American Journal of Gastroenterology ISSN 0002-9270

C 2005 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2005.41703.x
Published by Blackwell Publishing

Obesity Is an Independent Risk Factor for GERD

Symptoms and Erosive Esophagitis
Hashem B. El-Serag, M.D., M.P.H., David Y. Graham, M.D., Jessie A. Satia, Ph.D., M.P.H., and Linda
Rabeneck, M.D., M.P.H.
Sections of Gastroenterology and Health Services Research at the Houston Department of Veterans Affairs
Medical Center and Baylor College of Medicine, Houston, Texas; Department of Medicine, Baylor College of
Medicine, Houston, Texas; Department of Nutrition, University of North Carolina at Chapel Hill, North
Carolina; Department of Medicine, University of Toronto, Canada

INTRODUCTION: An association between obesity and GERD symptoms has been reported; however, study results
have been inconsistent and it is not known whether an association persists after adjusting for other
known GERD risk factors.
METHODS: We carried out a cross-sectional study to determine the prevalence and risk factors of GERD in
volunteers (VA employees). Participants completed a Gastroesophageal Reflux Questionnaire, the
Block 98 Food Frequency Questionnaire, provided height and weight information, and were invited
for upper endoscopy with biopsies. Associations of body mass index (BMI) with GERD symptoms
and erosive esophagitis were examined separately in multiple logistic regression analyses adjusting
for age, sex, race, GERD symptoms, dietary intake, education level, family history of GERD, H. pylori
infection, and the presence and distribution of gastritis.
RESULTS: Four hundred and fifty-three persons (mean age 44 yr, 70% women and 43% black) provided
complete information on heartburn, regurgitation, and BMI (50% of 915 who received
questionnaires). Of the 196 who underwent endoscopy, 44 (22%) had esophageal erosions and 118
(26%) reported at least weekly heartburn or regurgitation. A dose–response relationship between
frequency of heartburn or regurgitation and higher BMI was observed. Compared to participants
without weekly symptoms, a significantly larger proportion of the 118 with these symptoms were
either overweight (BMI 25–30) (35% vs 32%) or obese (BMI >30) (39% vs 26%), p for linear trend
0.004. Relative to those with no esophageal erosions, those with erosions were more likely to be
overweight (39% vs 26%) or obese (41% vs 32%), p = 0.04. Obese participants were 2.5 times as
likely as those with normal BMI (<25) to have reflux symptoms or esophageal erosions. The
association between BMI and GERD symptoms persisted in direction and magnitude after
adjustment for potential confounders.
CONCLUSIONS: Overweight and obesity are strong independent risk factor of GERD symptoms and esophageal
erosions. The amount or composition of dietary intake does not appear to be a likely explanation
for these findings.
(Am J Gastroenterol 2005;100:1243–1250)

INTRODUCTION of GERD symptoms (e.g., heartburn and /or regurgitation).

The prevalence of obesity in the United States has reached
epidemic proportions. Recent results of the Third National
Health and Nutrition Examination Survey (NHANES III) in
1999 indicate that an estimated 61% of U.S. adults are either
overweight (defined as a body mass index (BMI) between 25
and 30) or obese (BMI > 30.0) (1). The prevalence of obesity
has nearly doubled from approximately 15% in 1980 to an
estimated 27% in 1999 (2).
Gastroesophageal reflux disease (GERD) is a common dis-
order that has been linked to obesity. Some but not all studies
have shown that high BMI is associated with an elevated risk
At least four previous population-based cross-sectional stud-
ies found positive associations between overweight or obe-
sity and GERD symptoms in the United States, UK, Norwe-
gian, and Spanish populations (4, 5, 7–10), and two studies
showed a “dose–response” relationship (4, 5). In contrast,
two other large population-based studies from Sweden and
Denmark found no such association (3, 6). Several studies
have examined associations between obesity and GERD-
related esophageal erosions: three reported a modest posi-
tive association (11–13), one found no association (14), and
one study found a positive association in women but not
in men (15). However, differences in the age, sex, and race

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