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By David Kiefer, MD
Synopsis: A 4-week educational intervention about diet and stress for people with GERD showed improvement in perception and overall impact, but no change in scales that measured depression and anxiety.
Source: Dibley LB, et al. Non-pharmacological intervention for gastro-oesophageal reflux disease in primary care. Br J Gen Pract 2010;60:e459-465.
The researchers’ goal was to address the fact that therapies that are adjunctive to proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD) have been under studied. In this clinical trial, an education intervention was examined in adult patients with GERD recruited from rural general practices in England. Inclusion criteria were a GERD diagnosis and taking PPIs for at least 6 months. Exclusion criteria included any other physical morbidity or a veto for participation by the primary care provider. A total of 179 patients agreed to participate in some aspect of this study.
The educational intervention was developed by reviewing proven programs from the medical literature, as well as from semi-structured interviews in 23 of the 179 participants. The interviews focused on aspects of the patients’ GERD that concerned them and if the GERD was related to diet, alcohol, smoking, activity, posture, and dinner-to-bed time. The most commonly mentioned GERD-exacerbating factors were diet and stress, which then became the focus of the educational intervention.
Fifty-three people expressed interest in participating in the educational intervention. Of these, 42 were able to attend the four sessions, 1.5 hours weekly. At the first session and 3 months after the last session, the patients completed the Brief Illness Perception Questionnaire (BIPQ), the Gastro-oesophageal Reflux Disease Impact Scale (GIS), and the Hospital Anxiety and Depression Scale (HADS).
Data from 39 people were analyzed; the three patients with incomplete data were not included in an intention-to-treat analysis. After the intervention, the overall BIPQ decreased (37.5 to 18.0; P < 0.001), as did the GIS (18.0 to 14.0; P = 0.008). Of the eight domains contained within the BIPQ, all improved, except perception of the impact of the GERD on their lives or how long it would last. Both of these parameters were relatively high at baseline and deemed difficult to improve. As per the HADS, there was no significant change in depression (5.0 to 4.0; P = 0.101) nor anxiety (6.0 to 6.0; P = 0.361).
It is a bit tough to tease out the effects of dietary and stress education; both were involved in the intervention that was analyzed in this clinical trial. The authors highlight the improvements in illness perception and illness experience when the baseline results are compared to testing 3 months after the training was completed. It is true there were improvements, but the numbers were small (n = 39, though 42 should have been included statistically as intention-to-treat), and there was no control group. To validate and corroborate these findings, a control group, blinding, and randomization would be key in the next study.
What makes this study compelling is how it fits in with other research about the effect of stress on GERD symptoms. Studies have shown that GERD flares after traumatic events such as the World Trade Center attacks,1 as well as with other stressors such as on-the-job stress.2 This is probably mediated through nerves that connect the central nervous system (CNS) with plexi along the gastrointestinal tract.3 In some cases, stress via the CNS-gut connection can open the lower esophageal sphincter, a known physiological factor with GERD. But this doesn’t always occur. For example, stress may worsen GERD even though the quantity and acidity of the refluxate doesn’t change.3 In such cases, it is the perception of GERD that changes, hence, one rationale behind the intervention in the trial reviewed here. If an intervention, such as stress management, could affect the perception of GERD symptoms, then it could be a useful adjuvant to physiological shifts accomplished by pharmaceuticals. Interestingly, in this trial, the use of PPIs didn’t change in the 3 months before the intervention compared to the 3 months after (statistics not provided), seeming to imply a stable acid physiology that was nudged toward improvement with the diet and stress management education. Of course, this is mostly conjecture, and there are likely many factors involved. Nonetheless, this pilot trial showed some positive effects to this intervention, and there is likely little downside except for the time commitment and cost of leading the educational sessions. It behooves the health care provider to inquire about the presence of stress in any of their patients with GERD, and then take the next step and brainstorm with them about what can be done about it.