Onions have been shown to increase the frequency of reflux episodes as well as esophageal acid exposure time.⁹ One survey of patients with GERD reported that 88% of patients listed spicy foods as a precipitant of heartburn.¹⁰ Avoidance of onions and spicy foods may be a useful dietary modification in patients with GERD.

The acidity of citrus and tomato-based products may increase the overall gastric acidity in patients prone to GERD and further irritate an already inflamed esophageal lining with reflux episodes.

Obesity may contribute to GERD symptoms by various mechanisms. Increased abdominal girth puts pressure on the stomach and may provoke reflux into the esophagus through the LES. The presence of a hiatal hernia, often found in association with obesity, may also be a predisposing factor.¹¹ Even a moderate amount of weight loss tends to effect a marked improvement in patients with GERD who are overweight. Similarly, tight-fitting clothing should be avoided, as it may exert pressure on the abdomen and increase the tendency toward reflux through a weakened LES.

Beverages that contain alcohol have been found to increase gastric acid production both by direct activation of parietal cells and by histamine release from enterochromaffin-like cells. Alcohol consumption may also precipitate GERD by reducing LES pressure and impairing esophageal motility and gastric emptying so that acid entering the esophagus is not easily cleared. Reduction or elimination of alcohol intake is a useful lifestyle modification in the treatment of GERD.^12,13

Cigarette smoking has been shown to exacerbate acid reflux. Studies have found that patients who smoke have chronically diminished LES pressures. In addition, a further acute reduction in these pressures appears to occur during episodes of active smoking. Smoking is also thought to diminish the production of saliva, which results in prolonged acid clearance time. Saliva is also helpful in neutralizing refluxed acid. In addition, the coughing provoked by smoking serves to lower intrathoracic pressure and further facilitates reflux of stomach contents into the esophagus. Smoking should be avoided in the clinical management of GERD.^3,14-16

Gastric acid production is at its peak immediately after eating. Most physicians recommend that patients wait 3 hours after eating before lying down in order to reduce the likelihood of acid reflux by giving the stomach time to empty. Moreover, large meals stimulate the body to slow the passage of food out of the stomach. This prolonged presence of a large amount of food in the stomach may exert upward pressure onto the LES and increase the tendency toward reflux. Smaller, more frequent meals throughout the day may help reduce GERD in patients who find that their symptoms worsen after meals. A larger meal at lunchtime and a lighter one for dinner may also be helpful.

Gravity plays an important role in controlling reflux. When a person is recumbent, stomach contents are more likely to reflux into the esophagus. Studies have documented that, as compared with patients who sleep flat on their backs, patients who elevate the head of the bed have significantly fewer reflux episodes. Furthermore, the episodes that do occur are shorter and produce generally milder symptoms. For these reasons, an elevation of 4-8 inches is suggested.¹⁷ To achieve this effect, commercially-available foam wedges can be placed under the head of the mattress. Alternatively, books or blocks can be placed beneath the feet of the head of the bed. The use of multiple pillows to provide head elevation in the treatment of GERD is generally not recommended, as this can create a postural change that may actually promote reflux rather than curb it.

Sleeping on the left side as opposed to the right side may reduce the frequency and duration of reflux episodes in patients prone to symptoms during the night. The mechanism for this reduction is not entirely clear but has been thought to be related to an increase in the frequency of transient reductions in LES pressure in the right lateral decubitus position.^18,19 This may be a difficult lifestyle modification for many patients but is still mentioned here for consideration.

Chewing gum or using lozenges increases saliva production and swallowing frequency, which can help clear away acid that has refluxed from the stomach into the esophagus. A clear reduction in acidic esophageal reflux has been documented in patients who chewed sugar-free gum for 30 minutes after a meal.²⁰ This may be a useful adjunctive treatment option for patients with mild postprandial GERD.

Some medications may exacerbate or mimic GERD symptoms; this should be considered in the initial evaluation of this condition. Such medications include potassium supplements, tetracycline, oral bisphosphonates (eg, alendronate sodium), calcium channel blockers, beta-agonists, nitrates, and some sedatives.²¹ Patients should be advised to take these medications with a large amount of water to help flush them through the esophagus.

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