January 2021 Hot Topic: Lifestyle Factors Prevent GERD in Women

Woman about to exercise outside


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Gastroesophageal reflux disease (GERD) is one of the more common presenting complaints in primary care, affecting nearly 30% of the US population.1 Acid-blocking medications to relieve the symptoms of GERD, such as histamine receptor antagonists (H2RAs) and especially proton pump inhibitors (PPIs), which are easily available over the counter and by prescription, have increasingly been found to raise the risk of several chronic diseases, including bone fractures,2 chronic kidney disease,3 pneumonia,2 enteric infections,4 gastric cancer,5 and diabetes,6 and are also well-known to be difficult to stop due to rebound reflux.7,8 Despite clinical expertise showing that lifestyle changes can be highly effective at treating GERD, very little prospective evidence exists to support the connection between lifestyle and GERD risk. Now, a new study demonstrates that living an “antireflux” lifestyle can greatly reduce the risk of GERD in women, even among those who begin taking acid-blocking medications.9

The study, published in JAMA Internal Medicine, examined the association of dietary and lifestyle factors with the risk of GERD symptoms in nearly 43,000 women in the Nurses’ Health Study II.9 Women were excluded if at baseline they reported GERD symptoms weekly or more, had cancer, or regularly used PPIs or H2RAs. They found that five factors reduce the incidence of reflux symptoms by 40%: maintaining a healthy body weight, staying physically active, not smoking, minimizing intake of coffee, tea, or soda, and eating a healthy diet. Specifically, the researchers calculated an antireflux lifestyle score from zero to five based on five binary factors: normal weight (BMI >18.5 and <25.0); never smoking; moderate-to-vigorous physical activity for at least 30 minutes daily; no more than two cups of coffee, tea, or soda daily; and a prudent diet, which is characterized by higher intakes of fruits, vegetables, legumes, fish, poultry, and whole grains.10 Women were considered to have GERD symptoms if they reported acid reflux or heartburn at least weekly.

The results showed that, compared with women who did not have the antireflux lifestyle factors, the hazard ratio for GERD symptoms was 0.50 for those with all five antireflux lifestyle factors. The proportion of cases of GERD symptoms that may be prevented by all five factors included in the antireflux lifestyle score was 37%. Adhering to an antireflux lifestyle was associated with a decreased risk of GERD symptoms even among the subset of women who initiated a PPI and/or H2RA during follow-up (HR=0.32 for those with all five factors versus none).

The authors also quantified the role that each of the five factors played individually in preventing GERD, and never smoking had the least impact (multivariable HR=0.94), followed by coffee, soda, and tea intake (0.92), physical activity (0.91), healthy diet (0.87), and healthy weight (0.69).

While these results may not be particularly surprising, they do provide more prospective evidence that lifestyle changes can both prevent and treat common complaints like GERD. While only four of the five factors in the study are truly modifiable (the smoking factor was “never smoked,” which current and former smokers cannot modify), the other four (attaining a healthy weight, getting moderate exercise, moderate intake of coffee, tea, or soda, and a healthy dietary pattern) are aligned with general advice given to many chronic disease patients. Functional medicine is especially suited to helping patients make these changes successfully and sustainably, which is a big part of the reason that patients often see functional medicine practitioners for both GERD symptoms and to help them get off of their acid-blocking medications.


  1. Peery AF, Crockett SD, Murphy CC, et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018. Gastroenterology. 2019;156(1):254-272.e11. doi:1053/j.gastro.2018.08.063
  2. Takagi T, Naito Y, Inoue R, et al. The influence of long-term use of proton pump inhibitors on the gut microbiota: an age-sex-matched case-control study. J Clin Biochem Nutr. 2018;62(1):100-105. doi:3164/jcbn.17-78
  3. Li T, Xie Y, Al-Aly Z. The association of proton pump inhibitors and chronic kidney disease: cause or confounding? Curr Opin Nephrol Hypertens. 2018;27(3):182-187. doi:1097/MNH.0000000000000406
  4. Moayyedi P, Eikelboom JW, Bosch J, et al. Safety of proton pump inhibitors based on large, multi-year, randomized trial of patients receiving rivaroxaban or aspirin. Gastroenterology. 2019;157(3):682-691.e2. doi:1053/j.gastro.2019.05.056
  5. Cheung KS, Chan EW, Wong AYS, Chen L, Wong ICK, Leung WK. Long-term proton pump inhibitors and risk of gastric cancer development after treatment for Helicobacter pylori: a population-based study. 2018;67(1):28-35. doi:10.1136/gutjnl-2017-314605
  6. Yuan J, He Q, Nguyen LH, et alRegular use of proton pump inhibitors and risk of type 2 diabetes: results from three prospective cohort studies. Published online September 28, 2020. doi:10.1136/gutjnl-2020-322557
  7. Pandolfino J. Discontinuation of proton pump inhibitor therapy and the role of esophageal testing. Gastroenterol Hepatol (NY). 2013;9(11):747-764.
  8. Helgadottir H, Bjornsson ES. Problems associated with deprescribing of proton pump inhibitors. Int J Mol Sci. 2019;20(21):5469. doi:3390/ijms20215469
  9. Mehta RS, Nguyen LH, Ma W, Staller K, Song M, Chan AT. Association of diet and lifestyle with the risk of gastroesophageal reflux disease symptoms in US women.
    JAMA Intern Med. Published online January 4, 2021. doi:1001/jamainternmed.2020.7238
  10. Fung T, Hu FB, Fuchs C, et al. Major dietary patterns and the risk of colorectal cancer in women. Arch Intern Med. 2003;163(3):309-314. doi:1001/archinte.163.3.309