Dietary patterns and gastroesophageal reflux disease in Sri Lanka: A regional food culture perspective

Abstract

In this editorial, we comment on the article by Wickramasinghe et al published in the recent issue of the World Journal of Gastrointestinal Surgery 2026; 24: 3908-3918. Gastroesophageal reflux disease (GERD) is a common gastrointestinal diseases and dietary factors are often considered important in symptom generation. However, the associations among specific food, eating behavior ,nutritional intake and GERD remain inconsistent and may vary across regional and cultural contexts. The Sri Lankan nationwide community-based study included 1200 adults from 25 administrative regions and evaluated dietary triggers, eating habits, nutritional intake, and GERD symptoms. The study suggests that greasy foods, wheat products, coffee and acidic or vinegar foods are correlated with GERD symptoms. Skipping breakfast, nighttime meals and lying down shortly after meals were also related to symptom occurrence. In contrast, total calorie intake and obesity-related indicators were not clearly associated with reflux symptoms. The proposed explanations involving bread, wheat, fermentable oligosaccharides, disaccharides, monosaccharides and polyols, yeast fermentation, delayed gastric emptying, and gluten sensitivity remain hypothetical and require further verification. Overall, this study provides important South Asian population evidence and supports culturally tailored dietary and lifestyle interventions in GERD management.

Key Words: Diet; Eating habits; Gastroesophageal reflux disease; Cultural differences; Cross-sectional research; Commentary

Core Tip: This editorial highlights the regional and cultural specificity of dietary factors associated with gastroesophageal reflux disease (GERD). Based on a nationwide Sri Lanka study greasy foods, wheat products, coffee, acidic foods, skipping breakfast, nighttime meals, and lying down shortly after meals were associated with GERD symptoms. In contrast, total calorie intake and obesity-related indicators were not clearly related to reflow symptoms. In summary, the article puts forward the view that in the clinical intervention of GERD, in addition to drug treatment, a diet and lifestyle adjustment plan in line with local cultural habits should also be implemented.

This editorial refers to “Dietary and nutritional correlates of gastroesophageal reflux disease symptoms: A comprehensive island-wide study in Sri Lanka” by Wickramasinghe et al, 2026; https://doi.org/10.4240/wjgs.v18.i3.113687.

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INTRODUCTION

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases worldwide, and its prevalence has increased in recent years. Previous studies have reported GERD prevalence rates of 18%-28% in North America and 9%-26% in Europe, respectively[1]. In China, the prevalence of GERD has also increased. Changes in age distribution, eating habits, and lifestyle are considered the main factors contributing to this increase[2]. GERD is a chronic disease in which gastric contents reflux into the esophagus and damage the esophageal mucosa. Common symptoms include reflux, heartburn, acid reflux, and extraesophageal symptoms[3,4]. At present, the pathophysiological mechanisms of GERD are relatively clear[5-7]: GERD is mainly associated with factors such as lower esophageal sphincter (LES) dysfunction, increased transient LES relaxation, decreased esophageal clearance, increased gastric acid exposure, and increased sensitivity of the esophageal mucosa. However, pathophysiological mechanisms alone cannot fully explain why patients with GERD in different regions have different symptoms and diet-related factors. Therefore, daily dietary structure, food-processing methods, eating habits, and cultural background should be further considered. In existing studies, high-fat foods, coffee, alcohol, spicy foods, and acidic foods are often considered related to GERD symptoms. However, the specific food triggers reported across countries and regions are not identical[8-12]. The experience of a single region cannot simply be generalized; instead, GERD should be analyzed in relation to local food culture and regional lifestyle. Against this background, Sri Lanka provides an important but under-researched South Asian sample for exploring differences in food culture in GERD. In Sri Lanka, rice is the main staple food. Oily cooking, coffee or tea consumption, sour food intake, and wheat and bread products are also common, and bread and wheat products account for a high proportion of the daily diet among some urban residents. This dietary pattern differs from those in the West, East Asia, and India, but the relationship between bread and wheat products and GERD symptoms has not been fully discussed in previous studies. Therefore, a study of the national community population in Sri Lanka may supplement epidemiological evidence on GERD in South Asia and provide a new perspective for understanding the relationship among food culture, regional differences, and GERD symptoms.

DIETARY PATTERNS AND GERD RISK

The global prevalence of GERD continues to rise, and eating habits and lifestyle are considered key factors that trigger GERD. However, existing studies show considerable inconsistency regarding the relationships among specific foods, eating habits, overall nutritional intake, and GERD[8,13]. This inconsistency may occur because findings often vary by region and are strongly influenced by cultural dietary structures, food-processing methods, and individual behavioral patterns[8]. Therefore, large-sample studies from non-Western countries that are grounded in local food culture are particularly important for understanding the geographical heterogeneity of GERD. Against this background, the national community-based cross-sectional study in Sri Lanka conducted by Wickramasinghe et al[14] in the World Journal of Gastrointestinal Surgery provides important and unique evidence for diet-related research on GERD in South Asia. The study included 1200 adults from 25 administrative regions across Sri Lanka. It used stratified random cluster sampling and locally validated GERD symptom screening tools and food frequency questionnaires covering the main dietary structure in Sri Lanka to systematically evaluate the relationships among dietary triggers, eating habits, nutritional intake, and GERD symptoms[14].

In previous studies on GERD, high-fat diets, irritating foods, coffee, and alcohol have frequently been mentioned. High-fat food intake is thought to reduce LES pressure and increase transient LES relaxation, thereby causing reflux[15,16]. The effects of coffee and alcohol on sphincter function have also been observed[17,18]. In addition, pH monitoring studies have confirmed that high-fat meals can aggravate acid exposure[19]. The study is consistent with previous literature and confirms that greasy foods, coffee, and acidic foods are significantly associated with GERD symptoms. However, the most noteworthy diet-related finding is the systematic analysis of “wheat and bread products” in this study. Previous mainstream studies have rarely considered wheat a typical trigger food for GERD[8,9]. For the first time, this study identified a significant population-level correlation between bread and GERD symptoms, and this association was independent of total energy and fat intake, thereby proposing a new hypothesis for dietary research on GERD. It should be emphasized that the specific mechanism linking bread or wheat products to GERD symptoms is currently based only on assumptions derived from physiology and nutrition, rather than confirmed conclusions. First, wheat contains fermentable carbohydrates and is considered a fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP)-containing food. A high-FODMAP diet may produce gas during colonic fermentation, causing abdominal distension, and increased intra-abdominal pressure may induce reflux[20,21]. Second, yeast fermentation in some bread-making processes may increase food acidity or gas production, aggravating postprandial gastric pressure; however, this has not been directly measured in Sri Lankan samples, and its relationship with GERD symptoms requires further verification. Third, the combination of high carbohydrates and protein may delay gastric emptying, thereby prolonging the exposure time of gastric contents[22,23]. Fourth, non-celiac wheat sensitivity or gluten-related diseases may be associated with mucosal inflammation and visceral hypersensitivity, and their relationship with GERD symptoms also requires verification[24]. These mechanisms have rarely been systematically integrated in previous GERD research, and they remain hypothetical explanations in this article. In the future, 24-hour pH-impedance monitoring, gastric emptying assessment, dietary intervention tests, and food composition analysis should be combined to further determine whether bread or wheat products affect GERD symptoms through these pathways. By integrating these factors into a demographic analysis, this study not only provides important clues for future mechanistic research from the perspectives of food science, microbial fermentation, and gastroesophageal dynamics but also suggests that “the same food” may have completely different physiological and symptomatic effects in different cultural contexts. Therefore, GERD research should not rely solely on the limitations of Western dietary classification systems.

The occurrence of GERD is related not only to “what to eat”, but also to “when to eat” and “how to eat”. The same food may have different effects on reflux symptoms depending on meal timing, eating methods, and post-meal behaviors. Many studies have suggested that irregular eating patterns are significantly associated with GERD[25], and nocturnal reflux and sleep disorders may influence each other[26]. Nighttime eating, lying down shortly after meals, and changes in body position may also increase the risk of reflux symptoms. However, most of these studies focus on single behaviors and lack integration with nutritional intake. In contrast, this study simultaneously incorporated food type, nutritional structure, and behavioral patterns and used a nationally validated GERD scale and food frequency questionnaire, thereby improving the internal consistency and cultural adaptability of the measurements. The study also adopted a hierarchical sampling design across 25 administrative regions nationwide, which is superior to most regional studies. The study found that skipping breakfast, eating extra meals at night, and resting in bed after meals were all significantly associated with GERD symptoms. The mechanism may be related to decreased nocturnal gastric acid clearance, increased postprandial reflux, and circadian rhythm disorders[27,28], whereas no obvious differences were found for rapid eating or meal intake. This finding suggests that dietary management of GERD should not be limited to restricting certain food types but should also consider meal timing, post-meal position, and daily eating rhythm. For patients, adjusting nighttime eating, avoiding lying down immediately after meals, and maintaining a regular diet may be more acceptable and sustainable than simply prohibiting certain foods.

Regarding obesity, existing studies remain controversial about whether obesity is significantly associated with GERD. Most evidence supports a close link between obesity and GERD. Studies have shown that increased body mass index (BMI) significantly increases the risk of GERD symptoms and complications[29,30]. Mechanistically, obesity may promote reflux by increasing intra-abdominal pressure and the risk of hiatal hernia[31], and by increasing the frequency of transient LES relaxation[32]. Other prospective data show that weight loss can alleviate reflux symptoms[27], and a similar association has been observed in Asian populations[33]. However, a small number of studies have reported opposing findings. A study of adult groups in Iran found that the correlation between BMI and GERD was unstable[34]. This study echoes the Iranian data and also found no significant correlation of BMI or waist-to-hip ratio with GERD. When interpreting this finding, it is important to consider whether such cross-sectional research may be affected by reverse causality. In other words, certain eating habits may not necessarily cause GERD symptoms; rather, patients may actively change their diet after experiencing acid reflux, heartburn, or postprandial discomfort, such as by eating fewer high-fat or acidic foods and avoiding overeating or late meals. Thus, the relationships of total calories, fat intake, BMI, or waist-to-hip ratio with GERD symptoms observed in the study may be weakened or may appear nonsignificant. Therefore, the lack of a significant association between BMI or waist-to-hip ratio and GERD in the study does not mean that these factors have no effect. The findings may be influenced by various factors, including active dietary adjustment by patients, symptom severity, body-size differences, and overall eating habits. Notably, this study found that the bloating score was significantly associated with fat, protein, fiber, and BMI, suggesting that bloating may play a “bridge role” between nutritional intake and reflux symptoms. However, no obvious differences in total calories or fat intake were found between patients, indicating that the effect of fat intake on reflux symptoms may not be determined by intake alone but is more likely related to body structure, eating habits, and overall dietary patterns in different groups (Table 1).

Table 1 Proposed mechanisms and clinical manifestations of dietary factors and eating habits associated with gastroesophageal reflux disease.

Dietary factor or habit	Proposed mechanism	Primary pathway	Clinical manifestation(s)	Evidence boundary	Ref.
High-fat diet or high dietary fat load	May increase transient LES relaxations and delay gastric emptying	LES function; gastric emptying	Increased postprandial reflux and more severe retrosternal burning	Established mechanism	[15,16,19]
High-carbohydrate or high simple-sugar diet	May increase postprandial gastric load and prolong esophageal acid exposure	Gastric content load; acid exposure	Worsened reflux symptoms and greater postprandial discomfort	Inferred mechanism	[8,13,14,22,23]
Wheat-based or high-FODMAP diet	May increase intestinal fermentation and gas production and raise the frequency of transient LES relaxations	Intestinal fermentation; intra-abdominal pressure; TLESR	More bloating, acid regurgitation, and belching	Hypothetical mechanism	[14,20,21]
Spicy foods or capsaicin	May increase sensory sensitivity in the esophagus and stomach	Mucosal sensation; neural sensitivity	More prominent heartburn, irritation, and related symptoms	Inferred mechanism	[8,9,12,18]
Carbonated beverages	May increase intragastric gas and reduce LES pressure	Intragastric pressure; LES function	More belching and greater susceptibility to reflux	Inferred mechanism	[9,12]
Coffee or caffeinated beverages	May stimulate gastric acid secretion and alter LES tone	Gastric acid secretion; LES function	Possible worsening of acid regurgitation and heartburn	Inferred mechanism	[9,12,14,17,18]
Acidic foods or vinegar-based foods	May directly intensify esophageal mucosal irritation and symptom perception	Mucosal irritation; acid sensitivity	More prominent heartburn and retrosternal discomfort	Inferred mechanism	[9,14]
Short interval between dinner and sleep, or nighttime eating	May increase esophageal acid exposure in the supine position	Nocturnal acid exposure; position-related reflux	Nocturnal heartburn, sleep disturbance, and morning discomfort	Inferred mechanism	[25-28]
Irregular eating, midnight snacks, or skipping breakfast	May disrupt eating rhythm and increase opportunities for nocturnal or postprandial reflux	Meal timing; GI motility	Greater symptom fluctuation and more obvious nighttime or post-fasting discomfort	Inferred mechanism	[14,25-27]
Rapid eating or binge eating	May rapidly distend the stomach and increase intragastric pressure	Gastric distension; intragastric pressure	More postprandial reflux, belching, and upper abdominal fullness	Inferred mechanism	[8,14,25]
High-fiber diet or supplementation with soluble dietary fiber	May increase resting LES pressure and reduce the number of reflux episodes	LES function; gastrointestinal motility	Fewer episodes of heartburn and reflux	Inferred protective mechanism	[8,10]
Diet rich in vegetables, fruits, and fish	May reduce symptoms by improving overall dietary quality and lowering the intake of high-fat and highly processed foods	Overall dietary pattern; inflammation; gastrointestinal function	Potentially lower risk of GERD symptoms	Inferred association	[8,10,11]
Mediterranean dietary pattern	May exert protective effects through the combined actions of unsaturated fatty acids, dietary fiber, and antioxidant components	Overall dietary pattern; inflammatory regulation; gastrointestinal function	Potentially lower reflux symptom burden and GERD risk	Inferred protective association	[11]
Fried foods	Often combine high fat, high energy density, and strong irritation, which may promote postprandial reflux	Gastric emptying; LES function; intragastric pressure	Worsened heartburn, acid regurgitation, and postprandial heaviness	Inferred mechanism	[9,12,14,18]
Alcohol	May reduce LES pressure and irritate the esophageal and gastric mucosa	LES function; mucosal irritation	More acid regurgitation, heartburn, and retrosternal discomfort	Established/inferred mechanism	[9,12,17,18]

LES: Lower esophageal sphincter; FODMAP: Fermentable oligosaccharides, disaccharides, monosaccharides and polyols; GI: Gastrointestinal; TLESR: Transient lower esophageal sphincter relaxation; GERD: Gastroesophageal reflux disease.

EXPLORATORY RESEARCH ON THE CORRELATION BETWEEN CULTURALLY SPECIFIC DIET PATTERNS AND GERD

In recent years, an increasing number of studies have focused on the potential impact of different cultural dietary structures on GERD. Although factors such as high-fat diet, coffee, and alcohol are considered associated with GERD symptoms in many countries, specific food types and their effects differ substantially across regions. This suggests that dietary culture, food-processing methods, and eating structure may play important roles in the geographical heterogeneity of GERD.

Research in East Asia mainly emphasizes that a highly refined carbohydrate diet may be an important risk factor, whereas a diet rich in vegetables and seafood may have a protective effect. A Korean case-control study found that noodles, spicy foods, greasy meals, sweets, alcohol, bread, carbonated drinks, and caffeinated drinks were all associated with aggravated reflux-related symptoms. Among noodles, instant noodles were the most frequently reported food that induced symptoms[9]. Another large-sample study in South Korea further showed that, in non-erosive reflux disease, higher intake of beans, vegetables, fruits, fish, and milk was associated with lower risk, whereas reflux esophagitis was more closely related to BMI and total energy intake[10].

In Mediterranean-related regions, studies suggest that diets rich in olive oil, vegetables, fruits, and fish may be associated with a lower risk of GERD, whereas diets characterized by fried, highly processed, and high-sugar foods may carry a greater risk. Existing research generally supports the protective effect of the Mediterranean diet. A population study in Albania divided dietary patterns into a “Mediterranean diet based on traditional complex vegetables, fresh fruits and vegetables, olive oil, and fish” and a “non-Mediterranean diet based on red meat, fried food, sweets, and fast food”. The results showed that the non-Mediterranean diet was associated with an increased risk of GERD[11].

Evidence from South Asia shows another characteristic, especially in India, where dietary factors related to GERD are mainly concentrated in spicy seasonings, non-vegetarian foods, and some high-oil dietary exposures. A multicenter study by the Indian Society of Gastroenterology showed that, in univariate analysis, non-vegetarian food, fried food, carbonated drinks, tea, and coffee intake were all associated with GERD. In multivariate analysis, non-vegetarian intake remained an independent related factor[12]. Later, an Indian expert consensus further summarized that the dietary factors related to GERD in India mainly include the use of spices and non-vegetarian intake[18].

The Sri Lankan study discussed here has a distinctive finding: Bread intake may be associated with GERD symptoms. This association may be related to excessive yeast use in some bread-making processes; greater gas and organic acid production during fermentation; higher FODMAP components in wheat products, which may increase intestinal fermentation and gas production; and greater dependence of urban residents in Sri Lanka on industrialized bread, with the locally common “van culture” making bread a high-frequency staple food. Therefore, high-frequency bread consumption and its production technology may constitute a unique regional GERD-related dietary risk. However, this association is less common in the literature and requires further study to determine whether it is linked to gluten or local production methods (Table 2).

Table 2 Region-specific dietary factors associated with gastroesophageal reflux disease and their reported manifestations.

Region	Region-specific dietary exposure(s)	Reported association(s)	Evidence source	Ref.
East Asia (Korea)	Noodles, spicy foods, greasy meals, sweets, alcohol, bread, carbonated beverages, and caffeinated drinks	Mostly associated with worsening reflux symptoms	Case-control study	[9]
East Asia (Korea)	Legumes, vegetables, fruits, fish, milk, and related foods	Associated with lower NERD risk; reflux esophagitis is more strongly related to BMI and total energy intake	Large cross-sectional study	[10]
East Asia (Japan)	Large dinners, eating before sleep, midnight snacks, skipping breakfast, and irregular eating	Associated with increased GERD or NERD symptoms	Mixed observational/review evidence	[25-28]
Mediterranean region	Mediterranean diet rich in olive oil, vegetables, fruits, and fish; contrasted with non-Mediterranean diets	The Mediterranean diet is associated with lower GERD risk, whereas non-Mediterranean diets are associated with higher risk	Population-based cross-sectional study	[11]
South Asia (India)	Spices or spicy seasonings, non-vegetarian diet, fried foods, carbonated drinks, tea, or coffee	Associated with GERD, with non-vegetarian intake appearing to be a relatively stable associated factor	Epidemiological study; expert consensus	[12,18]
South Asia (Sri Lanka)	Oily foods, bread, wheat, coffee, and acidic or vinegar-based foods	Significantly associated with GERD symptoms	Nationwide cross-sectional study	[14]
South Asia (Sri Lanka)	Bread, but not other wheat products	Some patients reported heartburn or reflux only after eating bread; this remains a relatively distinctive observation	Cross-sectional finding; mechanistic support	[14,20,21]

BMI: Body mass index; NERD: Non-erosive reflux disease; GERD: Gastroesophageal reflux disease.

CONCLUSION

Compared with previous studies of the same type, the advantages of this study are reflected in three aspects: First, the potential role of wheat and bread is emphasized at the population level for the first time to fill the gap in international literature. Second, integrate and analyze diet types, nutritional structure and behavior patterns. Third, the correction of the classic obesity reflex model with geographical characteristics is proposed. The pathogenesis of GERD may not be a single “fat-obesity-reflow” path, but may be regulated by a variety of factors such as cultural diet structure, fermented food intake, eating rhythm and functional gastrointestinal symptoms. The study did not stop at verifying the existing conclusions, but emphasized that the cultural background would significantly affect people’s “feeling” of symptoms. GERD is not a non-black or white disease entity, but more likely a continuous process of gradual degree. Whether the symptoms are detected and how they are described is not only related to the sensitivity of the individual’s body[35,36], but also deeply influenced by the cultural concept[37].

The author also clearly pointed out some limitations of the research. First of all, because the study is a cross-sectional design, the research results can only suggest the correlation between dietary factors and GERD symptoms, which cannot directly prove the causal relationship between the two, and it is difficult to determine the causal relationship between dietary exposure and the appearance of symptoms. Some patients may take the initiative to reduce high-fat foods, acidic foods, heavy eating or eating at night after acid reflux, heartburn or post-meal discomfort. In this case, the relationship between total energy intake, fat intake, BMI or waist-to-hip ratio and GERD symptoms may be weakened, but this does not mean that these factors are completely unrelated to GERD, but may be affected by factors such as the patient’s initiative to change diet, symptom severity and overall diet pattern. Secondly, the study mainly judges GERD based on symptom questionnaires, not on objective diagnostic methods such as endoscopy, 24 hours pH monitoring or pH-impedance monitoring. Although symptomatic GERD classification is suitable for large-scale epidemiological investigation, it is not completely equivalent to objectively confirmed GERD. Some patients may only have functional heartburn, are particularly sensitive to reflow, or have other upper gastrointestinal discomforts. These symptoms look similar to GERD, but their pathological mechanisms may not be exactly the same[38], therefore, judging whether it is GERD based on the symptom questionnaire alone may cause some misjudgment, which will also affect our understanding of the real backflow situation. In recent years, the development of objective mucosal observation technology has also reminded us that future GERD-related research should not only rely on symptom judgment, but also need to combine more refined mucosal assessment and reflow detection methods. For example, high spectral imaging technology can help to observe the digestive tract mucosa more clearly[39]. Although this technology is not specifically used for the study of dietary factors of GERD, it suggests that we can improve the accuracy of symptomatic GERD judgment and classification through more objective mucosal visualization methods in the future. In addition, the study only uses BMI to assess the degree of obesity, which is difficult to accurately reflect the distribution of abdominal fat, and the increase in abdominal fat is considered to be more closely related to the risk of reflux[40]. Finally, although the food frequency questionnaire has been verified, it mainly depends on the subjects’ own memories, or it is difficult to accurately determine the intake frequency of certain foods, such as the amount of oil, cooking method, the degree of bread fermentation and the post-meal position and other details. In addition, even if the study has controlled some variables, there may still be residual confounding factors, such as socioeconomic status, drug use, smoking and drinking, psychological stress, sleep quality, physical activity, regional differences and combined functional gastrointestinal diseases. These factors that are not fully measured or controlled may affect the observation between dietary factors and GERD symptoms. These problems are not unique to the institute, but are long-standing common challenges in the fields of nutrition epidemiology and GERD research[41,42].

Nevertheless, the study still relies on national layered sampling and combined with the verified GERD symptom scale and food frequency questionnaire. A comprehensive analysis of food types, nutritional structure and eating behavior suggests that food and eating habits have certain cultural specificity in the occurrence of GERD. The research results show that in GERD management, in addition to drugs[43], it can also be considered to give more targeted dietary and life advice according to the eating habits and lifestyle of the patient’s region. However, at present, these conclusions mainly come from cross-sectional studies, which can only show that there is a correlation, but cannot prove that these dietary or lifestyle changes are necessarily effective. In the future, it needs to be further confirmed through long-term follow-up research and intervention experiments.

Although this study is limited by factors such as cross-sectional design, But the discovery of wheat intake and eating rhythm provides us with new clues. So as to further explore the relationship between GERD and diet. Future research and design can be carried out from the following aspects: First, future research can adopt a longitudinal research design, combined with repeated diet evaluation, to more accurately understand the causal relationship between dietary changes and GERD symptoms. At the same time, it can also reduce the error caused by the onetime survey or the patient’s initiative to change the diet. Second, the research can also use 24 hours pH-impedance monitoring, gastric emptying test, endoscopy and more advanced mucosal visualization technology[7]. From the perspective of objective backflow monitoring and physiological mechanism, explore whether wheat intake promotes backflow by delaying gastric emptying or increasing intestinal gas production. Third, combine intestinal microbiology and metabolomics research[44] to better understand the potential impact of wheat and fermented food on gastrointestinal dynamics and reflow symptoms. And the improvement effect of low FODMAP or low-fermented carbohydrate diet on GERD symptoms was evaluated through randomized controlled trials. In obesity-related research, visceral fat and subcutaneous fat can be distinguished through imaging or body composition analysis, and the path of abdominal distension between “diet intake - abdominal pressure change - reflow symptoms” can be further explored. In a word, combined with longitudinal research design, repeated diet evaluation, objective backflow monitoring, mucosal visualization technology and mechanism research[45], it will help to further decrypt GERD’s “geographical code” and promote GERD from a “one-size-fits-all” management model to more accurate and culturally sensitive clinical practice.