The Role of Obesity

Weight loss is generally recognized as an important lifestyle measure to observe in the treatment of GERD, and obesity is felt to be a significant risk factor for GERD. Until fairly recently, this approach was based only on the logical assumption that increased girth promotes an increase in intra-abdominal pressure, thereby facilitating the retrograde flow of gastric contents into the esophagus. In more carefully analyzing the relationship between obesity and GERD, the relationship between GE reflux per se and the symptoms of GERD must be taken into account. For example, it is now well-established that 50% or fewer of reflux events are associated with a symptom such as heartburn or regurgitation, and the relationship between 24-hour esophageal pH measures of esophageal acid contact and the presence or absence of esophagitis is relatively poor. Therefore, any indictment of weight loss simply because it does not reduce the absolute percent of esophageal acid contact time is probably not warranted. Further complicating the assessment of these relationships is the fact that there appears to be a significant difference between males and females in the relationship between obesity and GERD. Female susceptibility has been demonstrated in epidemi-ological studies (Nilsson et al, 2003). Thus, any study with a preponderance of men in the subject population would be most likely not to show any particular relationship between obesity and the presence or absence of GERD symptoms.

An example of the complexity of these relationships can be illustrated in two studies done by the same large group of collaborators (Nilsson et al, 2003; Lagergren et al, 2000). In a study published in 1999, the authors concluded that there was no relationship between body mass and GERD symptoms, and this applied to both severity and duration of reflux symptoms. In a more recent study, published in 2003, the authors reached a very different conclusion. In this study they reported a significant association between body mass and symptoms of GERD. They noted that the association was stronger in women, particularly in premenopausal women, and that the use of hormone therapy appears to strengthen this association. In the discussion of this article, the authors commented on their previous work and suggested that a paucity of males in that particular study biased the results toward negativity. Other epidemiological studies

*Editor's Note: Foods that delay gastric emptying, such as fatty meals, will also contribute to gastric distension and should be limited. Patients often cite meals with tomato sauce, which are possibly multifactorial.

have documented a strong relationship between obesity, GERD symptoms, and the presence of adenocarcinoma (AC) in the distal esophagus (Mayne and Navarro, 2002). Another epidemiological study has shown a significant relationship between increased body mass index, hiatal hernia, and esophagitis (Wilson et al, 1999).

Thus, the preponderance of epidemiological data would suggest a strong association between obesity and GERD symptoms, as well as the well-known complications of GE reflux per se, such as esophagitis and AC of the esophagus. On the basis of these data, it would seem prudent to recommend weight loss in patients with GERD, or preferably the prevention of substantial weight gain to levels that would be significantly beyond the patient's ideal body weight.

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