Dietary Recommendations for Esophageal Hypersensitivity

Gastroesophageal reflux disease (GERD) is a prevalent esophageal condition marked by bothersome symptoms linked to heightened esophageal acid exposure. While acid-suppressive medications like proton pump inhibitors (PPIs) and lifestyle changes, including dietary adjustments, form the cornerstone of treatment, the latter lacks clear definition. As concerns surrounding long-term PPI usage continue to emerge, both patients and healthcare providers are showing increased interest in the role of diet in managing the disease. This article explores dietary approaches for GERD, emphasizing the impact of food components on its pathophysiology and management.

Understanding GERD and Esophageal Hypersensitivity

GERD arises when troublesome symptoms or mucosal disease develop due to the reflux of stomach contents. It commonly manifests as burning mid-sternal chest pain, regurgitation of fluid or food, or the development of esophageal inflammation that can impair swallowing. Extraesophageal symptoms like cough, bronchospasms, and hoarseness may also occur. GERD's incidence is high, affecting up to a third of the global population. Risk factors include central adiposity, smoking, and genetic predisposition.

First-line treatments involve acid-suppressive therapy and lifestyle modifications, with the latter gaining traction due to potential side effects of pharmacotherapy. Common lifestyle interventions include dietary changes, weight management, smoking cessation, and elevating the head of the bed during sleep. However, despite the widespread use of dietary manipulation in clinical practice, definitive recommendations remain conflicting.

Esophageal hypersensitivity, a component of GERD, involves increased sensitivity to stimuli in the esophagus, leading to heightened symptom perception.

Pathophysiology of GERD: The Role of Diet

GERD and its complications develop when the esophageal mucosa is abnormally exposed to refluxed stomach contents, potentially due to incompetence of the gastroesophageal barrier, inadequate clearance of refluxed fluid, or alterations in the content of the refluxed fluid. Repeated exposure can compromise mucosal integrity and cellular composition, leading to inflammation, scar tissue formation, and changes in visceral sensitivity. This can result in esophageal and extraesophageal symptoms, stricture development, dysmotility, and even carcinogenesis.

Read also: Nourishing Meals for Esophageal Health

The gastroesophageal barrier comprises the intrinsic tone of the lower esophageal sphincter (LES), external pressure from the crural diaphragm, and an intact angle of His. Among these, dietary intake primarily affects LES pressure. The LES tone relies on neural, hormonal, and paracrine factors to maintain intrinsic contraction. The myenteric plexus provides innervation, with excitatory neurons controlled by acetylcholine and substance P, while inhibitory neurons use vasoactive intestinal peptide and nitric oxide.

Transient lower esophageal sphincter relaxations (TLESRs), during which the LES relaxes to release excess gas from the stomach, can also disrupt the gastroesophageal barrier. Gastric distention triggers TLESRs via a vasovagal reflex, leading to LES relaxation.

Besides the LES, esophageal mucosa is protected by peristalsis, the involuntary esophageal contractions that propel contents proximally, minimizing the duration of refluxed stomach contents in the esophagus. Contraction amplitude depends on sensory feedback from the esophagus, meaning that large or viscous food boluses may slow down contractions.

Refluxed stomach fluid contains esophageal mucosal irritants, including gastric acid, digestive enzymes, and bile salts. Dietary intake influences the secretion of these digestive components, which can be altered through changes in nutritional composition.

Nutritional Composition and Dietary Manipulation

Understanding nutritional composition is crucial when considering dietary manipulation for GERD. The human diet mainly consists of three macronutrients with varying caloric densities and biochemical compositions: carbohydrates, fats, and proteins.

Read also: Managing Esophageal Varices with Diet

Carbohydrates

Carbohydrates are a primary energy source, providing glucose molecules. They are classified as monosaccharides, oligosaccharides, and polysaccharides based on chemical complexity. Monosaccharides, or simple sugars like fructose, galactose, and glucose, are metabolized quickly, rapidly increasing blood sugar levels and producing an osmotic effect in the gastrointestinal tract. Oligosaccharides, such as lactose, maltose, and sucrose, and polysaccharides, longer chains including starch and fiber, are more complex. Some complex carbohydrates can be digested by endogenous enzymes, while others are not metabolically available.

Fats

Fats are the most calorically dense macronutrient, providing nine kilocalories per gram. They are classified based on the type of bonds between carbon molecules and the length of the carbon molecule chain, including saturated fats (no carbon-carbon double bonds), monosaturated fats (one double bond), and polyunsaturated fats (more than one double bond). The chemical composition of bonds affects how easily a fat can be metabolized.

Proteins

Proteins, composed of amino acids, are the body's main nitrogen source. They are categorized as complete (containing all essential amino acids) or incomplete based on their amino acid profile.

Dietary Therapy for GERD: Specific Foods and Eating Patterns

Dietary therapy is a common approach for GERD, although supporting data for specific interventions varies. Earlier studies focused on the effects of specific foods or beverages on GERD pathophysiology and symptoms.

Beverages

Eliminating entire food or beverage categories is a common practice, but recommendations are based on limited data and should be personalized. Acidic beverages are often thought to worsen GERD, and physiologically acidic fluids can lower the pH of refluxed stomach contents and increase esophageal clearance time. However, the correlation between acidity and symptoms is not always clear. Some highly acidic beverages don't induce symptoms, while others with low acidity do, suggesting other factors are involved.

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Carbonated beverages have been shown to transiently alter intra-abdominal pressure and TLESR frequency, reducing LES tone. However, these physiological changes are transient and haven't been consistently correlated with GERD symptoms. Similarly, while early literature suggested coffee decreases LES tone after ingestion, recent meta-analyses show no clear association between coffee intake, GERD symptoms, or mucosal disease.

Data on alcoholic beverages and GERD is mixed. Some small studies show an increase in reflux episodes after beer or wine ingestion compared to water. However, larger cohort studies have not shown a relationship. A recent meta-analysis reported a positive correlation between alcohol use and GERD symptoms, particularly in patients with reflux esophagitis.

Foods and Spices

Patients are often advised to avoid certain foods and spices, but these recommendations should be personalized due to limited data. Chocolate, containing caffeine and cacao, induces LES relaxation, but this doesn't always correlate with symptom frequency. Mint is a commonly reported trigger, but may only affect a small percentage of GERD patients. Spicy foods may not induce physiological changes, but can directly irritate the esophageal mucosa.

Macronutrient Manipulation and Eating Patterns

Recent research has shifted towards examining eating patterns and macronutrient manipulation.

High-Fat Diets

High-fat diets, especially those including fried or greasy foods, are thought to worsen GERD symptoms. However, data remains inconsistent, necessitating personalized recommendations. Fat digestion requires secretion of potential esophageal irritants (i.e., bile salts) and neurohormonal mediators of LES tone (i.e., Cholecystokinin). Physiological studies have shown mixed results, with some showing no effect on LES pressures, TLESR frequency, or the number of reflux episodes with isocaloric low-fat meals compared to high-fat meals, while others report increased esophageal acid exposure time and alterations in LES pressures after fat ingestion. Population studies have shown a correlation between fat intake and GERD symptoms, but confounding factors include total caloric intake and BMI. The type of fat (saturated vs. unsaturated, or medium-chain triglyceride (MCT) vs. long-chain triglyceride (LCT)) may also be clinically important.

Carbohydrate Intake

Modulation of carbohydrate intake has shown more conclusive findings. Disaccharides and starches are only partially absorbed in the small bowel, undergoing fermentation by colonic bacteria, which induces neurohormonal release and LES relaxation, potentially leading to heartburn. Studies have linked GERD symptoms, reflux episodes, and carbohydrate ingestion. High carbohydrate meals have been shown to increase total esophageal acid exposure time and the number of reflux episodes. Very low carbohydrate diets have shown a reduction in esophageal acid exposure time, and alterations in starch ingestion and simple sugar intake have led to symptom resolution in obese women with GERD.

Fiber Intake

While monosaccharides and starches have been linked to increased symptoms, fiber intake has shown the opposite effect. An inverse relationship between heartburn symptoms and fiber intake has been noted, even after correcting for confounding variables. Soluble fiber preparations have shown equal improvement in heartburn symptoms compared to antacids, and increased fiber intake has been found to reduce both symptoms and mean reflux episodes.

Protein Intake

Few studies have examined the role of dietary protein in relation to GERD, despite early research linking protein intake with increased LES pressures. However, one large survey reported no difference in protein intake between groups with high and low risks of GERD symptoms.

Eating Patterns

Eating patterns, including avoiding late-night eating and reducing overall meal size and caloric density, are also implicated in GERD. Eating small, frequent meals and snacks is recommended.

Elimination Diets: Eosinophilic Esophagitis (EoE)

Research shows a strong connection between food allergies and eosinophilic esophagitis (EOE). Eosinophilic esophagitis (EoE) is a chronic (lifelong), allergic disease of the esophagus (the tube that links your mouth and stomach). Unfortunately, there is no accurate test to identify food allergies connected with EOE. Eosinophilic gastrointestinal disorders (EGIDs) can happen when there are high levels of eosinophils in one or more parts of the digestive system. These disorders occur when a type of white blood cell involved in allergic reactions, the eosinophil, builds up in the esophagus or other part of the digestive tract.

Steps for Identifying Trigger Foods

1. Identification: Work with your healthcare team to identify which foods might be causing symptoms. Plan a time to start the diet when you know you can be successful.
2. Elimination: Remove all 6 foods from your diet for 4-6 weeks without any exceptions.
3. Challenge Phase: If your symptoms have improved, start the challenge phase with ONE of the foods you stopped eating at a time. Symptoms of a failed food challenge may range from mild reflux, or pains, to severe cramps, vomiting, or difficulty swallowing – even food impaction. Any of these changes after reintroducing a food should be written down and considered a reaction. Introduce ONE new food per week. Add 1 serving of the food in the morning.

Common Trigger Foods

The foods that most commonly trigger EoE reactions include:

• Milk and other dairy products
• Wheat products that contain gluten
• Food containing egg
• Soy and legumes, such as beans, lentils, green peas, and peanuts
• Nuts
• Seafood

According to a 2018 study, the most common triggers are cow’s milk, gluten, and egg. Soy, legumes, nuts, and seafood are triggers for some people, although this is rarer. However, it is important to note that triggers may vary between individuals with EoE.

Types of Elimination Diets for EoE

Adjusting the diet is a common treatment for people with EoE. A healthcare professional may recommend certain diets, including the elemental diet and empirical food elimination diet (FED).

• FED: This diet excludes some known trigger foods. The first FED, or 6-FED, involved excluding all six most common trigger foods from the previous section above. However, some doctors may recommend starting out with a less restrictive version, such as 4-FED or 2-FED. This only restricts four or two common trigger foods.
• Elemental diet: This option involves cutting out all foods and instead consuming a formula containing amino acids, which are the building blocks of protein. Research suggests that it is highly effective to induce remission for both adults and children with EoE.

Approaches to Identifying Trigger Foods

• Top-down method: Cutting out the six trigger foods and reintroducing each one at a time. After each reintroduction, the doctor recommends an endoscopy to check the effects of the food on a person’s esophagus.
• Step up” approach: Cutting out one or two of the more common triggers, including milk and wheat. If this does not resolve symptoms completely, the doctor may try a 4-FED or 6-FED approach.

A 2023 randomized trial followed 129 people on either a 6-FED or a 1-FED program that excluded only animal milk. The study concluded that cutting out animal milk led to similar remission rates as a 6-FED program. Therefore, removing milk alone from the diet could be an effective initial management strategy for EoE.

Additional Tips

• Keeping a food diary helpful. They may record what they eat each day and whether they experience any EoE symptoms. A healthcare professional may also find a person’s food diary useful for identifying trigger foods.
• Some medications can help reduce certain symptoms of EoE. However, people with EoE may need several treatments or balance dietary approaches with different medications. This may vary between each person depending on their age and other factors.
• Steroids may also help reduce inflammation in the esophagus. People may take them through an inhaler or drink them as a liquid. However, a doctor may prescribe steroids in pill form for those whose symptoms are not well controlled with other medications or those experiencing significant weight loss.
• A person needs to speak with a healthcare professional before making any significant dietary changes relating to suspected allergic reactions. A doctor will first need to diagnose EoE and rule out other conditions that may be causing any symptoms. They will then recommend appropriate treatment if necessary.
• Additionally, people who experience regular or severe symptoms of EoE should consult with a physician. This includes individuals who require over-the-counter heartburn medication more than twice each week.

EoE is a chronic inflammatory disorder that affects a person’s esophagus. People with EoE may benefit from managing their diet to control their exposure to trigger foods. There are different types of elimination diets for EoE, which involve removing common trigger foods from a person’s diet. Some of these foods include dairy products, gluten, and eggs. A healthcare professional can help someone work out which foods trigger their EoE symptoms. Some individuals may need to take either steroids or acid-reducing medications to manage other symptoms.

Silent Reflux Diet

The silent reflux diet is an alternative treatment that can help relieve reflux symptoms by limiting or eliminating foods known to inflame or weaken your esophageal muscles. Unlike acid reflux or GERD, silent reflux causes few or no symptoms until it has progressed to later stages, such as sore throat, hoarseness, difficulty swallowing, and shortness of breath or cough.

The muscles in your lower esophagus, also known as the esophageal sphincter, act as a one-way valve between your esophagus and stomach. They allow food to travel from your esophagus to your stomach, and they prevent stomach acid and food from traveling back up from your stomach to your esophagus. When it’s relaxed, the esophageal sphincter can’t close properly. This can cause a backward flow of food and acid from your stomach, which leads to reflux symptoms.

The silent reflux diet eliminates foods that can relax muscles in your lower esophagus and worsen reflux symptoms. Paired with medication, it can help prevent reflux symptoms and identify the trigger foods that might worsen your condition.

Foods to Avoid

If you decide to try the silent reflux diet, doctors recommend eliminating high fat foods, sugary foods, and acidic fruits and beverages from your diet. Foods to avoid include:

• Whole fat dairy products
• Fried foods
• Fatty cuts of meat
• Caffeine
• Alcohol
• Soda
• Onions
• Kiwi
• Oranges
• Limes
• Lemons
• Grapefruit
• Pineapples
• Tomatoes and tomato-based foods

It’s also important to avoid chocolate, mints, and spicy foods because they’re known to weaken the esophageal sphincter. However, it’s worth noting that common trigger foods can affect people differently. Pay close attention to what foods cause you more discomfort or worsen your upper endoscopy results.

Foods to Eat

• Lean meats
• Low fat dairy
• Whole grains
• Most fruits and vegetables (but avoid acidic ones like citrus, rhubarb, and pineapples)
• Caffeine-free beverages
• Water
• Leafy green vegetables
• Legumes

The silent reflux diet is a food-based approach for reducing reflux symptoms. Though effective, these dietary changes may not treat the underlying cause of silent reflux. It’s best to follow traditional treatment methods advised by your doctor in combination with this diet. Before adding the silent reflux diet to your treatment plan, discuss your options and risks with a doctor.

Esophageal Soft Food Diet

When irritation occurs in the throat or lower chest when eating certain foods or following a medical procedure, an easily digestible esophageal soft food diet may be necessary to make eating easier. Food passes from our mouths to our stomachs through a tubelike organ called the esophagus. A burning sensation in the lower chest or pain after swallowing and the feeling that food gets "stuck" in the throat may be caused by esophagitis, which is an irritation or inflammation along the lining of the esophagus. Acid reflux, hiatal hernias, vomiting, complications from radiation therapy, and certain oral medications are among the reasons the esophagus can develop inflamed tissue.

Esophagitis can usually heal without intervention, but to aid in the recovery, eaters can adopt what's known as an esophageal, or soft food, diet.

Tips for Following an Esophageal Soft Food Diet

• Take small bites of food and chew foods well.
• Avoid tough meats, fresh “doughy” bread or rolls, hard bread crust, and abrasive foods.
• Sip fluids when taking solids at meals and snacks to moisten foods.
• Stop eating when you start to feel full.
• Eat slowly in a relaxed atmosphere.
• Choose decaffeinated coffee, tea, or caffeine-free soft drinks.
• Sit upright when eating.
• Remain in a sitting position for at least 45-60 minutes after eating.
• Try to avoid eating for 3 hours before bedtime.
• Eat small, frequent meals and snacks.
• Easily digestible foods are the best choice, as is avoiding carbonated drinks or beverages that are very hot or very cold.

Food Choices for an Esophageal Soft Food Diet

• Dairy: There is no prohibition on milk and other dairy products, but when eating cheese, select softer options such as cream cheese, brie, Neufchâtel, and ricotta. Yogurt also can be a good choice for someone with esophagitis, but avoid adding fruit, granola, or seeds. Milk, malted milk, or milkshakes. Soft cheese such as grated Parmesan or Ricotta, cheese sauces and cottage cheese.
• Fruits: To keep foods soft, raw fruits and vegetables can be replaced with canned and frozen fruits—like applesauce and fruit cups. Avocados and bananas also work well. All fruit juices; all baked, canned, cooked fruit (without seeds, membranes or tough skins), fresh ripe banana, peeled ripe apricot, peach, nectarine, and pear.
• Vegetables: Soups and broths will help soften squash, potatoes (without the skins), carrots, peas, and other vegetables. Season vegetables with butter or margarine and ground spices.
• Starches: For starch, consider putting crackers or bread into soups or broths to soften them. Cooked cereals that don’t have nuts or seeds are gentle enough for an esophageal soft food diet. Cooked cereals without nuts or dried fruits, ready to eat cereals softened in milk.
• Proteins: Ground or pureed beef, pork, and poultry will protect the esophagus, as will broths made with those ingredients. Avoid dry roast beef, bacon, link or patty sausage, and meat seasoned with peppercorns. Boneless white fish, such as cod and tilapia, will also be easy to swallow. Some people with esophagitis do well with soft scrambled eggs or egg substitutes. Well cooked tender lean beef, veal, lamb, liver, fresh pork, fish, and poultry with gravy or sauce or in soups. Meat should be broiled, baked, stewed, roasted, or creamed. Meat may be ground or chopped, fish may be flaked. Eggs (except fried), cooked beans, casseroles with ground or shredded meat;
• Crackers or matzo balls softened in soup or beverage.

Foods to Avoid on an Esophageal Soft Food Diet

• All breads and sweet breads; rolls, biscuits, cornbread, saltine and graham crackers, dressing or stuffing. Fresh or "doughy" breads may cause “sticking”.
• All fresh and dried fruit with seeds or skins
• Raw, coarse or abrasive fresh fruits.
• All raw vegetables, including salads.
• Highly cured, seasoned, smoked, pickled meats and fish; ie. frankfurters, cold cuts, corned beef, sausage.
• Fatty or tough meats.
• Stringy, dry or fibrous-type meats (i.e. steak and spare ribs).
• Meats containing gristle or peppercorn. Sausage and bacon.
• Highly seasoned foods, condiments not tolerated by patient, mustard seed, pickles, popcorn, olives, nuts, coconut, crunchy peanut butter, chili pepper, garlic.

If the esophagus is irritated as a symptom of an underlying illness, or from the treatment of an illness, it is especially important for patients to maintain good nutrition and body weight to regain and stay in good health.

General Recommendations for Managing GERD and Esophageal Hypersensitivity

Beyond specific diets, several general recommendations can help manage GERD and esophageal hypersensitivity:

• Identify Trigger Foods: Keep a food symptom log to track trigger foods, as a GERD-friendly diet may vary for each individual.
• High-Fiber Foods: Incorporate high-fiber foods to aid with digestive motility, reduce pressure on the esophageal sphincter, and lessen some symptoms.
• Mediterranean Diet: Consider the Mediterranean diet, which is based on a high intake of fruits, veggies, and whole grains, and moderate intake of lean sources of protein, all of which tend to be GERD friendly.
• Lifestyle Changes:
  • Time Between Eating and Lying Down: Maintain longer intervals between eating and lying down to reduce GERD symptoms.
  • Elevate Head: Elevate your head slightly when you go to bed.
  • Smaller, More Frequent Meals: Eat smaller, more frequent meals throughout the day to combat GERD.
  • Loose Clothing: Stick to looser styles of clothing as much as possible. Tight belts, waistbands, and more can all contribute to GERD by increasing abdominal pressure, especially after a meal.
  • Quit Smoking: If you smoke or use other tobacco products, quitting will likely alleviate some of your GERD symptoms. Tobacco can have a negative effect on saliva production.
  • Reduce Alcohol Consumption: Also try reducing or eliminating alcohol consumption.
  • Weight Management: Having obesity is a risk factor for the development of GERD. This is because obesity can impair the motility of food through the GI tract, cause dysfunction of the esophageal sphincter, and increase intragastric pressure.
  • Stress Management: Address stress through techniques to manage the gut-brain axis.

Reflux Hypersensitivity

Some people experiencing reflux may have reflux hypersensitivity. In these cases, a person may experience GERD symptoms, such as heartburn, but they have normal test results. ACEs change the body’s natural stress response and may cause visceral hypersensitivity, which is when the usual functioning of your organs causes unexplained pain.

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