GERD/Heartburn and Metabolic Syndrome

This article is a segment of the series, Diseases Associated with Metabolic Syndrome (MetS). Metabolic Syndrome is diagnosed if three of the following conditions are present: fasting blood sugar more than 100 mg/dl, obesity, hypertriglyceridemia, low HDL, and high blood pressure of more than 130/85. Please refer to this article for more details.

Gastroesophageal Reflux Disease (GERD) is common in 2% to 25% of a given population. It presents as heartburn and acid regurgitation.1 GERD can also perform as a non-productive cough and can exacerbate asthma. The most common complication is Barrett’s esophagus, which has been described as precancerous.

Normal Function

During and after eating, the food should go from the esophagus ⇒  stomach ⇒ small intestine promptly. The esophagus has a sphincter mechanism at the lower part that ensures that the stomach contents stay inside the stomach.  A decrease in the stomach movement (peristalsis) and weakening of the sphincter will result in reflux. The stomach has innate protection against hydrochloric acid, but the esophagus does not. That is why, when the acid reaches the esophagus, it produces a “burning” sensation. If the reflux is vigorous enough, it can reach the back of the throat and elicit an annoying, unannounced cough. GERD is also a common reason for the aggravation of asthma and chronic obstructive pulmonary disease and emphysema (COPD) symptoms.

How does metabolic syndrome cause reflux?

Obesity is associated with relaxation of the lower esophageal sphincter.2

Among overweight subjects, the degree of the acid reflux, ph <4.0 (DeMeester score) correlated with the Body Mass Index (BMI).3

In a study of 100 patients had a pH electrode in their esophagus for 24 hours. 54 have bad GERD. The GERD correlated with age ≥ 30, hyperglycemia, and abnormal waist circumference. Abnormal waist circumference and fasting glucose level ≥ 100 mg/L were the only independent factors among the five components of metabolic syndrome. Metabolic syndrome but not BMI was an independent factor associated with GERD.4 The study just cited is interesting because they were able to go beyond BMI in associating GERD with MetS. Not all patients with a high BMI are obese. A high BMI can also be seen in a muscular individual or somebody with more subcutaneous fat than visceral fat. The fat under the skin (subcutaneous) is metabolically stable and does not produce inflammatory cytokines compared to visceral fat.

771 patients who had GERD, and their Waist Hip Ratio (WHR) were measured. The result showed that WHR is a better predictor for esophageal acid exposure than BMI.5 This is consistent with someone who may look Thin Outside and Fat Inside (TOFI) phenotype who can also have metabolic syndrome.

The next study relates to the article Diseases Associated with Metabolic Syndrome. Part 11.1 Gastrointestinal, Gallbladder Diseases where we talked about the how high blood sugar contributes to gallstone formation by interfering with gallbladder contraction. Gallstone patients had a significantly larger fasting and residual gallbladder volume with slower and less complete gastric emptying than healthy control subjects.

This study shows that a subgroup of gallstone patients with small-mainly asymptomatic-stones have impaired gallbladder and gastric motility as well as abnormal gastro-esophageal pH-profiles.6

A diagnosis of any disease associated with Metabolic Syndrome should prompt a query if you are at risk of developing ischemic heart disease. Talk to your doctor if there is a need to do a fasting blood sugar, serum triglyceride, and HDL level. Monitor your blood pressure and measure your waistline. Intermittent fasting can reverse insulin resistance.

Related Readings:

1. Metabolic Syndrome and the Pancreas
2. Fatty Liver and Metabolic Syndrome
3. GERD/Heartburn and Metabolic Syndrome
4. Crohn’s Disease and Metabolic Syndrome Part 1
5. Crohn’s Disease and Metabolic Syndrome Part 2
6. Gallbladder Diseases and Metabolic Syndrome
7. How Does Exercise Prolong Life?
8. How to be Active from Sedentary
9. How to Do Intermittent Fasting
10. If You Know Anybody Male who is 55 and Older, Read This!

References:

1. Savarino E, de Bortoli N, De Cassan C, Della Coletta M, Bartolo O, Furnari M, et al. The natural history of gastroesophageal reflux disease: a comprehensive review. Dis Esophagus. 2017;30:1–9. [PubMed] [Google Scholar]
2. Wu JC, Mui 2. LM, Cheung CM, Chan Y, Sung JJ. Obesity is associated with increased transient lower esophageal sphincter relaxation. Gastroenterology. 2007 Mar;132(3):883-9. Epub 2006 Dec 19.
3. Kouklakis G¹, Moschos J, Kountouras J, Mpoumponaris A, Molyvas E, Minopoulos G.

   Relationship between obesity and gastroesophageal reflux disease as recorded by 3-hour esophageal pH monitoring. Rom J Gastroenterol. 2005 Jun;14(2):117-21.

4. Kallel L¹, Bibani N, Fekih M, Matri S, Karoui S, Mustapha NB, Serghini M, Zouiten L, Feki M, Zouari B, Boubaker J, Kaabachi N, Filali A., Metabolic syndrome is associated with gastroesophageal reflux disease based on a 24-hour ambulatory pH monitoring. Dis Esophagus. 2011 Apr;24(3):153-9.
5. Ringhofer C, Lenglinger J, Riegler M, Kristo I, Kainz A, Schoppmann SF. Waist to hip ratio is a better predictor of esophageal acid exposure than body mass index. Neurogastroenterol Motil. 2017 Jul;29(7).
6. Portincasa P¹, Di Ciaula A, Palmieri V, Velardi A, VanBerge-Henegouwen GP, Palasciano G. Impaired gallbladder and gastric motility and pathological gastro-oesophageal reflux in gallstone patients. Eur J Clin Invest. 1997 Aug;27(8):653-61.