Human Nutrition & Metabolism 33 (2023) 200203

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Human Nutrition & Metabolism

journal homepage: www.sciencedirect.com/journal/human-nutrition-and-metabolism

The relationship of gastroesophageal reflux with nutritional habits and

mental disorders
Aliye Özenoğlu a, *, Nejla Anul b, Büşra Özçelikçi b
a
İstanbul Bilgi University, Faculty of Health Science, Nutrition and Dietetics Department, İstanbul, Turkey
b
Demiroğlu Bilim University, Faculty of Health Science, Nutrition and Dietetics Department, İstanbul, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Gastroesophageal reflux disease (GERD) is one of the most common health problems of the upper gastrointestinal
Stress system, in which complex biopsychosocial factors play a role in its development. In addition to bad nutritional
Anxiety habits, it is known that psychological stress has aggravating effects on gastroesophageal reflux symptoms. Pre­
Depression
senting the current evidence obtained from studies on this subject can be a guide for both clinicians and patients.
Mood
Lifestyle
The role of various factors such as poor eating habits, obesity, stress, anxiety, sedentary lifestyle, sleep dis­
Eating habits orders, smoking and alcohol in the etiology of GERD is emphasized. Pharmacotherapy is considered first-line
Obesity therapy for patients with GERD, but lifestyle modification, including dietary changes, is an important element
Gastroesophagial reflux in supporting the treatment of the disease. However, although lifestyle change offers a more effective, lower cost
Quality of life and less side-effect treatment, it is often seen to be insufficient in practice.
The results of the studies show that reflux is closely related to mental state and eating habits affect both reflux
and mood. In the management of GERD, the evaluation of biopsychosocial factors together and the application of
a multidisciplinary approach can make a significant contribution to increase the success of the treatment and
quality of life.

1. Introduction The most characteristic symptom of the disease is heartburn, which

occurs at least once a week. Other symptoms are chest pain not related to
Gastroesophageal reflux disease (GERD) is an important health ischemic heart disease, effortless regurgitation, paroxysmal cough
problem which occurs due to the reflux of stomach contents into the (mostly at night), sore throat, gingivitis or damage to tooth enamel.
esophagus or oral cavity [1]. The global incidence of GERD has been Heliobacter pylori gastritis, obstructive sleep apnea, obesity and hiatal
reported as 13.98%. While it is seen at relatively higher rates hernia are risk factors for GERD [4].
(10.0–33.0%) in North America, Europe and the Middle East, it varies GERD can cause various physiological problems (such as regurgita­
between 2.5% and 7.8% in East Asia, while in Turkey it is similar to tion of food or sour stomach contents, difficulty swallowing, laryngitis,
western countries (10.0–20.0%) [2]. chronic cough, burning sensation in the chest, abdominal pain)3,5,6 as
Gastroesophageal reflux (GER) can be defined as the involuntary well as psychosocial problems such as depression, anxiety, behavioral
passage of stomach contents into the esophagus, which develops phys­ maladaptations and sleep disorders.7,8,9,10 These problems all
iologically during the adaptation of the stomach to foods in the post­ contribute to the reduction of quality of life.
prandial period, also in healthy individuals. Temporary relaxation of the If the disease is not treated, it can lead to complications such as
lower esophageal sphincter (LES) or the inability of the sphincter tone to esophageal stricture, gastrointestinal bleeding, and esophageal adeno­
adapt to changes in intra-abdominal pressure may cause reflux. Stomach carcinoma [5]. GERD is generally classified into three subtypes: reflux
contents that have escaped into the esophagus are often made up of acid, esophagitis (RE), non-erosive reflux disease (NERD), and Barrett’s
pepsin, and sometimes bile. Physiological reflux is short-lived and does esophagus (BE).
not cause any symptoms. If reflux causes disturbing symptoms or Treatment of the disease is usually with drugs known as proton pump
esophageal injuries and negatively affects quality of life, this condition is inhibitors (PPIs). Long-term use of PPIs is known to associate with bone
defined as gastroesophageal reflux disease (GERD) [1,3]. fractures, chronic or acute renal disease, pneumonia, and intestinal

* Corresponding author. İstanbul Bilgi University, Faculty of Health Science, Nutrition and Dietetics Department, Dolapdere, İstanbul, Turkey.
E-mail addresses: aozenoglu@yahoo.com (A. Özenoğlu), nejla.anul@demiroglu.bilim.edu.tr (N. Anul), dyt.busraozcelikci@gmail.com (B. Özçelikçi).

https://doi.org/10.1016/j.hnm.2023.200203
Received 8 May 2023; Received in revised form 18 June 2023; Accepted 21 June 2023
Available online 29 June 2023
2666-1497/© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
A. Özenoğlu et al. Human Nutrition & Metabolism 33 (2023) 200203

infections [1]. A significant proportion of patients, ranging from 10 to examining the relationship of GERD with eating habits, anger level and
40%, do not respond adequately to PPI treatment. This condition is anxiety status in hospital employees [17], Beck Anxiety Scale (BAI)
known as refractory GERD (rGERD), which is not only impairs patients’ scores were found to be significantly higher in those with reflux (14.74
quality of life, but also significantly increases healthcare costs [5]. In ± 1.64 and 8.82 ± 0.58, respectively; t = 4.2; p < 0.001). In addition,
addition to drug therapy, behavioral changes in dietary habits and the rate of those who reported that their lifestyle was stressful was
lifestyle may be helpful in preventing reflux symptoms. Suggestions for higher in the group with reflux (χ2 = 13.149, p = 0.001). Wang et al.
behavioral change include not going to bed right after dinner or [12] in their study in which they compared the RE group (n = 361)
avoiding eating late at night; not to consume mint, chocolate, spicy or consisting of individuals diagnosed with definite reflux esophagitis (RE)
acidic foods; avoiding coffee, tea, carbonated drinks and smoking; and the control group (n = 328) consisting of healthy individuals
raising the head of bed by 15–20 cm are considered. Weight loss may without heartburn, regurgitation and other gastrointestinal symptoms;
also be helpful in obese individuals [2,6]. drinking brewed tea, preferring acidic foods, overeating, having a short
It is known that the relationship between systemic and psychiatric interval between dinner and sleep, and a history of anxiety, depression,
diseases is bidirectional and this situation further increases the constipation and hypertension have been associated with reflux.
complexity of the underlying pathophysiological processes [7]. The re­ Sleep disorders are often caused by lifestyles, wrong eating habits
sults of a recent meta-analysis showed a significant positive association and/or digestive system diseases. The most important cause of sleep
between psychosocial disorders and GERD. GERD patients are more disturbance is awakening due to problems such as indigestion, heart­
likely to develop psychosocial disorders than healthy people; it has also burn, increased acidity, cough or respiratory distress. It is believed that
been reported that psychosocial disorders may increase the risk of GERD there is a reciprocal relationship between reflux and sleep disorders. On
[8]. Studies have found that the most common psychiatric disorders the one hand, GERD symptoms cause difficulty in falling asleep, inter­
associated with GERD are anxiety disorders and depression [8,11–14]. rupted sleep, and early morning awakenings; while on the other hand,
Physical and/or psychological stress associated with systemic disease insomnia has an increasing effect on esophageal hyperalgesia [6]. Some
may lead to the activation of the immune response system, resulting in occupations that affect sleep patterns and lifestyle habits (such as shift
increased local and systemic release of proinflammatory cytokines [11]. work occupations) may play a role in the etiology of GERD [2].
Increased levels of inflammatory mediators in the central nervous sys­ It has been suggested that reflux negatively affects the quality of life
tem (CNS) are potentially important contributors to the deleterious of individuals and may impair their daily activities [19]. In a study
cellular and morphological adaptations that underlie the development aiming to determine the main variables affecting the quality of life of
of comorbid mental illness (Fig. 1). GERD patients [20], it was found that their quality of life was negatively
Studies have found that different emotions underlie various physio­ affected by increasing age and high body mass index (BMI). It was
logical diseases experienced in the body [1,15]. In this context, it was determined that none of the other demographic variables and accom­
observed that emotions such as rage-anger settled in the stomach area. It panying diseases had a significant effect on the quality of life of the
has been determined that, with the elimination of rage and anger feel­ participants. Similar to individuals with inflammatory bowel disease, an
ings with psychotherapies, much faster recovery with medication is assessment of quality of life can be an important guide for treatment, as
experienced in physiological disorders of the stomach [12,14]. individuals with GERD also experience a decline in their quality of life.
The increasing effects of psychological stress on gastroesophageal In this article, the relationships of GERD with food, nutritional
reflux have been shown in various studies [8,13,16]. In a study habits, some nutritional components and mental disorders were
examined.

1.1. The relationship between reflux and diet

Diet has an important role as an environmental factor in GERD,

which is a multifactorial disease affected by both genetic predisposition
and environmental factors. Obesity, smoking, alcohol and excessive
caffeine consumption, fatty or fried foods, chocolate and hiatal hernia
are among the factors that increase the risk of GERD [21]. Modifiable
risk factors related to diet include long meal-sleep intervals, rate of
eating, and quantity and temperature of food. Alcohol, chocolate and
high-fat food intake reduces esophageal sphincter pressure and increases
esophageal exposure to gastric fluids. In a systematic review examining
the relationship between reflux disease and diet [22], it was concluded
that consumption of citrus fruits, fizzy drinks, spicy and fried foods
increased the risk of developing this disorder, while diets rich in vege­
tables, fiber, antioxidants and caffeine were not significantly associated
with increased risk of dysphagia. In addition, a specific diet that plays an
effective role in GERD has not been determined.
It is seen that the nutrition and lifestyle changes that form the basis of
GERD treatment are generally ignored by the experts and are not applied
sufficiently by the patients. Patients mostly report that nicotine, alcohol,
carbonated drinks, caffeine or coffee, chocolate, onions, tomato sauce,
mint, citrus fruits and their juices, fatty and spicy meals aggravate
GERD-related symptoms [2]. However, the effect of avoiding these foods
or the role of dietary therapy and its mode of administration is not well
defined. While concerns remain about the side effects of long-term use of
PPIs, patients and healthcare professionals are becoming increasingly
interested in the role of diet in reflux management [23].
Fig. 1. The relationship of GERD as a systemic disease with psychiat­ Obesity is considered a risk factor not only associated with GERD,
ric disorders. but also with its complications such as reflux esophagitis, Barrett’s

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A. Özenoğlu et al. Human Nutrition & Metabolism 33 (2023) 200203

esophagus, and esophageal adenocarcinoma. It has been reported that Table 1

this relationship is associated with central obesity triggering reflux by GERD and diet relationship.
increasing intra-abdominal pressure and disrupting anti-reflux mecha­ Dietary components Effect on GERD symptoms
nisms [2]. However, it has been suggested that visceral adipose tissue
Specific food and drinks
(VAT) produces a large number of cytokines, leading to esophageal Acidic foods/drinks Irritation of the esophageal mucosa
inflammation and disruption of mucosal barrier integrity, thereby Carbonated drinks Increase in gastric distension/Temporary LES relaxation
sensitizing the esophageal mucosa to GERD-induced injury [24]. Coffee Decreased LES tone
In their study Ahmet et al. [25] investigated the relationship between Alcohol Decreased LES tone and gastric motility
Chocolate Decreased LES tone
GERD and lifestyle and eating habits in a total of 2000 outpatients in Mint Decreased LES tone
Pakistan. In the study, some lifestyle factors such as less exercise time Spicy food Irritation of the esophageal mucosa
(90.9%), the habit of eating snacks in the middle of the night (78.3%), Macronutrients
and the time between dinner and sleep less than 2 h (87.3%), were found Fats Decreased LES tone and gastric motility
Carbohydrates Decreased LES tone
to be highly correlated with GERD. Among lifestyle factors, it has been
Eating behaviors
reported that especially lack of physical activity, smoking, insufficient Eating late at night Increased gastric acid production
sleep, late evening meals and going to bed after dinner were closely Large meal Increased gastric distension and transient LES relaxation
associated with GERD symptoms. Calorie-dense meal Increased gastric distension and transient LES relaxation
A systematic review investigating the relationship between GERD (GERD, gastroesophageal reflux disease; LES, lower esophageal sphincter).
occurrence and different foods and dietary patterns found a significant
relationship between adherence to high-fat diets and increased risk of
understanding the pathophysiology of the disease. Carbohydrates, pro­
GERD [22]. Consumption of large, high-fat meals was associated with
teins and fats, the three main macronutrients of the human diet, have
increased acid exposure time in patients compared to low-fat meals, as
different biochemical compositions and calorie densities. These dietary
well as accelerate the development of GERD by reducing lower esoph­
components have various tasks in the body, such as generating energy
ageal sphincter (LES) pressure. This review also concluded that, contrary
and maintaining cellular metabolic activities.
to what is known, consuming high-salt foods, spicy foods, smoked foods
and fast foods does not significantly increase the risk of GERD. It has
1.2.1. Carbohydrates
been reported that increased salt intake is only effective in reducing LES
When disaccharides and polysaccharides from carbohydrates are
pressure and cannot increase the risk of GERD alone, and in Asian
consumed in the diet, they are partially absorbed in the small intestine
populations, consuming spicy foods and then going to bed after a meal
and then fermented by bacteria in the colon. It has been shown that this
are effective in increasing the risk of GERD. Vegetables (raw or cooked
fermentation process can induce heartburn by inducing neurohormonal
vegetables), dietary fiber, dairy products, and antioxidants were not
release (cholecystokinin = CCK) and lower esophageal sphincter (LES)
significantly associated with an increased incidence of GERD. This result
relaxation [30]. Various studies have reported that diets high in total
suggests that adherence to a Mediterranean diet (rich in vegetables, fiber
carbohydrates and simple sugars increase esophageal acid exposure time
and antioxidants) may play a preventive role in GERD, especially in
and the number of reflux episodes [30,31]. In contrast, a study of pa­
patients with underlying disease. Furthermore, consumption of tea,
tients on a low-glycemic diet found a statistically significant improve­
coffee, chocolate and alcohol was not found to be significantly associ­
ment in symptoms, but the patients lost surprisingly weight over the
ated with the risk of developing GERD. Fizzy drinks can increase the
same time period [32].
likelihood of dysphagia reflex by altering the acidity of the gastroin­
While increased intake of monosaccharides and starch was associ­
testinal tract, especially the stomach, and affecting digestion. It should
ated with increased symptoms, the opposite effects were found for fiber
also be noted that these beverages contain high levels of acidity, added
intake [33]. It was determined that 36 patients who previously
sugars and artificial sweeteners, and caffeine, which alter LES pressures
consumed a low-fiber diet (<20 g/day) followed by psyllium three times
and intraesophageal pH [23].
a day had a reduction in both symptoms and mean reflux episodes [34].
A study [26] examining the relationship between the DASH-style diet
Although the mechanism of fiber healing heartburn is not well known, it
approach and GERD risk and symptoms in adolescents found that ado­
should be noted that excessive fiber consumption may increase reflux
lescents with the highest adherence to the DASH-style diet had a lower
symptoms.
chance of developing GERD.
In addition, it can be thought that prebiotics taken with fibrous foods
Although inconsistent results were found in some studies due to the
may play a role. Prebiotics contribute to the bidirectional communica­
problems arising from the method of the studies, the following sugges­
tion between the gut and the brain by enabling the reproduction and
tions can be developed in the light of the findings of the existing studies:
colonization of probiotics in the gut. Products containing pre- and pro­
These include reducing the portion size consumed at meals; consume
biotics together are called symbiotics and have a stronger effect
less foods rich in fat, sugar and animal protein; avoiding triggers and
potential.
allergens such as soda, cigarettes, alcohol, caffeine; avoiding food within
3 h of bedtime; raising the head of the bed, regular exercise and main­
1.2.2. Proteins
taining healthy eating habits such as the Mediterranean diet. Further­
Although there are opinions that proteins will increase LES pressure,
more, dietary supplements such as digestive enzymes, glutamine,
there have not been enough studies examining the relationship between
licorice root, magnesium, and probiotics have been suggested to alle­
GERD and dietary proteins. In a study [35] conducted to evaluate the
viate the severity and frequency of symptoms [27,28].
effect of diet on the occurrence of proximal reflux attacks in lar­
The relationship between GERD and diet is summarized in Table 1.
yngopharyngeal reflux (LPR) patients, a multi-channel intraluminal
Studies examining the effectiveness of certain elimination diets (soft
impedance-pH monitoring (MII-pH) method was used. As a result of the
drinks, carbonated beverages, tea, coffee, chocolate, fatty and fried
study, it was determined that the consumption of foods with high fat and
foods, spices, etc.) yield conflicting results [5,12,23,29], has encouraged
sugar content but low in protein, and acidic foods and beverages were
researchers to explore the role of macronutrients.
associated with more reflux attacks in LPR patients. In another study
[27] examining the effects of a diet rich in animal or vegetable protein in
1.2. Effects of macronutrients a group of patients with different reflux symptoms, vegetable proteins
were associated with fewer reflux, especially acid reflux, and fewer
Understanding the mechanisms of action of dietary components can symptoms in the first hour after a meal.
make an important contribution to the management of GERD, as well as

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A. Özenoğlu et al. Human Nutrition & Metabolism 33 (2023) 200203

In a systematic review of dietary and lifestyle factors related to GERD effects on some GERD symptoms (regurgitation, indigestion, heartburn
[36], vegetarian diets were negatively correlated with GERD, while and nausea, abdominal pain, and flatulence) [47].
protein and fat were positively correlated. In non-erosive reflux patients
(NERD), consumption of vegetables, fruits, milk and tea was negatively 1.4. The influence of nutrition and mood
associated with NERD, while the relationship between egg and NERD
was inconsistent. In this review, based on studies examining the rela­ In addition to contributing directly to the development of reflux,
tionship between reflux esophagitis (RE) and diet, it was determined foods and nutritional components can indirectly affect the development
that refined carbohydrate, protein, fat and energy intake were positively or severity of reflux symptoms by affecting the mood. Because it is
associated with RE. known that there is a reciprocal relationship between food preferences
Studies of dietary intervention also suggest that reducing the con­ and diet and mood, and that this relationship is mediated by the gut-
sumption of a diet rich in fat and refined sugars may have a positive microbiota-brain axis [48]. It has been suggested that depression may
effect by reducing the risk of progression of BE to adenocarcinoma [21, develop as a result of the effects of changes in the gastrointestinal system
22,29–31]. microbiome caused by diet-related factors in reflux on the brain [49]. It
is now better understood that the gut-brain axis plays an important role
1.2.3. Fats in the relationship between nutrition and psychological disorders.
It is hypothesized that high-fat diets, especially foods rich in fat or Accordingly, dietary interventions such as the use of pre- and probiotics
fried, worsen GERD symptoms. Fat is the nutrient with the highest en­ for modulation of the gut microbiota have been shown to be promising
ergy value, and its digestion requires the secretion of bile salts and in improving depressive symptoms [45].
cholecystokinin. Bile salts have esophageal irritant potential, while The central nervous system (CNS) plays an important role in the
cholecystokinin can stimulate LES tone by neurohormonal pathways. conscious perception of the senses and maintaining homeostasis, as well
Study results regarding the effects of high- and low-fat diets on reflux as the control of food intake. The entire process of digestion and ab­
symptoms are conflicting. It was thought that the fact that variables such sorption is precisely driven by complex neuro-humoral feedback
as total calorie intake, BMI values, and fatty acid types (saturated, un­ mechanisms through which the gut can sense and respond to intra­
saturated, medium (MCT) and long (LCT) chain triglycerides) were not luminal stimuli. These reflex pathways are distributed within the auto­
taken into account in these studies may have led to conflicting results nomic and enteric nervous system. Stimuli in the gut can also activate
[37–39]. afferent brain pathways. Thus, when a food is consumed, sensory ex­
Kubo et al. [40] investigated protein and fat as dietary factors, and periences such as satiety are induced, as well as digestive responses.
lifestyle factors such as smoking and alcohol consumption (excluding These experiences are related to the hedonic dimension of sensory
beer and wine). The study included 317 individuals diagnosed with experience. There is a dynamic bidirectional communication mediated
GERD and 182 individuals as the control group. According to the results by neural and humoral pathways between the host and the microbiota.
of the study, while vegetarian diets, consumption of fruits, vegetables, Both the compounds released during the digestion-absorption process of
vitamins and fiber, 3 h or more between dinner and sleep or physical foods and the metabolites produced in the microbiota may play a role in
exercise, the frequency of GERD was negatively correlated, while poor mood [50].
eating habits showed a positive correlation. Neurobiological mechanisms thought to play an important role in the
A study examining the effects of specific diets found that those comorbidity of GERD and depression are summarized below [8].
following a traditional Mediterranean diet had a lower incidence of Psychological disorders can affect the perception of esophageal pain,
GERD symptoms [41]. It is known that the Mediterranean diet, in which causing patients to feel hypersensitive to internal organs. Because the
refined sugars, saturated fats, red meat and processed foods are neurotransmitter serotonin, which is effective in mood, is also effective
consumed less, but whole grains, legumes, vegetables and fruits, nuts, in pain perception and an important part of serotonin synthesis is done
fish and olive oil are consumed more, have positive effects on both by intestinal bacteria [48].
physical and mental health [42]. Stress disrupts the tight junctions of the esophageal epithelium,
which weakens the barrier function of the esophageal mucosa.
1.3. Effects of probiotics Mental health problems such as anxiety can impair motor function of
the esophagus. This may result in decreased lower esophageal sphincter
Probiotics are defined as live microorganisms that have positive ef­ pressure and esophageal motility disorders.
fects on the health of the host when consumed in sufficient quantities. A It has been reported that exposure to acid in patients with GERD
new class of probiotic microorganisms known to have positive effects on causes faster and more brain activity compared to healthy individuals.
mental health through the microbiota-gut-brain axis is referred to as Mental disorders increase the perception of mucosal stimuli in the
psychobiotics [43]. It is thought that taking psychobiotics in the esophagus through the brain-gut axis. Thus, it makes them more sus­
composition of fermented foods or as nutritional supplements will have ceptible to pain sensations and heartburn. In addition, the
beneficial effects on general health as well as mental health [44]. inflammation-triggering effect of chronic stress may increase the
Since it is known that there will be no physical health or vice versa occurrence of reflux symptoms.
without mental health, it can be predicted that pre- and probiotics will It has been suggested that the poor efficacy of PPI treatment in pa­
have indirect effects on reflux symptoms. Evidence suggests a link be­ tients with GERD may also be due to psychological factors [8].
tween gut dysbiosis, or an imbalance of the organisms that make up the It is known that some foods and diet types have negative effects on
gut microflora, and various mental illnesses, including anxiety and mood, similar to their effects on the development of reflux symptoms
depression [45]. [48]. It has been shown that a Western-style diet with high consumption
It has been accepted that probiotics benefit intestinal health by of saturated fats, trans fats, processed foods and added sugar is associ­
improving intestinal functions. Furthermore, it has been suggested to ated with an increase in the prevalence of depression and anxiety, while
have a wide variety of activities, such as metabolic effects resulting from a Mediterranean diet has a lower risk of depression [51]. Plenty of ev­
enzymatic activities, effects on the barrier function of the gut, and ef­ idence shows that consuming well-balanced meals rich in fruit and fiber,
fects on the central nervous system and enteric immunity [46]. The ef­ with optimum amounts of protein and healthy fats, and relatively low
fects of probiotics, especially on the lower digestive system, are better levels of sugar and carbohydrates (especially those with a high glycemic
understood, and their activities in the upper gastrointestinal (GI) tract index), with an overall lower amount of calories, supports physical and
are not well known. In a systematic review examining the effects of mental health [42,52].
probiotics in GERD, it was reported that probiotics have beneficial In a study conducted to examine the relationship between common

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A. Özenoğlu et al. Human Nutrition & Metabolism 33 (2023) 200203

mental disorders (CMD) and dietary intake among Brazilian under­ significantly more common in individuals with GERD compared to in­
graduate students, the overall prevalence of CMD was found to be dividuals without (19.5%), and individuals with GERD had a higher
44.5%. Individuals with CMD have been reported to have a higher prevalence of depression.
average intake of added sugar and saturated fat and a lower average In a study conducted to observe the relationship between lar­
fiber intake [53]. yngopharyngeal reflux disease (LPRD) and the sleep status of patients
All processes involved in the regulation of eating behavior are and to investigate the factors related to LPRD, it was reported that those
managed by the brain. Changes in brain function depending on mood in the reflux group consumed more tobacco, alcohol, and high-fat diet.
can affect food preferences and eating behavior. Or, changes in brain While a high-fat diet and sleep disturbance have been identified as in­
structure and function caused by diet may affect their mood [54]. In­ dependent risk factors for reflux, it has been reported that sleep
dividuals with mood disorders are known to exhibit different protein, disturbance may cause or exacerbate anxiety and depression in patients
fat, and carbohydrate consumption compared to the general population with LPRD [9]. In another cross-sectional study, it was shown that
[55,56]. The effects of macronutrients on mood can be summarized as anxiety and depression levels in individuals with GERD, especially in the
follows: non-erosive reflux disease (NERD) subtype, were significantly higher
Protein: Low protein consumption is associated with a significantly than in control groups [13].
increased risk of depression compared to normal protein consumption. In a cross-sectional study examining the prevalence of anxiety and
The positive effect of adequate protein intake on mood can be explained depression in 258 GERD patients with and without chest pain; the fre­
in part by its involvement in the synthesis of a number of neuropeptides quency of anxiety and depression was found to be significantly higher in
and neurotransmitters in the brain and gut [48]. It has been reported those with GERD, especially those who reported chest pain [59].
that the prevalence of depression decreased significantly when the rate It has been shown that there is a bidirectional relationship between
of calories provided from protein was increased by 10% [56]. gastroesophageal reflux disease and depression [10]. It is important to
Fat: Chronic high-fat diet has been shown to be associated with consider both reflux symptoms and depression and anxiety in the
negative emotional states such as anxiety and depression in both animals treatment plan. Some medications to avoid in the treatment of anxiety
and humans [54]. High-fat foods may cause temporary changes in mood, and acid reflux are tricyclic antidepressants, benzodiazepines, and se­
possibly through neural signals in the brain-gut axis. It is hypothesized lective serotonin reuptake inhibitors (SSRIs). Tricyclic antidepressants
that fats interfere with the synthesis of serotonin, an important brain have been proven to reduce the pressure in the lower esophageal
chemical involved in the development of depression, and therefore a sphincter, esophageal motility due to the use of SSRIs is impaired and
high-fat diet causes mood disorders [49]. High-fat diets can lead to may subsequently lead to acid reflux attacks. In addition, other factors
dysbiosis in the intestinal epithelium, resulting in the release of in­ such as obesity, eating habits such as excessive consumption of fried
flammatory factors, which may further increase the risk of depression foods, smoking and alcohol consumption, and insomnia cause high
through changes in signaling pathways to the brain. Furthermore, it has stress that can contribute to the development of depression and GERD
been reported that a high omega 6/omega 3 fatty acid ratios in the blood [4].
is associated with an increased risk of suicide in depressed patients.
Improvement of depression has been associated with a reduction in fat 2. Conclusion
intake, but it is unclear whether a reduction in fat intake leads to
improvement in depression or improvement of depression leads to Gastroesophageal reflux is one of the most common health problems
improved eating habits [55–57]. of the upper gastrointestinal system today, and complex biopsychosocial
Carbohydrate: Some evidence suggests that carbohydrate consump­ factors play a role in its etiology. Factors such as poor eating habits,
tion improves mood in the short term while increasing psychological stress, anxiety, sedentary lifestyle, and sleep disorders are conditions
distress in the long term. Carbohydrate craving, which is generally that can be controlled and changed in the prevention and treatment of
observed in seasonal affective disorder (SAD) and unipolar depression, GERD development. The results of the studies show that reflux are
has been associated with fatigue, depression, paranoia, and disordered closely related to the psychological state, and that dietary habits affect
eating behaviors. In addition, sucrose consumption is higher in mood both reflux and the psychic state. Various working conditions and life­
disorders than in the general population, and increased consumption of styles can affect the level of stress and anxiety, as well as nutrition,
processed foods has been shown to be associated with depressive exercise, sleep patterns and some habits of individuals. It is clear that a
symptoms [54]. multidisciplinary approach to the assessment and management of these
psychological and lifestyle factors is required for the treatment of GERD.
1.5. The relationship between reflux and psychic state In summary, it was determined that protein and fat as dietary factors
and smoking, alcohol consumption and mental status as lifestyle factors
The etiology of GERD is multifactorial. It has been reported that were positively correlated with GERD and other types of reflux. Vege­
mental disorders, especially anxiety and depression, are closely related tarian diets, fruits, vegetables, vitamins, and fiber are negatively
to the onset and prognosis of the disease [18]. Various medical condi­ correlated with GERD and other types of reflux, while poor dietary
tions and drug treatments, such as cancer, cardiovascular disease, and habits are positively correlated with GERD.
diabetes, can contribute to the development of depression. Psychologi­ GERD is a chronic digestive system disease in which multiple factors
cal factors such as depression and anxiety can affect the severity of play a role. Various dietary and lifestyle factors are known to affect the
GERD symptoms by both lowering the sensory threshold in the human occurrence of GERD. For this reason, providing individualized nutri­
body and increasing esophageal stimulation [4]. GERD plays an tional counseling and psychological support in addition to medical
important role in health-related quality of life by causing difficulties in treatment in the management of the disease may contribute to reducing
daily social activities as well as in the emotional and physical well-being complications and increasing the quality of life.
of affected patients.
In the cross-sectional study of Bai et al. [58] to determine the rela­ Financial disclosure
tionship between GERD and anxiety and depression in the young pop­
ulation, 2500 individuals between the ages of 18 and 40 years This study had received no financial support.
participated. The Frequency Scale for GERD Symptoms (FSSG) was used
to diagnose the disease and the Hospital Anxiety and Depression Scale Declaration of competing interest
(HADS) was used to assess anxiety and depression. In the study, GERD
was diagnosed in 401 (16%) of the participants. Anxiety (40.3%) was The authors declare that they have no known competing financial

5
A. Özenoğlu et al. Human Nutrition & Metabolism 33 (2023) 200203

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