Akram’s lifestyle: An effective remedy for the management of gastroesophageal reflux disease

Abstract

INTRODUCTION:

The prevalence of gastroesophageal reflux disease (GERD) has generally increased worldwide. Irregular pattern of intake of meals are known to be the most prevalent cause of GERD. The intake of food on top of another meal may cause gastroesophageal reflux either by generating transient lower-esophageal sphincter relaxations (TLESRs) subsequent to distention of the upper part of the stomach or/and delayed gastric emptying due to inhibition of migrating motor complexes (MMCs) in the distal part of the stomach. Present study evaluated the effect of authors suggested regimen “Akram’s lifestyle”, taking meals twice-a-day with the liberty to consume only liquids in the intervening periods on the outcome of patients presenting with mild to moderate GERD.

MATERIALS AND METHODS:

Study included 60 patients with symptoms of GERD who agreed to follow “Akram’s lifestyle”, took two meals a day about 10-12 hours apart, consuming liquids in between meals for a period of two weeks. Typical GERD symptoms of heartburn, acid reflux, nausea, vomiting and dyspepsia as reported by the patients were scored on visual analog scale (VAS). Gastrointestinal and associated complaints were also evaluated by “Yes/No” response. Data obtained before and after two weeks of intervention was analyzed using SPSS version 28.0.

RESULTS:

Final data after 2 weeks were available for 45 patients. There was a highly significant improvement in GERD symptoms (heartburn, reflux, nausea, vomiting, and dyspepsia) within 2 weeks of dietary intervention (P < 0.000). Improvement was also reflected in the significant reduction (>69%) in the gastrointestinal complaints as evaluated by “Yes/No” responses after the dietary intervention.

CONCLUSIONS:

Adherence to “Akram’s lifestyle” for GERD for 2 weeks resulted in a significant improvement or complete relief of symptoms of patients with GERD. Reduced gastric acid secretion, TLESRs and enhanced gastric emptying could be the potential contributing factors in causing this improvement. Further investigations with larger samples are needed to confirm the findings.

Introduction

Gastroesophageal reflux disease (GERD) is frequently encountered in medical and gastroenterology clinics. The prevalence of this chronic disease varies greatly among regions ranging between 8.8% and 27.8% in North America, South America, and Europe, and from 8.7% to 33.1% in the Middle East. Lower figures are reported in Australia (11.6%) and in East Asia (2.5%–7.8%).[1] The overall global prevalence has been calculated to be around 13.98%.[2] A recent study conducted to estimate the occurrence of GERD in a region of South Punjab in Pakistan revealed a prevalence of 26.6%.[3]

Common risk factors associated with GERD may be nonmodifiable or modifiable. Among the nonmodifiable factors, age, gender (seen during pregnancy), and genetic factors, for example, genetic predisposition to hyperacidity or lower esophageal sphincter incompetency are recognized. Considering age, a higher frequency of GERD is seen in the 30s and 70s, which could be related to increased stress and irregular diet in these age groups. While modifiable factors are related to lifestyle, diet, eating habits, and excessive body weight. The risk factors relating to lifestyle that can contribute to GERD include smoking, excess alcohol consumption, and lack of regular physical activity. Dietary factors include fat-rich foods, eating fried, or spicy foods; drinking orange juice or grapefruit juice; and excessive consumption of chocolate, coffee, tea, and carbonated soda drinks and beverages. Dietary patterns such as irregular meals, larger meal volumes, and having meals just before bedtime could aggravate GERD symptoms. Excessive body weight and obesity are also important risk factors.[4]

In a study conducted in Southern Saudi Arabia, an increase in the incidence of upper gastrointestinal lesions compared to a decade ago was correlated with changes in lifestyle and irregular meal patterns.[5] According to another study conducted in Japan, irregular dietary habits had a strong association with GERD. It was also suggested that the usual medication, i.e., the proton pump inhibitors (PPIs) in recommended doses, was not effective in controlling the disease.[6]

PPIs are safe medicines and are used widely as first-line agents in patients presenting with GERD. Their long-term use is, however, not without serious side effects. Most patients end up with months and years of treatment with PPIs. They can cause severe achlorhydria with which patients can develop serious infections such as diarrhea and pneumonia. Their prolonged use can result in the deficiency of Vitamin B12 as well as essential minerals, for example, calcium, iron, and magnesium, in patients causing osteoporosis, anemia, spontaneous fractures, and cardiac arrhythmia.[7] To avoid causing more harm, alternative remedies and management options are recommended for the management of GERD.

Evidence suggests that GERD has a convincing association with irregular dietary habits. Taking another meal on top of an already filled stomach can not only lead to distention of the upper part of the stomach but also trigger a surge in the secretion of gastric acid. Gastric distension may trigger the generation of transient lower esophageal sphincter relaxations (TLESRs). TLESRs occur outside of the swallowing mechanism and are considered the primary mechanism of gastric acid reflux.[8,9]

Repeated refluxes owing to frequent irregular meals lead to inflammation and ulceration of the lower esophagus and GERD symptoms. Uncontrolled chronic GERD could result in many complications including stricture formation, Barrett metaplasia, hyperplasia, and esophageal adenocarcinoma.[10] Moreover, meals taken during the fasting phase of a previous meal prevent the generation of migrating motor complexes (MMCs) in the distal part of the stomach which then travel to the intestines. These MMCs develop during the interdigestive state or the fasting phase, clear the stomach of unwanted waste materials, and push the chyme forward toward the intestines. Lack of the generation of these MMCs results in delayed gastric emptying, aggravating reflux.[11]

Taking into consideration the pathophysiological aspects of GERD and its well-established link with irregular intake of meals shown in literature, an innovative lifestyle approach named, “Akram’s lifestyle” is suggested. “Akram’s lifestyle” is a dietary regimen of taking meals twice a day spaced out between the morning and evening, with the option to consume liquids at the interval when the patient has the desire to eat or drink. This dietary regimen can be an effective alternate remedy used in the management of GERD.

In an earlier pilot study of 20 patients with symptoms of GERD ranging from mild to severe who had been diagnosed with GERD by endoscopy, the patients followed the two meals a day dietary schedule for 2 weeks.[12] They were allowed to have antacids for epigastric pain or reflux as and when needed. Fifteen patients (75%) became symptom free after 2 weeks reporting complete relief, whereas two patients reported partial relief.[12]

One of the participating patients in the abovementioned pilot study was diagnosed by endoscopy to have esophagitis characterized by erosions and ulcerations in the lower part of esophagus, a sliding hiatus hernia, a small Barrett’s, and partial Schatzki’s ring. He followed the suggested “Akram’s lifestyle” advice, i.e., “two meals a day” dietary regimen for several years and continued to be free of reflux symptoms without requiring any medication. An endoscopic examination after an interval of 7 years confirmed the integrity of the sphincter at the lower end of esophagus and no erosions or ulceration in the esophagus.[13]

The objective of the present study was to determine the effect of short-term practice of our recommended dietary regimen, Akram’s lifestyle, on a larger sample in an entirely different set-up and population.

Materials and Methods

The study was conducted at Holy Family Hospital, a teaching hospital of Rawalpindi Medical University (RMU), Rawalpindi, Pakistan, from February 2022 to January 2023. Sixty patients with mild-to-moderate intensity symptoms of GERD (heartburn, nausea, vomiting, dyspepsia, and acid reflux), were randomly included in the study.[14] The objectives and importance of the study were explained to them in detail. The patients were educated about our suggested dietary regimen, i.e. “Akram’s lifestyle,” which recommends two meals a day, 10-12 hours apart (morning and evening) with the freedom to consume liquids in between as and when required. Those who agreed to follow the dietary regimen were requested to follow this regimen for a 2-week period. The liquids allowed to be taken in between the meals were water, fruit juice, tea, coffee, and milk and the like. Patients suffering from esophageal atresia, dysplasia, or cancer were excluded. Ethical approval was obtained from the Institutional Review Board vide Letter No. 137/IREF\RMU\2021 dated 03/09/2021 and written informed consent was taken from all participants in the study.

The demographic data and clinical data of the study participants were recorded on a predesigned questionnaire, derived from a well-documented Reflux Disease Questionnaire, having high consistency and reliability levels, with alpha coefficients ranging from 0.80–0.85 for various GERD symptoms.[15] The presenting gastrointestinal complaints and associated throat and/or nasal symptoms were evaluated by “Yes/No” responses. Classical symptoms of GERD (i.e., heartburn, nausea, vomiting, reflux, and dyspepsia) were also measured on Visual Analog Scale (VAS).

Pre- and post-intervention data obtained after 2 weeks were analyzed by Statistical Package for the Social Sciences software version 28 (SPSS, IBM Corporation, Armonk, NY: USA). Qualitative data were evaluated by the percentage (%) of Yes/No response and quantitative data measured by mean ± standard deviation (SD). As the distribution of data was found to be normal by the Shapiro–Wilk test, the comparison of pre- and post-intervention data was done by Student’s t-test, and P < 0.5 was taken as statistically significant.

Results

Out of 60 patients enrolled in the study, 46 (76.7%) were females. Their ages ranged from 23 to 61 years (mean ± SD: 41.1 ± 12.72 years). The VAS interpretation of GERD symptoms, before and post-dietary intervention, are presented in Table 1 which shows a highly significant improvement in reflux symptoms.

Table 1.

Cumulative visual analogue score for various gastrointestinal symptoms of gastroesophageal reflux disease (GERD), before and after dietary intervention, among patients with GERD at Holy Family Hospital, Rawalpindi, Pakistan, 2023

Symptoms	VAS score before dietary intervention (n=62) Mean±SD	VAS score after dietary intervention (n=45) Mean±SD	P-value
Heartburn	7.75±1.91	0.83±1.43	<0.001
Reflux	5.77±3.09	0.64±1.55	<0.001
Nausea	5.28±3.37	0.13±0.45	<0.001
Vomiting	2.38±3.38	0.04±0.20	<0.001
Dyspepsia	3.13±3.31	0.09±0.35	<0.001

VAS=Visual analog score, SD=Standard deviation

The results of “Yes/No” response to gastrointestinal complaints are given in Table 2. A reduction of 69.1%–88.6% in symptoms of GERD indicates marked improvement after intervention. The “Yes” responses after the intervention were mostly mild, while they were moderate/severe before intervention.

Table 2.

Response to gastrointestinal symptoms, before and after dietary intervention among patients with gastroesophageal reflux disease at Holy Family Hospital, Rawalpindi, Pakistan, 2023

Gastrointestinal symptoms	Before dietary intervention (n=60) Yes (%)	After dietary intervention (n=45) Yes (%)	Absolute reduction %	Percentage reduction %
Heart burn	56/4 (93.3)	13/32 (28.8)	64.5	69.1
Reflux	52/8 (86.6)	6/39 (15.4)	71.2	82.2
Nausea	47/13 (78.3)	5/40 (11.1)	67.2	85.8
Vomiting	24/36 (40.0)	4/41 (8.8)	31.2	72.0
Dyspepsia	35/25 (58.0)	3/42 (6.6)	51.4	88.6

Improvement is estimated from a percentage (%) reduction in the “Yes” response. The “Yes” responses after intervention were mostly mild, whereas they were moderate/severe before intervention

The symptoms related to the throat and nose, such as sore throat, cough, and hoarseness of voice also disappeared with the improvement of classical GERD symptoms.

Discussion

“Akram’s lifestyle” for the prevention and treatment of GERD comprises taking meals twice a day with the authorisation to consume drinks in the intervening period. An adequate interval between two meals prevents repeated surges of hydrochloric acid, distension of the upper stomach, and development of TLESRs, an important factor attributed to Gastric reflux.

Moreover, the interdigestive fasting period between meals generates MMCs in the distal stomach, which propel the food onward, facilitating gastric emptying and thereby preventing reflux. Thus, the proposed dietary regimen serves as the function similar to that of drugs that either reduce HCI secretion or neutralize HCI, as well as prokinetic drugs which reduce gastric emptying time.

The question is Why two meals a day? The emptying time of the stomach is around four to 5 h and that of the upper intestines is also about four to 5 h.[16] Therefore, a suitable interval between 2 meals is around 10 h, i.e., morning and evening. Intake of meals on an empty stomach and intestines is least likely to induce reflux. The suggestions by Fiorentino concur with our proposal of two meals a day but are not in agreement with the intake of fluids in between the meals.[17] We posit that because fluids transit time through the stomach is very brief as discussed below, we do not restrict the intake of fluids between the meals as per the requirement of the individual.[18,19]

Why only liquids during the interval? The rates of gastric emptying are affected by the physical characteristics of the food and its caloric content. The fastest transit is of water as only 50% remains in the stomach at the 10^th min. Liquids with low-caloric value empty at an intermediate rate, 50% leave the stomach by 1 h, whereas the high-calorie liquids leave the stomach at a slower pace with 50% remaining in the stomach at the end of the 2^nd h. Solids take time to start leaving, and they empty from the stomach slowly. The total gastric emptying time of solids is about 4–5 h.[19,20]

It might be argued that taking only two meals in 24 h could lead to an increase in meal size that could exaggerate the symptoms of GERD, but our results do not support this. Although the International guidelines for the management of GERD also recommend the intake of smaller meals, the evidence for this is weak.[21]

Akram’s dietary regimen avoids hyperacidity, allows MMCs to work effectively, and prevents delays in gastric emptying caused by a solid meal on top of a previous meal. Other lifestyle changes, such as reduction in body weight in obese patients, taking dinner at least 3 h before going to bed, raising the head-end of the bed could bring some benefit to certain individuals. Moreover, avoidance of smoking, alcohol, and foods that can potentially trigger reflux can also give favorable outcomes in selected cases.[21,22,23]

Putting together the key causative factors in the pathophysiology of GERD, i.e. the irregular dietary habits, with the clear outcomes of the present study, it appears that allowing sufficient interval between meals of 10–12 h with only liquids in the intervening period could be the most beneficial remedy in the overall management of GERD. This observation is supported by recent investigations pertaining to the effect of intermittent fasting on GERD. A study conducted in the USA showed that intermittent fasting improved symptoms of both heartburn and regurgitation.[24] But compared to the intermittent fasting that involves a caloric intake window of 8 consecutive hours with no caloric intake during the remaining 16 h, Akram’s diet plan is more convenient for patients. Similarly, another study done in Saudi Arabia demonstrated that fasting during the month of Ramadan improved GERD symptoms.[25] Therefore, it is perhaps the interval between meals, rather than the type of food that matters most in the control of GERD symptoms.

Historically, “Akram’s lifestyle” for the management of GERD, suggesting the intake of two meals a day and the avoidance of a meal on top of another, is based on the instruction by Luqman the Wise (1100 BC) to his son: Luqman (Allah be pleased with him) advised him, “Oh my son, do not eat anything after you have taken to your satisfaction. It is better to leave it for a dog than you eat on a full stomach.”[26] It is narrated in the Noble Quran that in the hereafter, people of paradise will be served meals twice a day, in the morning and evening: “They shall not hear therein (in Paradise) any “Laghw” (dirty, false, evil, vain talk), but only “Salam” (salutations of peace). Moreover, they will have their sustenance (food) in the morning and late afternoon.”[27]

One of the limitations of the present study was that after the intervention, only 45 out of 60 participants (75%) responded to evaluation. However, a response rate of above 60% is acceptable in a study such as ours.[28] Another limitation of the study was that the weight and the body mass index were not followed in this short intervention study. It is highly unlikely that there could be a significant change in these parameters over a period of 2 weeks except what could affect the clinical outcomes we were looking for, i.e., the improvement of GERD symptoms.

Conclusion

The prevalence of GERD is on the increase because of changes in dietary habits. Medications used for GERD are becoming ineffective and their long-term use results in serious side effects. Long-term practice of “Akram’s lifestyle”, comprising two meals a day with only liquids in between treats GERD and prevents its complications. This lifestyle has a strong physiological basis as it can reduce the development of TLESRs and acid surges, favor the occurrence of MMCs and gastric emptying, and therefore, control acid reflux. It is recommended that further investigations with larger samples should be undertaken to confirm the findings.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.