Gastroesophageal reflux disease (GERD) is a prevalent gastrointestinal disorder affecting a significant portion of the global population. It's characterized by the backflow of stomach acid into the esophagus, leading to symptoms like heartburn, regurgitation, and even difficulty swallowing. While GERD affects the upper GI tract, irritable bowel syndrome (IBS) primarily impacts the lower GI tract, including the small and large intestines. It is common for more than one gastrointestinal (GI) disorder to develop in some individuals, whereby different disorders affect various sections of the GI tract. In some individuals, it may be just the lower GI tract that is affected. Some studies estimate that among individuals with functional GI disorders (FGIDs) - which themselves have an estimated worldwide prevalence of about 20-40% of the population anywhere between 8-35% have one or more “overlapping” (multiple) FGIDs. The focus of this article is on the combination of GERD and IBS, as these are the two most frequent upper and lower GI disorders, and they often occur together.
The association between GERD and IBS is notable, with individuals with IBS being four times more likely to experience GERD symptoms. This overlap can complicate treatment, as pressure or symptoms from one area of the GI tract can influence or exacerbate symptoms in the other.
Understanding FODMAPs
FODMAP stands for Fermentable Oligo-, Di-, Mono-saccharides, and Polyols. These are short-chain carbohydrates (sugars) that are poorly absorbed in the small intestine. When FODMAPs reach the large intestine, they are fermented by gut bacteria, which can lead to gas production, bloating, cramping, wind, and sometimes diarrhea or constipation.
The Low-FODMAP Diet: A Three-Step Approach
A low-FODMAP diet is a three-step elimination diet:
- Elimination: Removing high FODMAP containing foods usually for two to eight weeks. High FODMAP foods include dairy-based food and drink, wheat-based products (especially bread), beans and lentils, some vegetables (broccoli, artichokes, asparagus, onions, garlic), and some fruits (peaches, apples, cherries, pears).
- Reintroduction: Slow reintroduction of FODMAPS to identify which cause symptoms.
- Maintenance: Subsequent avoidance of specific trigger foods high in FODMAPS.
The Role of a Low-FODMAP Diet in IBS
A low FODMAP diet plays an important role in IBS treatment. Randomized controlled studies reported the benefit of consuming a low FODMAP diet on gastrointestinal symptoms and quality of life in patients with IBS. Studies show 75% of IBS patients felt better quickly, with peak relief after one week. A low FODMAP diet helps many people with bloating, gas, and IBS.
Read also: Weight Loss with Low-FODMAP
FODMAPs and GERD: Is There a Connection?
In theory, a low-FODMAP diet should not help with acid reflux, because FODMAPs cause issues in the large intestine (hence ‘bowel’ in IBS). However, the relationship between FODMAPs and GERD is complex and not fully understood. Some studies suggest that colonic fermentation of carbohydrates can impact gastric and esophageal motility, potentially influencing the occurrence of reflux episodes.
Up to 20% of carbohydrates escape digestion and absorption in the human small intestine, and they are mostly fermented into short-chain fatty acids (SCFAs) and hydrogen by the colonic microflora. Studies showed that the exposure of the proximal colon to SCFAs contributes to the regulation of gastric motility, and lower esophageal sphincter (LES) function. A colonic fermentation of ingested lactulose and direct colonic infusion of a mixture of SCFAs, resulting in a relaxation of the proximal stomach, then triggered transient lower esophageal sphincter relaxations (TLESRs). Thus, a high FODMAP diet may aggravate gastroesophageal refluxes and GERD symptoms.
Transient lower esophageal sphincter relaxations (TLESRs) are a major cause of GERD. TLESR may occur with or without a GER event, identified by a retrograde propagation of the decrease in impedance.
A randomized crossover study in eight patients with overlapping GERD-IBS (non-constipation) was conducted to evaluate the effects of rice noodle vs. wheat noodle meals for breakfast and lunch on postprandial TLESR, intestinal gas production, and GERD/GI symptoms. Wheat ingestion was significantly associated with more frequent TLESR after lunch than rice. After lunch, wheat ingestion was significantly associated with higher H2 and CH4 levels compared to rice ingestion. The area under curve of H2 concentration until 2 h after lunch significantly correlated with the TLESR number. Postprandial regurgitation, bloating, satiety, and belching symptom scores were significantly greater after wheat compared to rice noodle ingestion. Wheat noodle meals, part of a high FODMAP diet, induced a higher frequency of TLESRs, a higher GERD, and higher upper-GI symptom scores than rice noodle meals, part of a low FODMAP diet, in patients with overlapping IBS-GERD. These effects were associated with more intestinal gas production. Thus, a low FODMAP diet may relieve GERD symptoms in GERD patients with overlapping IBS.
Contradictory Evidence: A Recent Study
However, not all research supports the benefit of a low-FODMAP diet for GERD. A multicenter, randomised, open-label study from France compared the efficacy of a 4-week low-FODMAPs diet with a standard diet in 31 patients with symptomatic PPI-refractory GERD. The study demonstrated that a low-FODMAPs diet did not show any benefit over a standard diet to improve symptoms in patients with PPI-refractory GERD.
Read also: Delicious low-FODMAP vegan recipes
Modifying a Low-FODMAP Diet for GERD
If you have both IBS and GERD, you might want to modify both how, when, and what you eat during your FODMAP elimination diet.
Top 5 tips for GERD:
- Lose a few pounds if you are overweight.
- Eat at least 3 to 4 hours before bedtime.
- Don’t overfill your stomach with foods or beverages.
- Reduce your fat intake.
- Avoid the infamous GERD triggers, which relax the LES and allow reflux to occur: Coffee, tea, chocolate, alcohol, and peppermint. Other infamous GERD triggers are high acid foods and beverages such as tomatoes, citrus fruits, hot peppers, and vinegars.
Other Dietary and Lifestyle Changes for GERD
Regardless of whether you follow a low-FODMAP diet, certain dietary and lifestyle modifications can help manage GERD symptoms:
- Identify trigger foods: Keep a food and symptoms diary for 2 weeks to determine which foods trigger your symptoms. Common triggers include citrus juices, tomato products, coffee, alcohol, chocolate, peppermint, and spicy foods.
- Eat smaller, more frequent meals: This can help prevent overfilling the stomach and reducing acid production.
- Avoid eating close to bedtime: Eating at least 3-4 hours before lying down allows the stomach to empty and reduces the risk of reflux.
- Elevate the head of your bed: This helps gravity keep stomach contents down.
- Maintain a healthy weight: Excess weight can increase pressure on the stomach, contributing to reflux.
- Quit smoking: Smoking weakens the LES.
- Limit alcohol consumption: Alcohol can relax the LES.
- Reduce dairy intake, especially high fat dairy products.
Alternative Remedies for Acid Reflux
Natural or alternative remedies are an option if other treatment options don’t work. For dealing with immediate symptoms, consider supplements and pharmaceutical medications.
Pharmaceutical Interventions
In cases of severe acid reflux, pharmaceutical intervention is necessary. For dealing with immediate symptoms, consider supplements and pharmaceutical medications.
Read also: Delicious Low FODMAP Chicken