Appendix:
Gastroesophageal Reflux Epidemiology and
the Rationale for Physician Counseling
Changing Impact of Gastroesophageal Reflux in
Medical and Otolaryngology Practice
A1
There has been a significantly increased interest in the literature regarding
gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) over the
last two decades. This interest seems to be in response to an apparent increasing number
of patients with GERD and LPR, although there are no studies in the literature that
adequately document the rate of rise. Epidemiology research is often limited by the
absence of large-scale databases that track individual subjects over time, so studies on the
subject of GERD usually focus on specific populations for a given period of time.
The goals of this appendix are to summarize the current understanding of the
epidemiology of GERD, and to review the rationale for physician counseling of lifestyle
modification to patients with GERD and LPR. As lifestyle modification may play an
integral role in the treatment of disease, then it has the potential to affect the overall
prevalence of disease.
The epidemiology of GERD has been studied using a number of different approaches.
Kennedy and Jones (A1) presented a postal survey of 3179 adults in the United Kingdom,
in which 28.7% of the population reported heartburn and acid regurgitation symptoms.
Less than 25% of subjects with these symptoms presented for medical evaluation and
treatment. In a similar study, Louis et al. (A2) reported their interview study involving
2000 adults in Belgium. In this project, 28.4% of the respondents reported symptoms of
heartburn at some point of the preceding year, and 56% of these individuals sought
medical advice. In the United States, Locke et al. (A3) found 20% of their questionnaire
sample to have weekly heartburn and almost 60% with occasional symptoms.
A2
Haque et al. (A4) conducted a similar survey with a postal questionnaire. Of the 778
respondents, there was significant overlap between the 30% with reported symptoms
attributable to reflux, and the 34.2% with dyspepsia over the preceding year, with an
overall “prevalence” of 45.2%. This study further suggests that the symptomatic overlap
may in fact be a similarity in pathophysiology of the disease. The “global definition” of
dyspepsia suggests that this term is a “variable mix of upper gastrointestinal symptoms”
(A5).
Endoscopic evaluation of patients with reflux symptoms would be expected to most
informative of the state of disease, however this is a relatively unsensitive finding in
refluxs disease. Voutilainen et al. (A6) evaluated 1128 consecutive patients referred for
endoscopy due to dyspeptic and reflux symptoms. For the purposes of this study GERD
was defined as the presence of symptoms for more than six months, accounting for 238
patients. Of these, overall esophagoscopy was normal in 33%, but 85% of patients under
50 years old had a negative exam. This suggests that the disease is often symptomatic
with negative objective findings, comparable to dyspepsia.
Johanson (A7) reported a summary of epidemiological studies that suggests a prevalence
of occasional or monthly heartburn at 21-58%, and daily heartburn at 4-7%. However, the
studies referenced were published over a fairly broad range from1982-1997. Perhaps
more informative, the incidence of GERD was reported in one study published in 1969 at
0.086%/year (A8), which is starkly smaller than that reported in 1992 at 6%/year (A9).
A3
This suggests a significant rise in the incidence of disease over the time period 19691992, although there are substantial limitations in such a meta-analysis. These limitations
include comparing studies with different recruitment criteria, and from different study
populations or databases.
Sonnenberg (A10) analyzed the rate of all physician contacts for esophagitis in 1985 with
the use of the National Ambulatory Medical Care Survey (NAMCS) and the National
Disease and Therapeutic Index (NDTI). These databases do not report prevalence or
incidence of GERD/esophagitis in the general population since the data is limited to
physician contacts and some people with disease may not present for treatment. However,
there is significant value in these results when considering the impact of
GERD/esophagitis on physician practice. The NAMCS figure for total contacts with
esophagitis was 797/100,000 population in the United States (0.797%), and the NDTI
figure was 1,246/100,000 (1.246%). Incidence may be inferred from the NDTI as less
than 20% of physician contacts were first time visits, placing the figure at 0.249/year in
1985. This crude estimation figure is consistent with other reported trends of 0.086%/year
in 1969 (A8) and 6%/year in 1992 (A9).
One additional way of determining a rising rate of disease is to study the rate of
complications from the disease. Panos et al. (A11) documented a rising death rate from
non-malignant disease of the esophagus (esophagitis and esophageal perforation)
between 1968 and 1991. An association between GERD and esophageal adenocarcinoma
has also been noted. Pera et al. (A12) demonstrated increasing incidence of
A4
adenocarcinoma of the esophagus, from approximately 0.2/100,000/year in 1974-1979 to
1/100,000/year in 1985-1989. However, these trends may have been impacted by the
increased availability and accuracy of non-invasive diagnostic techniques.
While GERD seems to be on the rise in developed countries, it does not appear to be as
prominent in developing countries (A13, A14). This raises the possibility of lifestyle and
diet as an etiology of disease in industrialized nations.
GERD is a disease that is significantly lifestyle driven, although there is certainly
physiologic and anatomic predisposition. It is therefore straightforward that lifestyle
modification should be integral to the care of the reflux patient. Counseling that patients
receive on triggers of GERD usually include avoidance of caffeine, alcohol, tobacco,
spicy foods, fatty foods and mints. Individual patients may experience exacerbation of
their disease with other food products (such as wheat), and they may be more sensitive to
food and liquids with a lower pH (such as citrus and tomato-based products).
While there is generally a widespread consensus that diet and behavior modification is
helpful in the treatment of patients with gastroesophageal reflux, objective studies have
been based on small numbers of subjects that do not meet strict statistical significance
(A15). Further controversy is sparked by a study involving one-hundred consecutive
patients undergoing pH probe monitoring, in which lifestyle alteration did not show
significant effect on gastroesophageal reflux (A16).
A5
Coffee is a classic example of a beverage that has caffeine (considered to exacerbate
predisposition to reflux) as well as triggering increased awareness of heartburn. In one
study Pehl et al. (A17) investigated the effects of caffeine and coffee on a reflux
population using 3-hour pH probe monitoring. Following the ingestion of caffeinated
coffee the median time of pH < 4 was 18%, compared to 3% for subjects receiving
decaffeinated coffee. In a prior study, Wendl et al. (A18) demonstrated that caffeinated
coffee induced significant reflux, however, subjects did not develop notable reflux in
response to caffeinated tea or caffeinated water.
Alcohol is known to affect lower esophageal sphincter pressure and esophageal motility
(A19), so one would expect that reducing alcohol intake would affect severity and
frequency of GERD. There is also considerable evidence to support tobacco cessation as
a lifestyle modification for reflux since smoking reduces lower esophageal sphincter
pressure and prolongs acid exposure due to decreased salivation (A20). However, there
are conflicting reports regarding actual changes seen on pH-probe monitoring in subjects
while smoking (A21, A22, A23).
While intake of fatty foods may exacerbate GERD by slowing digestion, the effect of fat
on postprandial gastroesophageal reflux is still controvertial. Colombo et al. (A24) used
6-hour pH monitoring in thirteen healthy volunteers to monitor changes after high fat,
balanced fat and balanced low calorie meals. In their study, the balanced low calorie meal
resulted in fewer episodes of reflux and less time under pH 4 than the balanced calorie or
high fat meals, suggesting that the caloric load of meals is more critical than fat content
A6
in affecting gastroesophageal reflux. These data supports empiric observation of the
effects of low calorie diet on GERD patients (A25).
However, Pehl et al. (A26) were not able to demonstrate any significantly different
effects of low calorie meals compared to high calorie meals on reflux time and lower
esophageal sphincter tone. In another study by this group, Pehl et al. (A27) were not able
to demonstrate a significant difference in pH or lower esophageal sphincter pressure in a
group of twelve volunteers after eating low versus high fat meals. This suggests that the
volume of the meal may have more of an effect on reflux than the calorie content.
Lifestyle modification alone may only dampen symptoms of the disease, although patient
reduction of these triggers is well known to control flare-ups of symptoms. However,
lifestyle changes are presently considered to be adjuncts to medical management of
GERD with pharmacotherapy (A28). It is still not clear whether lifestyle modification
alone has the potential to substantially affect overall epidemiologic trends in GERD and
LPR.
A7
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A8
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A9
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A10
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A11
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A12