Diet and Heartburn
Bart Chernow, MD, Donald O. Castell, MD
SYMPTOMATIC gastroesophageal
reflux (heartburn) is a ubiquitous
postprandial complaint. Although
usually a recurring complaint, it can
be transient (as in the third trimester
of pregnancy) or persistent and pro-
gressive (as in progressive systemic
sclerosis). Regardless of frequency,
gastroesophageal reflux produces an-
noying symptoms for which medical
attention is sought. A characteristic
feature of heartburn is its relation to
food ingestion. Thus, medical advice
concerning antireflux dietary adjust-
ments is appropriate.
Although no specific smooth mus-
cle sphincter is demonstrable ana-
tomically at the esophagogastric
junction, physiological high-pres-
a
sure zone exists in this region to
prevent regurgitation of acid-peptic
stomach contents into the esophagus.
In the normal human esophagus, this
lower esophageal sphincter (LES)
exerts a squeezing pressure of ap-
proximately 15 to 20 mm Hg greater
than that within the stomach. Failure
to maintain this normal pressure
barrier results in sphincter incompe-
tence and creates the potential for
gastroesophageal reflux.1
From the Digestive Diseases Division, Depart-
ment of Internal Medicine, National Naval Medical
Center, and the Uniformed Services University of
the Health Sciences, Bethesda, Md.
Reprint requests to National Naval Medical
Center, Bethesda, MD 20014 (Dr Chernow).
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Effects of Foods on the
Genesis of Heartburn
A variety of foods have been shown
to affect LES pressure, which may
explain the clinical association be¬
tween food ingestion and heartburn.
Carminatives are volatile oils of plant
extracts used in food seasoners,
flavoring, and after-dinner liqueurs.
These agents include the oils of spear¬
mint, peppermint, garlic, and onion.
Peppermint has been shown to pro¬
duce hypotension of the LES, an
effect that may account for the rela¬
tionship of these foods to heartburn.
Protein meals cause an increase in
sphincter pressure, which is revers¬
ible acidification of the meal. This
by
may be related to increases in plasma
gastrin levels observed after protein
ingestion. Carbohydrate meals cause
only small changes in LES pressure,
whereas sphincter pressure decreases
significantly (P<.05) in response to a
fat meal.2 This inhibitory effect of fat
on the LES, most likely mediated by
release of the duodenal enterogas-
trone cholecystokinin, may explain
many of the indigestion syndromes of
fatty food intolerance. In addition, fat
content probably accounts for the
different effects of whole milk (de¬
crease) and skim milk (increase) on
sphincter pressure.
Coffee is a methylxanthine-con-
taining compound that has created
considerable clinical interest in rela¬
tion to its role in the production of
heartburn. Caffeine alone has been
shown to produce either minimal
decreases or no change in LES pres¬
sure. However, when the whole brew
of coffee (with or without caffeine)
was studied, significant increases in
LES pressure were noted. Thus, it
seems unlikely that heartburn occur¬
ring after coffee ingestion is related
to LES hypotension. Recently, pa¬
tients with chronic heartburn and
apparent esophagitis, measured by
esophageal acid sensitivity (Bernstein
test), were also shown to be sensitive
to the direct instillation of coffee into
the esophagus. In these patients
coffee may well produce symptoms by
a direct irritating effect on the
already inflamed esophagus irrespec¬
tive of any reflux.
Alcohol is frequently incriminated
as a heartburn producer. Ethanol
adversely effects both the LES and
esophageal peristalsis, producing LES
hypotension, disordered esophageal
motility, and decreased peristaltic
force. The resultant esophageal dys-
motility may decrease the peristaltic
action necessary for acid clearing in
the body of the esophagus.
Patients with heartburn incrimi¬
nate specific foods as précipitants of
If you wish to suggest a topic or write
an answer for this feature, write to William
H. Crosby, MD, Scripps Clinic and
Research Foundation, La Jolla, CA
92037.
 their symptoms. Nearly all heartburn
sufferers complain about symptoms
caused by fatty, spicy, and fried foods.
Patients with daily heartburn also
relate that many other foods, particu¬
larly peppers, tomatoes, radishes, and
salad dressings, are frequent offend¬
ers.
Orange and tomato juices are
frequently blamed for heartburn;
however, these juices cause no sus¬
tained LES pressure changes. In addi¬
tion, patients with only occasional
reflux symptoms rarely identify these
juices as offenders. Therefore, in
chronic reflux esophagitis, orange
juice, tomato juice, and others (in¬
cluding coffee) cause heartburn by a
direct irritant effect on an already
injured esophageal mucosa. This hy¬
pothesis was confirmed when it was
shown that orange juice, spicy tomato
drink, and coffee all produce heart¬
burn when instilled directly into the
midesophagus.
The common habit of "enjoying" a
cigarette following a meal may con¬
tribute to reflux. Cigarette smoking
has been shown to depress LES pres¬
sure,' with the proposed mechanism
being either through the action of
nicotine or by the release of ß-adren-
ergic agents.
An Antireflux Diet
Based on the aforementioned infor¬
mation, recommendation of an antire¬
flux diet seems reasonable. Small
meals divided into four or more feed¬
ings will diminish postprandial gas¬
tric volume and obviate reflux symp¬
toms experienced after ingestion of
large meals. The more frequent feed¬
ings will limit glucagon release,
which by competitive inhibition of
gastrin may diminish LES pressure.4
If weight reduction is indicated, the
diet should be prescribed with appro¬
priate caloric restriction to achieve a
steady reduction in body weight. Loss
in excess body weight is often accom¬
panied by a reduction in reflux symp¬
toms.
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The diet should be high in protein
and low in fat, with carbohydrates
providing the remainder of the calo¬
ries. Broiled (or baked) beef, chicken,
ham, fish, skim milk, and milk prod¬
ucts can provide the basis for protein
calories. Potatoes, corn, apples, and
bananas are fruits and vegetables
that rarely cause heartburn. Skim
milk, water, apple juice, and decaf¬
feinated coffee (the latter only if the
patient finds it does not precipitate
heartburn) are suitable liquids. Some
patients with reflux will find other
juices and sodas acceptable. Baked
cakes, soups (without garlic or onion),
ice cream, and some candies (dental
precautions noted) complete the diet
selection. Individual preference and
avoidance of specific foods by the
patients should be respected by the
physician. The professional dietician
can help construct a diet within the
framework of these guidelines.
Considerations for
Cardiologists and Others
Making the distinction between
cardiac chest pain and gastroesopha¬
geal reflux can be difficult. The astute
emergency room or coronary care
physician might consider advising all
patients experiencing chest pain of
noncardiac origin about antireflux
dietary precautions. Such advice
might also be prudent in patients who
have suffered myocardial infarction,
to minimize episodes of nonanginal
chest discomfort.
Patients who require medications
containing the theophylline deriva¬
tives or isoproterenol hydrochloride
may be prone to have hypotensive
LESs. Advice to such patients about
an antireflux diet is important,
because gastroesophageal reflux may
lead to aspiration, which may be an
etiologic component to their pulmo¬
nary affliction.
Considering the frequency with
which heartburn develops in preg¬
nant women, obstetricians should
make efforts to educate their patients
about reflux. Similarly, physicians
caring for those with progressive
systemic sclerosis should pay particu¬
lar attention to the prescribing of
dietary restrictions, because reflux in
this setting often leads to esophageal
strictures with devastating sequelae.
Exclusive of these two causes for LES
hypotension and secondary reflux, the
vast majority of patients with per¬
sistent heartburn have a defective
antireflux sphincter mechanism of
uncertain etiology. The primary de¬
fect appears to be one of abnormal
sphincteric circular smooth muscle,
although a deficiency in gastrointes¬
tinal hormone release (particularly
gastrin) has been suggested. Regard¬
less of origin, a simple, noninvasive,
inexpensive, therapeutic first step in
the treatment of heartburn is dietary
advice.
Gastric alkalinization has been the
cornerstone treatment of reflux
symptoms. Alkalinization has been
shown to increase LES pressure and
decrease reflux in addition to neutral¬
ization of gastric acidity. Thus, ant¬
acids are an important adjunct to the
diet in patients with active reflux
symptoms. An antacid in appropriate
dosage should be considered the final
component of each meal in the
patient with reflux. The antireflux
diet should assume a critical role in
the care of patients with heartburn.
This study was supported in part by the
Department of the Navy Clinical Investigation
Program 5-06-530R.
References
DO, Johnson LF: The lower esopha-
1. Castell
geal sphincter: Its function in health and
disease, in Berk JE (ed): Developments in Diges-
tive Diseases. Philadelphia, Lea & Febiger, 1977,
pp 25-46.
2. Nebel OT, Castell DO: Lower esophageal
sphincter pressure changes after food ingestion.
Gastroenterology 63:778-783,1972.
3. Dennish GW, Castell DO: Inhibitory effect
of smoking on the lower esophageal sphincter. N
Engl J Med 284:1136-1137, 1971.
4. Jennewein HM, Waldeck F, Siewert T, et al:
The interaction of glucagon and pentagastrin on
the LES in man and dog. Gut 14:861-864, 1973.