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Release Date: June 2, 2006; Valid for credit through June 2, 2007

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June 2, 2006 -- For women, even moderate weight gain increases the likelihood of gastroesophageal reflux disease (GERD), and symptoms of reflux are associated with body mass index (BMI), according to an analysis of a sample from the Nurses' Health Study reported in the June 1 issue of The New England Journal of Medicine.

"Overweight and obese persons are at increased risk for GERD," write Brian C. Jacobson, MD, MPH, from the Boston University School of Medicine and Boston Medical Center, and the Brigham and Women's Hospital and Harvard Medical School in Boston, Mass, and colleagues. "An association between body-mass index (BMI) -- the weight in kilograms divided by the square of the height in meters -- and symptoms of GERD in persons of normal weight has not been demonstrated."

The investigators evaluated the frequency, severity, and duration of symptoms of GERD in randomly selected participants in the Nurses' Health Study. They categorized women according to their BMI measured in 1998, and they used logistic-regression models to study the association between BMI and symptoms of GERD.

Of 10,545 women who completed the questionnaire (response rate, 86%), 2310 (22%) reported having symptoms of GERD at least once per week, and 3419 (55% of those who had any symptoms) described their symptoms as moderate in severity. There was a dose-dependent relationship between increasing BMI and frequent reflux symptoms (multivariate P for trend < .001). Compared with women who had a BMI of 20.0 to 22.4 kg/m², the multivariate odds ratios for frequent symptoms were 0.67 (95% confidence interval [CI], 0.48 - 0.93) for a BMI of less than 20.0 kg/m²; 1.38 (95% CI, 1.13 - 1.67) for a BMI of 22.5 to 24.9 kg/m²; 2.20 (95% CI, 1.81 - 2.66) for a BMI of 25.0 to 27.4 kg/m²; 2.43 (95% CI, 1.96 - 3.01) for a BMI of 27.5 to 29.9 kg/m²; 2.92 (95% CI, 2.35 - 3.62) for a BMI of 30.0 to 34.9 kg/m²; and 2.93 (95% CI, 2.24 - 3.85) for a BMI of 35.0 kg/m² or more.

Compared with no weight changes, an increase in BMI of more than 3.5, even in women with a normal baseline BMI, was associated with increased risk for frequent symptoms of reflux (odds ratio, 2.80; 95% CI, 1.63 - 4.82).

"BMI is associated with symptoms of GERD in both normal-weight and overweight women," the authors write. "Moderate weight gain among persons of normal weight may cause or exacerbate symptoms of reflux."

Study limitations include inability to determine a causative mechanism for the association between BMI and reflux symptoms; cross-sectional design; use of a questionnaire to define GERD; and study sample limited to women.

"Our findings suggest that the risk of symptoms of GERD rises progressively with increasing BMI, even among normal-weight persons," the authors conclude. "This seems true for all degrees of severity and duration of symptoms, as well as for nocturnal symptoms. Notably, weight loss was associated with a decreased risk of symptoms."

The National Institutes of Health and Janssen-Eisai supported this study. One of the authors has disclosed serving as a consultant to AstraZeneca and receiving lecture fees from GlaxoSmithKline.

N Engl J Med. 2006;354:2340-2348

Learning Objectives for This Educational Activity

• Describe the effects of GERD.
• Explain the relationship between the symptoms of GERD and BMI in women.

Clinical Context

Study Highlights

• In 2000, a supplemental questionnaire was distributed to randomly selected participants in the Nurses' Health Study to determine the frequency, severity, and duration of symptoms of GERD.
• Symptoms of GERD were defined as the presence of heartburn, acid regurgitation, or both. Symptoms occurring once a week were considered frequent.
• For these analyses, women with a BMI of 20.0 to 22.4 kg/m² served as the reference population.
• After categorizing women according to BMI as measured in 1998, logistic-regression models were used to study the association between BMI and symptoms of GERD.
• Of 10,545 women who completed the questionnaire (response rate, 86%), 2310 (22%) reported having symptoms at least once a week, and 3419 (55% of those who had any symptoms) described their symptoms as moderate in severity.
• Among those who provided information of duration, 1180 (43%) had had symptoms of GERD for less than 5 years, 400 (14%) had had symptoms for 5 to 9 years, and 1185 (43%) had had symptoms for at least 10 years.
• Findings revealed a dose-dependent relationship between increasing BMI and frequent reflux symptoms (multivariate P for trend < .001).
• This relationship continued across all categories of BMI, suggesting that the risk for symptoms rises with BMI in both normal-weight and overweight person.
• In women with a normal baseline BMI, an increase in BMI of more than 3.5 kg/m², as compared with no weight changes, was associated with an increased risk for frequent symptoms of reflux (odds ratio, 2.80; 95% CI, 1.63 - 4.82).
• In addition, women with frequent symptoms were more likely than women without symptoms to have used hormone therapy or asthma or antihypertensive medications, to have a greater daily caloric intake, and to be less active.
• The association was not altered significantly after controlling for multiple potential confounding variables, including smoking, the consumption of alcohol, the use of medications that lowers the pressure at the lower esophageal sphincter, diabetes, and dietary habits.
• The relationship between BMI and symptoms of GERD persisted when severity of symptoms was evaluated (P for trend < .001 for all models). Compared with women with a BMI of 20.0 to 22.4 kg/m², women with a BMI of 22.4 to 24.9 kg/m² had a 36% to 50% increase in the risk of having mild or moderate symptoms on multivariate analysis.
• Regardless of duration of symptoms, the same dose-response relationships for symptoms were found across all categories of BMI.
• Also, a dose-response relationship between the risk for reflux symptoms and increasing waist-to-hip ratios (P for trend < .001 for all models) was observed; however, this contribution was blunted when BMI was introduced simultaneously into this model.
• Limitations of this study include the cross-sectional design of the study, the use of a questionnaire to define the symptoms of GERD, and its inclusion of only women.

Pearls for Practice

• The effects of GERD are impaired health-related quality of life and esophageal adenocarcinoma, and it contributes to time lost from work.
• BMI is associated with symptoms of GERD in both normal-weight and overweight women. Even moderate weight gain among persons of normal weight may cause or exacerbate symptoms of reflux.

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Target Audience

This article is intended for primary care clinicians, gastroenterologists, and other specialists who care for patients with GERD.

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Authors and Disclosures

News Author

Laurie Barclay, MD
is a freelance writer for Medscape.

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Clinical Reviewer

Gary Vogin, MD
Senior Medical Editor, Medscape

Disclosure: Gary Vogin, MD, has disclosed no relevant financial relationships.

CME Author

Hien T. Nghiem, MD
Writer for Medscape Medical News

Disclosure: Hien T. Nghiem, MD, has disclosed no relevant financial relationships.

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