERD or possible GERD patients (n = 36)

Frequent inducersFrequent or occasional inducers


Food itemsPatients (%)Food itemsPatients (%)
Hot spicy stews68.8Hot spicy stews84.4
Rice cakes58.8Fried foods80.0
Ramen noodles57.6Ramen noodles75.8
Fried foods56.0Rice cakes73.5
Breads54.3Breads71.4
Topokki51.9Topokki66.7
Pizzas62.5
Doughnuts59.1
Coffee58.1
Hand-pulled dough soups57.1
Champon56.3
Hamburgers56.0
Alcohols55.6
Jajangmyeon54.8
Oranges53.1
Biscuits51.9
Cola51.9
Plain noodles50.0

Discussion

It is commonly accepted that meals can trigger symptoms in GERD patients, but accurate and objective data are limited. Most of the recommendations on changes in dietary habits are not strongly supported by objective measurements. The relationship between foods and GERD in the Korean population still remains unclear. The results of our study show that hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki are frequently inducing typical GERD symptoms in Korean GERD patients.

Although some studies reported that some nutrients and foods are related to the presence of GERD symptoms in Western patients,10,12 there are no well-organized data regarding foods associated with GERD symptoms in Asian patients. In Europe and the United States, some investigators have shown that dietary fat, cholesterol, saturated fatty acid, dietary fiber, and other nutrients are associated with GERD.10,12 They believe that both improved socioeconomic status and the westernized pattern of diet consumption may be associated with the increasing prevalence of GERD in Asians.13 However, the currently available data do not support a strong relationship between GERD and dietary factors in Asians including Koreans. Taken together, our findings support a recommendation for Korean patients with GERD and possible GERD to avoid specific foods because GERD symptoms appear more frequently after consumption of the common symptom-inducing foods. This study also systematically evaluated the role of daily consumed Korean traditional foods as well as westernized foods in GERD symptom generation.

Supporting data exist regarding some specific meals in relation to GERD symptoms. The role of fat in symptom generation has been demonstrated in several studies.6,1416 In some clinical studies, it was shown that esophageal pH monitoring provides direct evidence on the association between dietary fat and acid reflux, and that high-fat meal decreases the lower esophageal sphincter pressure, increases the rate of transient lower esophageal sphincter relaxation, and delays the gastric emptying,5 which may lead to a greater incidence of reflux.14,15 Spicy foods attributable to direct irritation of already inflamed lower esophageal mucosa may exacerbate heartburn.17 Red pepper, which contains the neurotoxin capsaicin, has been shown to delay gastric emptying,18,19 and it can possibly provoke reflux. Some previous studies have found that an increase in salt consumption was associated with GERD, which was attributed to the inhibited gastric motor activity and delayed gastric emptying after high salt intake.20,21 It was also found that a low-carbohydrate diet reduces distal esophageal acid exposure in 24-hour pH testing and improves GERD symptoms.22 In a study, ingestion of lactose resulted in an increased number of transient lower esophageal sphincter relaxations, increased reflux episodes, higher esophageal acid exposure, and more severe GERD symptoms in healthy volunteers.23 Similarly, our results also revealed a relationship between the above mentioned tastes or nutrients and GERD symptoms. Many GERD patients are more likely to experience a perceived reflux event when they eat some fatty, spicy, salty foods, and meals with high carbohydrate content. Ramen noodles, hot spicy stews, and topokki are typically spicy and salty Korean traditional foods. Rice cake and bread contain high carbohydrate nutrients. These are the foods to which Koreans have easy access and they are frequently used for main meal replacement.

Conflicting data exist regarding the roles of specific meals in relation to GERD symptoms. In several studies investigating the effect of diet on gastroesophageal reflux, the results have not been consistent.2426 Certain eating habits, such as eating quickly and irregularly, eating big meals, eating between meals, or eating directly before sleeping, individualized acid hypersensitivity and psychological stress may contribute to the appearance of symptoms.11,27,28 As shown in our study, females were predominant among possible GERD patients with food related symptoms. It may be that females have a tendency to have a sensitive esophagus or to relate to psychological stress.

This is the first study that systematically and prospectively evaluated the role of 152 variable diets with frequency in symptom generation among patients with GERD and possible GERD by permitting multiple choices and using a comprehensive diet tool. In addition, many possible GERD patients, who are commonly encountered in one-third to one-half of the Korean population with GERD symptoms, were enrolled.29 Hence, this study can reflect the actual aspects of the racial, geographic, and cultural specificities in Korean patients with GERD symptoms. Interestingly, most symptom-inducing foods are Korean traditional foods which have been consumed since a long time ago. The recent increase in GERD prevalence in Korea cannot be fully explained by the change to westernized foods. Finally, although a high BMI is a well-known independent risk factor for esophageal erosions, it did not affect esophageal inflammation particularly in patients with food-induced symptoms in our study. This finding is in contrast with patients without food-related symptoms.

This study could be used as a reference for the development and validation of diet recommendations for GERD patients that are applicable to Korean patients. A recent cross-sectional study demonstrated that GERD patients consumed symptom-inducing foods more frequently than in asymptomatic individuals. This suggested that dietary modification could be effective in reducing and managing GERD symptoms.30 Based on our study, a dietary education program for GERD patients could be developed using figures of foods which are familiar to the patients and are encountered daily. It could help physicians and patients to gain an insight into the symptoms possibly related to foods and reinsure avoidance of these foods. Regardless of the emergence of potent medicines (such as improved proton pump inhibitors, transient lower esophageal sphincter relaxation reducers, mucosal protectants, and esophageal-specific pain modulators),31 correctable diet modifications should be emphasized. Avoiding such foods may be important for maintaining patients in a symptom-free state which was attained with medications, although it may not be helpful to induce healing of GERD. Dietary advice such as avoidance of symptom-inducing foods may not be very difficult to follow and can reduce unnecessary medical costs.

Our study has some limitations. First, although we used a rather short time window of 3 months, the recall bias and residual confounding factors (eating habits, lifestyle, and genetic risk factors) might have influenced the results. Second, this study has a limitation stemming from its small sample size. The reason why we could not recruit more cases was that we included only new patients with typical GERD symptoms while excluding users of NSAIDs, oral steroids or aspirin, users of proton pump inhibitors or histamine h3 receptor antagonists over the preceding 3 months, and we included only those who underwent both upper gastrointestinal endoscopy and 24-hour ambulatory pH monitoring. Further researches with a larger scale multicenter national study seem to warrant better clarification of the relationship between foods and GERD symptoms in Korea.

In conclusion, hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki are most common foods that induce typical GERD symptoms in Korean GERD patients. The list of food items that produce typical GERD symptoms in patients from Asian countries needs to be revised substantially from the Western literature based on their own local experiences.

Footnotes

Conflicts of interest: None.

Author contributions: Jung Wan Choe: data analysis, data interpretation, and writing the manuscript; Young-Tae Bak: data acquisition, data analysis, data interpretation, and drafting the manuscript; and Moon Kyung Joo, Hyo Jung Kim, Beom Jae Lee, Ji Hoon Kim, Jong Eun Yeon, Jong-Jae Park, Jae Seon Kim, and Kwan Soo Byun: data acquisition and critical revision of the manuscript.

Financial support: None.

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;101:1900–1920. doi: 10.1111/j.1572-0241.2006.00630.x. [PubMed] [CrossRef] [Google Scholar]2. Kao SS, Chen WC, Hsu PI, et al. The frequencies of gastroesophageal and extragastroesophageal symptoms in patients with mild erosive esophagitis, severe erosive esophagitis, and barrett’s esophagus in Taiwan. Gastroenterol Res Pract. 2013;2013:480325. doi: 10.1155/2013/480325. [PMC free article] [PubMed] [CrossRef] [Google Scholar]3. Falk GW. Gastroesophageal reflux disease and Barrett’s esophagus. Endoscopy. 2001;33:109–118. doi: 10.1055/s-2001-11669. [PubMed] [CrossRef] [Google Scholar]4. Dore MP, Maragkoudakis E, Fraley K, et al. Diet, lifestyle and gender in gastro-esophageal reflux disease. Dig Dis Sci. 2008;53:2027–2032. doi: 10.1007/s10620-007-0108-7. [PubMed] [CrossRef] [Google Scholar]5. Kulig M, Nocon M, Vieth M, et al. Risk factors of gastroesophageal reflux disease: methodology and first epidemiological results of the ProGERD study. J Clin Epidemiol. 2004;57:580–589. doi: 10.1016/j.jclinepi.2003.10.010. [PubMed] [CrossRef] [Google Scholar]6. Shapiro M, Green C, Bautista JM, et al. Assessment of dietary nutrients that influence perception of intra-oesophageal acid reflux events in patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2007;25:93–101. doi: 10.1111/j.1365-2036.2006.03170.x. [PubMed] [CrossRef] [Google Scholar]7. Ravi K, Francis DL, See JA, Geno DM, Katzka DA. The effects of a weakly acidic meal on gastric buffering and postprandial gastro-oesophageal reflux. Aliment Pharmacol Ther. 2011;34:568–575. doi: 10.1111/j.1365-2036.2011.04761.x. [PubMed] [CrossRef] [Google Scholar]8. Schönfeld J, Evans DF. [Fat, spices and gastro-oesophageal reflux]. Z Gastroenterol. 2007;45:171–175. doi: 10.1055/s-2006-927271. [German] [PubMed] [CrossRef] [Google Scholar]9. Vemulapalli R. Diet and lifestyle modifications in the management of gastroesophageal reflux disease. Nutr Clin Pract. 2008;23:293–298. doi: 10.1177/0884533608318106. [PubMed] [CrossRef] [Google Scholar]10. Wu P, Zhao XH, Ai ZS, et al. Dietary intake and risk for reflux esophagitis: a case-control study. Gastroenterol Res Pract. 2013;2013:691026. doi: 10.1155/2013/691026. [PMC free article] [PubMed] [CrossRef] [Google Scholar]11. Song JH, Chung SJ, Lee JH, et al. Relationship between gastroesophageal reflux symptoms and dietary factors in Korea. J Neurogastroenterol Motil. 2011;17:54–60. doi: 10.5056/jnm.2011.17.1.54. [PMC free article] [PubMed] [CrossRef] [Google Scholar]12. Festi D, Scaioli E, Baldi F, et al. Body weight, lifestyle, dietary habits and gastroesophageal reflux disease. World J Gastroenterol. 2009;15:1690–1701. doi: 10.3748/wjg.15.1690. [PMC free article] [PubMed] [CrossRef] [Google Scholar]13. Wu JC. Gastroesophageal reflux disease: an Asian perspective. J Gastroenterol Hepatol. 2008;23:1785–1793. doi: 10.1111/j.1440-1746.2008.05684.x. [PubMed] [CrossRef] [Google Scholar]14. Iwakiri K, Kobayashi M, Kotoyori M, Yamada H, Sugiura T, Nakagawa Y. Relationship between postprandial esophageal acid exposure and meal volume and fat content. Dig Dis Sci. 1996;41:926–930. doi: 10.1007/BF02091532. [PubMed] [CrossRef] [Google Scholar]15. Holloway RH, Lyrenas E, Ireland A, Dent J. Effect of intraduodenal fat on lower oesophageal sphincter function and gastro-oesophageal reflux. Gut. 1997;40:449–453. doi: 10.1136/gut.40.4.449. [PMC free article] [PubMed] [CrossRef] [Google Scholar]17. Milke P, Diaz A, Valdovinos MA, Moran S. Gastroesophageal reflux in healthy subjects induced by two different species of chilli (Capsicum annum) Dig Dis. 2006;24:184–188. doi: 10.1159/000090323. [PubMed] [CrossRef] [Google Scholar]18. Park HJ, Na SK, Lee SI, Kang JK, Park IS. The effect of red pepper and capsaicin on gastric emptying in human volunteers. Gastroenterology. 1998;114:A818. [Google Scholar]19. Horowitz M, Wishart J, Maddox A, Russo A. The effect of chilli on gastrointestinal transit. J Gastroenterol Hepatol. 1992;7:52–56. doi: 10.1111/j.1440-1746.1992.tb00935.x. [PubMed] [CrossRef] [Google Scholar]20. Tanaka T, Mizumoto A, Muramatsu S, et al. Postprandial normal saline intake delays gastric emptying of solids in conscious dogs: partial involvement of CCK in its mechanism. Dig Dis Sci. 1999;44:1516–1524. doi: 10.1023/A:1026642422375. [PubMed] [CrossRef] [Google Scholar]21. Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux. Gut. 2004;53:1730–1735. doi: 10.1136/gut.2004.043265. [PMC free article] [PubMed] [CrossRef] [Google Scholar]22. Austin GL, Thiny MT, Westman EC, Yancy WS, Jr, Shaheen NJ. A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms. Dig Dis Sci. 2006;51:1307–1312. doi: 10.1007/s10620-005-9027-7. [PubMed] [CrossRef] [Google Scholar]23. Piche T, Zerbib F, Varannes SB, et al. Modulation by colonic fermentation of LES function in humans. Am J Physiol Gastrointest Liver Physiol. 2000;278:G578–G584. [PubMed] [Google Scholar]24. Zheng Z, Nordenstedt H, Pedersen NL, Lagergren J, Ye W. Lifestyle factors and risk for symptomatic gastroesophageal reflux in monozygotic twins. Gastroenterology. 2007;132:87–95. doi: 10.1053/j.gastro.2006.11.019. [PMC free article] [PubMed] [CrossRef] [Google Scholar]25. Nandurkar S, Locke Gr, 3rd, Fett S, Zinsmeister AR, Cameron AJ, Talley NJ. Relationship between body mass index, diet, exercise and gastro-oesophageal reflux symptoms in a community. Aliment Pharmacol Ther. 2004;20:497–505. doi: 10.1111/j.1365-2036.2004.02156.x. [PubMed] [CrossRef] [Google Scholar]26. Ruhl CE, Everhart JE. Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization: the NHANES I epidemiologic followup study. First national health and nutrition ezamination survey. Ann Epidemiol. 1999;9:424–435. doi: 10.1016/S1047-2797(99)00020-4. [PubMed] [CrossRef] [Google Scholar]27. Yang JH, Kang HS, Lee SY, et al. Recurrence of gastroesophageal reflux disease correlated with a short dinner-to-bedtime interval. J Gastroenterol Hepatol. 2014;29:730–735. doi: 10.1111/jgh.12455. [PubMed] [CrossRef] [Google Scholar]28. Matsuki N, Fujita T, Watanabe N, et al. Lifestyle factors associated with gastroesophageal reflux disease in the Japanese population. J Gastroenterol. 2013;48:340–349. doi: 10.1007/s00535-012-0649-1. [PubMed] [CrossRef] [Google Scholar]29. Kim N, Lee SW, Cho SI, et al. The prevalence of and risk factors for erosive oesophagitis and non-erosive reflux disease: a nationwide multicentre prospective study in Korea. Aliment Pharmacol Ther. 2008;27:173–185. doi: 10.1111/j.1365-2036.2007.03561.x. [PubMed] [CrossRef] [Google Scholar]30. Kubo A, Block G, Quesenberry CP, Buffler P, Corley DA. Dietary guideline adherence for gastroesophageal reflux disease. BMC Gastroenterol. 2014;14:144. doi: 10.1186/1471-230X-14-144. [PMC free article] [PubMed] [CrossRef] [Google Scholar]31. Maradey-Romero C, Fass R. New and future drug development for gastroesophageal reflux disease. J Neurogastroenterol Motil. 2014;20:6–16. doi: 10.5056/jnm.2014.20.1.6. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

Spicy Foods You Should Avoid If You Get Heartburn

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If you find that shortly after eating something spicy you start to experience the discomfort of heartburn, it’s no coincidence. While the connection between diet and heartburn has been poorly understood in the past, according to research published in Current Opinion in Gastroenterology, there’s increasing scientific evidence that suggests certain trigger foods can cause heartburn in people.

The tricky part is that everyone’s heartburn triggers are different, explains Dr. Marvin Singh, MD, an integrative gastroenterologist and voluntary assistant clinical professor at the University of California San Diego’s Department of Family Medicine and Public Health. “Some people may experience heartburn from nuts and others have no problem,” Dr. Singh says. “Some people can drink a pot of coffee and be fine, and others drink half a cup and may have heartburn.”

Here, Dr. Singh shares some of the most common spicy foods to avoid if you’re prone to getting heartburn.

Why You Should Avoid Spicy Food If You Get Heartburn

Spicy foods can often be a trigger because, according to Dr. Singh, they contain a compound called capsaicin, which is known to slow down the rate of digestion and increase the risk that food in the stomach will reflux upwards. “Spicy foods can act directly as an irritant to the esophagus, which may already be inflamed, and that can also aggravate symptoms,” Dr. Singh adds.

If you’re prone to heartburn,

avoid spicy foods like:

  • Salsa
  • Spicy Asian or Indian meals, like pork vindaloo, curry, and Sichuan cuisine
  • Anything marinated or with hot sauce
  • Foods that contain red chili paste
  • Foods that contain sriracha
  • Wasabi
  • Foods that contain horseradish
  • Jalapeño

“Capsaicin can activate the release of a compound called substance P, and this transmits pain and burning sensations,” says Dr. Singh. This explains why spicy foods can have such a kick to them, and along with irritating the esophagus and increasing the risk of reflux, can make it easy for heartburn to occur.

If you’ve eaten spicy food or another trigger food that causes heartburn, try TUMS Chewy Bites for fast heartburn relief you can count on.

Minimally Invasive & Robotic Surgery

Surgery can be necessary in severe cases of GERD, but you can avoid the need for invasive procedures by controlling your gastroesophageal reflux disease with conservative treatments. One of the best ways to keep symptoms of GERD under control is to avoid dietary triggers. This, however, assumes you know what your triggers are.

While everyone is different, most people with GERD find specific categories of food troublesome. The team at the Center for Minimally Invasive and Robotic Surgery can help you identify and avoid the foods that cause your GERD and help keep your symptoms at bay.

If you find you still experience chest pain, unpleasant regurgitation of food, and heartburn after cutting these foods out, consult with the doctors to learn about other treatment options.

Why care about easing GERD?

Of course you want relief from GERD, because it affects your day-to-day quality of life. Experiencing the discomfort caused by the frequent backflow of stomach acid into your esophagus can make mealtime stressful. You may also experience disturbed sleep, regular coughing, and a sore throat.

GERD can also cause long-term damage to your body. You may have scar tissue form in the esophagus. You may also develop a condition known as Barrett’s esophagus, which is characterized by cancerous changes to the lining of the esophagus.

Specific foods to avoid with GERD

Relieving GERD symptoms can be as simple as making some smart meal choices. Spicy foods, including curry, salsa, chili, and hot sauce aggravate GERD symptoms. The spices make stomach acid stir up and become more likely to kick back up into your throat.

Garlic and onions are also aggravating foods. Beware as these are ingredients in many recipes, including holiday stuffing, stews, and some salads.

Fatty meals from fast-food restaurants or barbecue joints can slow digestion, so food sits and stomach acid releases over a longer period of time. Greasy cuts of meat, French fries, and burgers are best kept off your plate. Opt for grilled chicken, baked potatoes, and flatbread instead.

Pizza is a double whammy as it’s often fatty and covered in acidic tomato sauce, which exacerbates GERD. Classic or spicy marinara sauces over pasta can be triggers for GERD symptoms, too.

Citrus fruits and chocolate are highly acidic, meaning you should also avoid these if you’ve been diagnosed with GERD. Coffee, alcohol, carbonated drinks, and alcohol also irritate your digestive tract.

Sometimes, the simple after-dinner mint — which seems entirely harmless — can also set off a surge of GERD symptoms.

How you eat your food matters

It’s not just the foods you choose. How you eat and where you eat makes a difference in your GERD symptoms. Avoid overstuffing yourself at meals. Large meals take longer to digest, meaning more time to regurgitate acid and food into your esophagus.

Plan ahead for meals. Eating a meal within an hour or two of bedtime can also be triggering for GERD symptoms. Much of the food remains undigested and can cause reflux symptoms just as you try to get some shuteye. The same is true for late-night snacking.

Smart eating habits go a long way in minimizing the effects of GERD. Know if you’re struggling with chronic heartburn and acid reflux, the team at the Center for Minimally Invasive and Robotic Surgery can help. Call the office in Peoria, Arizona or schedule online to learn your full array of treatment options. 

What is heartburn and how to get rid of it

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What is heartburn

Heartburn is a burning sensation that sometimes occurs behind the breastbone and rises to the throat. It appears due to the fact that gastric juice accidentally enters the esophagus and irritates its walls. This process is called acid reflux.

Acid reflux usually occurs or worsens after eating, in the evening, when lying down, or when bending over.

From time to time almost everyone faces heartburn. If the attacks recur regularly, at least several times a week, doctors talk about gastroesophageal reflux disease (GERD).

Where does heartburn come from?

Normally, the esophagus provides one-way movement of food or liquid. When you swallow, a ring of muscles at the bottom of your mouth (called the esophageal sphincter) relaxes to allow the swallow to pass into your stomach. And then it contracts again so as not to release the contents of the organ back.

But sometimes the sphincter weakens. Or he becomes too relaxed – this can also happen under the influence of certain foods eaten. Or, for example, the pressure in the stomach increases so much that the muscle ring cannot withstand the load and stretches. And then the contents of the organ, together with gastric juice, rises higher up the esophagus, causing a burning sensation.

Why heartburn is dangerous and when you need to see a doctor as soon as possible

Heartburn itself, especially if it appears infrequently, does not threaten anything.But GERD is a far from harmless condition: regular emissions of gastric juice can damage the esophagus 90,010, complicate 90,010 swallowing, cause a permanent feeling of a lump in the throat and even lead to degeneration of the esophageal epithelium (the so-called Barrett’s syndrome), and later, if you are not lucky, and cancer.

Another thing is dangerous: more serious health problems can be masked under heartburn. In particular – heart attack .

Call an ambulance immediately if, in addition to heartburn, you feel :

  • Severe chest pain or pressure.
  • Chest pain that radiates to the arm or jaw.
  • Breathing problems. It may be shortness of breath or just a feeling that it is impossible to inhale deeply.

Schedule a visit to a gastroenterologist in the near future if:

  • Heartburn occurs more than twice a week.
  • Symptoms persist despite the fact that you have already consulted a doctor and are taking the drugs they recommend.
  • You have trouble swallowing.
  • You have nausea or wanton vomiting.
  • You are losing weight due to persistent poor appetite or discomfort when swallowing.

How the doctor will treat heartburn

No self-medication, if you have the symptoms listed above, is unacceptable. It is important to understand that regular heartburn is not an independent disease, but a symptom of some disturbance in the functioning of the body. Most often we are talking about GERD, but in some cases, a burning sensation behind the sternum manifests itself 90,010 angina pectoris, hiatal hernia or even esophageal cancer.What exactly the problem is, only a doctor can find out.

To establish an accurate diagnosis, the gastroenterologist will ask you about your health, conduct a physical examination and, possibly, prescribe additional examinations. For example, it will send you for an X-ray: find out what condition the esophagus and stomach are in. Or for endoscopy: during this procedure, an optical probe will be inserted into the esophagus, which will allow you to examine in detail the condition of the walls of the organ.

When the diagnosis is made, the doctor will prescribe treatment.

How to get rid of heartburn right now

Only if there are no dangerous signs, and heartburn visits you infrequently, you can try to cope with it with home methods. Which one will be most effective in your case cannot be predicted. So experiment with each one in turn.

  1. Take antacid medication . These are over-the-counter drugs that quickly neutralize gastric juice and thus reduce irritation to the esophagus.Note: it is impossible to cure an already damaged esophagus with antacids. You will need more serious medications that your doctor will prescribe for you.
  2. Raise your shoulders and head. If you are lying down, stand up. Or at least place a higher pillow under your head. This will obstruct the route of gastric juice into the esophagus .
  3. Chew gum. One small study of found that when you use an elastic band for half an hour, heartburn subsides. This is because chewing gum stimulates the production of saliva, which in turn flushes gastric juice from the walls of the esophagus.
  4. Take soda solution – it is analogous to antacids. Stir a teaspoon of baking soda in a glass of warm water and drink in small sips.
  5. Drink milk . But only low fat: Fat can make acid reflux more pronounced. Milk will create a temporary barrier between the esophagus and the acidic contents of the stomach and thereby quickly reduce the burning sensation.
  6. Drink herbal tea – chamomile, ginger or licorice will do.Such drinks can reduce irritation to the esophagus. Pour boiling water over a teaspoon of dried chamomile, licorice or grated ginger root, or brew ready-made tea in a bag.
  7. Drink homemade lemonade. Although lemon juice is obviously acidic, a small amount mixed with water can reduce stomach acidity during digestion. This is the opinion of some experts, for example, M.D. Deborah Wetherspoon, who is referred to by the American medical resource Healthline .This tool does not help everyone. But if you decide to try it, you need to prepare lemonade like this: stir a tablespoon of lemon juice in a glass of warm water. And drink 20 minutes before meals.

How to prevent heartburn in the future

Most often, in order to forget about the unpleasant sensations behind the breastbone after eating, it is enough to slightly change your lifestyle.

  1. Get rid of excess weight. Fat deposits around the waist press on the stomach, forcing the juice up the esophagus.
  2. Avoid tight clothing. Too tight jeans, tight-fitting T-shirts, tight belts – all this also increases the pressure on the organ.
  3. Try to avoid foods that can cause heartburn. These are spicy foods, citrus fruits, onions, fatty and fried foods, tomatoes and products from them (for example, ketchup), chocolate, strong coffee, tea, carbonated and alcoholic drinks, peppermint.
  4. Don’t overeat. It is best to eat small meals five to six times a day. Breakfast, lunch, and dinner that are too dense will increase the pressure in the stomach.
  5. Do not bend over or exercise immediately after eating.
  6. Do not lie down after eating. It is optimal to wait at least three hours.
  7. Avoid late meals.
  8. Raise the head of the bed so that your head and shoulders are above your belly.
  9. Stop smoking. It also provokes heartburn.

This story was originally published in September 2016. In April 2021, we updated the text.

Read also 💊👩🏻‍⚕️🩺

What are the most common causes of heartburn?

Contrary to what most people believe, experts suggest that heartburn is not necessarily caused by eating spicy foods, eating late at night, or mental stress.These are just a few of the factors that can make the condition worse, but they are not the main causes. It is believed that the two main causes of heartburn are overeating at any time of the day or night and obesity. Another less obvious cause of heartburn can be exercise before or after meals. All of these conditions can lead to malfunctioning of the lower esophageal sphincter, which is the main cause of this common condition – many people may confuse what is causing the burning sensation with the actual cause of heartburn.

Anyone who suffers from heartburn usually has a flaccid lower esophageal sphincter, which can lead to heartburn if there is enough acid in the stomach. When this valve responds normally, it opens and closes to allow food to pass into the esophagus. If it remains open even partially, acids can be secreted into the esophagus, which causes a burning sensation; the pain is usually located just below the heart, as it is called “heartburn”. It is believed that an overfilled or excessive stomach contributes to the development of this condition, as both situations put too much pressure on the sphincter, allowing it to remain open when it should be closed.This is one of the reasons why heartburn is often a common problem during pregnancy.

Spicy food usually does not lead to this condition, unless the person suffers from one of the main causes of heartburn; however, they are considered to be triggers in those who do. Other triggers include caffeine, smoking, alcohol, and certain medications. They can sometimes weaken the sphincter of the lower esophagus, leading to the release of acids. The more acid is present, the worse the episode can be.For this reason, people with heartburn should generally try to avoid highly acidic foods such as tomatoes, citrus fruits, and high-fat foods.

Heartburn is considered by most to be a relatively common condition, with millions of patients worldwide. Long-term heartburn usually needs to be treated by a doctor because it can lead to more serious complications such as Barrett’s esophagus and esophageal cancer. Common treatments that doctors sometimes prescribe include weight loss, dietary changes, and prescription medications such as Reglan® or Nexium®.

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90,000 Will dietary changes affect GERD?

To reduce the symptoms of GERD, you need to:

  • Avoid foods that cause your symptoms
  • eat more often, in smaller portions, as overeating can cause symptoms

Certain foods can affect how well the lower esophageal sphincter works or irritate the tissues lining the esophagus.If you have GERD, you need to avoid foods that cause these problems. You should also eat less and more often because large meals can increase your risk of reflux.

Which foods should I avoid?

Here are some common food types that can play a role in your
GERD
. These recommended dietary changes do not mean that you are limited to a soft diet. When planning, you can enjoy a delicious meal while keeping GERD in check.

Food type Specific products

How food causes symptoms
Foods with a high fat content
  • cheese
  • fatty beef
  • hot dogs
  • slows down gastric emptying, which increases the risk of reflux
  • weakens or interferes with the proper functioning of the lower esophageal sphincter or LES
Fried food
  • donuts
  • fried potatoes
  • slows down gastric emptying
  • weakens or interferes with normal operation of LES
Tomato-based products
  • BBQ sauce
  • chile
  • ketchup
  • pizza
  • salsa
  • spaghetti sauce
  • tomato juice
  • tomatoes
  • irritates the esophageal mucosa
Citrus based products
  • lemonade
  • lemons
  • limes
  • orange juice
  • oranges
  • pineapple
  • irritates the esophageal mucosa

Some candy

  • cake
  • sweets, including chocolate, peppermint and spearmint
  • biscuits
  • hot cocoa
  • relaxes or relaxes LES
Alcohol
  • beer
  • Strong liquor
  • relaxes LES
Caffeinated beverages
  • irritates the esophageal mucosa
  • can weaken LES
Carbonated drinks
  • seltzer / club soda
  • soft drinks
  • May cause bloating and reflux
Spicy food
  • curry
  • garlic

  • hot sauce
  • jalepeno pepper / hot pepper
  • mustard
  • bow
  • salsa
  • irritates the esophageal mucosa
  • weakens or interferes with the normal operation of the LES

90,000 Heartburn – When Should You See Your Doctor? – HTI CENTERS

Heartburn is a burning sensation, pain in the chest, behind the sternum.

The cause of this restless feeling is irritation of the esophagus containing stomach acid. The pain is aggravated after eating or when the patient lies down or bends down.

burnt

Typical for heartburn:

  • Burning pain in the chest that comes on after eating;
  • Pain that is worse when lying down or bending forward;
  • Bitter or sour taste in the mouth.

When to see a doctor?

The patient should be immediately transferred to the clinic if he complains of severe chest pain or a certain feeling of heaviness and along with this discomfort there are other symptoms (difficulty breathing, pain in the side or jaw).Chest pain could be a sign of a heart attack!

It is recommended to make an appointment with a doctor if you are familiar with the following symptoms:

  • Heartburn occurs two or more times per week;
  • Without a prescription, took medication willfully and symptoms persisted;
  • Difficulty swallowing;
  • Constantly disturbed by the feeling of nausea and vomiting;
  • From lack of appetite, they lost weight.

The doctor will prescribe a course of treatment for heartburn.

It should be noted that certain foods and beverages can cause heartburn (fatty and fried or spicy foods, onions, citrus fruits, ketchup, garden mint, chocolate, alcohol, coffee, and other drinks that include caffeine).

Doctors explain that if you are overweight or during pregnancy, the risk of heartburn may increase.

As we read in the article, regular heartburn that interferes with your usual rhythm of life is considered gastroesophageal reflux.

In order for the doctor to find out whether heartburn is a symptom of gastroesophageal reflux disease, an endoscopic and fluoroscopic examination is prescribed.

Source:

https://www.mayoclinic.org/diseases-conditions/heartburn/symptoms-causes/syc-20373223

Heartburn: where does it come from and how to get rid of it

Still from the cartoon “Dobrynya Nikitich and the Serpent Gorynych”

What is heartburn and how does it manifest

This burning sensation behind the breastbone occurs due to stomach acid entering the esophagus … Doctors call this process gastroesophageal reflux.In fact, the acid burns, as it were, the lining of the esophagus, which is more delicate than that of the stomach.

Heartburn most often occurs after eating and sometimes at night. It gets worse when lying down or when you bend over. Usually accompanied by a bitter or sour taste in the mouth. Less common are coughs, hiccups, hoarse voice, bloating, and nausea.

Why does it occur

Normally, acid does not leave the stomach – the esophageal sphincter does not pass it. It is an annular muscle that contracts and closes the inlet.

In a healthy person, the sphincter relaxes only while eating. With heartburn, it weakens and can open at any time, causing acid to enter the esophagus.

Heartburn sometimes occurs in healthy people. It can be provoked by the following reasons:

  • overweight;
  • coffee, alcohol, chocolate, fatty or spicy foods;
  • 90,038 smoking;

  • pregnancy in which the growing uterus compresses the abdominal organs;
  • stress and anxiety;
  • Anti-inflammatory pain relievers (eg, ibuprofen or paracetamol).

In healthy people, heartburn is rare (less than twice a week) and quickly goes away.

If this happens all the time, you probably have gastroesophageal reflux disease (GERD).

Heartburn can also be caused by a hiatal hernia when part of the stomach is pushed through the diaphragm into the chest.

What foods cause heartburn

Related news

Avoid them if you suffer from heartburn:

  • spicy foods;
  • bow;
  • citrus fruits;
  • 90,038 tomato products such as ketchup;

  • fatty or fried foods;
  • peppermint;
  • chocolate;
  • alcohol, soda, coffee, or other caffeinated beverages;
  • fatty meals.

Any other food, if you eat too much of it, can cause heartburn – from a full stomach, acid easily penetrates the esophagus.

Why heartburn is dangerous

If it is rare, then nothing. But constant irritation of the mucous membrane in gastroesophageal reflux disease causes dangerous lesions of the esophagus, for example, esophagitis, Barrett’s esophagus, or even cancer.

12 facts about cancer – in our gallery:

When to see a doctor

Call an ambulance if you feel severe burning or tight chest pain, especially when it is combined with pain in the arm, jaw or back, as well as shortness of breath.Sometimes a heart attack is disguised as heartburn.

Make an appointment with a physician if:

  • Heartburn occurs more than twice a week.
  • The pills don’t work.
  • It is difficult for you to swallow food.
  • Along with heartburn, constant nausea or vomiting worries.
  • You are losing weight due to lack of appetite or fear of heartburn.

What helps with heartburn

If you need to get rid of heartburn right now, try these OTC drugs:

  • Antacids (maalox, almagel).They neutralize stomach acid. Antacids will quickly remove the symptom, but they do not protect the esophagus from the harmful effects of acid.
  • h3-receptor blockers (famotidine, ranitidine). They reduce the production of stomach acid, thereby preventing damage to the esophagus. They act slower than antacids.
  • Proton pump inhibitors (omeprazole, rabeprazole). They also reduce the acidity of gastric juice.

If tablets are not on hand, chew gum.Research shows that this produces more saliva, which flows down the esophagus and neutralizes the acid.

How to prevent this symptom

To keep heartburn from bothering you as rarely as possible, stock up not only on medications, but also on good habits

Do not overeat

Even if the esophageal sphincter is not weakened, too much food in the stomach increases pressure, and acid can enter the esophagus.

Lose weight

Excess belly fat increases pressure on the sphincter, making it weaker and easier to open.

The gallery has collected 19 films about food and weight loss for the New Year holidays:

Eat less carbohydrates

The more carbohydrates in the stomach, the longer they are digested. This stimulates the growth of bacteria that produce gases. The latter, in turn, put pressure on the sphincter and weaken it.

Drink less alcohol

Ethanol increases acid production, relaxes the esophageal sphincter and reduces the ability of the esophagus to expel gastric acid.

Drink less coffee

Coffee temporarily weakens the lower esophageal sphincter, increasing the risk of acid reflux.

Avoid raw onions

Onions can irritate damaged esophageal lining. It also stimulates the growth of bacteria.

Do not drink too much citrus juice

It does not cause reflux, but irritates the mucous membrane like stomach acid.

Raise the head of the bed

If heartburn bothers you at night, place a higher pillow under your head.

Also try to sleep on your left side. When you lie on your right, stomach acid coats the lower esophageal sphincter. In this position, it is easier for her to penetrate the esophagus.

Do not eat three hours before bed

This will reduce the amount of stomach acid before bed.

Do not wear tight clothing

It also increases pressure inside the abdomen, which weakens the esophageal sphincter.

Read also:

Spare the pancreas! How to protect yourself from pancreatitis

Obesity in youth threatens pancreatic cancer in old age

What exactly oatmeal is good for the stomach

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9 Ways to Make Life With Acid Reflux Easier

While you may have been diagnosed with gastroesophageal reflux disease (GERD), that doesn’t mean you can’t enjoy life to the fullest. There are ways to control GERD that may not necessarily make you get rid of acid reflux, but they can relieve your symptoms enough that you forget you are there.

Several lifestyle changes are usually required to control acid reflux symptoms.Following one of these tips can help, but it probably won’t give you the results you deserve. By taking a more holistic approach, you are more likely to achieve long-term control of your GERD symptoms.

There are 9 simple tips that can help:

Eat less than

If you eat small meals, your stomach will be less full and produce much less stomach acid. This, in turn, lowers gastric pressure.According to a 2019 research review published in the Journal of Thoracic Disease, eating more food combined with a higher calorie intake is implicitly associated with increased esophageal acid levels and bloating in people with GERD.

A stomach that is too full also puts physical pressure on a valve between the stomach and the esophagus known as the lower esophageal sphincter (LES). This allows more gastric juice to drain from the stomach into the esophagus.

To reduce your risk of GERD while meeting your daily nutritional needs, eat six small meals at regular intervals throughout the day, rather than three regular meals.

Eat slowly

When you eat, chemical messengers are sent from the stomach to the brain, signaling the presence of food. When the stomach is full, the brain responds with a feeling of satiety (in other words, a feeling of satiety and satisfaction).

However, it can take up to 15 minutes for these signals to reach the brain. By eating quickly, you run the risk of overfilling your stomach before the messenger signals reach your brain. If you eat slowly, your brain can catch up with your stomach and tell you when it’s full.

To slow down your food intake, follow these simple guidelines:

  • Eat at the table, not on the couch or on the run.
  • Do not eat while watching TV or sitting at your computer.
  • Place a fork or spoon between bites.
  • Mix food with conversation.

If all else fails, try eating with your non-dominant hand. If you are not comfortable with both hands, this simple solution is almost guaranteed to slow down the pace of your meal.

Avoid this if you have GERD

Avoid eating before bed

Late night snacking is a bad idea if you have GERD. When you lie down after eating, gravity forces the contents of your stomach to approach the LES (located at the top of the stomach). If you eat a lot of food, the pressure on the LES increases even more.

To avoid this, do not eat or drink at least two hours before bedtime. If you have severe symptoms of GERD, you can stop four hours before.

According to a 2011 study published in the Journal of Neurogastroenterology and Motility, eating earlier not only keeps your stomach empty while you sleep, but also reduces nocturnal stomach acid levels.

Raise your head while sleeping

When you sleep with your head above your belly, gravity can help relieve pressure on the LPS and keep stomach contents from refluxing into the esophagus. There are several ways to raise your head:

  • Place extra pillows under your head (ideally stiffer foam pillows that will not fold down).
  • Place bricks or blocks under the legs at the head of the bed.
  • Buy a wedge pillow online or at most mattress stores.

The same general approach applies to daytime sleep. Some people find that sleeping in a chair during the day helps prevent heartburn better than sleeping in bed.

Avoid trigger foods

You probably already know which foods are causing you heartburn.Some cause heartburn by increasing the acidity of the stomach, while others do it by relaxing the NPS. There are also foods that can directly irritate the lining of the esophagus, such as spicy foods, citrus fruits, coffee, and juices.

Alcohol is especially problematic. It not only increases the production of stomach acid, but also relaxes the LES, allowing the acid to reflux into the esophagus.

It can sometimes be difficult to determine which foods are causing the symptoms of GERD. If so, consider keeping a heartburn journal (similar to a diet diary) in which you write down the foods you eat and the degree of heartburn you experience after eating.

By rating your heartburn on a scale of 1 to 101, representing mild heartburn, and 10, representing severe and debilitating heartburn, you can better characterize your symptoms and determine which foods are causing the most problems.

Use antacids correctly

Antacids can be very effective in treating acute heartburn. With that said, taking antacids at the slightest hint of heartburn can do more harm than good.

Excessive use of antacids can cause constipation, diarrhea, discoloration of stools and stomach cramps. Foods containing calcium can even cause kidney stones.

In addition, antacids can interfere with the action of some medicines, including medicines for HIV, thyroid hormones, and blood thinners such as Coumadin (warfarin). To avoid interactions, an antacid may take two to four hours before or after taking certain medications.

Because it may take an hour or more for antacids to take effect, your doctor may recommend taking an h3 blocker such as Zantac (ranitidine) in combination with an antacid. If you still don’t feel relief, your doctor may recommend a proton pump inhibitor such as Prilosec (omeprazole).

When to see a doctor

If symptoms of GERD persist for more than two weeks, worsen, or continue despite treatment with over-the-counter drugs, see a gastroenterologist rather than self-treatment.

Avoid tight clothing

Clothes that are tight around the waist can squeeze the belly, pushing food up towards the LES. As much as these clothes can make you slimmer, they can also increase your chances of acid reflux, even if you don’t have GERD.

Generally, for GERD, it is best to avoid tight belts, delicate underwear, yoga pants, and tight trousers. Choose loose-fitting clothing, slip-on shirts and suspenders instead of belts.

Relax

Stress can worsen the symptoms of GERD.According to a 2013 study in the Journal of Digestive Diseases and Science, stress does not so much “cause” GERD as it enhances the perception of symptoms5.

During times of stress, people are more susceptible to reflux symptoms, so stress appears to be the trigger. By stopping, taking a few deep breaths, and relaxing, you can ease the anxiety that often accompany acute episodes of GERD and experience a more rapid relief of symptoms.

At the same time, daily stress management can serve as a “preventative” therapy by reducing stress levels on a daily basis. Some of the practices that can help:

  • Biofeedback
  • Controlled breathing
  • Guided images
  • Progressive Muscle Relaxation (PMR)

Don’t smoke

Smoking is one of the worst things you can do if you have GERD.Cigarette smoke not only irritates the esophagus, but also increases the production of stomach acid, causing inflammation of the stomach lining.

In addition, smoking slows down digestion, allowing food to remain in the stomach longer while reducing the production of saliva needed to neutralize gastric acid. Smoking can also decrease the overall tone of LES6 over time.

Quitting smoking may not be easy, but the benefits always outweigh the risks. Avoiding cigarettes will not only lower your risk of GERD, but it will also lower your chances of developing certain cancers, including esophageal cancer.

If you cannot quit smoking, ask your doctor about prescription smoking cessation drugs, many of which are fully covered under the Affordable Care Act.

90,000 Allergies or intolerances: difference, diagnosis, treatment

This section is only for specialists in the field of medicine, pharmacy and healthcare!

Contents

  1. Food Intolerance
  2. What is the difference between allergies and intolerances?
  3. Signs of food intolerance
  4. Food allergy
  5. Prevalence of food allergy
  6. Food allergy risk factors
  7. Manifestations of food allergies
  8. Food allergens
  9. Diagnostics of food allergy
  10. Avoiding allergenic foods
  11. References

Food allergies are adverse reactions to food due to immunological mechanisms.Most of the adverse food reactions in adults are due to various forms of food intolerances that are not immunological reactions.

Non-allergic adverse food reactions can occur as a result of gastroesophageal reflux disease (GERD), gastrointestinal infections, digestive enzyme deficiencies, disorders resulting from anatomical and neurological abnormalities, metabolic diseases, toxin-mediated reactions, and many other processes.

Food intolerances means difficulty digesting or metabolizing certain foods. Food intolerance disorders are a subset of all adverse food reactions reported by 15 to 20% of the population. Food intolerances are even more common among patients with irritable bowel syndrome and other functional gastrointestinal disorders, with 50 to 80% reporting persistent problems with certain foods.

Food intolerances are not immunological reactions like allergies and do not carry the same risk, although patients cannot appreciate the difference. A simple way to explain the difference is that food intolerances usually affect the digestive system, the amount of food consumed is directly related to the severity of symptoms, and the same food causes similar symptoms with each exposure. In contrast, food allergies affect the immune system, and in immunoglobulin E (IgE) mediated food allergies, even a small amount of food can cause serious reactions.Finally, IgE-mediated food allergic reactions are unpredictable and can develop into a serious or life-threatening reaction called anaphylaxis.

Signs of food intolerance

The clinical features of food intolerances vary with the type of specific disorder, although most involve the most common gastrointestinal symptoms. Excessive intestinal gas, bloating, abdominal pain and diarrhea are common.

For food intolerances, the amount of food eaten is usually directly related to the severity of symptoms, compared to immunologically mediated food allergies, in which even small amounts of food can cause explosive reactions. For example, a patient who can eat one or two strawberries without symptoms, but who develops erythema and irritation around the mouth from a whole bowl of strawberries, most likely has a strawberry intolerance rather than an IgE-mediated allergy.A possible explanation for these symptoms is that some berries (such as strawberries and blueberries) contain naturally occurring histamine-like or histamine-releasing compounds and can cause mild skin rashes, itching, or hives in some children and adults. Other foods that naturally contain relatively large amounts of “biogenic amines” include chocolate, tomatoes, cheeses, wine, and the like.

Types of food intolerances:

  • Lactase deficiency (also known as lactose intolerance).Lactose intolerance manifests itself in the form of bloating, flatulence, abdominal cramps and / or diarrhea after consuming lactose in dairy products.
  • Malabsorption of fructose (or fructose intolerance). Fructose intolerance manifests itself as bloating, flatulence, or diarrhea after eating fruits and fruit sweeteners (including high fructose corn syrup).
  • Alcohol dehydrogenase deficiency . Alcohol dehydrogenase deficiency manifests itself in the form of “hot flashes” after drinking and is more common in people from Southeast Asia.
  • Glucose-6-phosphate dehydrogenase deficiency (G6PD). G6PD deficiency is manifested by hemolysis (usually in men) after ingestion of beans, red wine, legumes, blueberries, soy, tonic, or certain medications (such as nitrofurantoin or dapsone).
  • Intolerance to short-chain fermentable carbohydrates . Flatulence, abdominal pain, bloating, or diarrhea following foods containing fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs), variously referred to as carbohydrate intolerance, is thought to be more common in patients with irritable bowel syndrome.
  • Migraine can be considered as a manifestation of food intolerance if it is caused by certain foods in a particular patient, and in this case we are talking about foods with a high content of biogenic amines. Biogenic amines increase with maturation, aging and spoilage of food.
  • Mast cell activation . Patients with mast cell diseases may experience episodes of mast cell activation in the absence of IgE-mediated food allergy.Occasional symptoms may include hot flashes, itching, hives, diarrhea, or abdominal cramps after spicy or seasoned food or alcohol. The disease is believed to be rare, although data on its prevalence are lacking.
  • Sulphite sensitivity . Sensitivity to ingested sulfites is thought to disproportionately affect patients with severe asthma who may experience bouts of bronchospasm in response to dietary sulfites.It is believed that true allergic reactions are rare in this situation.

Food allergy can be defined as an adverse reaction to food due to an abnormal immunological response following exposure to an allergen, most commonly after ingestion. The terms “allergy” and “hypersensitivity” are often used interchangeably in the literature, although it is more correct to say “allergy”.

There are several types of food allergy, each with its own clinical and pathophysiological characteristics.Food allergy is broadly categorized into immunoglobulin E (IgE) or non-IgE-mediated processes (eg, food protein-induced enterocolitis, food contact dermatitis). Some disorders, such as eosinophilic gastrointestinal disorders, show characteristics of both mechanisms.

The IgE-mediated response is called “immediate” because signs and symptoms usually develop rapidly after the culprit food is consumed (seconds to minutes).In rare cases, reactions lasting up to two hours or more can also occur. Pathophysiology includes sudden widespread activation of mast cells and basophils.

Prevalence of food allergy

Food allergies are estimated to affect 2 to 5% of adults compared to 8% of children. Food allergies can develop at any age, but most often during childhood. In a retrospective review of medical records, approximately 15% of patients with an initial diagnosis of food allergy developed the problem in adulthood.The same study found that the age of first reaction peaks at the beginning of 30 years of age, although it varies widely, up to 86 years. It should be noted that older age was associated with a higher risk of severe reactions.

Risk factors for food allergy

There are several factors that can lead to the development of sensitization (i.e. the formation of IgE to a particular substance) and subsequent food allergy in an adult, although in many cases the predisposing effects cannot be identified:

  • Pollen exposure and sensitization are present in the majority of patients with oral allergy syndrome and most of them have a comorbid allergic airway disease (rhinitis or asthma).
  • Occupational exposure (eg inhalation or contact) can lead to sensitization and subsequent reactions to food.
  • Repeated tick or jellyfish bites may cause sensitization to red meat and some soy products, respectively.
  • Cutaneous exposure to hydrolyzed wheat protein in facial soap has been associated with exercise-induced wheat-dependent anaphylaxis in Japanese women.
  • Sudden changes in diet for weight loss or protein supplementation combined with a new exercise regimen were reported sporadically in the months leading up to food allergies, especially to wheat and cow’s milk.

It has been suggested that the use of acid suppressants predisposes to food sensitization, although the study found that current antacid prescriptions were prescribed by 19% of all adult food allergy patients, an indicator that does not differ in the estimated incidence of GERD. Thus, the role of acid suppression remains unclear.

Manifestations of food allergies

Combinations of the following signs and symptoms are typical:

  • Itching
  • Urticaria
  • Swelling of lips, face or throat
  • Nausea
  • Vomiting
  • Spasms
  • Diarrhea
  • Fainting
  • Hypotension

Acute urticaria is probably the most common cutaneous manifestation of IgE-mediated food reactions, usually occurring within minutes of a trigger food.In comparison, food allergies are rarely the leading cause of chronic urticaria, defined as recurrent outbreaks for more than six weeks.

The severity of IgE-mediated reactions is variable and unpredictable, so a person may develop hives on one occasion, but life-threatening anaphylaxis the next time an allergen is ingested. Even a small amount of food can cause severe reactions. Factors that can make an allergic reaction worse include:

  • Concomitant asthma: Patients with asthma are at a higher risk for foodborne anaphylaxis.
  • Intestinal permeability enhancers such as alcohol and aspirin.
  • Certain medications: angiotensin-converting enzyme (ACE) inhibitors and beta-blockers, which can interfere with the body’s compensatory responses to hypotension and affect the action of adrenaline, respectively.
  • Exercise, tension or stress.
  • Concomitant diseases (viral infections, etc.).

Food can also cause acute contact urticaria.In this condition, urticaria develops only on the skin that has been in direct contact with food. In addition to common allergens, raw meat, seafood, raw vegetables and fruits, mustard, rice and beer are some of the triggers involved in this form of reaction.

Isolated dermatitis, in addition to urticaria, is a rare manifestation of IgE-mediated food allergy in adults. In contrast, among children with severe eczema (atopic dermatitis), food allergy has been found to exacerbate eczema and cause other symptoms in one third of subjects in some studies.

Food allergens

Although any food can cause IgE-mediated allergies, a few foods cause most of these reactions. Fish / seafood and peanuts / tree nuts are the two food groups that cause the majority of food allergies in adults, estimated to affect up to 2% of the population. Other foods that cause allergies in adults vary across the world, likely due to their high dietary profile.

Most food allergens are proteins.Sometimes carbohydrate allergens are involved in allergic reactions to certain types of meat (for example, beef, pork, and lamb).

Patients often suspect that pesticides, additives, artificial colors and antibiotics in animal feed are the cause of an allergic food reaction, but in fact these substances are rare causes of allergies. Patients may also ask if organic foods are less allergenic than non-organic foods. There is no difference in allergenicity because both contain the same proteins and most food allergens are proteins.Small amounts of additives that are involved in IgE-mediated reactions are often obtained from natural substances such as carrageenan (from seaweed), lupine flour, pectin (from fruits and vegetables), gelatin, annatto (a red dye obtained from the seeds of the achiote tree ) and carmine red (derived from insect bodies).

Diagnosis of food allergy

The presence of IgE to food or a positive food skin test demonstrates that the patient is “sensitized” to that food, indicating a possible allergy.A definitive diagnosis of IgE-mediated food allergy requires both sensitization and a history of persistent signs and symptoms of exposure to this food. Sensitization alone is not enough to diagnose food allergy, because people can be sensitized to food, which is not uncommon, but without any clinical manifestations when eating. For example, patients with a dust mite respiratory allergy may have positive serum IgE for shrimp or other shellfish because testing cannot distinguish between different allergens in the two phylogenetically related organisms, but not be allergic to shrimp.For this reason, finding the culprit with extensive panels of IgE immunoassays with an uncertain history is rarely productive and can be misleading.

In contrast, an IgE immunoassay for the particular food in question can be very helpful if the medical history is associated with one or a few suspicious foods. For example, it is advisable for a generalist to carry out an enzyme immunoassay for shrimp IgE if the patient develops hives, itching and nausea while taking a shrimp cocktail.When a medical history suggests an allergy to a particular food (high tentative likelihood), a positive in vitro test is often sufficient to make a diagnosis.

Food-specific IgE immunoassays are widely available and are not dependent on antihistamines or other medications the patient may be taking. Higher food IgE concentrations correlate with an increased likelihood of an oral reaction, although a patient with significant food allergy may have a high, medium, low, or even negative in vitro test.The patient may also have a low-positive level of food tolerance. The use and interpretation of IgE immunoassays and food skin tests are discussed in detail separately.

An improved form of IgE immunoassay called component resolution diagnostics is being developed for foods that commonly cause IgE-mediated allergies.

Avoiding allergenic foods

Patients should avoid consuming suspicious food until further examination.In the case of allergies to both seafood and nuts, patients allergic to one food are often allergic to other related foods. Thus, until the patient is examined by an allergist, it is prudent to recommend avoiding related foods. One of the goals of an allergy assessment is to identify related foods that can be safely eaten.


References / References

  1. Böhn L, Störsrud S, Törnblom H, et al.Self-reported food-related gastrointestinal symptoms in IBS are common and associated with more severe symptoms and reduced quality of life // Am J Gastroenterol 2013; 108: 634.
  2. Bruijnzeel-Koomen C, Ortolani C, Aas K, et al. Adverse reactions to food. European Academy of Allergology and Clinical Immunology Subcommittee // Allergy 1995; 50: 623.
  3. Burks AW, Tang M, Sicherer S, et al. ICON: food allergy // J Allergy Clin Immunol 2012; 129: 906.
  4. Delgado J, Castillo R, Quiralte J, et al. Contact urticaria in a child from raw potato // Contact Dermatitis 1996; 35: 179.
  5. Doutre MS. Occupational contact urticaria and protein contact dermatitis // Eur J Dermatol 2005; 15: 419.
  6. Fisher AA. Contact urticaria from handling meats and fowl // Cutis 1982; 30: 726, 729.
  7. Hayes PA, Fraher MH, Quigley EM. Irritable bowel syndrome: the role of food in pathogenesis and management // Gastroenterol Hepatol (N Y) 2014; 10: 164.
  8. Inomata N, Chin K, Aihara M. Anaphylaxis caused by ingesting jellyfish in a subject with fermented soybean allergy: the possibility of epicutaneous sensitization to poly-gamma-glutamic acid by jellyfish stings // J Dermatol 2014; 41: 752.
  9. Inomata N, Nagashima M, Hakuta A, Aihara M. Food allergy preceded by contact urticaria due to the same food: involvement of epicutaneous sensitization in food allergy // Allergol Int 2015; 64:73.
  10. Jovanovic M, Oliwiecki S, Beck MH.Occupational contact urticaria from beef associated with hand eczema // Contact Dermatitis 1992; 27: 188.
  11. Kaddu S, Smolle J, Komericki P, Kerl H. Auriculotemporal (Frey) syndrome in late childhood: an unusual variant presenting as gustatory flushing mimicking food allergy // Pediatr Dermatol 2000; 17: 126.
  12. Kamdar TA, Peterson S, Lau CH, et al. Prevalence and characteristics of adult-onset food allergy // J Allergy Clin Immunol Pract 2015; 3: 114.
  13. Kleine-Tebbe J, Herold DA. Cross-reactive allergen clusters in pollen-associated food allergy // Hautarzt 2003; 54: 130.
  14. Lomer MC. Review article: the aetiology, diagnosis, mechanisms and clinical evidence for food intolerance // Aliment Pharmacol Ther 2015; 41: 262.
  15. Lukács J, Schliemann S, Elsner P. Occupational contact urticaria caused by food – a systematic clinical review // Contact Dermatitis 2016; 75: 195.
  16. Mohamed GG, El-Hameed AK, El-Din AM, El-Din LA. High performance liquid chromatography, thin layer chromatography and spectrophotometric studies on the removal of biogenic amines from some Egyptian foods using organic, inorganic and natural compounds // J Toxicol Sci 2010; 35: 175.
  17. Moneret-Vautrin DA, Morisset M. Adult food allergy // Curr Allergy Asthma Rep 2005; 5:80.
  18. Monsbakken KW, Vandvik PO, Farup PG. Perceived food intolerance in subjects with irritable bowel syndrome – etiology, prevalence and consequences // Eur J Clin Nutr 2006; 60: 667.
  19. Moscato G, Pala G, Crivellaro M, Siracusa A. Anaphylaxis as occupational risk // Curr Opin Allergy Clin Immunol 2014; 14: 328.
  20. NIAID-Sponsored Expert Panel, Boyce JA, Assa’ad A, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel // J Allergy Clin Immunol 2010; 126: S1.
  21. Reese I, Ballmer-Weber B, Beyer K, et al. German guideline for the management of adverse reactions to ingested histamine: Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the German Society for Pediatric Allergology and Environmental Medicine (GPA), the German Association of Allergologists (AeDA), and the Swiss Society for Allergology and Immunology (SGAI) // Allergo J Int 2017; 26:72.