Lifestyle Factors and Risk for Symptomatic Gastroesophageal Reflux in Monozygotic Twins

doi:10.1053/j.gastro.2006.11.019

Gastroenterology

Volume 132, Issue 1, January 2007, Pages 87-95

https://doi.org/10.1053/j.gastro.2006.11.019 Get rights and content

Background & Aims: Lifestyle and genetic factors dominate the etiology of gastroesophageal reflux disease. We investigated associations between lifestyle factors and gastroesophageal reflux (GER) symptoms, with and without controlling for genetic predisposition. Methods: In 1967 and 1973, questionnaires including lifestyle exposures were mailed to twins in the Swedish Twin Registry, and data on GER symptoms were collected by telephone interview during 1998–2002. Two analytic methods were used: external control analysis (4083 twins with GER symptoms and 21,383 controls) and monozygotic co-twin control analysis (869 monozygotic twin pairs discordant for GER symptoms). Results: In the external control analysis, leanness (body mass index [BMI] <20), upper normal weight (BMI 22.5–24.9), overweight (BMI 25–29.9), and obese (BMI ≥30) conferred −19%, 25%, 46%, and 59% increased risk of frequent GER symptoms compared with normal weight (BMI 20–22.4), respectively, among women, whereas no such associations were evident among men. When adjusted for genetic and nongenetic familial factors, these estimates were −28%, 44%, 187%, and 277%, respectively, among men. Frequent smoking rendered a 37% increased risk of frequent GER symptoms among women and 53% among men compared with nonsmokers. Physical activity at work was dose dependently associated with increased risk of frequent GER symptoms, and recreational physical activity decreased this risk. Conclusions: BMI, tobacco smoking, and physical activity at work appear to be risk factors for frequent GER symptoms, whereas recreational physical activity appears to be beneficial. Association between BMI and frequent GER symptoms among men seems to be attenuated by genetic factors.

Section snippets

Subjects

In 1967 and 1973, questionnaires including lifestyle exposures were mailed to same-sex twins in the Swedish Twin Registry who were born in 1958 or earlier.³³ During the period 1998 to 2002, the Screening Across the Lifespan of Twins (SALT) study collected data on GER symptoms through telephone interviews with all twins born in 1958 or earlier. A total of 28,486 twin individuals responded both to the questionnaires about lifestyle in the 1960–1970s and to the questions regarding GER symptoms in

Results

In total, 15,014 women and 12,703 men were included in this study, with 523 and 346 MZ twin pairs discordant for frequent GER symptoms in women and men, respectively. The prevalence of frequent GER symptoms was 15.5% in women and 13.8% in men. The study subjects suffered from GER symptoms at a median start age of 45 years (Table 1).

Discussion

This monozygotic co-twin study, based on twins in the nationwide Swedish Twin Registry, provides compelling evidence that BMI, tobacco smoking, and physical activity at work increase the risks for occurrence of frequent GER symptoms, whereas physical activity at leisure time decreases the risk. Heavy coffee intake may decrease the risk for frequent GER symptoms in men, and lower education may increase the risk in women. Moreover, the study revealed no evidence of an association between intake

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Lifestyle plays an important role in preventing and managing gastroesophageal reflux disease (GERD). In response to the conflicting results in previous studies, we performed a systematic review and meta-analysis to investigate this association.
Relevant studies published until January 2023 were retrieved from 6 databases, and the prevalence of symptomatic gastroesophageal reflux (GER) or GERD was determined from the original studies. A random effects model was employed to meta-analyze the association by computing the pooled relative risk (RR) with 95% confidence intervals (95%CIs). Furthermore, subgroup and dose–response analyses were performed to explore subgroup differences and the association between cumulative physical activity (PA) time and GERD.
This meta-analysis included 33 studies comprising 242,850 participants. A significant negative association was observed between PA and the prevalence of symptomatic GER (RR = 0.74, 95%CI: 0.66–0.83; p < 0.01) or GERD (RR = 0.80, 95%CI: 0.76–0.84; p < 0.01), suggesting that engaging in PA might confer a protective benefit against GERD. Subgroup analyses consistently indicated the presence of this association across nearly all subgroups, particularly among the older individuals (RR_{<40 years}:RR_{≥40 years} = 0.85:0.69, p < 0.01) and smokers (RR_smoker:RR_non-smoker = 0.67:0.82, p = 0.03). Furthermore, a dose–response analysis revealed that individuals who engaged in 150 min of PA per week had a 72.09% lower risk of developing GERD.
Maintaining high levels of PA decreased the risk of GERD, particularly among older adults and smokers. Meeting the recommended PA level of 150 min per week may significantly decrease the prevalence of GERD.
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The aim of this overview of reviews was to retrieve and evaluate the available evidence concerning the prevalence and association between gastroesophageal reflux disease (GERD) and erosive tooth wear (ETW).
A literature search was conducted in electronic databases and relative systematic reviews with or without meta-analyses were located. Updated supplemental search was also undertaken to identify additional primary studies.
Medline (via Pubmed), Embase, Scopus, Cochrane Register of Systematic Reviews, PROSPERO and Epistemonikos.org database were searched. Additional search of the gray literature, abstracts of conferences and meetings as well as manual search of the reference lists of retrieved studies, was also performed.
The search retrieved 116 systematic reviews of which 10 were considered eligible and eight additional primary studies.
GERD constitutes a risk factor for ETW and there is a positive association between the two conditions. In the present overview, despite the heterogeneity between studies and the low level of evidence, it was clearly supported that individuals with GERD have an increased probability of also presenting with signs of ETW. In special groups of population, a high association was found between GERD and ETW. The geographic location may affect the association between GERD and ETW, while regarding the effect of flow rate, buffering capacity of saliva and oral microbial changes caused by GERD, the results were controversial.
Appropriate preventive dental care should be considered for individuals with GERD and a multidisciplinary medical and dental approach for the management of individuals with ETW is advised. The results of this study can be used by dentists dealing with typical and atypical GERD signs and symptoms in the oral environment, but also by the physicians and gastroenterologists who need to motivate their patients for oral examination.
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Gastroesophageal reflux disease (GERD) is extremely common, and even modest weight gain has been associated with higher symptom burden as well as objective evidence of reflux on endoscopy and physiological measurement. Certain trigger foods, especially citrus, coffee, chocolate, fried food, spicy food and red sauces are frequently reported to worsen reflux symptoms, although hard evidence linking these items to objective GERD is lacking. There is better evidence that large meal volume and high calorie content can increase esophageal reflux burden. Conversely, sleeping with the head end of the bed raised, avoiding lying down close to meals, sleeping on the left side and weight loss can improve reflux symptoms and objective reflux evidence, especially when the esophagogastric junction ‘reflux barrier’ is compromised (e.g., in the presence of a hiatus hernia). Consequently, attention to diet and weight loss are both important elements of management of GERD, and need to be incorporated into management plans.
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: Supported by grants from the Swedish Department of Higher Education, the Swedish Scientific Council, and Astra Zeneca for The Swedish Twin Registry; by funds from the NIH (AG 08724) for data collection in SALT; and the Swedish Research Council and the Swedish Medical Society for analyses.

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Clinical–alimentary tractLifestyle Factors and Risk for Symptomatic Gastroesophageal Reflux in Monozygotic Twins

Section snippets

Subjects

Results

Discussion

Gastroenterology

Gastroenterology

Am J Med

Gastroenterology

Am J Med

Ann Epidemiol

Gastroenterology

Am J Med Sci

Baillieres Best Pract Res Clin Gastroenterol

Gastroenterol Clin North Am

Mayo Clin Proc

Lancet

Am J Clin Nutr

Symptomatic gastroesophageal reflux: incidence and precipitating factors

Am J Dig Dis

Prevalence of gastro-oesophageal reflux symptoms and the influence of age and sex

Scand J Gastroenterol

Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma

N Engl J Med

Changing patterns in the incidence of esophageal and gastric carcinoma in the United States

Cancer

Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease

Am J Gastroenterol

Gastroesophageal reflux, Barrett esophagus, and esophageal cancer: clinical applications

JAMA

Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications

Ann Intern Med

Body-mass index and symptoms of gastroesophageal reflux in women

N Engl J Med

Inhibitory effect of smoking on the lower esophageal sphincter

N Engl J Med

Impact of smoking cessation on salivary function in healthy volunteers

Scand J Gastroenterol

Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux

Gut

Genetic influences in gastro-oesophageal reflux disease: a twin study

Gut

Clinical–alimentary tract
Lifestyle Factors and Risk for Symptomatic Gastroesophageal Reflux in Monozygotic Twins