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100 Questions & Answers About Gastroesophageal Reflux Disease (GERD): A Lahey Clinic Guide David L. Burns, MD, CNSP Department of Gastroenterology Lahey Clinic Burlington, MA Neeral L. Shah, MD Department of Gastroenterology Lahey Clinic Burlington, MA40470_FMxx_Burns.qxd 8/23/06 9:21 AM Page iJones and Bartlett’s books and products are available through most bookstores and online booksellers. To contact Jones and Bartlett Publishers directly, call 800-832-0034, fax 978-443-8000, or visit our website atwww.jbpub.com. Substantial discounts on bulk quantities of Jones and Bartlett’s publications are available to corpora-tions, professional associations, and other qualified organizations. For details and specific discountinformation, contact the special sales department at Jones and Bartlett via the above contact informa- tion or send an email to specialsales@jbpub.com. Copyright © 2007 by Jones and Bartlett Publishers, Inc. ISBN 13: 978-0-7637-4042-9 ISBN 10: 0-7637-4042-X Cover image: © Liquid Library PhotodiscAll rights reserved. No part of the material protected by this copyright notice may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or any information storage orretrieval system, without written permission from the copyright owner. The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this bookand take no responsibility for the use of the products and procedures described. Treatments and side effectsdescribed in this book may not be applicable to all people; likewise, some people may require a dose orexperience a side effect that is not described herein. Drugs and medical devices are discussed that may havelimited availability controlled by the Food and Drug Administration (FDA) for use only in a research studyor clinical trial. Research, clinical practice, and government regulations often change the accepted standardin this field. When consideration is being given to use of any drug in the clinical setting, the health careprovider or reader is responsible for determining FDA status of the drug, reading the package insert, andreviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important inthe case of drugs that are new or seldom used. Library of Congress Cataloging-in-Publication Data Burns, David L.100 questions & answers about gastroesophageal reflux disease (GERD): a Lahey Clinic guide / David L.Burns, Neeral L. Shah.p. cm.Includes bibliographical references and index.ISBN-13: 978-0-7637-4047-4 (alk. paper)ISBN-10: 0-7637-4047-0 (alk. paper)1. Gastroesophageal reflux—Miscellanea. 2. Gastroesophageal reflux—Popular works. I. Shah, Neeral L. II. Lahey Clinic. III. Title.IV. Title: One hundred questions & answers about gastroesophageal reflux disease (GERD). V. Title: 100questions and answers about gastroesophageal reflux disease (GERD).RC815.7.B87 2007616.3’24—dc22 2006016491 4189 Production Credits Executive Editor: Christopher DavisProduction Director: Amy RoseAssociate Production Editor: Rachel RossiAssociate Editor: Kathy RichardsonAssociate Marketing Manager: Laura KavigianManufacturing Buyer: Amy BacusComposition: Northeast Compositors, Inc. Cover Design: Kate TernulloPrinting and Binding: Malloy, Inc.Cover Printing: Malloy, Inc. Printed in the United States of America 10 09 08 07 06 10 9 8 7 6 5 4 3 2 1World Headquarters Jones and Bartlett Publishers40 Tall Pine DriveSudbury, MA 01776978-443-5000info@jbpub.comwww.jbpub.comJones and Bartlett Publishers Canada 6339 Ormindale WayMississauga, OntarioL5V 1J2CANADAJones and Bartlett Publishers International Barb House, Barb MewsLondon W6 7PAUK 40470_FMxx_Burns.qxd 8/23/06 9:21 AM Page iiContents Acknowledgments vii Preface ix Part 1: Gastroesophageal Reflux Disease: Definitions and Facts 1 1. What is gastroesophageal reflux disease, or GERD? 2. What is heartburn?3. What is acid reflux? 4. How many people are affected by GERD? 5. What factors cause GERD?6. Is there a link between obesity and GERD in the United States? 7. Do children get GERD? 8. Does GERD affect one gender more than the other?9. Is GERD serious? 10. What are some of the typical symptoms of GERD?11. What causes new-onset GERD? 12. How can I improve my symptoms of GERD? Part 2: Symptoms and Atypical Manifestations of GERD 25 13. How do I know whether my heart is causing the chest pain? 14. What about other chest symptoms with GERD?15. Can I have chest pain caused by conditions other than GERD? 16. Can I have GERD without any symptoms? 17. Can GERD manifest as mouth symptoms in the absence of typical chest dis- comfort? 18. Is there a difference between daytime and nighttime GERD?19. Can GERD cause changes in my voice?20. What are alarm signs of GERD? Part 3: Hiatal Hernias, the Lower Esophageal Sphincter, and Reflux 37 21. What do the lower esophageal sphincter (LES) and stomach have to do with reflux?40470_FMxx_Burns.qxd 8/23/06 9:21 AM Page iii22. What is a hiatal hernia and why does it cause reflux? 23. What are the symptoms of a hiatal hernia?24. Will my hiatal hernia get worse and what are the complications? Part 4: Lifestyle, Medications, Diet, and GERD 41 25. Can stress increase GERD symptoms? 26. Can smoking cause GERD?27. Can medicines exacerbate GERD? 28. Which specific medications can exacerbate GERD or damage the esophagus? 29. Which medications can affect both the esophagus and stomach?30. How can I avoid GERD problems if I have to take my pills? 31. Can exercise affect my reflux? 32. What kind of foods can make GERD worse?33. What kind of foods should I eat if I have GERD?34. Will eating fast food make my GERD worse?35. How else can I change my eating habits to prevent GERD? 36. Does GERD get worse with age? 37. Does my bed make a difference for nighttime symptoms?38. Can my weight affect my GERD?39. When should I consider medications for GERD? Part 5: Complications of Gastroesophageal Reflux Disease 69 40. What are the complications of GERD, and are they serious? 41. What is regurgitation?42. What is esophagitis? 43. What is an esophageal stricture or ring? 44. What is an esophageal dilation?45. What is Barrett’s esophagus? 46. Will I get cancer from Barrett’s esophagus? 47. What can be done to make Barrett’s esophagus better or make it go away?48. If I have Barrett’s esophagus, does it need to be followed?49. What are the “alarm” or concerning symptoms that might suggest esophageal cancer? 50. How can I decrease my risk of getting cancer of the esophagus?51. What is aspiration?52. What is laryngopharyneal reflux?53. Is there a relationship between GERD and asthma or chronic lung disease?54. Is there a relationship between GERD and a chronic cough? iv100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD)40470_FMxx_Burns.qxd 8/23/06 9:21 AM Page iv55. Does GERD play a role in chronic chest pain? 56. Is there a relationship between GERD and cancers of the head and neck? Part 6: Doctor’s Evaluation 97 57. When should I see my doctor about my GERD symptoms? 58. What kind of doctor treats GERD?59. What symptoms should prompt a doctor’s evaluation? 60. Should I just have a trial of medication for GERD? Part 7: Testing for GERD 103 61. What is a barium study or upper GI series? 62. What is an endoscopy?63. Is an endoscopy painful, and does it carry risks? 64. Do I need a biopsy of the esophagus, and does it hurt? 65. Should I be checked for H. pylori at the endoscopy? 66. What does an endoscopy show when patients have GERD? 67. Who should have an endoscopy and why? 68. What is a manometry or motility study and why is it done?69. What is a pH study and why is it done? Part 8: H. pylori, GERD, and Peptic Ulcer Disease 117 70. What is the relationship between ulcers and GERD? 71. Does gastrointestinal reflux disease cause ulcers?72. What is H. pylori ? 73. Does H. pylori cause GERD? 74. Do I need to be checked for H. pylori? 75. What are the tests for H. pylori ? 76. If I have H. pylori should I be treated? Part 9: Medications for Gastroesophageal Reflux Disease 125 77. What are antacids, and how and when should they be used? 78. Antacids seem benign. Do they have side effects?79. If antacids do not work or are not appropriate for my GERD, what is the next step or tier of medications to try? 80. What are the differences between the H2 blockers and proton pump inhibitors? 81. What are the different proton pump inhibitors? How should they be taken?82. What are the major side effects associated with H2 blockers and PPIs?83. How should I take the medications, and when will they work? v100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD)40470_FMxx_Burns.qxd 8/23/06 9:21 AM Page vvi100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) 84. Do I need to take the medication every day or just when I have reflux? 85. What should I do if the medication is not working?86. If my symptoms get better, can I stop taking medication? Part 10: Endoscopic and Surgical Options for GERD 145 87. If my GERD is chronic and possibly lifelong, do I need to take medications for life or are there any other options? 88. Should I have surgery for my GERD? 89. What are the surgeries for GERD?90. What are the long-term risks and benefits of surgery?91. Will I be able to stay off GERD medications if I have surgery?92. Will surgery make my Barrett’s esophagus improve or go away?93. Will surgery decrease my risk of getting Barrett’s-associated esophageal cancer?94. How do I find a surgeon?95. What are the endoscopic therapies for GERD?96. What is a Stretta procedure? 97. What is Enteryx? 98. What is an EndoCinch or endoscopic plication?99. Who performs noninvasive endoscopic anti-reflux procedures? 100. What are the long-term risks/benefits of endoscopic anti-reflux procedures? Part 11: Conclusion and Summary Thoughts 165 Bonus question: What would I do if I had chronic GERD? Appendix 167 Glossary 169 Index 17740470_FMxx_Burns.qxd 8/23/06 9:21 AM Page viThis book would not have been possible without the support of Jones and Bartlett Publishers and Executive Publisher Christopher Davis. I am also appre-ciative of the contribution of one of my patients, Mr. Richard Auth, whose unique understanding of GERD has been inspiring. I am thankful for the support, love, and patience of my family, my wife Margo Moskos, MD, and our children, Stacy and Alex, in the preparation of this book. I am also thankful to my parents, Hedy and Arthur Burns, who werethere for me through it all. They have had chronic heartburn forever, which I may have contributed to. David L. Burns, MD I would like to thank my parents, Lalit and Surekha, my family, and my friendsfor all of their support through the many years of medical education and train-ing. Without their support, I would not have accomplished all that I have, nei-ther would I have had the opportunity to write this book. To all of you, with theutmost sincerity, thank you. Neeral L. Shah, MDAcknowledgments40470_FMxx_Burns.qxd 8/23/06 9:21 AM Page viiIntentional Blank viii40470_FMxx_Burns.qxd 8/23/06 9:21 AM Page viii This page intentionally left blank Gastroesophageal reflux disease or heartburn affects all of us at sometime. About one-third of Americans experience reflux symptoms with some regularity. For agastroenterologist, reflux and its complications are two of the most common problems managed in the clinic, and the most common reason patients are referred for upper endoscopy. There are many myths regarding the causes andtreatment of heartburn. The purpose of this book is to dispel some of the mythsand explain the facts. Many feel that reflux is a benign problem and an annoy-ance. This may be true for some; however, it is a very common reason for doc- tor’s appointments and consumes many millions of dollars in over-the-counterand prescription drugs. Further, reflux truly is not a benign process; it has com-plications that include temporary or permanent acid damage to the esophagus.Certain cancers of the esophagus are associated with chronic heartburn. And asdoctors, we are starting to understand the contribution of GERD symptoms to chronic cough and asthma. Thankfully, there are some easy ways to improve heartburn symptoms. These may be changes in one’s lifestyle or can involve medications. These are all discussed in this book, including the different kinds of medications, theirroute of action, appropriate usage, and when to take the medication. Thereare also many issues and misconceptions about the medical and surgical pro-cedures that are done in an attempt to improve reflux symptoms. Recently,new nonsurgical procedures have become available for GERD; we wanted toreview and discuss each of these individually; focusing on long-term benefitslike eliminating or reducing the need for medications and complications asso-ciated with each procedure. We wrote this book for several reasons. We deal with GERD and its com- plications daily in medical practice and wanted to have a guide covering the entire spectrum of disease and all of its treatment options including appropriatediagnosis, treatment, and what to do if all fails. On a personal level, I (DLB)have had daily heartburn symptoms for over 20 years and can empathize with mypatients and explain how I have dealt with symptoms. Our hope is that this book is educational and explains some of the issues dealing with chronic GERD including: causes, complications, evaluation, med-ications, and surgical and medical treatment. It was written to explain the issuesPreface40470_FMxx_Burns.qxd 8/23/06 9:21 AM Page ixon a patient level rather than in “med speak.” We certainly learned a lot while preparing this book and will incorporate our improved understanding to thepractice of medicine. David L. Burns, MD Neeral L. Shah, MD x100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD)40470_FMxx_Burns.qxd 8/23/06 9:21 AM Page xGastroesophageal Reflux Disease: Definitions and Facts What is gastroesophageal reflux disease, or GERD? Is GERD serious? What are some of the typical symptoms of GERD? More. . .PART ONE40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 12100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) Figure 1 Reflux. 1. What is gastroesophageal reflux disease, or GERD? GERD is an abbreviation for gastroesophageal reflux disease. GERD has several manifestations. Classically, it can be a sensation of warmth or burning in the chest, which can be a mild discomfort to frank pain.You might regurgitate bitter material or burp it up intoyour mouth. These symptoms are caused by acidicstomach material refluxing from the stomach into theesophagus, which is the food pipe (Figure 1). Reflux can occur during the day or at night while you’re asleep. Several factors prevent reflux, among them is gravity and the fact that when you are upright,GERD is an abbreviationfor gastro- esophageal reflux disease.40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 23100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) the esophagus is above the stomach. GERD symptoms increase particularly at bedtime because the effects andbenefits of gravity are removed when you lie down.Generally, nocturnal or nighttime symptoms are moresevere; in addition to burning chest discomfort, theycan include excessive drooling, coughing, and choking.These symptoms can increase the risks of complica-tions of chronic GERD that may affect the esophagus,lungs, or airways. Reflux is affected by weight, diet, medications, and lifestyle habits such as smoking and alcohol consump-tion. A patient with GERD can change or modifymany of these factors to improve symptoms. If conser-vative measures fail, then many medications are avail-able for treatment of GERD. The spectrum ofmedications spans from over-the-counter antacids used to treat infrequent and episodic reflux, to power-ful prescription drugs that you take several times a dayto treat severe GERD and its complications. Patients and doctors may use several names for gas- troesophageal reflux disease interchangeably. Heart- burn, acid reflux, and regurgitation are all symptoms of GERD. These symptoms are discussed furtherthroughout this book and can be referenced in specificquestions. Richard’s comment: My acid reflux symptoms are most severe while sleeping. I wake up from a sound sleep with the sensation that I amdrowning. The bitter taste stays with me for the rest of thenight.Reflux is affected byweight, diet, medications, and lifestylehabits such assmoking andalcohol consumption.40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 34100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) Figure 2 Digestive System.2. What is heartburn? Heartburn is discomfort or pain in the chest that is caused by acid in the esophagus. It is a manifestationof how pain is felt in the esophagus. Heartburn feelslike burning, warmth, or pain in the midchest area.Although heartburn, a symptom of reflux, often feelslike burning and can be very similar to the pain or dis-comfort caused by heart problems or heart attacks,heartburn does not affect the heart, as its name sug-gests. The reason is that the esophagus passes throughthe chest almost directly behind the heart, so pain inthis area can easily be confused with pain caused byheart problems (see Figures 2 and 2a). Occasionally,the pain is so similar that people actually need toundergo testing to prove the pain is caused by acid inthe esophagus and not by a heart attack.Although heartburn, asymptom of reflux, often feels like burning andcan be verysimilar to the pain or discomfortcaused by heart problems orheart attacks,heartburn does not affect the heart, as its name suggests.40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 45100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) Figure 2a Anatomy of a normal esophagus, stomach, and duodenum. (Cut away view on right) 3. What is acid reflux? Acid for digestion of food is normally produced in the stomach in response to eating. Normally, acid can reflux,or move up, into the esophagus, but protective mecha-nisms are in place to remove or neutralize refluxed acid.These include saliva, which neutralizes acid, andesophageal pumping, which moves refluxed acid backdown to the stomach. Acid reflux disease occurs whenincreased or prolonged episodes of reflux overwhelm theprotective factors, resulting in symptoms. Excessive acid sitting in the esophagus causes burning discomfort and, in about half of those with chronicsymptoms, damage to the esophagus. A bitter or acidic taste can be a manifestation of high reflux called regur- gitation. Regurgitation can cause mouth, dental, sinus,and lung problems. Gastroesophageal reflux disease (GERD) is a disease that is caused by a combination of symptoms. Thesesymptoms can include heartburn, regurgitation,40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 56100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) Gastroesopha- geal reflux disease (GERD) is a disease that iscaused by acombinationof symptoms. These symptoms caninclude heart-burn,regurgitation,chest pain or discomfort, bitter taste inthe mouth,and difficulty swallowing.chest pain or discomfort, bitter taste in the mouth, and difficulty swallowing. Chronic GERD resultsfrom repeated reflux generally defined as symptomsoccurring in three or more episodes a week for 6months or longer. Chronic GERD is associated withdamage to the esophagus, which can manifest asinflammation called esophagitis and as ulcers, and it can predispose a patient to esophageal cancer.Thus, patients with chronic GERD should undergoa prompt evaluation by a doctor to ensure that nocomplications or damage has occurred. 4. How many people are affected by GERD? GERD is not a new disease; it is a common disease that affects many people. In 1994, the U.S. Depart-ment of Health and Human Services reported thatabout 7 million people in the United States at thattime suffered from chronic GERD. That number hasgrown since, likely because of the increasing incidenceof obesity and people being overweight, which are con-tributing factors to reflux problems. These days, Amer-icans work longer hours, buy more fast food, and eat onthe run. Poor dietary habits and the easy availability offast food at any hour of the day have to increasedGERD. Unfortunately, these factors have also causedmore obesity, diabetes, heart disease, cholesterol prob-lems, high blood pressure, and strokes, as well. Gastroesophageal reflux goes by several names that are used interchangeably, such as GERD, reflux, heart-burn, and indigestion. Approximately one in threeAmericans experiences occasional GERD as called byany of these names. Approximately one in threeAmericans experiences occasionalGERD ascalled by any of these names.40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 67100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) GERD does not affect any specific demographic group across the United States. In 2003, a national survey bythe National Heartburn Alliance showed how com-mon the symptom of heartburn was across the UnitedStates. The following ranking of cities and variabilityof GERD is likely related to the risk of obesity inthese cities, which roughly parallels the incidence ofGERD. The data were taken from http://www.-heartburnalliance.org/nosection/top24CityResults.jsp. America’s Top 24 Heartburn Cities in 2003 1. Charlotte, NC 2. Jacksonville, FL3. Roanoke, VA4. Louisville, KY5. Denver, CO6. Spokane, WA7. Miami, FL8. Tampa-St. Petersburg, FL9. Atlanta, GA 10. Grand Rapids, MI11. Orlando, FL12. Minneapolis-St. Paul, MN13. Milwaukee, WI14. Pittsburgh, PA15. Boston, MA16. Raleigh, NC17. Baltimore, MD18. Albany, NY19. Salt Lake City, UT20. Columbus, OH40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 78100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) 21. Cincinnati, OH 22. Omaha, NE23. Des Moines, IA24. Peoria, IL Surveys conducted by national organizations such as the American College of Gastroenterology (ACG) report that the majority of Americans suffer fromheartburn or GERD, and symptoms can affect qualityof life, sense of health, and enjoyment of food. Eatinglarge or spicy meals often can lead to acid reflux.When heartburn occurs regularly, people may losetheir taste for certain foods or become afraid to trynew foods for fear of developing symptoms again. The ACG survey states that more than half of all Americans experience some nighttime reflux symp-toms that affect sleep and that prevent many from get-ting a full night’s rest. Experiencing poor-quality sleepor delayed sleep can cause people to feel daytimefatigue and can affect overall health and work orschool functioning or productivity. Richard’s comment: I have found that whenever I discuss my acid reflux condi- tion in a group I am amazed at the number of people havesimilar symptoms. It would appear to me that there is atremendous number of sufferers out there. 5. What factors cause GERD? GERD is affected by many different factors. It can becaused by factors out of your control as well as other fac-tors that you can change or eliminate. A major cause ofGERD is affected bymany different factors. It can be caused byfactors out ofyour control aswell as other factors thatyou can change or eliminate.40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 89100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) Figure 3 Hiatal Hernia. GERD and regurgitation is an incompetent valve, or barrier, between the esophagus and stomach. The circularmuscle at the bottom of the esophagus is called the lower esophageal sphincter (LES) . The LES contributes to the high-pressure zone at the junction of the esophagusand stomach that keeps ingested material out of theesophagus once it has passed through the sphincter.Other components of the high-pressure zone include theligaments that hold the stomach in place and thediaphragm , which is the muscle separating the chest and abdomen. A hiatal hernia (or hiatus hernia) is a defect in this zone, when the ligaments are loosened and the topof the stomach moves inappropriately into the chest area(see Figure 3). The development of a hiatal herniadecreases the strength of the LES and promotes reflux.40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 910100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) Hiatal hernias likely are the greatest contributor to or cause of GERD. Factors out of a patient’s control include genetics and personal background. Some people have a family his-tory of GERD that is passed on through genes. Peoplemay have family members across several generationswho are affected by GERD because of a genetic com-ponent. Other inherited factors are body weight andtendency toward obesity. These characteristics tend torun in families and are further contributions to thedevelopment of reflux. Sometimes, however, geneticpredisposition to a disease can be confused with otherfamily factors. For instance, GERD in family membersmay be caused by family members who eat the sametypes of foods or develop the same eating or exercisehabits, and not necessarily by a genetic factor. Other factors called lifestyle choices are within your control; you can change your choices to decrease yoursymptoms of GERD. Keep in mind that somelifestyle modifications are easier said than donebecause they are habits that you have developed overyears. You might find it necessary to modify theselifestyle issues slowly over time. Lifestyle factorsinclude such choices as limiting alcohol, losingweight, quitting smoking, avoiding certain medica-tions, limiting carbonated beverages, eating smallermeals, and being careful about eating habits (i.e.,avoiding spicy, fatty, and fried foods, etc.). Caffeineconsumption increases GERD because it relaxes theLES that protects the esophagus from backflow ofacidic stomach contents. Caffeine is one lifestyle fac-tor that can easily be reduced, and caffeine is not justcontained in coffee; most teas, hot or iced, and many40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 1011100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) sodas contain caffeine, so it is important for you to read the label to identify foods and drinks that maymake your GERD symptoms worse. New cases of GERD are commonly associated with recent weight gain. In the United States, the epidemicof obesity is likely related to easy availability of food,low cost of food, and the opportunity to “super size”your meals. Obesity causes secondary problems,including complicating diseases such as diabetes, highblood pressure, stroke, heart disease, cancer, elevatedcholesterol, and GERD. Because food is readily available, people may eat one large meal a day rather than three smaller meals. A fullor overstuffed stomach is subject to increased pressureand takes longer to empty. Foods high in fat contentalso slow stomach emptying, giving more opportunityfor contents to backflow into the esophagus. The eat-ing habits of Americans are changing. Increasingly,people eat meals at irregular hours rather than at rela-tively fixed times each day. Normally, we might eat ourlast meal of the day, and then remain upright for sev-eral hours so that gravity helps keep fluid and fooddown in the stomach. Eating within 2 hours of bed-time increases reflux by adding “more fuel to the fire” by providing material to reflux as well as a stimulus for acid production. Thus, the lack of gravity worksagainst you at night when you lie flat in bed. The reasons given here are only a small number of all the factors that explain why people suffer from GERD.New cases of GERD arecommonly associated with recent weight gain.40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 1112100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) Figure 4 Obesity in the United States. 6. Is there a link between obesity and GERD in the United States? The average body weight of Americans is slowly going up. Obesity is becoming a major issue in oursociety, starting in young children and continuingthrough adulthood (See Figure 4.). Two-thirds ofAmericans are overweight, and 1 in 3 are obese orabout 30 pounds overweight and at increased risk ofobesity-related disease. The number of obese andmorbid obese (100 pounds over your normal weight)people is increasing annually and is considered anepidemic. Changes in the American diet are respon-sible. Food is cheap and available. Portion size isincreasing in an attempt to give the consumer bettervalue and to attract more customers. Food is morecalorie dense, meaning it contains more calories perportion and includes more fat and sugar. Sugar-ladensodas are ubiquitous and are marketed directly tochildren, creating a generation of people addicted to“liquid candy.” The world moves at a faster pace and people are affected by time constraints and convenience. WorkTwo-thirds of Americans areoverweight, and 1 in 3 are obese or about30 poundsoverweightand at increased riskof obesity- related disease.40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 1213100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) and home commitments cause people to make certain sacrifices, such as forgoing the time it takes to preparewholesome meals and eat at regular intervals. Peoplehave less time to eat and exercise; they drive to workand use elevators, which decreases the amount ofactivity they do. Eating is a major part of our lifestyle,but with less time available in busy days, people areless likely to prepare their own food. Fast food and eat-ing out in restaurants are becoming mainstays of oureveryday lives. Prepared foods tend to have higher fatcontent and contain more preservatives, which canrequire more stomach acid for proper digestion. Thiscombined with decreased activity levels can lead toweight issues and simply worsen the obesity epidemicin the United States. Extra body weight within the abdomen puts more pressure on the stomach forcing material back up intothe esophagus. Increased food consumption requiresmore processing and digestion by the gut, compound-ing the problem and leading to heartburn symptoms.The increasing average weight combined with lifestylechoices has not only led to an obesity epidemic, butalso contributes to the increasing problem of GERDin the United States. Richard’s comment: It has become apparent to me that as my weight increases and my exercise regime decreases, my incidents of nighttimeacid reflux go up dramatically. I can only assume that theweight and lack of activity put additional stress on thelower esophageal sphincter (LES). The added weightmakes my clothes tightfitting, especially around my stom-ach, and just adds to my overall physical discomfort.40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 1314100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) 7. Do children get GERD? Yes, children can also get GERD; it can affect anyone. Infants may exhibit symptoms different from adults.They may become irritable after eating, repeatedlybelch or vomit, or suffer from persistent coughing.These symptoms may manifest as poor feeding andimpaired weight gain or colic. GERD is often over-looked in young children because their symptoms arevery subtle and infants often outgrow the condition. Parents can take precautions to prevent GERD symp- toms in infants, such as keeping infants upright for 30minutes after feeding instead of placing them directlyin the crib. Also, burping the baby more frequentlyduring feeding time can help to avoid the buildup ofgas and pressure that may add to a baby’s GERD dis-comfort. If you feed your baby formula, considerchanging the formula to reduce symptoms; you shoulddiscuss this decision with your child’s doctor. If thesesimple measures do not help, medications may be inorder. Some H2 blockers and proton pump inhibitors (PPIs) are approved by the Food and Drug Adminis- tration (FDA) for use in children. Children experiencing reflux can exhibit typical symp- toms, such as heartburn and regurgitation, or atypicalsymptoms. Frequently, children with asthma haveGERD that may be silent and they exhibit no GERDsymptoms. These children can require multiple med-ications for asthma. A trial of antacid medication canbe helpful in improving asthma symptoms or decreasethe need for asthma medications. You can discuss thiswith your pediatrician.Yes, children can also getGERD; it can affect anyone.40470_CH01_Burns.qxd 8/22/06 7:35 AM Page 14