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

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.

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.