How being overweight/obese may cause reflux…
Emerenziani et al. (2020) highlighted a variety of ways in which obesity could contribute to reflux conditions (e.g. GERD) and a host of other gastrointestinal disorders. (R)
Transient LES relaxation (TLESR): This is thought to be the primary mechanism by which being overweight/obese causes/exacerbates reflux. The primary stimulus for generating TLESR is gastric distension – which leads to intense stimulation of stretch & tension mechanoreceptors in the proximal stomach. Higher intragastric pressure (IGP) after eating increases TLESR episodes. Studies confirm that overweight/obese individuals have significantly higher: (1) rates of TLESR episodes; (2) proportion of TLESR episodes accompanied by acid reflux; (3) total acid exposure – than normal weight persons.
Increases intra-abdominal pressure: It is thought that being overweight/obese increases intra-abdominal pressure which subsequently increases intra-gastric pressure (IGP) and gastroesophageal pressure gradient (GPEG). One study reported an average intra-gastric pressure increase of 0.3 mmHg per each BMI unit. This is problematic in that increased IGP/GPEG influence LES function and induce/exacerbate reflux.
Sleep apnea & UARS: Excessive fat throughout the neck/throat as a result of being overweight/obese can cause or exacerbate sleep apnea/UARS. Both sleep apnea and UARS can [in some cases] increase the amount of reflux that occurs by creating a “suction effect” – enabling stomach contents to be drawn up the esophagus for frequent nocturnal reflux. (The kicker? Each reflux event can inflame esophageal/nasopharyngeal structures to further interfere with breathing/respiration during sleep – creating a vicious circle/feedback loop.)
Increases occurrence of hiatal hernia: Being overweight/obese is an independent risk factor for hiatal hernia – wherein the upper part of the stomach bulges through the diaphragm into the chest cavity via the esophagus. Hiatal hernia can enable stomach acid, food particles, and other gastric contents to easily reflux into the esophagus. The larger the hiatal hernia, the more severe the reflux becomes.
Modulates intestinal motor reflexes: Being overweight/obese can alter intestinal motor reflexes – which could directly cause reflux for some individuals.
Inhibition of small bowel motility: Small intestinal dysmotility occurs when there is a failure of coordinated intestinal population – giving rise to symptoms/signs of intestinal obstruction (e.g. nausea, vomiting, distention, abdominal pain, etc.). Impaired or inhibited small bowel motility may contribute to reflux for some individuals.
Delay of intestinal gas transit: Being overweight/obese may delay intestinal gas transit. This is problematic in that it could force the lower esophageal sphincter (LES) to open such that the gas “refluxes” up the esophagus along with other material.
Modulation of gut microbiota composition: Being overweight/obese is associated with abnormalities in gut microbiome composition. Gut microbiome abnormalities may play a direct or indirect role in causing/exacerbating reflux conditions.
Visceral fat increases pro-inflammatory cytokines (TNF-alpha, IL-1B, IL-6) (low-grade inflammation): It is understood that an excessive amount of visceral fat (i.e. metabolically-active fat deep inside belly & around organs) can increase risk of reflux esophagitis by increasing levels of inflammatory cytokines. (R) Overweight/obese individuals have more visceral fat than non-overweight persons.
Adipocytes-released peptides altering GI motility (GI motor dysfunction): There’s evidence to suggests that adipocytes-released peptides (e.g. leptin, adiponectin, nesfatin-1, apelin) are abnormal among those who are overweight/obese. Abnormalities in these peptides may contribute to GI dysmotility and subsequent reflux.
Separation of LES & extrinsic crural diaphragm: Obesity is associated with separation between the LES and extrinsic crural diaphragm (i.e. esophagogastric junction disruption) – a manifestation that can predispose individuals to hiatal hernia. (R)
Excess steroid hormones: Individuals with extreme obesity have excess circulating steroid hormones which can have a direct effect in reducing lower esophageal sphincter (LES) pressure. (R)
Slower esophageal acid clearance: Studies show that obesity is associated with slower/less efficient clearance of esophageal acid. (R)
Hypotensive LES pressure: LES pressure below 12 mmHg may occur more frequently in overweight/obese individuals. Hypotensive LES tone and weak distal esophageal contractions can lead to increased reflux events and poorer acid clearance.
Nutcracker esophagus: Being overweight/obese may increase risk of nutcracker esophagus wherein the esophagus has strong spasms. A study of morbidly obese found nutcracker esophagus in 11% of patients. (R)
Esophageal motility disorders: One study of morbidly obese found nonspecific esophageal motility disorders in 23% of patients. These nonspecific esophageal motility disorders could certainly contribute to reflux. (R)
Note: Although it’s impossible to separately parse the effect of habits/diet/lifestyle from being overweight/obese – it’s possible that for some overweight/obese patients, habits/diet/lifestyle are the underlying causes of reflux rather than the excessive body weight/fat.
Weight Loss & GERD (Research)
Included below are summaries of reports in which the impact of body weight and/or weight loss on reflux conditions was evaluated/discussed.
Note: Studies linking “overweight” and/or “obesity” with reflux conditions are NOT the same as studies examining the effect of weight loss on reflux conditions.
Weight Management as a treatment option for GERD (R)
Lee (2018) wrote a paper discussing weight management as an intervention for GERD – discussing the mechanisms by which it might help. Included below are notable points from Lee’s publication.
- American College of Gastroenterology suggests that weight loss is an effective regimen for GERD symptom improvement and therefore is strongly recommended for patients with BMI above 25 kg/m2.
- Various RCTs and cohort studies assessing the effect of weight reduction for GERD-related symptoms in obese subjects sometimes demonstrate beneficial effects including: (1) normalization of pH and/or (2) dose-dependent reduction in GERD symptoms (post-weight loss).
- Other studies suggest that weight loss has zero effect on GERD
- The effect of weight loss on GERD is still unclear and subject to significant debate.
- Pathophysiologic mechanism of erosive esophagitis in obese/overweight may involve both: (A) mechanically-induced LES relaxation via increased intra-abdominal pressure AND (B) coexisting metabolic syndrome (inflammation, growth factors, etc.).
Conclusion: “Aside from pharmacologic or endoscopic treatment – the importance of weight management should be primarily considered as the foundation of the treatment of erosive esophagitis. Lifestyle modification in obese subjects is more important than other treatments.”
What can we learn here? Evidence regarding the effect of weight reduction on GERD are mixed and inconclusive. Some evidence suggests that weight loss improves GERD – other evidence suggests no significant effect on GERD. There’s stronger evidence that weight loss improves erosive esophagitis among those with obesity.
Weight Loss as Nonpharmacologic Strategy for Erosive Esophagitis (R)
Bang & Park (2018): “EE resolution is associated with a decrease in BMI, and weight loss is potentially an effective GERD treatment.”
- Investigated whether BMI reduction (i.e. weight loss) could resolve erosive esophagitis (EE).
- 1,126 individuals with EE who underwent health check-ups from 2006-2012 were enrolled in this study.
- Degree of esophagitis was determined via upper endoscopy and regularly examined over a 5-year follow-up.
- Significant weight loss was associated with resolution of erosive esophagitis (EE).
- Esophagitis resolution was related to the degree of BMI reduction (i.e. losing more weight = greater EE resolution).
- Resolution of EE was 2-fold higher in those who achieved a BMI reduction of more than 2 kg/m2 – relative to other groups.
- Authors’ thoughts? Increases in BMI might predispose to development of anatomical and/or hormonal changes – and substantial weight loss is required to offset the effects of longstanding pathophysiological changes induced by obesity over an extended duration.
- Substantial BMI reduction is required to induce resolution of EE in obese persons.
- In non-obese patients with EE, degree of BMI reduction was NOT associated with EE resolution.
- Limitations: Not enough participants with normal BMI; only 2% of non-obese participants achieved a BMI reduction greater than 2 kg/m2; usage of PPIs was NOT evaluated during follow-up period; resolution of GERD symptoms was NOT evaluated.
Weight loss & waist reduction is associated with improvement in GERD symptoms (R)
Park et al. (2017): “Weight loss or waist reduction was associated with improvement in GERD symptoms only in subjects with general or abdominal obesity. Weight loss or waist reduction will be an important treatment option in obese patients.”
- Investigated if weight loss or waist reduction improves GERD symptoms and esophagitis.
- 15,295 individuals who underwent gastroscopy for a health checkup and reported GERD symptoms between 2011-2013 were analyzed in a retrospective longitudinal study at baseline and again via checkup in 2014.
- Measures: GERD symptoms; esophagitis severity; weight change; waist size change – from baseline to checkup.
- Results: Weight loss or waist reduction was associated with GERD symptom improvements only in patients with general or abdominal obesity. No association was found between weight loss or waist reduction and esophagitis improvement.
What can we learn here?
Losing weight may improve GERD symptoms in the presence of erosive esophagitis only in patients with general obesity OR those with abdominal obesity – before the weight loss.
There was no mention of weight loss reducing GERD symptoms in persons who were overweight or normal weight.
There were some limitations including: use of GI medication (13.7%) – which could’ve contributed to healing/improvement in GERD symptoms over time (this was adjusted for but dosage/duration of usage was not); non-validated questionnaires used to assess GERD (failed to account for GERD severity).
Weight loss has independent beneficial effect on symptoms of GERD in overweight patients (R)
Fraser-Moodie et al. (1999): “This study has shown a significant association between weight loss and improvement in symptoms of gastroesophageal reflux. Patients who are overweight should be encouraged to lose weight as part of the first-line management.”
- Aim: Prospectively examine the independent effect of weight loss on reflux symptoms in overweight individuals with normal endoscopic findings or grade 1 esophagitis.
- 34 patients (18 male, 16 female, age: ~65) with: (A) GERD for at least 6 months and (B) BMI > 23.
- All patients were advised to lose weight (after receiving appropriate dietary advice) while making zero other changes to lifestyle.
- Measures: GERD symptoms (modified DeMeester questionnaire) & body weight – at 6, 18, and 26 weeks.
What were the results?
Baseline: Weight = ~83.4 kg; BMI = ~23.5 kg/m2; GERD symptom score = 5.4.
6 weeks: Weight = ~80.6 kg; BMI = ~21.8 kg/m2; GERD symptom score = 1.8.
The beneficial effect of weight reduction on GERD symptom score remained significant at a 26-week follow-up examination.
Patients were divided into 4 subgroups based on degree of weight change and symptom score:
- Weight loss & GERD improvement: 27 patients (80% of the total) lost weight (~4 kg) and improved GERD symptoms (by ~75%).
- Weight loss & GERD remission: 9 patients who lost weight experienced complete GERD symptom remission (zero symptoms after weight loss).
- Weight gain & GERD worsening: 3 patients gained weight and had a deterioration in GERD symptoms.
- Weight gain & GERD improvement: 4 patients gained weight and had a reduction in GERD symptoms.
Zero patients experienced worsening of GERD symptoms from weight loss.
Analyses by researchers indicated that ~25% reduction in GERD symptoms can be accounted for by a change in body weight alone.
- Small sample size: This study included a small sample of just 34 overweight patients with GERD. Due to the small sample – results may have been attributable to random chance rather than a true effect of weight reduction.
- Overweight-only: This study included overweight individuals (BMI over 23). It is unclear whether any individuals were “obese.” Results may not apply to obese and/or normal weight persons.
- No objective assessments: A modified DeMeester questionnaire was utilized to assess GERD symptoms. This means that change in GERD symptoms was completely “subjective” – and had no objective confirmation such as 24-hour pH monitoring would’ve provided (baseline vs. 26 weeks).
- Use of acid reducing agents: Although participants were instructed to refrain from using acid-reducing agents (e.g. PPIs, H2 blockers, antacids, etc.) – it’s possible that some used them but didn’t admit this to researchers (fearing scorn for doing so).
- No randomization, controlling, blinding: This study did not utilize any randomization, controlling, or blinding. As a result, it’s impossible to know whether GERD symptoms might’ve spontaneously improved after 6 weeks through 26 weeks – with no exercise.
- Weight loss in isolation (?): This study endeavored to examine the standalone effect of weight loss on GERD symptom scores (participants were instructed to only lose weight – not exercise, alter lifestyle, etc.). However, it’s possible that to achieve weight loss, some of the participants may have increased physical activity – making this a potential confound. It’s also impossible to know whether specific changes in macronutrient intake, meal size, eating times, etc. – associated with weight reduction – may have played a role in symptom reduction. Although this study sought to evaluate the effect of weight reduction in isolation – it’s unclear as to whether this effect was truly isolated (particularly because participants weren’t monitored 24/7).
Voluntary & controlled weight loss can reduce symptoms and PPI use/dosage in patients with GERD (R)
de Bortoli et al. (2016): “Weight loss of at least 10% is recommended in all patients with GERD in order to boost the effect of PPI on reflux symptom relief and to reduce chronic medication use.”
- Aim: Evaluate the effect of weight loss on reflux symptoms in overweight/obese patients with proven GERD.
- 101 patients were divided into 2 treatment groups: Group A (PPI + personalized hypocaloric diet + aerobic exercise) vs. Group B (PPI + standard-of-care diet).
- Diet was considered effective if at least 10% of weight loss was achieved within 6 months.
- Measures: Anthropometric data; GERD symptoms; PPI use.
What were the results?
Group A: BMI decreased from ~30.3 to ~25.7 and weight decreased from ~82.1 kg to ~69.9 kg. PPI therapy discontinued in 27/50 patients and halved in 16/50 patients. Only 7 patients continued on the same PPI dosage as at the start of the trial.
Group B: No change in BMI or weight. 22/51 patients halved PPI dosage; 29/51 maintained full dosage of PPI therapy. No patients were able to discontinue PPI after 6 months.
PPI therapy: Reduced symptom perception in both groups (A & B). Higher symptom improvement was reported in Group A.
What can we learn?
Weight loss of at least 10% among overweight/obese individuals with GERD may: (A) boost the effect of PPIs and (B) decrease chronic PPI use.
Limitations: Overweight/obese subjects (no normal weight); small study; subjective symptom measurements (may be unreliable); effect of time (6 months) may have played a role in symptom reduction (spontaneous remission); aerobic exercise (may have helped reduce symptoms irrespective of weight loss).
Weight Loss Can Lead to Resolution of GERD Symptoms (R)
Singh et al. (2013): “A structured weight loss program can lead to complete resolution of GERD symptoms in the majority of subjects.”
- Investigated the impact of weight loss on GERD symptoms in 332 overweight/obese adults in a prospective cohort study.
- Inclusion criteria: adults (18-65 years old); BMI 25-39.9 kg/m2; cleared for participation by primary care physicians (PCPs).
- Measures: BMI; waist circumference; validated reflux disease questionnaire.
What were the results?
At 6 months, most participants (97%) lost weight.
Average weight loss was ~13 kg (28.66 lbs.).
Prevalence of GERD significantly decreased after 6 months (15% vs. 37% at baseline).
Mean GERD symptom score significantly decreased after 6 months (1.8 vs. 5.5).
81% of participants had reduction in GERD symptom scores after 6 months.
- 65% had complete resolution of GERD symptoms
- 15% had partial resolution of GERD symptoms
There was a significant correlation between % body weight lost and GERD symptom score reduction.
What are the limitations associated with this study? (Important)
- No GERD diagnoses: A major limitation associated with this study is that patients were not required to have a GERD diagnosis to participate. This means we don’t actually know whether weight loss is an effective intervention among individuals with clinically diagnosed GERD. We only know that weight loss was associated with improvement in GERD symptoms.
- Only 37% with GERD symptoms at baseline: Of the 332 participants, only 124 (37%) had GERD symptoms at baseline. This means that a majority of the participants (63%) did NOT have GERD symptoms at baseline – and such were probably not good fits for a study measuring the effect of weight reduction on GERD symptoms.
- PPI & H2RAs permitted: A significant confound in this study is the fact that 35 individuals (11%) used PPIs and H2RAs at baseline and throughout a portion of the 6-month period. In fact, at the end of the 6 months, 26 individuals (8%) were still using PPIs/H2RAs. How is this a confound? Because PPIs in particularly can sometimes take months to full alleviate symptoms. Therefore, GERD symptom score reduction may have been fully or partially attributable to PPIs/H2RAs in some cases.
- Questionnaires: Questionnaires are notoriously unreliable due to recall inaccuracies and/or untruthfulness (e.g. giving socially desirable answers).
- No objective GERD measures: Zero endoscopy/pH monitoring to objectively measure reflux severity/frequency at baseline.
- Unclear impact of weight gain on GERD: Researchers stated that the impact of weight gain on GERD occurrence couldn’t be determined because most (97%) participants lost weight at 6 months and had improvement in reflux symptoms.
- No randomization or control group: Lack of randomization and a control group makes the data derived from this study less trustworthy/robust.
- Overweight/obese only: Unknown as to whether losing weight in high-end of normal BMI to achieve a mid-range or lower-range normal BMI would be helpful)
- Weight loss vs. changes associated with weight loss: Impossible to parse the specific effect of weight loss from dietary, behavioral, and physical activity changes that participants employed. Perhaps the reflux benefits were most attributable to dietary/behavioral/physical activity changes rather than the actual lost weight.
What can we learn here?
The main takeaway is that a combination of dietary, behavioral, and physical activity changes to produce ~10% reduction in body weight over a ~6-month period may significantly improve subjective symptoms of GERD in overweight/obese individuals.
We cannot know whether this applies to individuals with clinically diagnosed reflux conditions (e.g. GERD, LPRD, NERD). We also don’t know whether it was the changes (diet, behavior, activity), the weight loss, or a combination of both that may have improved GERD symptoms.
Specific strategies for weight loss in this study…
Participants received comprehensive notebook with instructions on weight loss/maintenance, various diets, exercise protocols, calendars, and instruction on class meetings. If you want to implement what they did – here’s the protocol.
Targeted body weight reduction of 10% within 6 months.
- Dietary modifications: Instructed to reduce calories to 1200-1500 cal/day using commercially-available prepackaged meals, combined with fruits, veggies, and beverages. Participants were advised to consume a minimum of 3 shakes at ~100 kcal each, 2 entrees between 200-270 kcal each, and 5 fruits/veggies per day.
- Physical activity: Self-directed instructions were provided to all participants to undergo moderately vigorous home-based physical activity of walking/other exercise (15-60 min/day) up to 5 days per week. Exercise progression started at 45 min/week (3 days/week, 15 min/day) and progressed to 300 min/week (5 days/week, 60 min/day) by week 12.
- Behavior change: Behavior shaping, goal setting, self-monitoring, feedback, reinforcement, social support, problem solving, relapse prevention were conducted by in-class discussions and activities and out-of-class assignments to help modify lifestyle for weight loss.
Weight loss & reduction in gastroesophageal reflux (R)
Ness-Jensen et al. (2013): “Weight loss was dose-dependently associated with both a reduction of gastroesophageal reflux symptoms and increased treatment success with antireflux medication in the general population.”
- Aim: Clarify whether weight loss reduces gastroesophageal reflux symptoms.
- Subjects: 58,869 and 44,997 individuals in 2 cohorts (HUNT 2: 1995-1997 & HUNT 3: 2006-2009). 29,610 individuals participated in both HUNT 2 & HUNT 3.
- Measures: Heartburn & acid regurgitation (questionnaire); body weight change.
- Researchers stratified analyses by antireflux medication and adjusted for sex, age, cigarette smoking, alcohol intake, education, and physical exercise.
What were the results?
Weight loss was dose-dependently associated with a reduction of gastroesophageal reflux symptoms and increased success with antireflux medications – even after adjusting for confounding factors.
Data indicated that greater benefits might be observed in overweight individuals who achieve a larger weight loss.
Limitations: Gastroesophageal reflux symptoms isn’t the same as “GERD” (the latter may be more difficult to reverse); associational design; questionnaire (subjective) data.
Are lifestyle measures effective in patients with GERD? (R)
Kaltenbach et al. (2006): “Weight loss improved pH profiles and symptoms. Weight loss and head-of-bed elevation are effective lifestyle interventions for GERD.”
- Aim: Determine the effectiveness of lifestyle changes for GERD management.
- Methods: Literature search (publications between 1975-2004) using appropriate keywords like GERD, smoking, alcohol, obesity, weight loss, caffeine, bed elevation, etc.
- 16 clinical trials examined the impact on GERD via lifestyle measures.
What were the findings?
Evidence B (cohort or case-control studies, non-randomized, uncontrolled) suggested that weight loss improves pH profiles and symptoms of GERD.
This was based upon 5/16 trials analyzed that examined the effect of weight loss on GERD symptoms and esophageal pH.
Limitations: None of the trials analyzed were randomized, controlled, or blinded.
Gastroesophageal reflux in obese subjects: Influence of overweight, weight loss, chronic gastric balloon distension (R)
Mathus-Vliegen & Tygat (2002): “Obesity predisposed to gastroesophageal reflux. Body weight loss and, strikingly, visceral fat loss resulted in improved reflux parameters.”
- Aim: Evaluate the prevalence of gastroesophageal reflux in untreated obese subjects and study the effect of weight loss with or without intragastric balloon treatment on reflux.
- 42 patients with severe obesity entered a randomized, double-blind, sham-controlled, trial over a 13-week period involving: (A) sham-balloon (22 patients) or (B) balloon-balloon (20 patients).
- Measures: 24-hour pH recordings (pre-trial & post-13 weeks & after 52 weeks); body weight & waist circumference.
What were the results?
Before weight loss
- No correlation was observed between BMI and acid reflux. A strong relationship was observed between fat distribution (intra-abdominal & visceral fat deposits) and acid reflux.
- pH data were highly abnormal in the 42 patients with severe obesity (~125.1 kg & BMI = ~43.4 kg/m2) and mainly a central, visceral fat distribution – relative to normal lab reference values.
- 22 of the 42 participants had some evidence of reflux at baseline.
After weight loss
- As a group, the 42 patients lost a mean body weight of ~12 kg and 4.2 kg/m2 in BMI units.
- Weight loss was similar between groups (sham-balloon vs. balloon-balloon).
- Following weight loss, participants exhibited a significant decrease in total reflux time.
- Total body weight loss, decrease in abdominal fat, balloon fill volume, balloon position, gender, and sham vs. balloon allocation did NOT predict nor explain reflux values in the first after 13 and 26 weeks post-procedure.
What can we learn here?
Patients with severe obesity (BMI = ~43.4 & weight = ~125.1 kg) experience significant reduction in symptoms of gastroesophageal reflux following weight loss/fat loss – regardless of the methods used to achieve weight loss.
Limitations: Severe obesity only; small sample size; GERD not required to participate (gastroesophageal reflux measured – not “GERD”).
Studies suggesting no significant benefit from weight loss for reflux conditions…
Included below are studies in which no significant improvement in reflux occurred following weight loss. Keep in mind that there are limitations associated with most of these studies.
Relationship between upper GI symptoms & changes in body weight (R)
Cremonini et al. (2006): “No association was found between weight loss >10 lbs. and studied symptom complexes. Moderate body weight increases and decreases are generally not associated with upper GI symptom changes over time in the general population.”
- Aim: Examine the association between changes in body weight and changes in upper GI symptoms among 637 participants.
- Prospective cohort study on random samples of Olmstead County, MN residents.
- Measures: Upper GI symptoms: GERD, chest pain, dyspepsia.
- Subjects with persistent, new-onset or disappearing symptoms were identified as cases vs. subjects with no reported symptoms served as controls – based on survey responses.
- Logistic regression models using: age, gender, baseline BMI, and somatic symptom score as covariates.
What were the results?
Baseline body weight was associated with GERD, chest pain, and dyspepsia-pain predominant symptom complexes.
However, moderate weight loss of 10+ lbs. did NOT affect GI symptom complexes significantly.
We must consider the fact that initial weight gain to become overweight/obese [in a subset of analyzed individuals] may have: (1) caused initial GI symptoms and/or (2) created irreversible feedback loops (such that symptoms have become a “disease” e.g. GERD).
Additionally, we should consider that ~10 lbs. (moderate) weight loss may not be sufficient for symptom improvement in this sample (on average) because individuals with GI symptoms may remain overweight/obese (such that far more weight loss would be needed for symptom resolution/remission).
What can we learn here? Although body weight was associated with GERD – moderate weight fluctuations (~10 lbs.) did NOT appear to significantly alter GI symptoms.
Gastroesophageal reflux in Obese Patients is NOT Reduced by Weight Reduction (R)
Kjellin et al. (1996): “Weight reduction does NOT improve the subjective or objective manifestations of reflux.”
- Aim: Evaluate whether weight reduction improves subjective & objective symptoms of gastroesophageal reflux.
- 20 obese individuals with gastroesophageal reflux evidenced by: (1) 24-hour pH monitoring AND (2) symptoms requiring daily medication – participated in this study.
- Participants were randomized into either: (Group A) very low-calorie diet (VLCD) or (Group B) control group – over a 6-month period.
- After the initial 6 months, Group B underwent the same weight loss intervention as Group A in the subsequent 6 months.
What were the results?
- Patients in Group A (VLCD) lost ~10.8 kg (~23.8 lbs.) whereas Group B (control) gained ~0.6 kg (1.3 lbs.).
- There were no significant changes in reflux symptoms (e.g. heartburn, regurgitation, chest pain, dysphagia) after 6 months.
- There was no significant objective reduction in gastroesophageal reflux (according to 24-hour pH monitoring).
- There was no statistically significant change in other factors such as: total number of reflux episodes, total number of reflux episodes longer than 5 minutes, longest reflux episodes, time with pH above 4, reflux in specific positions, postprandial reflux, etc.
- Peristaltic activity was unchanged in both groups.
- 5 patients in Group A & 3 patients in Group B no longer had signs of esophagitis after 6 months – but the difference between groups was not significant.
- All patients except one in Group B (control group) remained dependent on daily anti-reflux medication.
- Even when subjects with the most dramatic weight loss were analyzed separately – there was no clinical or laboratory improvement.
A strength of this study is that it evaluated reflux both: objectively (endoscopy with biopsy; esophageal manometry; 24-hour pH monitoring) AND subjectively (questionnaire).
BMI (Body Mass Index)
- Group A (VLCD): Average BMI = 28.8 (6 months)
- Group B (control): Average BMI = 30.3 (6 months)
24-hour pH monitoring
There was no significant reduction in gastroesophageal reflux according to 24-hour pH monitoring in Group A after ~23.8 lbs. weight loss over a 6-month period.
% of time pH < 4
Percentage of recording time with pH < 4 (less acidic) was: 21.3% at baseline and 24.2% after 6 months (negligible improvement) for Group A – and was 21% at baseline and 22.8% after 6 months for Group B (negligible improvement).
There was slightly greater increase in pH for Group A (~2.9%) after 6 months relative to Group B (~1.8%) – but this wasn’t substantial.
LES pressure (mmHg)
- Group A (VLCD): 11 (baseline) vs. 11.2 (6 months) – No significant change in lower esophageal sphincter pressure.
- Group B (control): 7.4 (baseline) vs. 10.5 (6 months)
LES length (cm)
- Group A (VLCD): 2.5 cm (baseline) vs. 2.1 cm (6 months)
- Group B (control): 1.5 cm (baseline) vs. 2.1 cm (6 months)
Consider the limitations…
BMI higher in Group A at baseline: Many will point out that the BMI was higher in Group A at baseline than Group B – such that it may have affected results. Though this is true, Group B eventually underwent the same weight loss intervention as Group A and didn’t achieve any significant improvement in reflux symptoms (objectively or subjectively).
Small sample size: This study analyzed just 20 obese individuals with obesity and gastroesophageal reflux. The small sample size may have resulted in underpowering such that a true effect of weight loss on reflux remained undetected.
Severe reflux: Authors acknowledged that the patients selected for this study had pathological reflux (erosive esophagitis & daily symptoms) – and that the sheer severity may have prevented significant improvement following weight loss. I think it’s also possible that severe reflux does respond to weight loss but that it takes more substantial weight loss and/or longer-term maintenance after weight loss to achieve healing and reflux reversal.
10% weight reduction & still overweight (?): Normal BMI is between 19-25 kg/m2. The individuals in this study that lost ~10.8 kg over a 6-month period were still “overweight.” In fact, they were still at the higher-end of overweight BMI (25-30). Perhaps achieving a normal BMI is required to significantly reduce and/or reverse reflux symptoms. (Authors noted that 10% weight reduction may not be sufficient to improve symptoms & objective signs of reflux in obese patients.)
Abdominal fat loss (?): Losing weight is healthy for obese individuals, but perhaps these individuals did NOT lose enough body fat (specifically intra-abdominal fat) – to facilitate reflux improvement. Group A consumed just 61.5 grams of protein per day for the first 6 weeks. It’s fair to speculate that this low protein intake may have caused significant lean mass/muscle loss (along with fat loss and water loss). In brief, participants may have lost insufficient body fat (especially belly fat) as a percentage of total weight lost to improve reflux (which would explain lack of LES pressure change post-6 months).
Valid hypothesis: There could be a specific amount of intra-abdominal fat needed to induce/sustain reflux disease such that even if a person gains additional weight – the reflux doesn’t dramatically worsen. Similarly, losing a significant amount of weight from an obese state may not fully reverse the reflux because not enough abdominal fat was lost in the process (instead: fat from other areas, lean mass/muscle, and water weight was lost).
Function of “time”: Some researchers speculate that many pathophysiologic feedback loops associated with obesity may require significant time to fully reverse. In other words, it’s possible that gastroesophageal reflux conditions might’ve improved significantly over an additional 6-12 months – if weight loss was maintained.
Medication confound (?): Medication was withheld 1 week before each examination. This is extremely problematic in that many of these patients were using PPIs & H2 blockers every day for months/years – and throughout the study. Stopping these medications abruptly ~1 week before objective measures (e.g. 24-hour pH monitoring) will massively interfere with detection of any therapeutic effect of weight reduction on reflux. Why? Rebound acid hypersecretion (RAH) as a physiological compensatory reaction that lasts 2-4 weeks upon stopping PPI therapy.
Obesity could cause irreversible reflux (?): If obesity contributed to the onset of reflux – this study indicates that reversal of the obesity may not reverse the reflux.
Based on the scientific literature, does weight loss help GERD & gastroesophageal reflux?
Probably (especially the overweight/obese).
There’s far more evidence suggesting benefit of weight loss on: (A) GERD symptoms/severity and (B) gastroesophageal reflux symptoms (non-disease) among overweight/obese individuals – than there is evidence suggesting no benefit.
The benefits derived from weight loss on gastroesophageal reflux appear to be dose-dependent (such that greater weight loss is associated with more symptom reduction than lesser weight loss). Losing at least 10% of one’s body weight may be a good starting point.
That said, there is technically no “high-level” evidence from large-scale, randomized, double-blinded, placebo-controlled trials to suggest that weight loss significantly reduces the frequency/severity of gastroesophageal reflux disease (GERD) – and some studies reported zero significant benefit following weight reduction.
Lee (2018) examined the scientific literature and emphasized the importance of weight management in the treatment of erosive esophagitis, but acknowledged that it was unclear whether weight loss would improve GERD.
Bang & Park (2018) reported resolution of erosive esophagitis only in obese patients who lost weight to achieve a significant decrease in BMI – but GERD symptoms were not evaluated and no benefits from weight loss were observed in overweight/normal weight persons.
Singh et al. (2013) noted a significant correlation between “percentage body weight lost” and “GERD symptom score reduction” in 332 overweight/obese adults. The adults utilized a combination of diet, exercise, and behavior change to lose weight.
65% achieved complete resolution and 15% partial resolution of GERD symptoms. Problems with Singh et al.’s study? None of the patients were actually diagnosed with GERD – and they were allowed to utilize acid reducers like PPIs and H2RAs throughout the study.
Park et al. (2017) found that weight loss and waist reduction was associated with GERD symptom improvement – but only in patients with general obesity or abdominal obesity (not in those who were overweight/normal weight).
Any problems here? patients were allowed to use medications and GERD symptom improvement was measured with a non-validated questionnaire.
de Bortoli et al. (2016) observed significant reduction in GERD symptoms from a combination of weight loss (via hypocaloric diet), aerobic exercise, and PPI therapy in 50 overweight/obese patients relative to 51 overweight/obese patients who only received PPI therapy – over a 6-month period.
Ness-Jensen et al. (2013) found that weight loss dose-dependently reduced gastroesophageal reflux symptoms (heartburn & acid regurgitation) in the general population (29,610 individuals).
Fraser-Moodie et al. (1999) reported that weight loss of ~4 kg (achieved only with dietary modifications) improved GERD symptoms by ~75% in 34 overweight (BMI above 23) adults. (9 of 34 participants in this study achieved complete GERD remission following weight loss.)
Problems with this study? Very small sample with zero randomization, controlling, or blinding. Interestingly it was reported that 4 of 34 patients that gained weight (instead of losing weight) experienced a reduction in GERD symptoms.
Kaltenbach et al. (2006) conducted a review of the literature and learned that weight loss improves pH profiles and symptoms in GERD – such that it is an effective lifestyle intervention for GERD management.
Cremonini et al. (2006) found zero association between loss of at least 10 lbs. and GI symptom complexes (including gastroesophageal reflux disease) among 637 participants.
Kjellin et al. (1996) noted that weight reduction (~23.8 lbs.) failed to improve the subjective or objective symptoms of reflux in obese patients after a very-low calorie diet (VLCD) for 6 months. However, this study had limitations like: small sample size; uneven comparison characteristics; patients still overweight after weight reduction; etc.
Everything considered – most evidence suggests that weight loss reduces the severity of GERD and gastroesophageal reflux among those who are overweight/obese (and possibly even in upper-normal weight individuals).
Although no firm conclusions can be drawn from the available literature due to massive limitations, the overarching findings suggest: (A) weight loss helps GERD and (B) zero worsening of GERD or gastroesophageal reflux following weight loss.
There’s zero downside associated with intentional weight loss among those who are overweight/obese as a non-pharmacological intervention for GERD and gastroesophageal reflux.
Will weight loss improve your reflux condition?
1. Depends on the underlying cause(s) of reflux
If being overweight/obese is a significant underlying cause of a person’s reflux condition – then losing weight should: (1) reduce reflux symptoms AND (2) might completely abolish (i.e. “cure”) the reflux condition if the weight loss is sufficient/significant.
A notable exception to this is overweight/obesity-induced hiatal hernia. If long-term obesity (and associated eating habits e.g. overeating/binge eating) caused a large hiatal hernia – simply losing the excess weight will NOT correct the hiatal hernia (such that reflux will continue to occur).
It’s also possible that weight loss will not help everyone reduce/reverse reflux – even if the reflux was originally caused by weight gain or being overweight/obese.
How would this be possible? Specific physiological feedback loops and/or epigenetic changes may have been induced by weight gain that simply never reverse even if the weight is lost. (Whether this is true remains unclear.)
That said, since reflux is seldom caused by one standalone factor (e.g. large hiatal hernia) – significant weight loss and subsequent normalization of BMI/height-waist-ratio/body fat % should still provide some therapeutic benefit (e.g. reduced intra-abdominal pressure, healing of LES, lower stomach acid secretion, etc.).
2. Depends on amount of fat loss & belly fat loss
“Weight loss” is an unspecific term in that a person could theoretically lose a significant percentage of lean mass (e.g. muscle) but not a significant amount of fat (such as on a low-protein diet) – yet weight loss still occurred.
Most individuals who lose weight will lose a combination of fat and lean mass, but those who consume high amounts of protein should preserve a greater amount of lean mass/muscle while on a hypocaloric diet – relative to those who don’t prioritize protein.
In general, higher amounts of body fat loss should help reflux to a greater extent than lower amounts of body fat loss, particularly if the fat loss occurs in the stomach/abdominal/belly region. This effect is likely to hold true regardless of the amount of lean mass that is lost.
That said, it is unclear as to whether preservation of lean mass/muscle during weight loss affects reflux conditions: favorably, unfavorably, or has no effect. (It’s possible that it could affect hormone profile which could subsequently affect GI function and reflux.)
Note: It would likely be impossible to parse the specific effect of lean mass preservation during weight loss from consuming higher protein and/or low fat diets (high protein and lower fat diets tend to improve reflux conditions – as protein reduces LES relaxation and fat may increase LES relaxation).
3. Depends on how the weight is lost (?)
Whether weight loss improves a reflux condition (e.g. GERD, LPR, etc.) may be contingent upon the specific method(s) employed to achieve the weight loss.
Diet: Longstanding dietary modifications (calorie restriction such that caloric intake doesn’t exceed caloric expenditure) seem to be the most scientifically-substantiated means of reducing acid reflux conditions (e.g. GERD) through weight loss.
Exercise: Increasing energy expenditure via exercise combined with dietary changes to achieve ongoing negative energy balance may be helpful in reducing reflux symptoms via weight loss (one study tested a combination of diet and exercise and found benefit). Some experts recommend low-impact exercise (e.g. walking) instead of high-intensity (e.g. sprinting, running, etc.) which may aggravate reflux conditions.
Weight loss surgery (?): Weight loss surgery has potential to both increase reflux and decrease reflux – depending on the specific surgery utilized and individual anatomical/morphological presentation of the recipient post-surgery. (R)
- Sleeve gastrectomy: Despite being helpful for weight loss – many patients without reflux prior to surgery actually develop GERD and esophagitis after surgery. Other studies found no change OR slight decrease in reflux post-surgery. (Sleeve gastrectomy is NOT recommended in patients with GERD).
- Gastric banding: A review of literature on gastric banding shows a pattern of short-term improvement of GERD (3 weeks to 2 years) and resolution of esophageal lesions (within 1 year). However, more research suggests that GERD relapse/worsening tends to occur after 3 years following gastric banding due to esophageal dilation and inhibition of trans-stomal flow by narrowing of the esophageal outlet. (Procedure not recommended for GERD patients).
- Gastric bypass: Roux-en-Y gastric bypass (RYGB) tends to have a favorable effect on GERD symptoms due to how it modifies anatomy. GERD symptom resolution occurs in a majority of patients who receive this procedure (extra-esophageal symptoms like laryngitis, aspiration, etc. also tend to improve). Valezi et al. (2018) state that Roux-en-Y gastric bypass induces greater weight loss and GERD symptom reduction than diet. (R)
Note: Although the weight loss/fat loss resulting from surgeries is probably beneficial as an isolated variable for reducing GERD – the specific procedures utilized can alter internal anatomy in specific ways that might worsen/improve GERD.
Body weight (overweight/obesity) & gastroesophageal reflux disease (GERD)
There are numerous studies linking being overweight with gastroesophageal reflux disease. There are no studies suggesting that overweight/obesity is NOT a risk factor for GERD.
- Thalheimer & Bueter (2021): “The incidence of GERD is strongly associated with excess body weight.” (R)
- Surdea-Blaga et al. (2019): “Several meta-analyses showed a positive correlation between increased body mass index and gastroesophageal reflux disease.” (R)
- Vaishnav et al. (2017): “The prevalence, frequency, and severity of symptoms of GERD increases with increase in the BMI.” (R)
- Abdelkader et al. (2015): “Obesity in general and central (abdominal) obesity specifically has significant impact on clinical and endoscopic severity of GERD.” (R)
- Singh et al. (2013): “Overall prevalence of GERD symptoms is high (37%) in overweight and obese subjects.” (R)
- Fornari et al. (2011): “Obese patients differed from non-obese in terms of esophageal motility and reflux, regardless of the presence of GERD. Obese patients showed stronger peristalsis and increased acid exposure in the esophagus.” (R)
- Sonnenberg (2011): “Overweight and obesity contribute to the development of hiatal hernia, increase intra-abdominal pressure, and promote gastroesophageal reflux.” (R)
- Anand & O Katz (2010): “Obesity and GERD are clearly related, both from a prevalence and causality association.” (R)
- El-Serag (2010): “An increase in GERD symptoms has been shown to occur in individuals who gain weight but continue to have a body mass index (BMI) in the normal range, contributing to the epidemiological evidence for a possible dose-response relationship between increasing BMI and increasing GERD.” (R)
- Festi et al. (2009): “Obesity, in particular, abdominal obesity plays a key role in determining GERD symptoms and complications through mechanical and metabolic effects. Controlled weight loss by diet or surgery is effective in improving GERD symptoms.” (R)
- Jacobson et al. (2009): “BMI is associated with GERD symptoms in both normal weight and overweight individuals. Our findings suggest that even modest weight gain among normal weight individuals may cause or exacerbate reflux symptoms.” (R)
- Kaplan (2008): “It has been known for quite some time that people who are overweight or obese have an increased prevalence of GERD.” (R)
- Wu et al. (2007): “Obesity is associated with increased transient lower esophageal sphincter relaxation and acid reflux during the postprandial period in subjects without GERD.” (R)
- Ruhl & Everhart (1999): “Overweight but not dietary fat intake, increases risk of GERD hospitalization.” (R)
Obesity/overweight causing reflux does NOT mean that weight normalization (via weight loss) automatically reverses or “cures” reflux…
Many individuals assume that because: (A) being obese or overweight is associated with increased rates of acid reflux conditions (e.g. GERD) that (B) weight loss will cure/fix the reflux condition.
The reality is that these are 2 distinct areas of study. Just because being obese or overweight is associated with acid reflux conditions (e.g. GERD) does NOT mean that being obese or overweight caused the reflux conditions.
Additionally, even if we assume that being obese/overweight is the primary cause of acid reflux conditions (e.g. GERD) – this does NOT mean that weight loss (normalization of body weight/fat) always reverses the condition.
It’s possible that once the disease is set in motion (e.g. lower esophageal sphincter becomes weakened and/or dysfunctional) – that the disease cannot be reversed. (Reversibility of GERD and reflux conditions may be subject to significant inter-individual variation).
Note: There’s also a possibility of hiatal hernia from being overweight/obese. The hiatal hernia will not necessarily be “fixed” following weight loss – such that reflux may still occur even after weight reduction.
Does being overweight/obese cause acid reflux?
Yes (in many cases). Being overweight, obese, and/or having excess body fat – particularly around the abdominal region – is associated with greater frequency/severity of acid reflux (on average) because it causes reflux via numerous mechanisms.
Being overweight/obese increases acid reflux via things like: (1) increasing intra-abdominal pressure; (2) inducing transient lower esophageal sphincter relaxation (TLESR); (3) altering LES pressure to a hypotensive state; (4) modifying intestinal motor reflexes; (5) causing hiatal hernia – and more.
In many cases, people can likely avoid developing gastroesophageal reflux disease (GERD) by staying at a healthy body weight with a normal level of body fat. Increasing total body weight and body fat directly causes acid reflux and related disease (e.g. GERD) for many people.
That said, not every single person who develops acid reflux or gastroesophageal reflux disease (GERD) is overweight, obese, or has excessive body fat.
Some individuals experience acid reflux due to anatomical/morphological abnormalities (e.g. hiatal hernia since birth), esophageal sphincter dysfunction, dietary habits (e.g. binge eating disorder), sleep disorders, neuropsychiatric conditions, and chronic usage of certain medications/supplements.
Still, there’s significantly more people who develop reflux conditions as a result of excessive body weight/fat – than those who develop reflux conditions for other reasons.
Jacobson et al. (2009) states that even modest weight gain among normal weight individuals may cause or exacerbate reflux symptoms. (R)
This means that even if a person is technically still at a normal body weight or “healthy BMI” after gaining some weight – any modest weight gain could increase the frequency/severity of reflux.
It is important to emphasize that while being overweight/obese may cause/contribute to many reflux conditions (particularly “GERD”) – it’s unclear as to whether this is the case with laryngopharyngeal reflux (LPR).
One associational study found an inverse relationship between BMI and LPR risk such that low BMI (under 20 kg/m2) was associated with increased risk of LPR. (R)
Therefore, we must consider the possibility that low body weight (BMI) might increase the risk of developing atypical reflux syndromes.
Overweight BMI vs. too much body fat & reflux…
Potentially both. We can say with a high degree of certainty that being overweight/obese (and associated habits/lifestyle) can cause/exacerbate reflux conditions in a significant number of individuals.
“Overweight” is somewhat of a vague term considering that individuals who regularly lift weights with healthy body fat %’s are often considered “overweight” based on BMI – and “skinny fat” individuals (high body fat % with minimal muscle) are considered “normal weight.”
It is possible that simply having a high BMI (regardless of body fat %) increases risk of developing reflux. Hypothetically a large amount of lean mass/muscle in the abdominal region could put pressure on the stomach to cause reflux – even if body fat % is low.
However, an overall lower body fat % would probably pose lower risk of developing reflux given that the visceral fat would be low (which may cause reflux via steroid hormone signaling and inflammation).
I’d guess that rates of reflux would be lower in those who have a low body fat % – even if overweight by BMI, but this guess should not be taken as gospel.
Additionally, individuals who are “skinny fat” but technically “normal weight” may have a considerable amount of belly fat (visceral & subcutaneous) – both of which may contribute to reflux by increasing LES relaxation and increasing inflammation.
What about weight loss for laryngopharyngeal reflux disease (LPR)?
Laryngopharyngeal reflux disease (LPRD) is a relatively vague diagnosis and is often overdiagnosed or a common misdiagnosis (as opposed to other laryngeal conditions).
Individuals with laryngopharyngeal reflux should receive diagnostic clarity from: (1) laryngeal examination (laryngologist); (2) esophageal examinations (gastroenterologist); and (3) subjective symptoms – all taken into consideration.
Empiric therapy with a combination of diet/lifestyle changes (e.g. small meals, low acid foods/drinks, loose clothing, head-of-bed elevation) – in addition to alginate suspension after each meal is recommended.
Empiric therapy with H2 antagonists and/or proton-pump inhibitors (PPIs) twice daily may be useful for a 1-6 month period to determine whether there’s benefit from lowering acid (LPR is slow to respond to treatment).
Individuals with laryngopharyngeal reflux who are overweight or obese when diagnosed may benefit significantly from weight loss. (Stanford’s treatment guideline for LPR recommends “weight loss”).
However, individuals who are normal weight or underweight should NOT attempt to lose additional weight. One study (2022) reported an association between low BMI and LPR – suggesting that BMI 20 kg/m2 or less could actually be a risk factor for LPR. (R)
Underweight patients with LPR may be best suited gaining weight – as it may help the condition via reversal of nutrient deficiencies; normalization of hormone profile; and/or improvement in PNS/CNS function.
Additionally, underweight/normal weight patients with LPR may benefit more from treatment with amitriptyline (a tricyclic antidepressant) because the LPR may be of psychogenic origin which triggers a functional GI disorder.
Currently there’s ZERO research examining the effect of weight loss and/or fat loss on the frequency and severity of laryngopharyngeal reflux disease (LPRD). Those who are overweight/obese may benefit from an empiric trial of calorie restriction until: a healthy BMI; normal height-to-waist ratio; and/or a healthy body fat % – are reached.
Recommendations for weight loss with reflux conditions…
Included below are some recommendations for losing weight with reflux conditions.
Track calories: Most people have no clue how many calories they’re consuming at each meal and throughout each day. Consuming too many calories per meal can increase reflux by overwhelming the LES (causing it to remain open) and consuming too many calories per day can cause fat gain, indigestion, and overall exacerbation of reflux.
Eat small meals: Large meals cause LES pressure to drop which increases transient LES relaxation. Smaller meals should help the LES stay closed for a greater percentage of the day – thus decreasing the frequency/severity of reflux episodes. Aiming for 6-8 small meals at evenly spaced time intervals – is far better than 3 or fewer meals.
Avoid intermittent fasting (?): Though intermittent fasting has anecdotally helped a small subset of individuals with reflux conditions (possibly by allowing for a larger percentage of time in which the LES is untaxed) – it generally isn’t a smart/logical strategy for those with reflux. Why? Stomach acid increases in fasted states AND when an individual eats a large amount of food during the “feeding window” it will force the LES open for a longer duration to cause more severe/prolonged reflux. (The detrimental effect will compound if the “feeding window” is in the evening or at night.)
Eat breakfast (daily): Those with reflux should strive to eat breakfast every single day within 30 minutes of waking. Why? the body digests food more efficiently in the morning than at night AND gravity is on your side – most people remain upright in the morning such that reflux occurs less frequently than at night (e.g. while lying down and sleeping). Furthermore, an early breakfast makes it easier to ingest a series of small meals over a longer period of time while still ceasing calorie intake by 6-7PM. Skipping breakfast means cramming more food in your stomach in a shorter feeding window (a recipe for reflux).
Finish calories before 6-7PM: Finishing calories earlier in the evening is smart because digestion slows during sleep and the body is positionally vulnerable (lying down instead of upright) – such that reflux will increase. Eating late at night can cause a massive reflux flare.
High protein diet: Consuming a diet high in lean protein is hypothesized to reduce reflux by increasing LES pressures – which helps keep the LES closed. Pathological LES relaxation (lower pressure) is associated with reflux conditions like GERD.
Low acid diet: It is recommended to consume foods that are “low acid” (i.e. alkaline) with a high pH. Avoid citrus fruits, spicy foods (e.g. peppers), onions/garlic, tomatoes, peppermint, chocolate, berries, etc. – as these will activate pepsinogens on the way down the GI tract and will increase gastric acid secretion such that reflux will cause more damage. Moreover, some of these foods may weaken the lower esophageal sphincter (LES) causing more reflux events.
Water only (alkaline or standard): Avoid consuming carbonated beverages and anything acidic. When in doubt, just drink purified water or alkaline water (more beneficial in LPR because it deactivates pepsinogens in the upper esophagus/laryngopharynx).
Walking for exercise: High-impact and/or intense exercise such as running, sprinting, HIIT, or weightlifting might make reflux symptoms worse. Eating before an intense workout can also exacerbate reflux. The simplest way to get exercise while on a diet is daily walking (at a slow-to-moderate pace). Research suggests that walking after meals may provide slight benefit in reducing postprandial reflux episodes.
Avoid stimulants: Things like caffeine, theobromine, amphetamine, etc. can reduce appetite for some individuals while simultaneously increasing energy/metabolism. The problem? They can increase stomach acid production and reduce basal LES pressure/distal esophageal contraction – causing reflux of gastric contents.
Optimize fiber intake: A fiber-enriched diet is associated with significant increase of minimal lower esophageal sphincter (LES) resting pressure, a decreased number of gastroesophageal refluxes, and a decrease in heartburn frequency per week in NERD. (R) Fiber also improves gut microbiome composition and may reduce constipation – both of which could be useful effects in reflux conditions.
That said, too much fiber could be problematic (particularly soluble fiber which ferments) in that it delays gastric emptying and may cause gas, bloating, and/or constipation – all of which could exacerbate reflux. (Total gastric emptying is delayed in 10-33% of adults with GERD). It is recommended to optimize both soluble and insoluble fiber intake via self-experimentation.
Surgery (?): If you cannot lose weight normally, the best bariatric surgery with regard to both GERD and weight reduction is Roux-en-Y gastric bypass (RYGB). Compared to other types of weight loss surgery (many of which worsen GERD) – this method is associated with greater reductions in GERD symptoms than diet-induced weight loss.
How weight loss helps reflux… (Hypothetical mechanisms)
Decreased intra-abdominal pressure: Intra-abdominal pressure should decrease from losing both subcutaneous and visceral fat in the abdominal region. As a result, the lower esophageal sphincter (LES) function should improve and/or normalize.
Fewer LES relaxations: Transient relaxations of the lower esophageal sphincter (LES) are associated with reflux events. Weight loss decreases both calorie intake and abdominal adiposity – both of which should play a role in allowing LES function to normalize.
Hiatal hernia shrinkage (?): Research suggests that weight loss may reduce the size of a hiatal hernia bulge. In some cases, the hiatal reduction is so significant that surgery is no longer needed for symptom relief. Weight loss will also prevent the hiatal hernia from worsening (e.g. becoming larger).
Healthy gut microbiome changes: It is thought that abnormal gut microbiome composition may play a direct and/or indirect role in the pathogenesis of reflux conditions. Because weight loss can improve gut microbiome composition, this could subsequently improve gut-brain axis signaling, GI function, and/or modulate the production of specific metabolites via digestion to reduce reflux events.
Decreased inflammation: Being overweight/obese causes chronic low-grade inflammation characterized by an upregulation of specific pro-inflammatory cytokines like IL-1 and IL-6. Reducing body fat, especially visceral fat, can normalize inflammation – which might subsequently decrease reflux and/or break pathogenic feedback loops involved in reflux.
Sleep apnea improvements: There’s a bidirectional relationship between sleep apnea and reflux diseases (e.g. GERD & LPR) in that: (A) “gasping for air” during apnea creates a suction effect which can draw gastric contents up the esophagus (i.e. cause reflux) and (B) reflux causes nasopharyngeal & esophageal inflammation which may interfere with breathing during sleep (further obstructing respiration and perpetuating apnea).
Obstructive sleep apnea can be caused and exacerbated by excessive amounts of body fat – particularly in the throat/neck. Being overweight/obese is a risk factor for OSA.
Losing a significant amount of weight may help treat obstructive sleep apnea by reducing fat cell density in the throat/neck region – enabling unobstructed or less obstructed respiration during sleep.
Among individuals with both obstructive sleep apnea and reflux conditions – any significant improvement in the former (apnea) could simultaneously improve the latter (reflux).
Note: A similar effect may be observed in the condition UARS (upper airway resistance syndrome).
Improved intestinal motor reflexes: Considering that being overweight/obese is associated with abnormalities in intestinal motor reflexes – and that these abnormalities may cause/exacerbate reflux conditions, it’s reasonable to suspect that normalization of intestinal motor reflexes following weight loss might help reduce/reverse reflux conditions.
Reversal of small bowel motility inhibition: Because excess body weight/fat may inhibit small bowel motility – losing weight/fat may reverse this occurrence such that small bowel motility normalizes and thus there’s fewer symptoms/signs of intestinal obstruction (e.g. distention, bloating, nausea, vomiting, etc.) and less reflux.
Normalization of intestinal gas transit: Excess body weight/fat is hypothesized to delay the transit of intestinal gas – which in turn could induce reflux via triggering the LES to open more frequently or for longer durations which would enable reflux. Body weight/fat reduction may help normalize previously abnormal intestinal gas transit associated with being overweight.
Habits associated with weight loss: Keep in mind that some individuals utilize specific habits/strategies to lose weight that may help reverse reflux symptoms just as much as (or possibly more than) the actual weight loss. (Understand that all of these habits are not inherently necessary for weight loss – only negative energy balance is required).
- Smaller meals: Fewer calories consumed at each meal can decrease reflux by reducing upward pressure on the LES and transient lower esophageal sphincter relaxations (TLESRs).
- Lower calorie diet: Stomach fills up less – and puts less upward pressure on the LES throughout the day. Stomach acid production is lower due to smaller meals as well.
- Eating earlier in the day (less at night)
- Exercising more frequently: Many people exercise more frequently in attempt to lose weight – and this frequent exercising may directly contribute to lower rates of reflux. How? Exercise helps the body burn/mobilize calories and may improve digestion. Exercise also might alter breathing patterns, hormone secretion, inflammatory status, and esophageal motility – all of which could improve reflux.
- Non-acidic foods/drinks: Some people follow a “low acid diet” wherein they avoid all acidic foods/drinks (e.g. pH 5 or less). This type of a diet is restrictive and may facilitate relatively effortless weight loss for some individuals. However, significant therapeutic benefit may be derived from the avoidance of acidic foods/drinks (rather than or in addition to – weight loss).
- Restrictive diet (bland foods): Consuming only non-acidic foods/drinks. This may be challenging for some individuals who lack knowledge of non-acid foods – causing them to eat the same few non-acidic foods repetitively (over-and-over).
- Drinking more water (?): Some people switch from juices and sodas to drinking “only water” during weight loss and this single switch may help enable healing of the esophagus and/or esophageal sphincters. Drinking water at appropriate times (e.g. later stages of digestion) is thought to help reduce acidity and reflux symptoms.
Autonomic nervous system (ANS) & vagal nerve function: Some researchers think that reflux conditions like GERD are caused in part by autonomic nervous system (ANS) and vagal nerve dysfunction in response to excess body fat. Obese individuals have diminished parasympathetic activity and the vagus nerve is the primary nerve of the PNS and chief modulator of the gut-brain axis (GBA). Weight loss is thought to restore parasympathetic tone and vagus nerve function – which might contribute to the reversal of gastroesophageal reflux. (R)
Hormone changes: When a person loses weight via negative energy balance, the first type of fat that is lost is “visceral fat” – or fat that is wrapped around the organs. Losing visceral fat can reduce inflammation, decrease the release of steroid hormones (which impact LES tension), and reduce LES opening (as there will be lower pressure on the LES from visceral fat). Fat loss is also associated with alterations in adiponectin, leptin, ghrelin, insulin, GLP-1, PP, Peptide YY, CCK – some or all of which might reverse the pathophysiologic signature of GERD.
Is weight loss always good for reflux conditions?
Nope. Not every reflux condition will benefit from weight loss. Many cases of gastroesophageal reflux disease (GERD) will improve following weight loss – particularly among overweight/obese individuals, but this is not a guarantee.
In the event that another medical condition (e.g. neurological disorder) or anatomical abnormality (e.g. hiatal hernia) is causing one’s reflux condition – then weight loss is less likely to provide clinically relevant benefit.
Additionally, there’s some evidence that low BMI is associated with increased severity of laryngopharyngeal reflux (LPR) vs. high BMI associated with decreased severity of LPR.
This could be due to the fact that LPR causes significant psychological distress and laryngeal discomfort – and some individuals with the condition dislike how they feel after eating/while eating and subsequently reduce eating frequency such that they lose significant weight.
However, it’s also possible that weight loss: (A) causes LPR to worsen OR (B) is a risk factor for developing LPR.
How could this be? Low levels of body fat may increase anxiety/stress and/or poor sleep – which could exacerbate LPR by: bolstering stomach acid production; modulating esophageal sphincter function/pressure; and/or increasing inflammation.
How do we know this to be the case? Because many individuals (particularly with LPR) are already normal weight or underweight.
It’s possible that low body weight has no effect on reflux in these cases such that reflux is being caused by diet, lifestyle, and habits:
- Fasting all day & eating late at night
- Eating large meals
- Binge eating
- Lying down after eating
- Medications & dietary supplements (acidic, increasing acid production, altering esophageal sphincter pressure)
- Alcohol, caffeine, nicotine intake
- Smoking & smoke exposure
- High-acid diet (spicy foods, citrus foods, low pH)
- Carbonated beverages
- Sleeping on right side/stomach
- Hiatal hernia & anatomical abnormalities
- Intense physical exercise (e.g. HIIT)
- High stress or depression
Among underweight and normal weight individuals with reflux conditions, the goal should be to: (1) rule out anatomical abnormalities; (2) treat neuropsychiatric disorders (e.g. anxiety, depression, etc.); and (3) improve diet composition, lifestyle, and habits.
Unintentional weight loss after reflux onset… (How it happens)
Unintentional weight loss can occur after reflux onset/diagnosis for a variety of reasons.
Although things like tracking calories, no late-night eating, sleep prioritization, and stress reduction are common strategies for intentional weight loss – individuals with reflux may be utilizing them simply to control the reflux without intentionally trying to lose weight.
- Eating less or smaller meals due to reflux-related pain: Eating causes reflux which can cause severe pain/burning sensations for some. Among individuals with laryngopharyngeal reflux, pain may occur in the ears (e.g. middle ear & eustachian tubes) and throat – and may be particularly frightening. Obviously if the pain becomes significant – it may cause individuals to eat smaller meals and fewer calories (resulting in weight reduction).
- Higher stress (?): In some cases, reflux conditions can significantly increase stress/anxiety. For certain people, high stress/anxiety can suppress appetite and result in lower caloric intake – which causes subsequent weight loss.
- Dietary adjustments & restrictions: Many people adjust their diets and avoid intakes of acidic foods/drinks in effort to reduce acid reflux. These dietary adjustments/restrictions may promote relatively effortless weight loss. How? Giving up calorie dense carbonated beverages (e.g. soda), fast food, ultra-processed foods, etc. in favor of healthier options. Most anti-reflux diets recommend consumption of unprocessed: high-fiber foods (e.g. vegetables), lean proteins, and healthy fats (e.g. nuts/seeds) – all of which promote satiety and could result in lower caloric intake.
- Treatments: Medications such as proton-pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2 blockers) are commonly used to treat reflux conditions. For a subset of users, appetite reduction may occur which results in consumption of fewer calories and subsequent weight loss.
- Walking after meals (?): Some doctors recommend that patients go on walks after meals because walking may enhance digestion and reduce the severity of postprandial reflux episodes. As a result of regularly walking, some reflux sufferers may burn more calories each day than pre-reflux and end up losing weight.
- Tracking calories (?): Some individuals begin tracking calories after a reflux diagnosis to ensure that they aren’t eating over a certain number of calories per meal (such as would trigger reflux). Tracking calories at each meal may reduce total calorie intake each day such
- No late-night eating (?): Many people stop eating late at night when diagnosed with reflux. Assuming calories that were formerly consumed at night (pre-diagnosis) are not shifted to an earlier time of day – weight will be lost. Most people with reflux try to eat all calories before 6-7 PM (~3-4 hours before bedtime).
- Sleep prioritization: Poor sleep is associated with onset and worsening of acid reflux. After getting diagnosed with reflux, many people focus on improving sleep quality/quantity. Significant improvement in sleep quality/quantity can favorably reduce cravings for unhealthy foods and improve hormonal profile – ultimately contributing to weight loss.
- Stress reduction: Stress and anxiety can aggravate and trigger reflux episodes for some people by increasing stomach acid production and possibly via modulation of esophageal sphincter function/pressure. Because many people become serious about managing stress after reflux diagnoses, this could contribute to weight loss via: reduced food cravings (and calorie intake) and better hormone profile (via lower stress/better sleep) for fat loss.
Did you lose weight to treat a reflux condition?
If you intentionally lost weight (regardless of the methods employed) in attempt to improve a specific reflux condition (e.g. GERD, LPR, NERD, etc.) – feel free to share some details about your experience in the comment section.
Body weight changes…
- BMI (body mass index) (What was it before the weight loss?) (What is it now?)
- Height-to-waist ratio (What was it before the weight loss?) (What is it now?)
- Pre-weight loss: underweight, normal weight, overweight, or obese? (What are you now?)
Weight loss details…
- How much weight did you lose?
- Was the weight loss mostly body fat?
- Was the weight loss intentional or unintentional?
- How often do you eat meals? (What is your eating frequency?)
- What is the average size of your meals? (e.g. 300 calories)
- How many total meals do you eat each day?
- Did you eat a more restrictive diet (e.g. low acid diet)?
- Do you track the number of calories you eat each day?
- Do you think exercise may have contributed to your weight loss?
- Did you have weight loss surgery (e.g. Roux-en-Y)?
- What is your specific reflux condition? (e.g. GERD, NERD, LPRD, etc.) Were you diagnosed by a medical doctor?
- How has your reflux changed after losing weight? (Discuss: Intensity, frequency, duration, etc.)
- If reflux improved after weight loss – how much weight did you lose before noticing significant improvement?
- If reflux worsened after weight loss – why do you think this happened?
- If your reflux improved after weight loss – do you think it was solely due to weight loss? (Why or why not?) (How big of an impact do you think weight loss had on your reflux?)
- Have you considered that things other than weight loss may have influenced the severity of your reflux condition? (e.g. PPIs, H2 blockers, antacids, low acid diet, smaller meals, eating earlier in the day, stress reduction, etc.).