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Gastroesophageal reflux disease (GERD), the chronic occurrence of acid reflux, has a proven connection to obesity in both sexes, though there is a stronger association between obesity and GERD in women.^1,2

The American Society for Gastrointestinal Endoscopy sites obesity as the leading cause of frequent acid reflux and heartburn.³ Any increase in weight increases the risk of GERD, including individuals whose weight is considered to be in a normal range.

Even a moderate weight increase may contribute to the development of GERD or increase the severity of GERD symptoms in individuals of normal weight.⁴

Fat distribution, specifically intra-abdominal obesity is a critical risk factor in the development of GERD. It’s interesting to note that the relationship between waist circumference (WC) and GERD is greater in Caucasians than in other ethnicities, and WC rather than body mass index (BMI) is the best obesity measurement for predicting the presence of GERD.⁴

BMI Categories and Measurements:

BMI is a commonly used measurement of body fat based on height and weight.

Underweight = <18.5
Normal weight = 18.5–24.9
Overweight = 25–29.9
Obesity = 30-40
Morbidly Obese = >40

The National Institutes of Health has a tool if you’d like to calculate your BMI.

Data from studies show:

• Individuals with a BMI >30 have twice the risk of developing GERD as compared to those with a normal BMI.⁴
• A connection between a BMI >25 and the occurrence of a hiatal hernia, a condition where increased pressure in the abdomen pushes part of the stomach through the diaphragm muscle into the chest cavity.⁴

Obesity Related Changes in Physiology

Obesity can lead to changes in physiology that lead to an increase in acid reflux symptoms and the development of GERD.

1) Lower Esophageal Sphincter

The lower esophageal sphincter (LES) is a group of muscles at the base of the esophagus that opens when food is swallowed allowing it to enter the stomach and closes to keep the stomach contents in place. The point where the esophagus and stomach connect is called the gastroesophageal (GE) junction.

Obesity causes low pressure in the LES. Meaning the pressure created when the LES tightens fails to be strong enough to keep the stomach contents in place. Low LES pressure will allow stomach contents to reflux into the esophagus to cause heartburn, the pain associated with acid irritation of the esophagus.

The weakened LES is caused by abdominal weight forcing stomach contents upward toward the LES and from overeating which increases pressure in the stomach to weaken the LES. Both prohibit the LES from closing properly.

2) Hiatal Hernia

Hiatal hernias are common especially in those who are overweight. Hiatal hernias can allow stomach contents to reflux into the esophagus. If acid-reducing drugs, dietary changes, and lifestyle modification don’t manage GERD symptoms caused by a hiatal hernia, surgery may be required.

3) Estrogen Levels

Estrogen levels in women and in men increase as BMI increases. Estrogen affects plasma nitric oxide levels.⁵ As estrogen levels increase plasma nitric oxide levels increase. Nitric oxide, in turn, causes smooth muscle relaxation. Smooth muscle relaxation causes the LES closure to weaken allowing acid reflux to occur.⁶

Treating Obesity and GERD

In the case of GERD caused by obesity, both obesity and GERD must be treated, though the underlining condition of obesity must be remedied before GERD can be cured. Mayo Clinic researchers found that even moderate weight gain can exacerbate GERD and that weight loss is an effective GERD treatment for overweight individuals.⁷

For treating GERD symptoms, prescription and over-the-counter (OTC) acid-reducing drugs are available. Acid-reducing drugs such as PPI’s, H2 blockers, and antacids can be used to mask the symptoms of GERD and allow irritation and acid erosion of the esophagus to heal. This, however, does not cure GERD. The underlining cause must be remedied in this case, obesity.

Before taking prescription or OTC acid-reducing drugs, read and adhere to the directions and to the recommendation of your physician and pharmacist. Acid-reducing drugs can have negative interactions with certain medications and their absorption rate and may not be appropriate for some individuals.

For treating obesity, weight loss from dietary and lifestyle changes is recommended for reducing GERD symptoms and to ultimately cure GERD. GERD symptoms have also been reduced in those who have had bariatric surgery, though it is not known if the improvement is due to the surgical procedure which also discourages reflux or to weight loss after the surgical intervention. Bariatric surgery should be discouraged if weight loss can be achieved without invasive measures.⁸

Relief of GERD symptoms due to obesity is dependent on the amount of weight lost. Greater the weight loss greater the improvement of GERD symptoms.

1) Dietary Changes for Treating Obesity and GERD

In many cases, foods that contribute to obesity are also foods that trigger heartburn. These would include processed foods and fatty foods. Therefore the elimination of heartburn trigger foods is highly important for the treatment of both obesity and GERD.

Heartburn Trigger Foods to Avoid:

• Foods high in fat
• Fried food
• High-fat meats
• Dairy products
• Spicy food
• Garlic
• Onions
• Tomatoes
• Citrus
• Caffeinated products
• Carbonated beverages
• Alcohol
• Mint
• Chocolate

Sugar should also be eliminated. Sugar is directly related to obesity and indirectly related to heartburn. Sugar promotes the growth of unhealthy bacteria and yeast infections in the digestive tract. Small intestine bacterial overgrowth (SIBO), Helicobacter pylori (H. pylori), and Candida overgrowth are three of these that can lead to the development of GERD symptoms by increasing abdominal pressure, weakening the LES, and slowing digestion.

Supplements to Consider for Improving GERD Symptoms

A properly functioning digestive system helps reduce the possibility of heartburn, acid reflux, and GERD. There are numerous dietary supplements that can help improve digestion and protect the digestive tract. These are a few popular supplements for preventing heartburn and repairing the body after long-term use of acid-reducing drugs.

• Probiotics are good bacteria that help improve digestion, thus reducing the instance of acid reflux.
• Prebiotics are nondigestible carbohydrates. Prebiotics provide the food source for probiotics to thrive.
• Digestive enzymes aid in digestion by helping with the breakdown of food.
• Fiber helps keep the digestive tract moving at a good pace.
• Mucilage is a natural remedy for coating and protecting the lining of the digestive tract to effectively prevent damage from acid irritation. Forms of mucilage to consider are deglycyrrhizinated licorice (DGL),
  aloe vera, slippery elm, and marshmallow root.
• Vitamins and minerals to consider replacing due to deficiencies caused by proton pump inhibitors (PPIs) are vitamin B₁₂, calcium, magnesium, and iron

2) Lifestyle Changes for Treating Obesity and GERD

Heartburn Friendly Exercises

Exercise is essential in burning calories and losing weight. There is, however, a time and place. Many exercises cause pressure on the LES while others are considered to be heartburn friendly exercises. To avoid heartburn while exercising, wait 2-3 hours after meals before exercising to give food time to digest and vacate the stomach. This will help prevent undue pressure on the LES while exercising.

Eliminate Nicotine Use

Nicotine relaxes the LES leading to the possibility of acid reflux. Forms of nicotine include smoking tobacco, chewing tobacco, nicotine gum, and nicotine patches. In addition, smoke from cigarettes and cigars also irritates the esophagus.

Related Content:

• 8 Ways Nicotine Increases Heartburn
• E-Cigarettes and Heartburn Connection

Reclining and Sleeping Habits

Follow the tips below to reduce heartburn at night or when reclining.

• Remain upright after eating and fast 2 or more hours before going to bed or lying down to prevent pressure on the LES.
• Reclined and slouched positions also cause added abdominal pressure on the LES and should be avoided after eating.
• Elevating your torso while sleeping or lounging helps prevent stomach acids from refluxing. Consider placing six-inch blocks under the head of your bed or the use of a mattress bed wedge or acid reflux pillow system.
• Sleep on your left side to reduce heartburn. The stomach hangs lower when on the left side than on the right putting less pressure on the LES.

Related Content: Elevation Therapy For Heartburn At Night: Time To Sleep On An Incline

When and How Food Is Consumed

When and how food is eaten are important for GERD prevention while the total caloric intake is more important for weight reduction.

Order In Which Foods Are Eaten: Faster digesting foods should be eaten first so contents will vacate the stomach faster. This will keep down stomach pressure created by excess stomach contents as well as cut down on stomach acid levels.

When We Eat: Pressure on the LES and thus chances of heartburn are reduced when smaller sized meals are eaten at regularly spaced intervals during the day. Consider 4-5 meals instead of the traditional three.

Heavy evening meals should also be avoided for both reducing obesity and GERD. Heavy meals take longer to digest and can cause heartburn if you lie down before they’re fully digested also there’s less of an opportunity to burn off calories from heavy meals eaten close to bedtime.

How We Eat: Eating slowly, taking small bites, and chewing properly improves digestion by reducing the amount of time and stomach acid needed for breaking down food. Properly chewing food increases saliva production. Saliva aids in predigestion and acts as bicarbonate to neutralize stomach acid.

How Much We Eat: Overeating increases pressure on the LES increasing the risk of GERD symptoms. Smaller meals reduce the risk of heartburn and also help reduce hunger cravings.

Avoid Tight Clothing

Avoid tight-fitting clothes. Clothes that fit tightly around the abdomen cause added pressure on the LES and contribute to acid reflux.

Conclusion of Obesity and GERD

Western societies have seen an alarming increase in the prevalence of both obesity and GERD.⁸ This is of great concern as GERD is the primary cause of Barrett’s esophagus and Barrett’s esophagus is the main risk factor for esophageal cancer.⁴ Thus, as weight increases the risk of developing esophageal cancer increases. Conversely, as weight decreases, the risk of GERD decreases lowering the risk of developing esophageal cancer.

References

1) Magnus Nilsson, MD; Roar Johnsen, MD, PhD; & Weimin Ye, MD. “Obesity and Estrogen as Risk Factors for Gastroesophageal Reflux Symptoms.” JAMA Network, July 2, 2003.

2) Hashem El-Serag, MD, MPH. “The Association Between Obesity and GERD: A Review of the Epidemiological Evidence.” National Center for Biotechnology Information, U.S. National Library of Medicine, Digestive Diseases and Sciences, September, 2008.

3) “Understanding Gastroesophageal Reflux Disease.” American Society for Gastrointestinal Endoscopy, September 9, 2018.

4) Anggiansah R, Sweis R, Anggiansah A, Wong T, Cooper D, & Fox M. “The effects of obesity on oesophageal function, acid exposure and the symptoms of gastro-oesophageal reflux disease.” National Center for Biotechnology Information, U.S. National Library of Medicine, Alimentary Pharmacology & Therapeutics, March 2013.

5) Best PJ, Berger PB, Miller VM, & Lerman A. “The effect of estrogen replacement therapy on plasma nitric oxide and endothelin-1 levels in postmenopausal women.” National Center for Biotechnology Information, U.S. National Library of Medicine, Annals of Internal Medicine, February 15, 1998.

6) Ravinder K. Mittal, M.D., & David H. Balaban, M.D. “The Esophagogastric Junction.” The New England Journal of Medicine, March 27, 1997.

7) Brian C. Jacobson, M.D., M.P.H., Samuel C. Somers, M.D., Charles S. Fuchs, M.D., M.P.H., Ciarán P. Kelly, M.D., & Carlos A. Camargo, Jr., M.D., Dr.P.H. “Body-Mass Index and Symptoms of Gastroesophageal Reflux in Women.” The New England Journal of Medicine, June 1, 2006.

8) De Groot NL, Burgerhart JS, Van De Meeberg PC, de Vries DR, & Smout AJ, Siersema PD. “Systematic review: the effects of conservative and surgical treatment for obesity on gastro-oesophageal reflux disease.” National Center for Biotechnology Information, U.S. National Library of Medicine, Alimentary Pharmacology & Therapeutics, December 1, 2009.