Ninety-Six Hour Wireless Esophageal pH Study in Patients with GERD Shows that Restrictive Diet Reduces Esophageal Acid Exposure

Abstract

Background

Prolonged (96 h) pH monitoring may explore the effect of diet on pH and symptoms in patients with GERD.

Aims

To assess the usefulness of a 96 h esophageal pH study in patients with GER symptoms under different diets (pro- and anti-GER).

Methods

Prospective study of 66 patients with GERD undergoing wireless 96 h pH monitoring. Two-day periods, one on liberal (pro-reflux) and another on restricted (anti-reflux) diet assessed esophageal acid exposure and symptoms. The primary end point was normalization of acid exposure time while on restricted diet. Secondary end point was a > 50% reduction in symptoms with restricted diet.

Results

Normal (pH time < 4 of < 6%) was found in 34 patients (51.5%) while on the initial 48 h (liberal) diet [median % time < 4: 3.2 (95% CI, 1.9, 4.0)] and remained normal while on restricted diet [median % time < 4: 2.6 (95% CI, 0.8, 3.4)]. Abnormal acid exposure (% pH time < 4: > 6%) was found in 32 patients (48.5%) while on initial 48 h liberal diet [median % time < 4: 10.5, (95% CI 8.9, 12.6)], and decreased significantly with restricted diet [median % time < 4: 4.5 (95% CI 3.1, 7.3)] (p = 0.001), and normalized with anti-GERD diet in 21 patients (65.6%). Only 11/66 patients were candidates for proton pump inhibitor (PPI) use; 34 had either normal pH studies or normalized them with restricted diet (n = 21). Symptoms did not improve with restricted diet.

Conclusions

The 96-h esophageal pH study tests for GERD under pro- and anti-GER diets and allows minimization of PPI therapy to only 16.6% of patients.

Appendix: Silicon Valley Gastroenterology 96-h pH Monitoring Diet Instructions

Depending on your effort to comply with the following general directions, the next 4 days will:

• 1. Prove that you have significant esophageal acid reflux (or not)

• 2. Identify certain dietary elements that may induce your reflux symptoms

• 3. Allow you to learn about dietary changes that would help alleviate your reflux symptoms

• 4. Help us determine what would be the best method to treat your acid reflux (GERD)

Please read the following instructions very carefully and make the relevant diet changes to maximize the information obtained by the test.

The “idea” behind this test is to identify “good” or “bad” things in your diet that could be causing your acid reflux symptoms. As you go through the 4-day study, please:

• 1. Apply the principles below (requires careful reading and implementation)

• 2. Keep a diary of what you ate every 24 h of the study and return it to us for analysis

• 3. Start counting each 24-h period from the time you left the hospital forward. Break the study in 4 periods, each ideally including breakfast, lunch, and dinner (plus snacks).

• 4. You should use the first 2 days (0–48 h) to eat anything you like, particularly anything that you know might cause your acid reflux symptoms. A McDonald’s meal, pizza, spaghetti with red sauce or alcohol, can be bad, particularly in large portions.

• 5. The last 2 days (48–96 h) should be very strict, based on the recommendations below (pages 2 to 5). During this time, you will have to avoid the “bad” things. General cooking suggestions are provided.

• 6. Please do not use a PPI (proton pump inhibitor) during the testing period (0–96 h). You can use antacids (such as Tums) for severe symptoms, as needed.

The following table helps you separate foodstuffs that cause reflux from those that either prevent reflux or alleviate it. Please read it carefully and apply its principles.

Good and bad foods

Foodstuffs with concentrated sugar that cause reflux and pain	Foodstuffs that prevent reflux or quickly alleviate symptoms
1. All grain products  All kinds of bread and pastries, cakes, all kinds of Muesli or porridge;  Noodles, dumplings, gnocchi, ravioli, rice, rice noodles, corn, and popcorn  Artificial sweeteners, aromas, preservatives	1. Animal products  Beef, pork, lamb, game, smoked meat, roast beef, ham and bacon without sugar (no packaged cold cuts, sausage, or ham!)  Chicken and turkey, all kinds of fresh or smoked fish and fresh seafood (exception: seafood may be frozen)  Hard-boiled eggs (no soft-boiled or fried eggs!)
2. Dairy products  Any kind of milk, yoghurt, milk shakes, or yoghurt drinks; butter, cream, cheese, mayonnaise
3. Vegetables  Onions, beans, green beans, peas, cabbage, beets; yellow, orange, and red bell peppers, carrots*), pumpkin, soybeans, tofu, potatoes in any form (incl. chips, French fries, etc.)	3. Vegetables (always unpeeled)  All kinds of lettuce, herbs, chicory, spinach, green peppers, tomatoes, cucumbers, radishes, fresh capers, chives, fennel, boiled asparagus, olives
4. Fruit  Apples (except for the kinds listed at the right), oranges, mandarin oranges, bananas, pears, lemons, limes, apricots, greengages, plums, cherries, strawberries, dates, mangos, pineapples, kiwis, carambola	4. Fruit (always unpeeled)  Green apples (e.g., Granny Smith),  Pink Lady apples, russet apples
5. Beverages  Cocoa, hot chocolate, fruit juices, all kinds of carbonated and lifestyle drinks (e.g., smoothies), energy drinks, even in low-calorie form!  All kinds of alcohol: beer, wine, champagne, hard liquor	5. Beverages  Mineral water, tea, coffee (espresso, without milk, sugar, or artificial sweeteners)
6. Preparation and spices  No steaming (incl. woks) or breading,  No pumpkin seed, canola, sunflower, flaxseed oil, and no margarine (not even diet margarine),  No ready-to-use spice mixtures, mustard, ketchup, dips, etc.  No vinegar  No soups, as the concentrated sugar is dissolved	6. Preparation and spices  Boil, grill, fry (pan or oven)  Olive oil, salt, pepper, any kind of herb (parsley, chives, marjoram, thyme, basil, oregano, dill, chili pepper without sugar, etc.), cress, garlic

Strict Reflux Diet—Only “Good” Things

The following recommendations are for orientation—give your creativity free rein for combining different foods:

Breakfast:

• Green apple (Granny Smith) + olive oil, pepper, and salt

• Green salad, chicory, spinach leaves mixed with olive oil

• Green pepper (if it does not cause regurgitation), tomatoes, cucumber, radishes, fresh capers, chives, fennel, olives; mix salad with pepper, salt, (see spices below)

• Olive oil with no sugar or preservatives

• Prosciutto, ham with no sugar, bacon with no sugar

• Raw fish (sashimi), smoked fish (salmon, eel, tuna), seafood, cold pork roast, cold smoked meat, cold roast beef, cold chicken

• Hard-boiled egg (no soft-boiled or fried eggs, they contain concentrated sugar!).

Mornings:

A small snack every hour:

A piece of cucumber/green apple/radish/green pepper, olives with or without olive oil, ham, bacon, meat, hard-boiled egg.

Why every hour? Eating every hour provides the body with energy, neutralizes gastric acid, strengthens the lower esophageal sphincter, and thus prevents reflux in the morning.

Lunch:

You have a large selection for lunch:

Raw:

See breakfast, or:

Raw fish with salad with no rice (sashimi), smoked salmon (with no sugar or preservatives), seafood (shrimp, scampi, etc.) with sauce containing no sugar.

and/or:

Cooked:

e.g., Beef: Boiled pork or beef with spinach leaves and green salad, but with no soup (= contains sugar solution!)

e.g., Boiled fish: poached trout/char/whitefish

and/or:

Grilled:

Beef: T-bone steak, filet, tenderloin steak, roast beef, etc.

Pork: pork tenderloin, pork chop

Poultry: chicken, turkey, ostrich

Lamb, goat

All kinds of fish and seafood: Fresh or saltwater fish (trout, zander, char, salmon, cod, halibut, sole, tuna, sea bass, octopus, etc.), crustaceans (shrimp, scampi, crabs)

All grilled with olive oil

and/or:

Fried:

Pork: Smoked pork (warm or cold) with or without horseradish, warm or cold pork roast with garlic, cabbage salad with bacon, but no sugar!

Beef: Beef roast (do not add any artificial sauce!)

Poultry: Chicken, turkey

Lamb, goat

All kinds of fish and seafood: Fresh or saltwater fish (trout, zander, char, salmon, cod, halibut, sole, tuna, sea bass, octopus, etc.), crustaceans (shrimp, scampi, crabs)

All fried (oven or pan) in olive oil

Salads:

Green salad, chicory, cucumber, fennel, tomatoes, radishes, radicchio, olives, hard-boiled egg, spinach leaves, boiled asparagus;

Marinate with pepper, salt, olive oil, garden herbs, and cress. Do not use vinegar because it contains sugar!

Caution:

Do not use butter, canola oil, sunflower seed oil, or pumpkin seed oil for frying

Do not eat anything steamed with onions (e.g., goulash, roast beef with onions)

Do not prepare food in a wok, as this steams it and dissolves the sugar

Do not eat anything breaded (wiener schnitzel, cordon bleu, fried chicken, fish, etc.).

Afternoons:

Eat a small snack every hour; see the recommendations for mornings for ideas

Supper:

See the suggestions for breakfast and lunch for ideas

The same applies after the evening meal: a small snack every hour!

Beverages throughout the day:

Water, espresso, or small espresso diluted with hot water without sugar, artificial sweeteners, or milk; all kinds of tea without sugar, preservatives, or artificial sweeteners.

Some delicious suggestions for meals:

Warm dishes:

• Grilled chicken breast wrapped in bacon with tomato confit (chopped tomatoes with garlic and olive oil heated briefly in the oven) and basil pesto

• Beef steak with warm spinach salad and caper and olive sauce with garlic, herbs, and anchovies

• Roast pork shoulder marinated in garlic and marjoram with warm cabbage and bacon salad

• Medium rare roast beef with green peppers and hard-boiled egg

• Boiled beef with spinach and fresh Granny Smith apple horseradish

• Grilled seafood with tomato-pepper confit and green salad

• Fried char with tomato and cucumber salad

Cold dishes:

• Seafood with green salad, cucumber, tomato, radish, green apple, marinated with olive oil, pepper, and salt

• Smoked salmon with tomatoes, cucumber, olives, capers, hard-boiled egg, and green salad

• Prosciutto with cucumber, tomato, radishes, olives, capers, pepper, and salt

• Lamb kebabs with tomato, olives, cucumber, salt, and pepper

Translated and modified from: Riegler M, HÖnig-Robier, K. Nie wieder sodbrennen. Reflux verstehen und in den griff bekommen. maudrich-Verlag 2014.