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Expert Critique

FROM THE ASCO Reading Room

Melinda Engevik, PhD Postdoctoral Fellow Baylor College of Medicine

Gastroesophageal reflux (GER) affects more than 30% of the U.S. population. Persistent reflux has been linked to additional complications, making the management of GER a high priority. Patients with GER are commonly advised to eliminate caffeinated drinks such as coffee, tea, and/or soda.

However, the evidence to support this recommendation was lacking. In a prospective study of 48,308 U.S. women, coffee, tea, and soda consumption was associated with an increased risk of GER symptoms. This relationship appeared to be dose-dependent and was independent of caffeine status. Importantly, it was observed that substitution of coffee, tea, or soda with water led to a modest reduction in GER symptoms.

This work provides strong evidence for the role of specific beverages in promoting GER symptoms. Additionally, it emphasizes that limiting the consumption of coffee, tea, and soda, even decaffeinated versions, may be beneficial for prevention of GER symptoms. This study has direct application for patients, and physicians should recommend removal of these items from the diets of patients dealing with GER symptoms.

Full Critique

Recently, gastroenterologist Andrew T. Chan, MD, MPH, of Massachusetts General Hospital and Harvard Medical School in Boston, and colleagues published an analysis of 7,961 women from the Nurses' Health Study II who reported weekly symptoms of gastroesophageal reflux (GER). The study, which appeared online in found a modest association between intake of coffee, tea, and soda and an increased risk of GER symptoms.

After multivariable adjustment, hazard ratios (HRs) for women with the highest intake of each beverage (more than 6 servings/day) compared with women with the lowest intake (0 servings/day) were 1.34 for coffee, 1.26 for tea, and 1.29 for soda.

In contrast, water, milk, and juice (even citrus) were not associated with symptoms, and drinking water instead of coffee, tea, or soda actually reduced the likelihood of symptoms. Replacing two servings/day of coffee, tea, or soda with two servings of water was associated with reduced HRs: coffee 0.96, tea 0.96, and soda 0.92.

What was the impetus for undertaking this study?

Chan: GER symptoms are incredibly common and, as physicians, we are often asked to counsel patients on how to manage them. "What do I drink? What do I avoid?" But we've largely based our recommendations on anecdotal observations without data to support them. Previous studies have been conflicting, and there has not been broad agreement on whether drinking beverages such as tea, coffee, or soda really made a difference. As a result, a lot of clinicians felt uncomfortable offering advice. Thus, we were motivated to provide data that would allow us to be a little more confident in making these recommendations.

Why did you not include alcoholic beverages in this analysis? Wouldn't beer, for example, have a similar effect on the lower esophageal sphincter (LES) to that of carbonated soda pop?

Chan: For this study, we wanted to limit the analysis to beverages that most people consume frequently throughout the day rather than occasionally or only at particular times of the day. However, our study did control for alcohol consumption. In the future we want to specifically take a look at the effect of alcoholic beverages.

Were you surprised at any of the findings or did they align with your expectations?

Chan: We were really surprised how much GER symptoms could be mitigated just by substituting water for these other drinks. It's pretty impressive that a simple lifestyle modification can make such a difference. However, we didn't have the data to tease out whether there was a difference in effect between carbonated water and regular water, and that is something we may be able to revisit later. What was also surprising was that we found no association with citrus juices, although patients commonly receive advice to avoid acidic juices.

Will the findings be sufficient to persuade patients to change their beverage consumption patterns?

Chan: I think the data will help by providing physicians with factual evidence to back these recommendations, which are quite easy to implement.

What are the mechanisms by which these beverages might promote GER symptoms?

Chan: One hypothesis is that these beverages may weaken the pressure of the LES. Another possibility is that they might change the acid balance of the stomach contents.

What other lifestyle changes could mitigate GER symptoms?

Chan: Weight loss as well as perhaps being more physically active. So far, there are no specific exercises known to strengthen the LES or ease GER symptoms, but this is a potential area for further study.

It's also possible that increased physical activity might lead to beneficial changes in physiology and perhaps alter the gastric microbiome or the balance of inflammatory markers. Exercise might also promote anatomic changes in terms of muscle mass or posture that could alter a person's predisposition to GER.

What do you foresee for the future?

Chan: GER is an unbelievably common problem, and patients are really motivated to do what they can to modify their lifestyle to control symptoms. It's important in the future to focus on doing studies like this so we have evidence-based recommendations for clinicians to be able to confidently spend time counseling patients about things they can do that really have an impact and spend less time discussing things that do not.