Smoking, Extra Salt Increase Heartburn Risk

Drinking Alcohol Doesn't Appear to Increase Acid Reflux Risk, Study Shows

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Nov. 11, 2004 -- A late night meal of pepperoni pizza paired with an amusing pinot noir may sound romantic to some, but for people with acid reflux disease it is a declaration of war -- a call for heartburn.

Most heartburn sufferers know the foods and situations that trigger their painful symptoms -- the burning or pressure sensation behind the breast bone, or sour taste of acid in the back of their throat. Yet much less is known about the lifestyle factors that cause the condition.

Researchers in Sweden recently set out to identify these lifestyle factors, and they came to some surprising conclusions. While smoking, as expected, strongly increased the risk for developing acid reflux disease, drinking alcohol had little impact.

The study also showed that coffee consumption, which commonly triggers symptoms, actually appeared to protect people from developing the disease. Lifestyle modification techniques are frequently recommended to control heart burn. Avoiding foods and beverages that contribute to heartburn such as chocolate, coffee, greasy or spicy foods, tomato products, and alcoholic beverages are typically recommended.

"We know that drinking alcohol causes symptoms to occur in people who already have acid reflux disease, so we were quite surprised to find that long-term use did not increase the risk of developing it," researcher Magnus Nilsson, MD, of Stockholm's Karolinska Hospital, tells WebMD.

He added that the protective effects of coffee were a weaker association and may not truly reflect a protective association.

Smoking and Salt Increase Heartburn Risk

Roughly one in five people suffer from heartburn or acid reflux, known medically as gastroesophageal reflux disease or GERD. While genetic predisposition, obesity, smoking, and alcohol consumption have all been implicated in the development of the condition, GERD expert Philip Jaffe, MD, says causality has been hard to pin down.

"We are talking about something that affects roughly 25% of the world's population," he says. "It is hard to isolate individual risk factors for something that is so common."

Nilsson and colleagues based their findings on two major public health surveys conducted in Norway in the 1980s and 1990s. Just more than 3,100 people who complained of having heartburn and 40,000 people without reflux symptoms answered questions about lifestyle factors including diet, exercise, alcohol consumption, and tobacco use. The average ages of those with and without acid reflux disease were 52 and 48, respectively.


Lifestyle was found to be strongly predictive of acid reflux disease. Among the major findings in the study:

  • People who had smoked for more than 20 years were 70% more likely to have acid reflux disease than nonsmokers.
  • People who ate large amounts of salt had a similar increase in risk for acid reflux as smokers. This finding was a surprise, and Nilsson says further research is needed to identify possible biological mechanisms that could prove or disprove the association. There was a 70% increased risk of developing heartburn among those who always used extra table salt daily compared with those who did not.
  • Engaging in 30 minutes of strenuous exercise as little as once a week appeared to cut acid reflux risk by half, as did regular consumption of high-fiber bread.

The researchers suggest that the protective benefits of dietary fiber may be due to the fact that it mops up large amounts of nitric oxide in the stomach. Nitric oxide relaxes the muscle in the digestive tract, which allows excess stomach acids to back up into the esophagus, causing symptoms of heartburn.

Tea drinking was not found to be a risk factor for developing acid reflux disease, but people who drank approximately seven cups of coffee a day were 40% less likely to develop the condition as those who abstained or those who drank just one cup a day. The authors conclude that the coffee finding was probably skewed by the fact that people with acid reflux often avoid coffee. The findings are reported in the latest issue of the journal Gut.

Using Common Sense With Heartburn

Identifying lifestyle factors that help cause acid reflux disease may be important at a public health level, but Jaffe says the relevance for individual patients is less clear. He adds that lifestyle modification has obvious benefits for patients with mild acid reflux disease, but there is less evidence that this is the case among patients with severe disease.

"The truth is we have relatively little data to support the idea that changes in diet and conservative lifestyle make a big difference in these patients," he says. "But you have to use common sense. If a patient has classic reflux symptoms that are worsened by, say, drinking alcohol, then they should stop drinking alcohol. It's like the old Vaudeville routine where the patient says, 'Doctor, it hurts when I do this,' and the doctor's response is, 'Don't do that.'"

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SOURCES: Nilsson, M. Gut 2004; vol 53: pp 1730-1735. Magnus Nilsson, MD, department of surgery, Karolinska Hospital, Stockholm, Sweden. Philip Jaffe, MD, associate professor of gastrointerology, University of Connecticut.
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