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GASTROESOPHAGEAL REFLUX SYMPTOMS AND ASSOCIATED FACTORS £ IN ADOLESCENTS: A COMMUNITY-BASED STUDY ¡j
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Oleg V. ReshetnikovA, MD, DSc; Svetlana A. KurilovichMD, DSc ¥
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* Novosibirsk State Medical University C
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A Institute of Internal and Prophilactic Medicine SB RAMS
Address for correspondence and reprint requests:
Oleg V. Reshetnikov, MD, DSc
Institute of Internal Medicine
B. Bogatkova St., 175/1
Novosibirsk 630089, Russia
Fax: +7 (383) 2642516
Phone: +7 (383) 2012493
E-mail: [email protected]
SUMMARY
Objectives. Gastroesophageal reflux (GER) is frequent among the general population affecting 10 - 20% of adults in the Western world. However, there is a notable lack of epidemiological data describing prevalence of GER in children. The aims of the present study were to assess the prevalence of GER symptoms (GERS) in adolescents and to evaluate factors associated with GERS including markers of H. pylori infection. Methods. All school students in grades 9 - 11 in four randomly selected secondary schools in Novosibirsk participated (449 adolescents, 189 boys, 260 girls aged 14 - 17). They completed the Bowel Disease Questionnaire, life-style questionnaire, and sera were tested for antibodies against Helicobacter pylori infection. Results. Overall, 60% of adolescents experienced GERS (heartburn and/or acid regurgitation) over the previous year. GER symptoms on a monthly basis were reported by 22% of students, weekly GERS were reported by 9% of adolescents with the same frequency in both genders. GERS were related to family history of dyspepsia or GER, mother's lower educational attainment, overweight, unhealthy eating patterns, alcohol consumption, smoking, and H. pylori infection, as well as concomitant dyspepsia and irritable bowel syndrome. The majority of associations were more prominent in girls. Visiting a physician, endoscopic study, and school absenteeism were reported in the last year more frequently by adolescents with GERS vs those without GERS.
Conclusions. Gastroesophageal reflux symptoms are frequent among the adolescent population and result in frequent use of health care resources. Some precipitated factors found in this study are modifiable and can be corrected in adolescent population.
Keywords: adolescents, risk factors, gastroesophageal reflux, prevalence Word count — Abstract 248, Text 2833
INTRODUCTION
Gastroesophageal reflux (GER) is a consequence of abnormal retrograde flow of gastric content into the esophagus. Heartburn and acid regurgitation are the most common and specific symptoms of GER [1].
GER is frequent among the general population affecting 10 - 20% of adults in the Western world [2]. According to sparse data, GER is not uncommon also in children and adolescents [3]. However, there is a notable lack of epidemiological data describing prevalence of GER symptoms (GERS) in children.
There are a number of factors associated with GER, namely genetic, demographic, behavioral, and comor-bid associations [2]. However, risk factors for GER are not clearly ascertained in pediatric population notwithstanding that GER in otherwise normal children can persist through adolescence and adulthood in a significant proportion of patients who continue to experience GER symptoms and use antisecretory medications [4].
Despite dozens of publications there is still a controversy over the relationship between Helicobacter pylori infection and GER. A recent systematic review
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demonstrated that the prevalence of H pylori infection was significantly lower in patients with than without gastroesophageal reflux, and patients from the Far East with reflux disease had a lower prevalence of H pylori infection than patients from Western Europe and North America, despite a higher prevalence in the general population [5]. The most likely mechanism by which H. pylori infection may protect against reflux is by decreasing the potency of the gastric refluxate in patients with corpus-predominant gastritis [6]. The most extensively studied virulence factor of H. pylori, CagA protein, leads to lower prevalence of reflux esophagitis in adults through development of severe corpus gastritis [7].
In children, some studies suggest a causative association between H. pylori infection and GER whereas others postulate a protective role for H. pylori [8]. The relationship between CagA status and GER has not been explored in children.
The aims of the present study were to assess the prevalence of GER symptoms in adolescents and to evaluate factors associated with GERS including markers of H. pylori infection.
MATERIAL AND METHODS
Study population. Novosibirsk is the largest city of Siberia and the third largest in Russia with a population of approximately 1.4 million. Novosibirsk residents are represented by descendants from different parts of the former Soviet Union. Eastern-European whites — Russians, Ukrainians and Beylorussians constitute 98% of the population of the city.
The study was performed in a single district of Novosibirsk, where the distribution by age, sex, income, occupational category, and other socioeconomic variables does not differ from the average for the city. The population of the district is 155,065 which constitutes 10% of the city's population.
In Russia, secondary education (8 - 10 years) is obligatory for every child and is guaranteed by the government. Four secondary schools were selected randomly for the examination. All the students in forms 9 - 11, aged 14 - 17 were invited to participate. The study was approved by the local ethic committee.
Examination. During school-hours each class was examined separately. Approximately one hour was consumed for the examination. Participation was virtually 95 - 100% among those in attendance at the time of the invitation. Non-participants usually were one or two of 25 - 30 students of the class. Life and disease history, smoking and alcohol consumption were recorded using structured questionnaires by experienced personnel. Weight and height were measured using standard procedure. Blood was collected after nocturnal fast from cubital vein, centrifuged at 1500 rpm for 15 min. The obtained sera were frozen and stored at -200C until the assay.
Questionnaire. Participants completed Russian version of Bowel Disease Questionnaire that was devised and validated by Talley et al. in the USA [9]. The
questionnaire has been proven to serve as a reliable, valid and reproducible instrument and has been widely applied in epidemiological and clinical studies around the world [10]. The time frame measured is the previous 12 months. A pilot study was performed in 30 adolescents to check understanding of questions by the students.
Heartburn was defined as a burning pain or discomfort behind the breast bone in the chest, and acid regurgitation was defined as a bitter or sour-tasting fluid coming into the throat or mouth. Symptom frequency was measured on a scale of 1 to 6 in the following categories: none in the past year, less than once a month, about once a month, about once a week, several times a week, or daily [11].
Dyspepsia was defined as upper abdominal pain or discomfort on more than six occasions during the previous year, and irritable bowel syndrome (IBS) was defined as abdominal pain occurring on more than six occasions in the previous year, with three or more of the Manning criteria [12].
Moreover, questions were included concerning frequency of alcohol consumption, smoking habits, family history of dyspepsia or GER, eating patterns (number of meals a day, daytime and bedtime snacks, irregular meals, long (> 6 hours) period between meals).
Parents' questionnaire. The questionnaire was sent to each schoolchild's parents 1 week before the examination. The questionnaire disclosed questions about parents' educational level, occupation, living conditions. The parents gave informed consent about participation of their children as well.
Serology. Serum antibodies (IgG) against H. pylori were detected according to the manufacturer's instruction using Pyloriseta — New EIA-G (Orion Diagnostica, Espoo, Finland). The test used has been previously validated and has been reported to have 95.8% sensitivity and 95.5% specificity [13]. In a study performed in Novosibirsk, the kit showed good accuracy with 96.3% sensitivity and 91.5% specificity.
Serum antibodies (IgG) against CagA protein of H. pylori and antibodies (IgG) against Giardia lamblia trophozoites antigens were detected according to the manufacturer's instruction using ELISA (Vector-Best Joint-Stock Company, Novosibirsk, Russia).
Statistical analysis. The data were analyzed using SPSS 10.0 software package. Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters. Mantel-Haenzsel summary chi-square test and Fisher exact test were used to compare frequencies. Moreover, the univariate odds ratios (OR) and their 95% confidence intervals (CI) were calculated. The level of significance was set at 0.05.
RESULTS
Questionnaires were completed by 449 adolescents (189 boys, 260 girls) (table 1).
The majority of them were 15 and 16 years of age.
Overall, 59.5% of adolescents experienced GER symptoms (heartburn and/or acid regurgitation) during
the previous year; 66.1% of boys and 54.6% of girls (p = 0.014). (table 2). GER symptoms on a monthly basis were reported by 22.0% of students; 23.8% of boys and 20.8% of girls (p = 0.44). Weekly heartburn and/or acid regurgitation was reported by 8.9% of adolescents (6.3% of boys and 10.8% of girls, p = 0.10). Among the 40 subjects with weekly GERS, 30 (75.0%) had weekly heartburn and 13 (32.5%) had weekly acid regurgitation. Overall prevalence of weekly heartburn was 6.7% and weekly acid regurgitation was 2.9%.
Associations of GERS with various risk factors are presented in Table 3. Since weekly GERS were experienced by only a minority of students (9%), we used monthly GERS definition to achieve sufficient number of subjects with GERS for analysis.
Family history of dyspepsia or GER was reported by 24.7% with small but significant association with symptoms in adolescents. Parents' occupation did not influence GER prevalence (data are not shown), however, mothers' lower educational attainment was associated with GER in children of both genders.
Among the studied parameters of dietary patterns, all but bedtime snacks were strongly associated with GERS. Smoking daily and alcohol consumption several times a month significantly increase the prevalence of GERS in girls (3.6 and 2.5 times respectively), but this was not true for boys. Body mass index > 23 kg/m2 was associated with GER only in girls.
Overall prevalence of H. pylori infection was 56.3%, the proportion of CagA positive students among those H. pylori positive was 63.7%, without gender difference. Both H. pylori and CagA positivity were associated with GER. Antibodies against G. lamblia were detected in 12.1% (7.6% in boys, 15.5% in girls, p = 0.02). Negative association was found between GERS and G. lamblia seropositivity.
Dyspepsia was reported by 20.7% of students with a higher prevalence in girls (25.4%) than in boys (14.3%, p = 0.004). GERS and dyspepsia commonly occurred together (OR = 2.8). The prevalence of IBS was 20.0%; 24.2% in girls and 14.3% in boys (p = 0.01). As well as dyspepsia, IBS was strongly associated with GER.
Adolescents with GERS more frequently visited a physician in the last year than students without GERS (36.4% vs 26.0%, p = 0.043). Upper endoscopy previously was performed in 24.2% GERS sufferers compared to 11.7% of adolescents without GERS (p = 0.002).
School absenteeism was reported in the last year by 40.4% of adolescents with GERS vs 24.3% without GERS (p = 0.002).
Health care utilization was significantly higher among adolescents with GERS compared to those without GERS, namely physician visits (36.9% vs 19.5%, OR = 2.41, 95% CI 1.31 - 4.42, p = 0.0018), and performed endoscopic studies (28.3% vs 19.6%, OR = 1.63, 95% CI 0.98 - 2.70, p = 0.044). A great negative impact on daily life was demonstrated by frequent school absenteeism reported in the last year by adolescents with GERS (32.0% vs 18.2%, OR = 2.11, 95% CI 1.28 - 3.49, p = 0.0016).
DISCUSSION
Many population-based studies on the prevalence of GER in adults were carried out in recent years, however, no such studies has yet been performed in children and adolescents.
Reflux symptoms are reliable and valid diagnostic indicators for GER because heartburn and acid regurgitation are highly specific for GER [1] Moreover, symptoms of GER in children are similar to those in adults [14].
We used validated in adults questionnaire for estimating GER symptoms in a representative sample of adolescent population. Problems with assessing symptom profile in children previously were related to nonspecific definition of Appley's «recurrent abdominal pain» in children. However, international working team in 1999 proposed to use criteria of dyspepsia and IBS for pediatric population because they seemed to apply equally well to children [15].
In our population, monthly heartburn and/or acid regurgitation was reported by 22% of adolescents and symptoms experienced weekly by 9% of them.
The first study that evaluated the prevalence of GER symptoms in children was the cross-sectional survey of 16 pediatric practices in Chicago, USA [3]. In that study, 615 children aged 10 - 17 reported heartburn and regurgitation in the past week in 5.2% and 8.2%, respectively. These figures are close to ours, however, more prevalent regurgitation than heartburn raise a doubt about definition and understanding of a child what he/ she is asked about. From the other side, the individual perception of feeling heartburn or regurgitated fluid in the mouth may vary.
Recent report from Northern Ireland studied epidemiology of upper gastrointestinal symptoms in 1133 adolescents aged 12 - 18 years. The study demonstrated weekly prevalence of heartburn and acid regurgitation to be 3.2% and 5.1%, respectively [16].
Another comparison could be made with adult population based studies. Recently Dent published a systematic review concerning epidemiology of gastro-oe-sophageal reflux disease. Fifteen papers were cited that used representative samples of adults, recall period of 1 year, and definition of GER as at least weekly heartburn and/or acid regurgitation [2]. Prevalence of GER symptoms in adolescents in our study (9%) was twice as low than in adults in the USA and the European populations (16.7 - 28%).
Risk factors for GER are difficult to evaluate in cross-sectional survey. It is more appropriate to use the term «factors associated with GER», which can be classified as genetic, demographic, behavioral, and comorbid associations [2]. We tried to assess most of these associations in our study.
Genetic. There is a growing body of evidence in favor of genetic susceptibility to GER [17]. Family history of dyspepsia or GER was marginally associated with GERS in adolescents in our study. Others showed strong relationships between adolescent and parental reporting of dyspeptic symptoms [16].
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Table 1
DISTRIBUTION OF PARTICIPANTS BY AGE AND SEX
Age (years) All ages
14 15 16 17
Boys 23 (12.2%) 71 (37.6%) 68 (36.0%) 27 (14.3%) 189 (42.1%)
Girls 33 (12.7%) 89 (34.2%) 95 (36.5%) 43 (16.5%) 260 (57.9%)
Both genders 56 (12.5%) 160 (35.6%) 163 (36.3%) 70 (15.6%) 449 (100%)
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PREVALENCE OF GER SYMPTOMS BY SEX AND FREQUENCY DURING THE PREVIOUS YEAR (%)
None in the past year Less than once a month About once a month About once a week Several times a week Daily P
Heartburn Boys 41.3 39.7 13.8 4.2 1.1 0.0 0,007
Girls 55.8 28.8 7.7 4.2 1.9 1.5
Total 49.7 33.4 10.2 4.2 1.6 0.9
Acid regurgitation Boys 76.7 16.4 5.8 0.5 0.5 0.0 0,46
Girls 73.8 16.5 5.4 2,3 0.8 1.2
Total 75.1 16.5 5.6 1.6 0.7 0.7
Table 3
RISK FACTORS FOR GERS (SYMPTOMS EXPERIENCED AT LEAST MONTHLY)
Variable Category Boys (n = 189) Odds Ratio (95% CI) Girls (n = 260) Odds Ratio (95% CI) Total (n = 449) Odds Ratio (95% CI)
Family history of dyspepsia or GER No Yes 155 (21.3%) 34 (35.3%) 1 2.0 (0.8 - 4.9) 183 (18.0%) 77 (27.3%) 1 1.7(0.9 - 3.4) 338 (19.5%) 111 (29.7%) 1 1.7(1.0 - 2.9)
Age (years) 14 - 15 16 - 17 94 (22.3%) 95 (25.3%) 1 1.2 (0.6 - 2.4) 122 (19.7%) 138 (21.7%) 1 1.1 (0.6 - 2.2) 216 (20.8%) 233 (23.2%) 1 1.2 (0.7 - 1.9)
Body mass index (kg/m2) < 23 > 23 179 (24.0%) 10 (20.0%) 1 0.8 (0.1 - 4.3) 239 (18.0%) 21 (52.4%) 1 5.0(1.8 - 13.9) 418 (20.6%) 31 (41.9%) 1 2.8 (1.2 - 6.3)
Eating patterns Regular meals Irregular meals 151 (20.5%) 38 (36.8%) 1 2.3 (1.0 - 5.2) 187 (17.6%) 73 (28.8%) 1 1.9 (1.0 - 3.7) 338 (18.9%) 11 (31.5%) 1 2.0(1.2 - 3.3)
Number of meals a day 3 and more 2 181 (22.7%) 8 (50.0%) 1 3.4 (0.7 - 17.4) 232 (19.4%) 28 (32.1%) 1 2.0(0.8 - 2.0) 413 (20.8%) 36 (36.1%) 1 2.2 (1.0 - 4.7)
Daytime snacks No Yes 171 (22.8%) 18 (33.3%) 1 1.7 (0.5 - 5.3) 227 (16.3%) 33 (51.5%) 1 5.5 (2.4 - 12.7) 398 (19.1%) 51 (54.9%) 1 3.5 (1.8 - 6.7)
Long period between meals No Yes 135 (19.3%) 54 (35,2%) 1 2.3 (1.2 - 4.9) 166 (16.9%) 94 (27.7%) 1 1.9(1.0 - 3.6) 301 (17.9%) 148 (30.4%) 1 2.0(1.2 - 3.3)
Bedtime snacks No Yes 175 (24.0%) 14 (21.4%) 1 0.9 (0.2 - 3.6) 245 (20.4%) 15 (26.7%) 1 1.4 (0.4 - 5.2) 420 (21.9%) 29 (24.1%) 1 1.1 (0.4 - 2.9)
Hasty meals No Yes 133 (25.6%) 56 (19.6%) 1 0.7(0.3 - 1.6) 154 (14.9%) 106 (29.2%) 1 2.4 (1.2 - 4.6) 287 (19.9%) 162 (25.9%) 1 1.4 (0.9 - 2.3)
Father's education* Higher Secondary 60 (15.0%) 48 (22.9%) 1 1.7(0.6 - 5.0) 58 (15.5%) 101 (24.8%) 1 1.8 (0.7 - 4.6) 118 (15.3%) 149 (24.2%) 1 1.8 (0.9 - 3.5)
Mother's education* Higher Secondary 57 (12.3%) 55 (29.1% 1 2.9 (1.0 - 8.9) 58 (8.6%) 118 (25.4%) 1 3.6(1.2 - 11.5) 115 (10.4%) 173 (26.6%) 1 3.1 (1.5 - 6.6)
RISK FACTORS FOR GERS (SYMPTOMS EXPERIENCED AT LEAST MONTHLY)
Variable Category Boys (n = 189) Odds Ratio (95% CI) Girls (n = 260) Odds Ratio (95% CI) Total (n = 449) Odds Ratio (95% CI)
G. lamblia* Negative Positive 158 (24.1%) 13 (0%) Not applicable 191 (20.9%) 35 (11.4%) 1 0.5 (0.1 - 1.6) 349 (22.3%) 48 (8.3%) 1 0.3 (0.1 - 1.0)
H. pylori* Negative Positive 80 (17.5%) 100 (28.0%) 1 1.8 (0.8 - 4.1) 105 (16.2%) 138 (23.2%) 1 1.6(0.8 - 3.2) 185 (16.8%) 238 (25.2%) 1 1.7(1.0 - 2.8)
CagA* Negative Positive 113 (20.4%) 61 (29.5%) 1 1.6(0.8 - 3.6) 148 (13.5%) 81 (30.9%) 1 2.9(1.4 - 5.9) 261 (16.5%) 142 (30.3%) 1 2.2 (1.3 - 3.7)
Alcohol Intake Never or rarely Monthly 94 (24.5%) 95 (23.2%) 1 0.9 (0.5 - 1.9) 143 (14.0%) 117 (29.1%) 1 2.5 (1.3 - 4.9) 237 (18.1%) 212 (26.4%) 1 1.6(1.0 - 2.6)
Smoking Never or rarely Daily 127 (25.2%) 62 (21.0%) 1 0.8 (0.4 - 1.7) 225 (17.3%) 35 (42.9%) 1 3.6(1.6 - 8.2) 352 (20.2%) 97 (28.9%) 1 1.6 (0.9 - 2.8)
Dyspepsia No Yes 162 (22.2%) 27 (33.3%) 1 1.8 (0.7 - 4.6) 194 (14.4%) 66 (39.4%) 1 3.9 (1.9 - 7.7) 356 (18.0%) 93 (37.6%) 1 2.8 (1.6 - 4.7)
IBS No Yes 162 (23.5%) 27 (25.9%) 1 1.1 (0.4 - 3.2) 197 (14.2%) 63 (41.3%) 1 4.2 (2.1 - 8.5) 359 (18.4%) 90 (36.7%) 1 2.6(1.5 - 4.4)
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Demographic. There was no difference in the prevalence of GER symptoms between boys and girls in our study. In adults, none of five population based studies have found sex influence on GERS prevalence [2].
Age was not associated with GER symptoms in our study, however age span was too small to make reliable comparison. In adults, the effect of increasing age on the prevalence of GER symptoms is unclear, with some studies reporting slight but significant association [2].
In adults, obesity is associated with a statistically significant increase in the risk for GER symptoms, erosive esophagitis, and esophageal adenocarcinoma. The risk for these disorders seems to progressively increase with increasing weight [18].
In our study, body mass index > 23 kg/m2 was strongly associated with GERS in girls, but not in boys. The possible explanation of this discrepancy may be pubertal transformation that is not equal in boys and girls in temporal terms. Almost all girls (98.2%) reported that they have already menstruated. However, mean body mass index was similar in both sexes and all ages. Association for obesity and acid regurgitation in children and adolescents was seen by others [16, 19].
GERS prevalence in adults is inversely related to educational level [20] and socio-economic status [21]. In our study, all the children were students of governmental secondary school with similar tutorial standards, thus parents' education was assessed. Mother's lower educational attainment was strongly associated with increased GER symptoms in adolescents. The reason for this finding is not clear. Possible explanations may be that more educated women support healthy lifestyle habits in the family including standards of rational nutrition, control of smoking and alcohol consumption of her children, etc.
Behavioral. The most commonly investigated factors are smoking and alcohol consumption that are triggers for reflux episodes in clinical and epidemiological studies. Both factors decrease the lower esophageal sphincter pressure and aborad esophageal peristaltis. We found that smoking daily and alcohol consumption several times a month significantly increase the prevalence of GERS in girls (3.6 and 2.6 times respectively), but this was not true for boys. This finding was to a certain extend unexpected, because exposure to them in children is not so intensive and long-term than in adults. However, in another pediatric study from the USA, heartburn reported by the children was also associated with cigarette use [3]. In a Northern Ireland study smoking and alcohol intake were associated with GERS in univariate but not in multivariate model [16].
Drug therapy may provoke GER (NSAIDs, nitrates, anticholinergics, calcium channel blockers, etc.). A great majority of adolescents were without serious chronic illnesses, and none used the above drugs constantly. Proton pump inhibitor exposure was limited and was not a significant risk factor.
Dietary factors frequently play a role in the development of heartburn, e. g. overeating can increase gastric volume, and various dietary components can promote lower esophageal sphincter relaxation. We studied a number of dietary habits that a priori were thought to provoke GER symptoms. Most of them actually were associated with GERS. Eating twice a day and long period between eating possibly result in overeating later. Long fasting may also predispose to decrease of gastric pH with subsequent reflux of more acidic gastric juice into esophagus.
Moreover, some people do not consider snack as a full meals. To snatch a meal especially a spicy one may result in stimulation of gastric chemoreceptors with
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excessive production of gastric juice without sufficient buffering effect of protein components of food or inhibitory effect of fats.
We studied infections that may potentially cause gastrointestinal damage. Contrary to most adult studies, H. pylori infection was positively associated with GERS. Moreover, CagA positivity was even more closely related to GERS. In line with our results, endoscopic study in children showed significantly higher prevalence of H. pylori among patients with reflux oesophagitis compared to patients with hyperaemic gastropathy alone [22]. Another recent study confirmed that among children age group (1 - 10 years), 100% of the H pylori-positive patients had reflux esophagitis (RE), whereas 44.6% of the H. pylori-negative patients had RE, despite age and gender differences. On a multivariate logistical regression, for the overall study cohort, H. pylori-positive patients had an odds ratio of 5.79 of developing RE compared with H pylori-negative patients (p < 0.05). [23]. Furthermore, infected healthy adult volunteers showed a threefold increase in acid response to gastrin-releasing peptide that resolved after eradication of H. pylori infection [24].
An unexpected finding was lower prevalence of GERS in students seropositive to G. lamblia. This association may be spurious and needs to be clarified further.
Comorbidity. As well as adults, significant proportion of adolescents reported dyspepsia and IBS. Both
of these were coincided with GERS. Joint pathophysiological mechanisms such as visceral hypersensitivity, abnormal gastric secretion and function, psychological distress, etc. may explain this association.
Study advantages and limitations
The value of the present study is recruitment of community-based sample of adolescents, high response rate, and the use of a previously validated Bowel Disease Questionnaire. In Russia almost all children visit public schools thus the sample is almost completely representative for the whole adolescent population. Moreover, adolescents in contrast to younger children may adequately realize and describe their perceptions and sensations concerning gastrointestinal symptoms.
In conclusion, the prevalence of GER symptoms in adolescents monthly is 22% and weekly is 9%. These figures are twice lower that in adults. The majority of factors associated with GER in adults proved to be the same in adolescents. Many of this factors are potentially modifiable and may be possible targets for interventions to reduce the burden of illness and healthcare costs of GERS in adolescence. Moreover, one not exclude that the adequate management of GER symptoms during adolescence and educational programs giving dietary and general lifestyle advises (no smoking, no alcohol, reducing weight, rational dietary intake patterns, H. pylori eradication) might protect from gastrooesophageal reflux disease in later life.
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