People who consumed lower quantities of simple sugars experienced significant improvement in total acid exposure time, number of reflux episodes, and subjective reports of heartburn and reflux symptoms compared with those consuming higher amounts of simple sugars, according to a new study
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11/07/2022 - Medscape
Minimizing dietary consumption of simple sugars may help alleviate symptoms of gastroesophageal reflux disease (GERD), new data suggest.
People who consumed lower quantities of simple sugars experienced significant improvement in total acid exposure time, number of reflux episodes, and subjective reports of heartburn and reflux symptoms compared with those consuming higher amounts of simple sugars, the authors report.
The authors call their study the first randomized controlled diet intervention trial to investigate both the amount and type of carbohydrate on symptomatic GERD and one of only a few to investigate any type of dietary intervention for GERD.
"There's really almost no rigorous scientific evidence on any of the foods or ingredients or nutrients that are often recommended to avoid if you have GERD," corresponding author Heidi J. Silver, RD, PhD, told Medscape Medical News. Silver is research professor of medicine at Vanderbilt University School of Medicine and director of the Vanderbilt Diet, Body Composition, and Human Metabolism Core in Nashville, Tennessee.
Even the avoidance of fatty foods, which has been long promoted as part of GERD management, has little evidence to support it.
"With fat, there's some belief that it may slow down gastric emptying. Therefore, if you had slower gastric emptying, you would have a longer time for the food to put pressure on the lower esophageal sphincter and create an environment for reflux. So, it's kind of conceptually what is thought but not really tested," she notes.
The findings were published online in the American Journal of Gastroenterology.
To test the role of dietary carbohydrates, Silver and her colleagues randomly assigned 98 US veterans with symptomatic GERD to intake of one of four diets with varying carbohydrate types and amounts for 9 weeks: high total/high simple (the control group), high total/low simple, low total/high simple, or low total/low simple. The total caloric intake was approximately the same for all groups.
At baseline, the average total carbohydrate consumption was 43.7% of calories, and the average simple sugar intake was 116.5 g/d. The two "low-total" groups averaged about a 10% reduction in carbohydrate calories. The "low-simple" groups reduced simple sugars by about half.
There were no changes in body weight in the control group, whereas all three of the other groups lost some weight, ranging from 1.5-2.0 kg (3.3-4.4 lb) despite calorie totals designed for weight maintenance.
There was a significant effect of diet on the two primary outcomes, total esophageal acid exposure time, and total number of reflux episodes, as measured by 24-hour ambulatory pH monitoring. The change in total acid exposure time was significantly greater for the high total/low simple group compared with the high total/high simple group.
The participants' ratings of symptoms assessed by the Gastroesophageal Reflux Disease Questionnaire and the GERD Symptom Assessment Scale, including heartburn frequency and severity, pain in throat/chest, and sleep disturbance, improved in all modified diet groups compared with the control group. The mean degree of improvement in heartburn and regurgitation was twice as great for the modified diets compared with the controls and was greatest for the two "low-simple" carb groups.
Silver and colleagues hypothesize that the differential effects of the diets may relate to the way that dietary carbohydrates are sensed in the gastrointestinal tract after being enzymatically degraded into monosaccharides, possibly affecting lower esophageal tone via the effects of gut-derived hormones including ghrelin and glucagon-like peptide 1 that are secreted in response to macronutrient intake.
Although more data are needed about the effects of carbohydrates in GERD, Silver advised, "I do think it would be smart for clinicians, when they're discussing diet, that they bring up the simple sugars. There's no potential harm in reducing simple sugars. You're only benefiting yourself in multiple ways. We know that the consumption of simple sugars is extremely excessive, not just in America but worldwide."
Asked to comment, Philip O. Katz, MD, professor of medicine and director of the GI Function Laboratories at Weill Cornell Medicine, New York, NY, told Medscape Medical News, "This is one of the better-designed studies with a lot of care looking at a lot of endpoints that are intriguing and useful."
"What it says to me is there is potential for nonpharmacologic interventions for GERD that include diet change for helping patients," he said. "This shows promise for a diet that doesn't just concentrate on fat or acidic products and is a possible way of augmenting reflux treatment."
However, Katz cautioned, "I don't think anybody should do more with a 9-week study than look at it as good potential."
"I would tell patients that this is something that they might try, but I wouldn't make it a rigid requirement based on these data," he added. "If I were involved in this study, the next thing I would do is transition it to real life and look at compliance to see if results were sustained at 18 weeks or 6 months."
Overall, Katz, who was the first author of the American College of Gastroenterology's Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease, pointed out that the main nonpharmacologic advice for GERD management includes "Eat smaller meals, don't eat before bed, don't lie down after you eat, and reduce any individually known trigger foods."
Essentially, he views dietary interventions as complementary to medication and other interventions.
"When people really have GERD — not just heartburn — dietary change is an adjunct," Katz said. "GERD is a real disease, like diabetes. For some with GERD, maybe this is the only thing they need to do. But, in general, this will be an adjunct to augment an overall reflux program."
And that program, both Silver and Katz said, should include referral to a dietitian or nutritionist.
"If you're going to invest time in getting your patients to change their diet, it should be done with professional help, a qualified nutritionist who can work with the patient. This should not be a fad," Katz said.
Silver noted, "In contrast to a physician, the dietitian looks at everything the person is eating. If they're consuming a lot of simple sugars, I certainly would make that recommendation to reduce, along with other recommendations for GERD. It could be easily incorporated. We included examples in the paper of what we did to achieve that reduction and some things clinicians could focus on."
One obvious approach, she said, is to advise patients to cut the amount of sugared soda they're drinking, if not eliminate it entirely.