Typically it has been presumed that there are two mechanisms that provoke heartburn via food intake. First, some foods with a more acidic pH, such as citrus fruits, have been shown to directly irritate the lining of the esophagus and produce heartburn, and, second, some foods have been shown to decrease the lower esophageal sphincter (LES) pressure, thereby predisposing to gastroesophageal (GE) reflux. Data with regard to the effect of a high fat meal are conflicting; however, there appears to be a consensus that chocolate does decrease the LES pressure (Nebel and Castell, 1973; Pehl et al, 1999; Murphy and Castell, 1988). Peppermint, garlic, and onions are food constituents that clinically appear to induce heartburn in many patients. These compounds have a similar derivation and are often categorized as carminatives. In our laboratory, we undertook a study to directly test one of these constituents (ie, raw onions), and its effect on postprandial reflux (Allen et al, 1990). In this study, we had normal individuals eat a hamburger with and without a large raw onion. In the onion condition it was shown that there was a significant postprandial increase in esophageal acid contact. Peppermint has also been shown to induce GE reflux, but this may be confounded by the fact that dissolving a peppermint may have the salubrious effect of enhancing salivation, which will facilitate acid clearance. Chewing gum may also induce increased salvation with similar effects on esophageal acid clearance.
Heartburn and esophageal irritation are common experiences in individuals with an acid sensitive esophagus who ingest citrus fruit juices. A recently published survey showed a significant correlation between the acidity of the citrus juices and heartburn score (Feldman and Barnett, 1994). On this basis, it would seem reasonable to advise patients to avoid chocolate, citrus fruits, and fruit juices, as well as carminatives, such as onions and garlic. Data with regard to high fat content on LES pressure are equivocal, but it would seem rational to advise individuals to avoid high fat foods, at least with regard to their effect on delayed gastric emptying and GE reflux. Two studies have been done that address the issue of carbonation and caffeine. Crookes and colleagues (1999), did not find any differences between carbonated water, caffeine-free Pepsi, or regular Pepsi, and concluded that LES changes are due to gas rather than caffeine level or pH. On the other hand, in a study designed to test the difference between regular coffee and decaffeinated coffee, Pehl and colleagues (1997) found that decaffeinated coffee indeed did reduce the percent of acid contact time in the esophagus.
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