Treating GERD: Lifestyle modifications vs medication

Dear colleagues,

Gastroesophageal reflux disease (GERD) is a common reason for referral to gastroenterology. It affects a broad cross-section of our population and is often managed through a combination of lifestyle modifications and proton pump inhibitors (PPIs). However, in the era of PPIs, we must ask: Are lifestyle changes still necessary? And were they ever truly effective?

While PPIs are highly effective, concerns about their potential side effects frequently make headlines. Moreover, the financial burden of lifelong PPI use is a growing consideration. In this issue of Perspectives, Dr. Brijesh B. Patel and Dr. Juan D. Gomez Cifuentes explore these questions. Dr. Gomez Cifuentes highlights the benefits of lifestyle changes and identifies which strategies have proved most effective in his practice. Dr. Patel examines the ubiquitous use of PPIs and the challenges of sustaining adherence to lifestyle modifications. We hope these discussions will spark new ideas for managing GERD in your own practice. 

 

 

We also welcome your thoughts on this topic — join the conversation on X at @AGA_GIHN. 

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.

Do Lifestyle Changes Still Apply in the Treatment of GERD?

BY JUAN D. GOMEZ CIFUENTES, MD

Lifestyle changes are an essential part of managing gastroesophageal reflux disease (GERD). Increasingly, patients are asking about non-medication approaches to control their symptoms. These lifestyle modifications can be categorized into four main areas: 1) Weight loss, the cornerstone intervention, with significant symptom improvement observed after losing as little as 1.7 BMI points. 2) Dietary modifications, which includes both the traditional avoidance of trigger foods and the newer focus on a diet low in simple carbohydrates. 3) Bedtime adjustments, strategies that include elevating the head of the bed, sleeping on the left side, using anti-reflux pillows, and avoiding late-night meals. 4) Tobacco cessation, a key measure for reducing GERD symptoms and promoting overall health. I routinely discuss these changes with my patients, as they not only help manage GERD but also foster healthy habits and have a positive impact beyond the gastrointestinal tract.

 

 

Weight loss is the most impactful lifestyle intervention for GERD. Research shows a clear linear improvement in symptoms with weight reduction. Traditionally, losing 10% of body weight is a widely accepted goal, extrapolated from other obesity-associated conditions. A reduction in 3.5 points of BMI led to significant symptom improvement in landmark studies but also a modest reduction of 1.7 BMI points has been shown to provide symptom relief.¹ Abdominal circumference is another key metric used to track progress, as central obesity rather than BMI alone is strongly linked with GERD. Goals are typically set at less than 40 inches for men and 35 inches for women. Patients using GLP-1 agonists should be informed that these medications may temporarily worsen GERD symptoms due to delayed gastric emptying, however in the long-term these symptoms are expected to improve once significant weight loss is achieved.

Food triggers vary among individuals, with common culprits including fatty meals, spicy foods, chocolate, tomato sauce, citrus fruits, and carbonated beverages. Patients tend to overemphasize diet elimination based on triggers and engage in strict diets. Patients are frequently afraid of these foods causing direct damage to the esophageal mucosa but the hypothesis is that these triggers worsen GERD by increasing transient relaxations of the lower esophageal sphincter. The evidence behind this and diet elimination based on triggers has always been weak. In my practice, I encourage patients to follow a diet low in simple carbohydrates. Simple carbohydrates are present in highly processed food, the average western diet contains ~140 g/day. In a trial, a diet low in simple sugars (monosaccharides and disaccharides < 62 g/day) without reducing total daily calories, objectively improved total acid exposure time in pH study.²

Thanks to gravity, nocturnal GERD symptoms are the culprit of many restless nights in these patients. I recommend avoiding food 3 hours before lying down. Since the stomach empties approximately 90% of its contents after 4 hours, waiting longer is not recommended and may result in hunger, making it harder to fall asleep. Sleeping on the left side, which takes advantage of the gastric anatomy, has proved to objectively decrease nocturnal acid exposure time, though some patients may find it challenging to maintain this position all night.³

Elevating the head of the bed is another effective intervention, but it must involve raising the upper body from the waist. Patients should avoid stacking ordinary pillows as this will only elevate the neck and place the body in an unnatural position for sleeping. The most effective strategies are putting blocks/bricks under the feet of the bed, using a bed wedge between the mattress and the box spring or using an adjustable bed frame. There are two types of pillows that have been shown to improve nocturnal GERD symptoms. The classic wedge pillows and the more expensive Medcline reflux relief system®. The Medcline pillow has a dual mechanism that elevates the upper body but also keeps the body on the left side position.⁴

Tobacco cessation is strongly recommended. Tobacco worsens GERD symptoms by reducing the lower esophageal sphincter pressure and decreasing saliva production which is one of the key components of the normal esophageal acid barrier. Moreover, it is a known risk factor for esophageal cancer. Alcohol has a variety of negative health impacts and decreasing alcohol intake is advised; however, the link between alcohol and GERD symptoms is less robust, especially in patients with low occasional consumption.

In summary, lifestyle modifications play a pivotal role in managing GERD symptoms, offering patients effective, non-pharmacologic strategies to complement medical treatments. Weight loss remains the cornerstone, with even modest reductions in BMI showing significant symptom relief. Dietary adjustments, particularly adopting a low-simple-carbohydrate diet, provide an evidence-based approach. Various bedtime interventions are available to improve nocturnal GERD symptoms. Finally, tobacco cessation is essential, not only for GERD symptom relief but also for overall health. By integrating these lifestyle changes into their routine, patients can improve GERD symptoms while building healthy habits.

Dr. Gomez Cifuentes is vice-chair in the section of gastroenterology at Presbyterian Healthcare Services, Albuquerque, New Mexico. He declares no conflicts of interest.

Medical Therapy Is the Cornerstone of Effective GERD Treatment

BY BRIJESH B. PATEL, MD

Today, I saw Mr. S in the office for gastroesophageal reflux disease (GERD). He has been on a trial of proton pump inhibitors (PPIs) and has implemented several lifestyle modifications to manage his reflux. He shared his frustrations, saying, “Doctor, I’ve tried changing my diet, sleeping in a recliner, and adjusting the timing of my meals. I’m practically not enjoying food anymore, and these lifestyle changes have affected my quality of life. Despite all this, I still wake up in the middle of the night with a ‘horrible taste’ in my mouth, and it’s ruining my sleep.”

 

 

Later that day, during a discussion with my trainees, one posed an important question: “What about lifestyle measures in the treatment of GERD?” This is a common query in both clinical and academic settings. GERD, with a prevalence estimated at ~20%, is often underreported as many patients begin self-medicating with over-the-counter acid suppressive therapies before seeking medical care. For gastroenterologists, PPIs, histamine-2 receptor antagonists (H2RAs), and now potassium-competitive acid blockers (PCABs) form the cornerstone of GERD management.

When I lecture medical students, residents, and fellows about GERD, I emphasize a standard approach: initiating an 8- to 12-week trial of PPIs followed by reassessment. I also stress the importance of combining medical therapy with lifestyle measures. However, the question remains: How adherent are our patients to these lifestyle changes? Similarly, how effectively are trainees integrating the value of lifestyle modifications into their practice? As an academic gastroenterologist, I can teach the theory, but is it being translated into real-world patient care?

The advent of PPIs has been a game changer for managing GERD symptoms and preventing disease progression. PPIs are the backbone of treatment in both gastroenterology and primary care, and they have profoundly improved patients’ quality of life. Most of my patients who present with GERD — whether due to uncontrolled reflux or acid exposure — have already been on a trial of PPIs before seeing me. My role often involves optimizing their timing of PPI administration, addressing incorrect usage, and reinforcing the importance of adherence. In some cases, I incorporate H2RAs as adjunctive therapy for patients who fail to respond adequately to PPIs, particularly when objective disease activity is confirmed through pH studies. These studies also highlight how challenging it is for many patients to maintain a refluxogenic-free lifestyle.

Lifestyle modifications should supplement and support GERD management. Regardless of medical specialty, lifestyle measures should be the first line of treatment. However, adherence and effectiveness vary widely. In reality, achieving sustained weight loss, meal timing adjustments, and dietary modifications (e.g., eliminating trigger foods like red wine, chocolate, coffee, and tomato-based sauces) is a significant challenge for patients. While these measures can reduce the need for PPIs in some cases, they are rarely sufficient as standalone treatments. Until lifestyle modifications are consistently and sustainably incorporated into daily routines, acid-suppressive therapy will remain the mainstay of GERD management.

Turning to newer therapies, PCABs are now FDA-approved for treating GERD. Early efficacy data suggest that PCABs are non-inferior to PPIs, with promising results in managing LA Class C and D esophagitis and maintaining symptom-free days. However, like PPIs, PCABs are associated with potential adverse effects, including C. difficile colitis, impacts on bone health, renal impairment, and mineral deficiencies. While these risks must be carefully discussed with patients, the benefits of medical therapy far outweigh the risks, especially for those with erosive esophagitis, Barrett’s esophagus, or a high-risk profile for esophageal cancer. In such cases, medical therapies provide superior disease control compared to lifestyle measures, supported by both subjective and objective data.

Managing GERD requires a multipronged approach. Relying solely on lifestyle measures rarely provides complete benefit, as restrictive dietary regimens are difficult to sustain long term. Like many, I can maintain a restrictive diet temporarily but find it unsustainable over time. Conversely, adherence to daily or twice-daily medications tends to be much higher than compliance with multi-level lifestyle changes (e.g., restrictive diets, weight loss, and trigger-food avoidance).

Our therapeutic arsenal for GERD continues to expand, enabling more effective management of patients with uncontrolled acid reflux. While I will continue to counsel patients and educate trainees on the value of lifestyle modifications, I emphasize the importance of adherence to timely medical therapy — whether with PPIs, H2RAs, or PCABs — as the cornerstone of effective GERD treatment.

Dr. Patel is associate program director in the division of digestive diseases & nutrition, at USF Health, Tampa, Fla. He declares no conflicts of interest.