Wed, Mar 19, 2025
[Archive]
Volume 10, Issue 1 (Feb 2025)
JNFS 2025, 10(1): 81-91 |
Back to browse issues page
Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
AhmadiVasmehjani A, Beigrezaei S, Nafei Z, Behniafard N, Darabi Z, Salehi-Abargouei A et al . Adherence to Mediterranean-Like Dietary Pattern in Association with Gastroesophageal Reflux Disease in Adolescents. JNFS 2025; 10 (1) :81-91
URL: http://jnfs.ssu.ac.ir/article-1-987-en.html
URL: http://jnfs.ssu.ac.ir/article-1-987-en.html
Azam AhmadiVasmehjani 
, Sara Beigrezaei , Zahra Nafei , Nasrin Behniafard , Zahra Darabi , Amin Salehi-Abargouei , Majid Aflatoonian *
, Sara Beigrezaei , Zahra Nafei , Nasrin Behniafard , Zahra Darabi , Amin Salehi-Abargouei , Majid Aflatoonian *
Children Growth Disorder Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
Keywords: Mediterranean diet, Gastroesophageal reflux Disease, Adolescents, Cross- sectional, Dietary pattern.
Full-Text [PDF 633 kb]
(135 Downloads)
| Abstract (HTML) (578 Views)
Introduction
Full-Text: (66 Views)
Adherence to Mediterranean-Like Dietary Pattern in Association with Gastroesophageal Reflux Disease in Adolescents
Azam AhmadiVasmehjani; PhD1,2, Sara Beigrezaei; PhD3, Zahra Nafei; MD4, Nasrin Behniafard; MD4,5, Zahra Darabi; PhD6, Amin Salehi-Abargouei; PhD1,2 & Majid Aflatoonian; MD*4
Azam AhmadiVasmehjani; PhD1,2, Sara Beigrezaei; PhD3, Zahra Nafei; MD4, Nasrin Behniafard; MD4,5, Zahra Darabi; PhD6, Amin Salehi-Abargouei; PhD1,2 & Majid Aflatoonian; MD*4
1Research Center for Food Hygiene and Safety, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; 2 Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; 3Julius center for health sciences and primary care, University of Medical Center Utrecht, Utrecht University, Utrecht, the Netherlan; 4 Children Growth Disorder Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; 5 Mother and Newborn Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; 6Nutritional Health Research Center, School of Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
.
| ARTICLE INFO | ABSTRACT | |
| ORIGINAL ARTICLE | Background: Gastroesophageal reflux disease (GERD) is a common esophageal disorder affecting adolescents. Recent studies have indicated that the risk of GERD may be influenced by different dietary patterns. This study aimed to examine the relationship between an adherence to Mediterranean-like dietary pattern and GERD in a large group of adolescents from central Iran. Methods: This cross-sectional study involved 5141 adolescents aged 13-14 years. Dietary intake was assessed using a food frequency method which included in a reliable and valid Global Asthma Network (GAN) core questionnaire. GERD symptoms and the frequency of their occurrence over the last week were assessed using a validated GERD questionnaire. A binary logistic regression was used to evaluate the relationship between adherence to Mediterranean-like dietary pattern and GERD and its related symptoms. Results: The results showed that after controlling for potential confounding variables including age, sex, watching TV and computer, and BMI, the adolescents in the highest adherence to the Mediterranean style diet (MedDiet) score had lower odds of GERD [odds ratio (OR)=0.53; 95% CI 0.35-0.80, Ptrend=0.005)], sense of reflux (OR=0.45; 95% CI 0.26-0.77, Ptrend=0.01) and poor sleep (OR=0.54; 95% CI 0.31-0.96, Ptrend=0.02) compared with those in the lowest adherence. No significant association found between MedDiet and other GERD symptoms. Conclusions: This study found a negative relationship between following a MedDiet and having GERD among Iranian adolescents. Following the MedDiet may be a useful strategy to prevent GERD in adolescents. |
|
| Article history: Received: 19 Oct 2023 Revised: 19 Feb 2024 Accepted:29 Feb 2024 |
||
| *Corresponding author: Aflatoonianm@yahoo.com Children Growth Disorder Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran Postal code: 8915173143 Tel: +98 913 3518107 |
||
| Keywords: Mediterranean diet; Gastroesophageal reflux Disease; Adolescents; Cross- sectional; Dietary pattern. |
Introduction
Gastroesophageal reflux disease (GERD) is a condition that occurs when stomach contents flow back into the esophagus, causing symptoms such as heartburn and regurgitation (Hom and Vaezi, 2013, Hungin et al., 2019, Silvia et al., 2018). The prevalence of GERD in all age groups is increasing in the worldwide (Sherman et al., 2009). GERD is one of the most common esophageal disorders (Herregods et al., 2015). Studies have shown that adolescents experience more severe symptoms of GERD and this condition can affect negatively on their health and quality of life (Lightdale et al., 2013, Wiklund, 2004). GERD is a multifactorial disorder (Çela et al., 2013). Diet may have an important role in the development and management of GERD (Jarosz and Taraszewska, 2014a). Dietary modifications are recommended as the first step in treating GERD (Kubo et al., 2014, Nandurkar et al., 2004). Some dietary components, such as high-fat and high-carbohydrate foods, tomato products (Salehi et al., 2019), chocolate (Roman and Kahrilas, 2013), alcohol (Pan et al., 2019), coffee or tea (Cao et al., 2019, Kim et al., 2014) citrus fruits (Roman and Kahrilas, 2013), spicy foods (Jarosz and Taraszewska, 2014b), acidic and fried foods (Roman and Kahrilas, 2013, Surdea-Blaga et al., 2019) and mint (Choe et al., 2017) have been reported to be potentially associated with GERD. However, previous studies have reported inconsistent results regarding the relationship between diet and GERD (Darvishmoghadam et al., 2016, Martinucci et al., 2018, Mone et al., 2016). Keshteli et al. proposed adults who consume fruits and vegetables that are rich in fiber and antioxidant vitamins have lower odds of GERD (Keshteli et al., 2017), which was consistent with other previous studies (El-Serag et al., 2005, Nocon et al., 2006). However, Zheng et al. found different results and suggested that other factors, such as genetics, body mass index (BMI), smoking, and physical activity, may affect the risk of GERD (Zheng et al., 2007). Additionally, a study suggested that functional foods that contain biologically active components could potentially protect against the risk of GERD (Elmaliklis et al., 2019). Current evidence shows that the assessment of dietary patterns may better elucidate the nutritional etiology of chronic diseases (Kant, 2004), this is because dietary patterns account possible interactions among all foods and nutrients, rather than a single food or nutrient (Tucker, 2010, Van Dam, 2005). The Mediterranean style diet (MedDiet) is high in plant food and vegetable oil, moderate in fish and dairy, and low in red meat and poultry (Mone et al., 2016), which were associated with reduced risk of several diseases including cancer (Zavala-Gonzales et al., 2014), cardiovascular disease (Owen et al., 2000), metabolic syndrome (MetS), and type 2 diabetes (Sotos-Prieto et al., 2021). Several studies have recommended that dietary modifications, such as increasing the intake of high-fiber diets and decreasing the intake of fat, may also have benefits in controlling GERD (Gong et al., 2019). Only one cross-sectional study has investigated the association between MedDiet and GERD in adults, indicating that a greater adherence to a MedDiet is inversely associated with GERD (Mone et al., 2016). However, to the best of our knowledge, there is no information on the adherence to MedDiet and its association with GERD in adolescents. Therefore, the aim of this study was to examine the relationship between adherence to Mediterranean-like dietary pattern and GERD in a large sample of adolescents from central Iran.
Methods and Materials
This cross-sectional study used data from an international multi-center cross-sectional population-based study (GAN-2020) (Behniafard et al., 2021, Ellwood et al., 2020, Nafei et al., 2021) conducted on Iranian adolescents aged 13–14 years from February 2020 to June 2020 in Yazd, Iran. The participants were recruited from 48 schools. The schools were selected from all public and private schools in Yazd city using cluster sampling and all students who met the inclusion criteria were recruited.
The questionnaire based on GAN was translated into Persian and its validity was assessed by experts. The reliability of the Persian version of the questionnaire was verified by a study on 100 students aged 13 to 14 years, using Cronbach's alpha coefficient. The internal consistency of the questionnaire for rhinitis and eczema symptoms was satisfactory, with an alpha coefficient of 0.74. Volunteer students completed electronic questionnaires on socio-demographic factors, dietary intake, and GERD symptoms, with the cooperation of school principals. All participants approved the informed consent through the electronic form before completing the questionnaires. Out of 7,214 adolescents who received the questionnaires, 5,141 people completed them (response rate of 71.3). Any unclear demographic information was re-checked by phone contact.
Diagnosis of GERD and its symptoms
Using the validated GERD questionnaire, participants' GERD symptoms and how often they occurred in the past week were reported (Jones et al., 2009). The questionnaire consisted of six items: four positive predictors of GERD were measured based on a four-point Likert scale including frequency of heartburn, regurgitation, sleep disturbance, and the use of over-the-counter medications for these symptoms, and also two negative predictors were scored with a reversed Likert scale including stomach pain and nausea. Participants received a clear and simple explanation before completing the reflux questionnaire. The GERDQ score was calculated by adding the scores of each item, ranging from 0 to 8 (Jones et al., 2009). The sum of the points for the aforementioned frequencies was considered as a participant’s GERDQ score, and a diagnosis of GERD could be possible if the sum of all scores was ≥ 8 points (Jones et al., 2009).
Dietary intake assessment
The dietary intake was assessed using a food questionnaire that listed 26 food items with standard serving sizes. The participants were asked how often they consumed each food item in the questionnaire during the past year, and the frequency of intake (never or very low/ one or two times per week/ often or every day) depending on the food type. A previous study confirmed the validity and reliability of this questionnaire (Nafei et al., 2021). Participants were divided into tertiles according to their Med Diet scores.
The calculation of MedDiet score
Questions on food consumption were included based on frequencies of “never”, "weekly" and "every day" as reported in the study of Garcia et al. (Garcia-Marcos et al., 2007); however, the Med Diet score was developed based on the score used by Psaltopoulou (Psaltopoulou et al., 2004) as follows: fruits, fish, vegetables, pulses, cereals, pasta, rice, and potatoes were considered as “pro-Mediterranean” food and scored 0, 1 or 2 from less frequent to more frequent intake, respectively. Meat, milk, and fast food were considered as “anti-Mediterranean” food scored 0, 1 or 2 from more frequent to less frequent intake, respectively.
Assessment of other variables
The participants’ weight was measured to the nearest 100 g using digital scales with minimal clothes while no wearing shoes and their height was measured to the nearest 0.5 cm using a tape measure fixed on a wall, while they stood without shoes and in a normal position. BMI was calculated by dividing weight (kg) to the square of height (m2). Data on race (Kord/Turk/fars/ Lor/Arab/Balooch) and watching television (TV) and computer use/ or internet (2-4 hours/ 5-8 hours/ 9-14 hours a day) were obtained through an electronic self-completed GAN questionnaire.
Ethical considerations
Written informed consent was obtained from all participants. Ethical approval was obtained from the Ethics Committee of Shahid Sadoughi University of Medical Sciences, IR.SSU.REC.1398.244). All procedures were performed in accordance with relevant guidelines.
Data analyses
General characteristics and dietary intakes across tertiles of MedDiet score are presented as means±SD for continuous variables and numbers (percentage) for categorical variables, respectively. One-way ANOVA and Chi-square test were used to compare continuous and categorical variables across tertiles of MedDiet score, respectively. Binary logistic regression was used to examine the association between adherence to MedDiet and GERD, as well as its symptoms, in the crude and multivariable adjusted models, age and sex in adjusted model I, and other variables like watching TV and using computer and/or internet in adjusted model II. In model III, BMI was also adjusted. All statistical analyses were performed using the statistical package for social sciences (SPSS, version 21, IBM Corporation and (USA). P-values less than 0.05 were considered statistically significant.
Results
Out of 5141 adolescents who completed the data for the analysis, 153 participants had GERD. General characteristics of adolescents across tertiles of MedDiet score are provided in Table 1. Watching TV and using computer and/or internet were significant across tertiles of MedDiet score (P=0.026) and (P<0.001), respectively. GERD symptoms including sense of reflux and poor sleep significantly decreased in the highest tertile of MedDiet score compared to the lowest (P=0.005) and (P=0.008), respectively. No significant difference was observed in other GERD symptoms, age, BMI, sex, and race across tertiles of MedDiet score.
Methods and Materials
This cross-sectional study used data from an international multi-center cross-sectional population-based study (GAN-2020) (Behniafard et al., 2021, Ellwood et al., 2020, Nafei et al., 2021) conducted on Iranian adolescents aged 13–14 years from February 2020 to June 2020 in Yazd, Iran. The participants were recruited from 48 schools. The schools were selected from all public and private schools in Yazd city using cluster sampling and all students who met the inclusion criteria were recruited.
The questionnaire based on GAN was translated into Persian and its validity was assessed by experts. The reliability of the Persian version of the questionnaire was verified by a study on 100 students aged 13 to 14 years, using Cronbach's alpha coefficient. The internal consistency of the questionnaire for rhinitis and eczema symptoms was satisfactory, with an alpha coefficient of 0.74. Volunteer students completed electronic questionnaires on socio-demographic factors, dietary intake, and GERD symptoms, with the cooperation of school principals. All participants approved the informed consent through the electronic form before completing the questionnaires. Out of 7,214 adolescents who received the questionnaires, 5,141 people completed them (response rate of 71.3). Any unclear demographic information was re-checked by phone contact.
Diagnosis of GERD and its symptoms
Using the validated GERD questionnaire, participants' GERD symptoms and how often they occurred in the past week were reported (Jones et al., 2009). The questionnaire consisted of six items: four positive predictors of GERD were measured based on a four-point Likert scale including frequency of heartburn, regurgitation, sleep disturbance, and the use of over-the-counter medications for these symptoms, and also two negative predictors were scored with a reversed Likert scale including stomach pain and nausea. Participants received a clear and simple explanation before completing the reflux questionnaire. The GERDQ score was calculated by adding the scores of each item, ranging from 0 to 8 (Jones et al., 2009). The sum of the points for the aforementioned frequencies was considered as a participant’s GERDQ score, and a diagnosis of GERD could be possible if the sum of all scores was ≥ 8 points (Jones et al., 2009).
Dietary intake assessment
The dietary intake was assessed using a food questionnaire that listed 26 food items with standard serving sizes. The participants were asked how often they consumed each food item in the questionnaire during the past year, and the frequency of intake (never or very low/ one or two times per week/ often or every day) depending on the food type. A previous study confirmed the validity and reliability of this questionnaire (Nafei et al., 2021). Participants were divided into tertiles according to their Med Diet scores.
The calculation of MedDiet score
Questions on food consumption were included based on frequencies of “never”, "weekly" and "every day" as reported in the study of Garcia et al. (Garcia-Marcos et al., 2007); however, the Med Diet score was developed based on the score used by Psaltopoulou (Psaltopoulou et al., 2004) as follows: fruits, fish, vegetables, pulses, cereals, pasta, rice, and potatoes were considered as “pro-Mediterranean” food and scored 0, 1 or 2 from less frequent to more frequent intake, respectively. Meat, milk, and fast food were considered as “anti-Mediterranean” food scored 0, 1 or 2 from more frequent to less frequent intake, respectively.
Assessment of other variables
The participants’ weight was measured to the nearest 100 g using digital scales with minimal clothes while no wearing shoes and their height was measured to the nearest 0.5 cm using a tape measure fixed on a wall, while they stood without shoes and in a normal position. BMI was calculated by dividing weight (kg) to the square of height (m2). Data on race (Kord/Turk/fars/ Lor/Arab/Balooch) and watching television (TV) and computer use/ or internet (2-4 hours/ 5-8 hours/ 9-14 hours a day) were obtained through an electronic self-completed GAN questionnaire.
Ethical considerations
Written informed consent was obtained from all participants. Ethical approval was obtained from the Ethics Committee of Shahid Sadoughi University of Medical Sciences, IR.SSU.REC.1398.244). All procedures were performed in accordance with relevant guidelines.
Data analyses
General characteristics and dietary intakes across tertiles of MedDiet score are presented as means±SD for continuous variables and numbers (percentage) for categorical variables, respectively. One-way ANOVA and Chi-square test were used to compare continuous and categorical variables across tertiles of MedDiet score, respectively. Binary logistic regression was used to examine the association between adherence to MedDiet and GERD, as well as its symptoms, in the crude and multivariable adjusted models, age and sex in adjusted model I, and other variables like watching TV and using computer and/or internet in adjusted model II. In model III, BMI was also adjusted. All statistical analyses were performed using the statistical package for social sciences (SPSS, version 21, IBM Corporation and (USA). P-values less than 0.05 were considered statistically significant.
Results
Out of 5141 adolescents who completed the data for the analysis, 153 participants had GERD. General characteristics of adolescents across tertiles of MedDiet score are provided in Table 1. Watching TV and using computer and/or internet were significant across tertiles of MedDiet score (P=0.026) and (P<0.001), respectively. GERD symptoms including sense of reflux and poor sleep significantly decreased in the highest tertile of MedDiet score compared to the lowest (P=0.005) and (P=0.008), respectively. No significant difference was observed in other GERD symptoms, age, BMI, sex, and race across tertiles of MedDiet score.
| Table 1. Baseline characteristics of participants according to tertiles of MedDiet score. | |||||
| P-valuec | 3rd Tertile (N =1660 ) |
2nd Tertile (N =2095 ) |
1st Tertile (N =1386 ) |
Total (N =5141 ) |
Variables |
| 0.73 | 13.32 ± 0.46 | 13.33 ± 0.47 | 13.32 ± 0.46 | 13.32 ± 0.46a | Age (y) |
| 0.49 | 20.77 ± 4.17 | 20.67 ± 4.09 | 20.59 ± 4.05 | 20.68 ± 4.10 | Body mass index (kg/m2) |
| 0.076 | Sex | ||||
| 655(39.5) | 823(39.3) | 594(42.9) | 2072(40.3)b | Girl | |
| 1005(60.5) | 1272(60.7) | 792(57.1) | 3069(59.7) | Boy | |
| 0.17 | Race | ||||
| 12(0.7) | 10(0.5) | 5(0.4) | 27(0.5) | Kurd | |
| 14(0.8) | 17(0.8) | 9(0.6) | 40 (0.8) | Turk | |
| 1600(96.4) | 2039(97.3) | 1342(96.8) | 4981(96.9) | Fars | |
| 17(1) | 10(0.5) | 10(0.7) | 37(0.7) | Lor | |
| 13(0.8) | 15(0.7) | 10(0.7) | 38(0.7) | Arab | |
| 4(0.2) | 4(0.2) | 10(0.7) | 18(0.4) | Balouch | |
| 0.026 | Watching TV (h/day) | ||||
| 199(12) | 258(12.3) | 192(13.9) | 649(12.6) | <1 | |
| 871(52.5) | 1088(51.9) | 663(47.8) | 2622(51) | 1-3 | |
| 419(25.2) | 529(25.3) | 345(24.9) | 1293(25.2) | 3-5 | |
| 171(10.3) | 220 (10.5) | 186(13.4) | 577(11.2) | >5 | |
| <0.001 | Computer and/or Internet use (h/day) | ||||
| 477(28.7) | 558(26.6) | 348(25.1) | 1383(26.9) | <1 | |
| 732(44.1) | 887(42.3) | 550(39.7) | 2169(42.2) | 1-3 | |
| 270(16.3) | 420(20) | 272(19.6) | 962(18.7) | 3-5 | |
| 181(10.9) | 230(11) | 216(15.6) | 627(12.2) | >5 | |
| 0.29 | Nausea and vomiting | ||||
| 1640(98.8) | 2071(98.9) | 1362(98.3) | 5073(98.7) | No | |
| 20(1.2) | 24(1.1) | 24(1.7) | 68(1.3) | Yes | |
| 0.056 | Epigastric pain | ||||
| 1601(96.4) | 2024(96.6) | 1318(95.1) | 4943(96.1) | No | |
| 59(3.6) | 71(3.4) | 68(4.9) | 198(3.9) | Yes | |
| 0.005 | Sense of reflux | ||||
| 1639(98.7) | 2050(97.9) | 1345(97) | 5034(97.9) | No | |
| 21(1.3) | 45(2.1) | 41(3) | 107(2.1) | Yes | |
| 0.11 | Heartburn | ||||
| 1628(98.1) | 2063(98.5) | 1351(97.5) | 5042(98.1) | No | |
| 32(1.9) | 32(1.5) | 35(2.5) | 99(1.9) | Yes | |
| 0.084 | Drug use | ||||
| 1644(99) | 2072(98.9) | 1361(98.2) | 5077(98.8) | No | |
| 16(1) | 23(1.1) | 25(1.8) | 64(1.2) | Yes | |
| 0.008 | Poor sleep | ||||
| 1640(98.8) | 2072(98.9) | 1354(97.7) | 5066(98.5) | No | |
| 20(1.2) | 23(1.1) | 32(2.3) | 75(1.5) | Yes | |
| a: Means±SD; b: n (%); c: Obtained from one-way ANOVA for continuous variables and Chi-square test for categorical variables. | |||||
| Table 2. Adolescents’ intake of food groups according to tertiles of MedDiet score . | |||||
| P-valueb | 3rd Tertile | 2nd Tertile | 1st Tertile | Total | Variables |
| <0.001 | Meat | ||||
| 718(43.3) | 1037(49.5) | 697(50.3) | 2452(47.7)a | Never | |
| 846(51.0) | 950(45.3) | 589(42.5) | 2385(46.4) | Weekly | |
| 96(5.8) | 108(5.2) | 100(7.2) | 304(5.9) | Every day | |
| <0.001 | Total fast food | ||||
| 47(2.8) | 62(3.0) | 81(5.8) | 190(3.7) | Never | |
| 598(36.0) | 917(43.8) | 648(46.8) | 2163(42.1) | Weekly | |
| 1015(61.1) | 1116(53.3) | 657(47.4) | 2788(54.2) | Every day | |
| <0.001 | Total dairy | ||||
| 1253(75.5) | 1537(73.4) | 989(71.4) | 3779(73.5) | Never | |
| 386(23.3) | 530(25.3) | 354(25.5) | 1270(24.7) | Weekly | |
| 21(1.3) | 28(1.3) | 43(3.1) | 92(1.8) | Every day | |
| <0.001 | Fish | ||||
| 652(39.3) | 1256(60) | 1106(79.8) | 3014(58.6) | Never | |
| 948(57.1) | 829(39.6) | 277(20) | 2054(40.0) | Weekly | |
| 60(3.6) | 10(0.5) | 3(0.2) | 73(1.4) | Every day | |
| <0.001 | Fruits | ||||
| 1(0.1) | 24(1.1) | 120(8.7) | 145(2.8) | Never | |
| 102(6.1) | 341(16.3) | 447(32.3) | 890(17.3) | Weekly | |
| 1557(93.8) | 1730(82.6) | 819(59.1) | 4106(79.9) | Every day | |
| <0.001 | Legumes | ||||
| 2(0.1) | 23(1.1) | 99(7.1) | 124(2.4) | Never | |
| 476(28.7) | 1281(61.1) | 1092(78.8) | 2849(55.4) | Weekly | |
| 1182(71.2) | 791(37.8) | 195(14.1) | 2168(42.2) | Every day | |
| <0.001 | Macaroni | ||||
| 191(11.5) | 522(24.9) | 652(47) | 1365(26.6) | Never | |
| 1350(81.3) | 1536(73.3) | 717(51.7) | 3603(70.1) | Weekly | |
| 119(7.2) | 37(1.8) | 17(1.2) | 173(3.4) | Every day | |
| <0.001 | Rice | ||||
| 0 (0.0) | 4(2.0) | 28(2.0) | 32(0.6) | Never | |
| 91(5.5) | 204(9.7) | 261(18.8) | 556(10.8) | Weekly | |
| 1569(94.5) | 1887(90.1) | 1097(79.1) | 4553(88.6) | Every day | |
| <0.001 | Total vegetables | ||||
| 97(5.8) | 426(20.3) | 760(54.8) | 1283(25.0) | Never | |
| 804(48.4) | 1381(65.9) | 577(41.6) | 2762(53.7) | Weekly | |
| 759(45.7) | 288(13.7) | 49(3.5) | 1096(21.3) | Every day | |
| <0.001 | Wheat, barley, Popcorn | ||||
| 152(9.2) | 611(29.2) | 939(67.7) | 1702(33.1) | Never | |
| 974(58.7) | 1302(62.1) | 412(29.7) | 2688(52.3) | Weekly | |
| 534(32.2) | 182(8.7) | 35(2.5) | 751(14.6) | Every day | |
| <0.001 | Potatoes | ||||
| 17(1.0) | 80(3.8) | 178(12.8) | 275(5.3) | Never | |
| 792(47.7) | 1512(72.2) | 1053(76) | 3357(65.3) | Weekly | |
| 851(51.3) | 503(24.0) | 155(11.2) | 1509(29.4) | Every day | |
| a: n (%); b: Obtained from Chi-square test. | |||||
Frequency of dietary intakes across tertiles of MedDiet score is presented in Table 2. Frequency of meat, fast food, dairy, fish, meat, fruits, vegetables, legumes, macaroni, rice, potatoes, wheat, barley and popcorn intake differed significantly between tertiles of MedDiet (P=<0.001).
Multivariable-adjusted ORs (95% CI) for GERD and its symptoms based on tertiles of MedDiet score are presented in Table 3. Adolescents in the third tertile of MedDiet score had lower odds of GERD (OR=0.53; 95% CI 0.35-0.80 Ptrend=0.005), sense of reflux (QR=0.45; 95% CI 0.26-0.77, Ptrend=0.01), and poor sleep (OR=0.54; 95% CI 0.31-0.96, Ptrend=0.02). This association was significant even after adjusting for confounding factors such as age, sex, watching TV and computer, and BMI. No significant association was found between adherence to MedDiet and other symptoms of GERD (P>0.05).
Multivariable-adjusted ORs (95% CI) for GERD and its symptoms based on tertiles of MedDiet score are presented in Table 3. Adolescents in the third tertile of MedDiet score had lower odds of GERD (OR=0.53; 95% CI 0.35-0.80 Ptrend=0.005), sense of reflux (QR=0.45; 95% CI 0.26-0.77, Ptrend=0.01), and poor sleep (OR=0.54; 95% CI 0.31-0.96, Ptrend=0.02). This association was significant even after adjusting for confounding factors such as age, sex, watching TV and computer, and BMI. No significant association was found between adherence to MedDiet and other symptoms of GERD (P>0.05).
| Table 3. Logistic regression analysis for GERD and its related symptoms among adolescents, according tertiles of MedDiet score. |
| Ptrend | 3rd tertile (N=1660) | 2nd tertile (N=2095) | 1st tertile (N=1386) | Variables |
| GERD | ||||
| 0.001 | 0.49(0.32-0.75) | 0.58 ( 0.40-0.84) | 1 | Crude |
| 0.001 | 0.49(0.32-0.74) | 0.58(0.40-0.84) | 1 | Model 1 |
| 0.005 | 0.53(0.35-0.81) | 0.62(0.42- 0.90) | 1 | Model 2 |
| 0.005 | 0.53(0.35-0.80) | 0.62(0.42-0.90) | 1 | Model 3 |
| Nausea and vomiting | ||||
| 0.29 | 0.69(0.38-1.25) | 0.65(0.37-1.16) | 1 | Crude |
| 0.24 | 0.67(0.37-1.22) | 0.63(0.36-1.12) | 1 | Model 1 |
| 0.39 | 0.73(0.40-1.34) | 0.68(0.38-1.21) | 1 | Model 2 |
| 0.39 | 0.73(0.40-1.34) | 0.68(0.38-1.21) | 1 | Model 3 |
| Sense of reflux | ||||
| 0.006 | 0.42(0.24-0.71) | 0.72(0.46-1.1) | 1 | Crude |
| 0.005 | 0.41(0.24-0.70) | 0.71(0.46-1.09) | 1 | Model 1 |
| 0.01 | 0.45(0.26-0.77) | 0.77(0.50-1.18) | 1 | Model 2 |
| 0.01 | 0.45(0.26-0.77) | 0.77(0.49-1.18) | 1 | Model 3 |
| Heartburn | ||||
| 0.11 | 0.75(0.46-1.23) | 0.59(0.36-0.97) | 1 | Crude |
| 0.10 | 0.75(0.46-1.22) | 0.59(0.36-0.96) | 1 | Model 1 |
| 0.21 | 0.82(0.50-1.35) | 0.64(0.39-1.05) | 1 | Model 2 |
| 0.21 | 0.82(0.50-1.34) | 0.64(0.39-1.05) | 1 | Model 3 |
| Epigastric pain | ||||
| 0.05 | 0.71(0.50-1.02) | 0.68(0.48-0.95) | 1 | Crude |
| 0.03 | 0.69(0.48-0.99) | 0.65(0.46-0.92) | 1 | Model 1 |
| 0.10 | 0.75(0.52-1.07) | 0.69(0.49-0.98) | 1 | Model 2 |
| 0.10 | 0.75(0.52-1.07) | 0.69(0.49-0.98) | 1 | Model 3 |
| Drug use | ||||
| 0.08 | 0.53(0.28-0.99) | 0.6 (0.34-1.06) | 1 | Crude |
| 0.06 | 0.51(0.27-0.96) | 0.58(0.33-1.03) | 1 | Model 1 |
| 0.11 | 0.55(0.29-1.04) | 0.61(0.34-1.09) | 1 | Model 2 |
| 0.11 | 0.55(0.29-1.04) | 0.61(0.34-1.09) | 1 | Model 3 |
| Poor sleep | ||||
| 0.01 | 0.51(0.29-0.90) | 0.47(0.27-0.80) | 1 | Crude |
| 0.006 | 0.49(0.28-0.87) | 0.45(0.26-0.77) | 1 | Model 1 |
| 0.02 | 0.54(0.31-0.96) | 0.48(0.28-0.84) | 1 | Model 2 |
| 0.02 | 0.54(0.31-.096) | 0.48(0.28-0.84) | 1 | Model 3 |
| GERD: Gastroesophageal reflux disease; Model 1: Age and sex adjusted; Model 2: Age, sex, watching TV, using computer and/or internet additionally adjusted; Model 3: Age, sex, watching TV, using computer and/or internet and body mass index was also adjusted.. | ||||
Discussion
The present study found that adolescents who followed more MedDiet had lower chances of GERD, sense of reflux, and poor sleep. The prevalence of GERD is increasing in Iran. According to a recent study, 43.07% of the Iranian population suffers from GERD symptoms (Azami et al., 2021). Behavioral changes such as quitting smoking, limiting alcohol intake, exercising regularly, and eating a healthy diet may help prevent GERD (Taraszewska, 2021). Thus, studying the association of these modifiable factors with GERD may be useful for public health organizations and patients. As far as we know, this is the first cross-sectional study that examined the relationship between the MedDiet and GERD among Iranian adolescents.
Diet is a factor that can be changed to prevent or reduce GERD (Darvishmoghadam et al., 2016). The present study revealed that higher adherence to MedDiet was linked to a 47% lower chance of having GERD. A cross-sectional study also reported that adults who scored higher on MedDiet had a lower risk of GERD (Mone et al., 2016). The MedDiet was characterized by high intake of food that may protect against GERD and low intake of food that may increase the risk of this condition (Mone et al., 2016). Only a few studies have examined how eating components such as fruits and vegetable (Keshteli et al., 2017), legumes (Martinucci et al., 2018) which are part of MedDiet associated with GERD. In a cross-sectional study, Keshteli et al. (Keshteli et al., 2017) found that people who ate more fruits had a 25% lower risk of GERD than those who ate less fruits. However, they did not find any association between vegetable intake and GERD, after adjusting for other factors (Gong et al., 2019). Mary-Joe et al. conducted a cross-sectional study and suggested that some food types in the Lebanese version of MedDiet may prevent GERD (Youssef et al., 2021). Another study found a positive correlation between meat consumption and GERD in Han Chinese people (Niu et al., 2012). Kim et al. found that eating more sweets, fatty food, and caffeinated drinks significantly increased the risk of GERD (Kim et al., 2019).
The possible mechanism of how the MedDiet prevents GERD may be related to fiber intake (Elmaliklis et al., 2019, Keshteli et al., 2017). Some components of MedDiet that are rich in fiber are fruits, vegetables, and legumes (Trichopoulou et al., 2014). Dietary fiber acts as a nitrite scavenger in the stomach, reducing the formation of carcinogenic compounds (Møller et al., 1988). Dietary nitrate converts to nitric oxide in stomach (McKnight et al., 1997), which increases the action of non-adrenergic non-cholinergic inhibitory nerves and reduces the lower esophageal sphincter pressure. Nitric oxide can be a risk factor for reflux esophagitis (Tomita et al., 2003). Nitrate is also used as a food additive in meat products, where it serves as a colorant, an antimicrobial agent, and a flavor enhancer (Dahle, 1979). Low processed food intake is recommended in MedDiet (Hoffman and Gerber, 2015). Vegetables and fruits, which are rich in antioxidants, may lower the risk of GERD (Lukić et al., 2012). GERD may be caused by the excessive production of reactive oxygen species (ROS) and the impairment of the natural antioxidant defense system in the body (Nelkine et al., 2020). Antioxidants are substances that neutralize free radicals and may protect the esophageal mucosa from damage by eliminating these harmful molecules (Lee et al., 2001). This study found that higher adherence to MedDiet was associated with less GERD poor sleep and sense of reflux. Some components of MedDiet such as olive oil, nuts, legumes, fruits, and vegetables (Widmer et al., 2015), are rich in antioxidants, magnesium, and monounsaturated fatty acids (MUFA) (Wahrburg et al., 2002). Magnesium may improve sleep quality by increasing the levels of cortisol and melatonin which are hormones that regulate the sleep-wake cycle (Abbasi et al., 2012). Higher adherence to the MedDiet was related to increased total antioxidant capacity (TAC) (Pitsavos et al., 2005). TAC was directly associated with the intake of fruits, vegetables, and olive oil, but it was inversely correlated with the intake of red meat (Pitsavos et al., 2005). Evidence has reported a negative association between dietary TAC (DTAC) and poor sleep (Daneshzad et al., 2020). Moreover, MedDiet includes food such as olives and grapes that are rich in melatonin that regulates the circadian rhythm (Iriti and Varoni, 2015). Melatonin is used in the management of sleep disorders (Ferracioli-Oda et al., 2013). A diet enriched with MUFA can affect rapid eye movement sleep (REM). Moreover, dietary intake of MUFA can improve insulin function in the brain, which in turn affects the cortical activity and sleep quality (Sartorius et al., 2012).
To the best of our knowledge, the present study is the first study investigated the association of adherence to MedDiet and odds of GERD in adolescents. It was conducted on large sample size of Iranian adolescents. The current study has also several limitations. Due to the nature of cross-sectional studies, they could not explore causal association (Van Der Stede, 2014). This study is prone to recall bias and measurement error should be considered, since questionnaires assessed both exposure and outcome variables; these errors can cause misclassification of the study subjects.
Conclusion
The present study revealed an inverse association between adherences to MedDiet and GERD among adolescents. Adherence to MedDiet may be a useful strategy to prevent and manage GERD in clinical settings. Future studies are required to confirm these findings.
Acknowledgments
Thanks are owed to the participants and co-researchers for their cooperation in this study.
Author's contributions
A AhmadiVasmehjani, Z Darabi, and S Beigrezaei participated in writing the first draft of the manuscript. S Beigrezaei and A Salehi-Abargouei conducted the statistical analyses. M Aflatoonian helped in data collection. N Behniafard and Z Nafei contributed to the conception and design. M Aflatoonian, Z Nafei and A Salehi-Abargouei supervised the study. All authors reviewed the final version of the manuscript.
Conflict of interests
The authors declare that they have no competing interests.
Funding
The present study found that adolescents who followed more MedDiet had lower chances of GERD, sense of reflux, and poor sleep. The prevalence of GERD is increasing in Iran. According to a recent study, 43.07% of the Iranian population suffers from GERD symptoms (Azami et al., 2021). Behavioral changes such as quitting smoking, limiting alcohol intake, exercising regularly, and eating a healthy diet may help prevent GERD (Taraszewska, 2021). Thus, studying the association of these modifiable factors with GERD may be useful for public health organizations and patients. As far as we know, this is the first cross-sectional study that examined the relationship between the MedDiet and GERD among Iranian adolescents.
Diet is a factor that can be changed to prevent or reduce GERD (Darvishmoghadam et al., 2016). The present study revealed that higher adherence to MedDiet was linked to a 47% lower chance of having GERD. A cross-sectional study also reported that adults who scored higher on MedDiet had a lower risk of GERD (Mone et al., 2016). The MedDiet was characterized by high intake of food that may protect against GERD and low intake of food that may increase the risk of this condition (Mone et al., 2016). Only a few studies have examined how eating components such as fruits and vegetable (Keshteli et al., 2017), legumes (Martinucci et al., 2018) which are part of MedDiet associated with GERD. In a cross-sectional study, Keshteli et al. (Keshteli et al., 2017) found that people who ate more fruits had a 25% lower risk of GERD than those who ate less fruits. However, they did not find any association between vegetable intake and GERD, after adjusting for other factors (Gong et al., 2019). Mary-Joe et al. conducted a cross-sectional study and suggested that some food types in the Lebanese version of MedDiet may prevent GERD (Youssef et al., 2021). Another study found a positive correlation between meat consumption and GERD in Han Chinese people (Niu et al., 2012). Kim et al. found that eating more sweets, fatty food, and caffeinated drinks significantly increased the risk of GERD (Kim et al., 2019).
The possible mechanism of how the MedDiet prevents GERD may be related to fiber intake (Elmaliklis et al., 2019, Keshteli et al., 2017). Some components of MedDiet that are rich in fiber are fruits, vegetables, and legumes (Trichopoulou et al., 2014). Dietary fiber acts as a nitrite scavenger in the stomach, reducing the formation of carcinogenic compounds (Møller et al., 1988). Dietary nitrate converts to nitric oxide in stomach (McKnight et al., 1997), which increases the action of non-adrenergic non-cholinergic inhibitory nerves and reduces the lower esophageal sphincter pressure. Nitric oxide can be a risk factor for reflux esophagitis (Tomita et al., 2003). Nitrate is also used as a food additive in meat products, where it serves as a colorant, an antimicrobial agent, and a flavor enhancer (Dahle, 1979). Low processed food intake is recommended in MedDiet (Hoffman and Gerber, 2015). Vegetables and fruits, which are rich in antioxidants, may lower the risk of GERD (Lukić et al., 2012). GERD may be caused by the excessive production of reactive oxygen species (ROS) and the impairment of the natural antioxidant defense system in the body (Nelkine et al., 2020). Antioxidants are substances that neutralize free radicals and may protect the esophageal mucosa from damage by eliminating these harmful molecules (Lee et al., 2001). This study found that higher adherence to MedDiet was associated with less GERD poor sleep and sense of reflux. Some components of MedDiet such as olive oil, nuts, legumes, fruits, and vegetables (Widmer et al., 2015), are rich in antioxidants, magnesium, and monounsaturated fatty acids (MUFA) (Wahrburg et al., 2002). Magnesium may improve sleep quality by increasing the levels of cortisol and melatonin which are hormones that regulate the sleep-wake cycle (Abbasi et al., 2012). Higher adherence to the MedDiet was related to increased total antioxidant capacity (TAC) (Pitsavos et al., 2005). TAC was directly associated with the intake of fruits, vegetables, and olive oil, but it was inversely correlated with the intake of red meat (Pitsavos et al., 2005). Evidence has reported a negative association between dietary TAC (DTAC) and poor sleep (Daneshzad et al., 2020). Moreover, MedDiet includes food such as olives and grapes that are rich in melatonin that regulates the circadian rhythm (Iriti and Varoni, 2015). Melatonin is used in the management of sleep disorders (Ferracioli-Oda et al., 2013). A diet enriched with MUFA can affect rapid eye movement sleep (REM). Moreover, dietary intake of MUFA can improve insulin function in the brain, which in turn affects the cortical activity and sleep quality (Sartorius et al., 2012).
To the best of our knowledge, the present study is the first study investigated the association of adherence to MedDiet and odds of GERD in adolescents. It was conducted on large sample size of Iranian adolescents. The current study has also several limitations. Due to the nature of cross-sectional studies, they could not explore causal association (Van Der Stede, 2014). This study is prone to recall bias and measurement error should be considered, since questionnaires assessed both exposure and outcome variables; these errors can cause misclassification of the study subjects.
Conclusion
The present study revealed an inverse association between adherences to MedDiet and GERD among adolescents. Adherence to MedDiet may be a useful strategy to prevent and manage GERD in clinical settings. Future studies are required to confirm these findings.
Acknowledgments
Thanks are owed to the participants and co-researchers for their cooperation in this study.
Author's contributions
A AhmadiVasmehjani, Z Darabi, and S Beigrezaei participated in writing the first draft of the manuscript. S Beigrezaei and A Salehi-Abargouei conducted the statistical analyses. M Aflatoonian helped in data collection. N Behniafard and Z Nafei contributed to the conception and design. M Aflatoonian, Z Nafei and A Salehi-Abargouei supervised the study. All authors reviewed the final version of the manuscript.
Conflict of interests
The authors declare that they have no competing interests.
Funding
The current study was financially supported by Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences
References
Abbasi B, et al. 2012. The effect of magnesium supplementation on primary insomnia in elderly: A double-blind placebo-controlled clinical trial. Journal of research in medical sciences. 17 (12): 1161.
Azami M, Hafezi Ahmadi M, Karimian M, Salamati M & Nourmohammadi H 2021. Epidemiology of gastroesophageal reflux disease in Iran; a systematic review and meta-analysis. Technology and research information system. 4 (3): 0-0.
Behniafard N, Nafei Z, Mirzaei M, Karimi M & Vakili M 2021. Prevalence and Severity of Adolescent Asthma in Yazd, Iran: Based on the 2020 Global Asthma Network (GAN) Survey. Iranian journal of allergy, asthma and immunology. 20 (1): 24-32.
Cao H, et al. 2019. Association between tea consumption and gastroesophageal reflux disease: a meta-analysis. Medicine. 98 (4): e14173.
Çela L, et al. 2013. Lifestyle characteristics and gastroesophageal reflux disease: a population-based study in Albania. Gastroenterology research and practice. 2013 (1.): 936792.
Choe JW, et al. 2017. Foods inducing typical gastroesophageal reflux disease symptoms in Korea. Journal of neurogastroenterology and motility. 23 (3): 363.
Dahle H 1979. Nitrite as a food additive. NIPH annals. 2 (2): 17-24.
Daneshzad E, Keshavarz S-A, Qorbani M, Larijani B & Azadbakht L 2020. Dietary total antioxidant capacity and its association with sleep, stress, anxiety, and depression score: A cross-sectional study among diabetic women. Clinical nutrition ESPEN. 37: 187-194.
Darvishmoghadam S, et al. 2016. Review of clinical spectrum of gastroesophageal reflux disease in a general population; a study from south-east Iran. Middle East journal of digestive diseases. 8 (4): 310.
El-Serag H, Satia J & Rabeneck L 2005. Dietary intake and the risk of gastro-oesophageal reflux disease: a cross sectional study in volunteers. Gut. 54 (1): 11-17.
Ellwood P, et al. 2020. Global Asthma Network Phase I surveillance: geographical coverage and response rates. Journal of clinical medicine. 9 (11): 3688.
Elmaliklis I-N, et al. 2019. Increased functional foods’ consumption and Mediterranean diet adherence may have a protective effect in the appearance of gastrointestinal diseases: a case–control study. Medicines. 6 (2): 50.
Ferracioli-Oda E, Qawasmi A & Bloch MH 2013. Meta-analysis: melatonin for the treatment of primary sleep disorders. PloS one. 8 (5): e63773.
Garcia-Marcos L, et al. 2007. Relationship of asthma and rhinoconjunctivitis with obesity, exercise and Mediterranean diet in Spanish schoolchildren. Thorax. 62 (6): 503-508.
Gong Y, Zeng Q, Yan Y, Han C & Zheng Y 2019. Association between lifestyle and gastroesophageal reflux disease questionnaire scores: a cross-sectional study of 37 442 chinese adults. Gastroenterology research and practice. 2019 (1): 5753813.
Herregods T, Bredenoord A & Smout A 2015. Pathophysiology of gastroesophageal reflux disease: new understanding in a new era. Neurogastroenterology & Motility. 27 (9): 1202-1213.
Hoffman R & Gerber M 2015. Food processing and the Mediterranean diet. Nutrients. 7 (9): 7925-7964.
Hom C & Vaezi MF 2013. Extra-esophageal manifestations of gastroesophageal reflux disease: diagnosis and treatment. Drugs. 73 (12): 1281-1295.
Hungin APS, Molloy-Bland M & Scarpignato C 2019. Revisiting Montreal: new insights into symptoms and their causes, and implications for the future of GERD. American journal of gastroenterology. 114 (3): 414.
Iriti M & Varoni EM 2015. Melatonin in Mediterranean diet, a new perspective. Journal of the science of food and agriculture. 95 (12): 2355-2359.
Jarosz M & Taraszewska A 2014a. Risk factors for gastroesophageal reflux disease: the role of diet. Przeglad gastroenterologiczny. 9 (5): 297–301.
Jarosz M & Taraszewska A 2014b. Risk factors for gastroesophageal reflux disease: the role of diet. Przeglad gastroenterologiczny. 9 (5): 297.
Jones R, et al. 2009. Development of the GerdQ, a tool for the diagnosis and management of gastro‐oesophageal reflux disease in primary care. Alimentary pharmacology & therapeutics. 30 (10): 1030-1038.
Kant AK 2004. Dietary patterns and health outcomes. Journal of the American Dietetic Association. 104 (4): 615-635.
Keshteli AH, et al. 2017. The relationship between fruit and vegetable intake with gastroesophageal reflux disease in Iranian adults. Journal of research in medical sciences. 22.
Kim J, et al. 2014. Association between coffee intake and gastroesophageal reflux disease: a meta-analysis. Diseases of the esophagus. 27 (4): 311-317.
Kim YM, et al. 2019. Association between skeletal muscle attenuation and gastroesophageal reflux disease: a health check-up cohort study. Scientific reports. 9 (1): 1-8.
Kubo A, Block G, Quesenberry CP, Buffler P & Corley DA 2014. Dietary guideline adherence for gastroesophageal reflux disease. BMC gastroenterology. 14 (1): 1-9.
Lee JS, et al. 2001. Involvement of oxidative stress in experimentally induced reflux esophagitis and Barrett’s esophagus: clue for the chemoprevention of esophageal carcinoma by antioxidants. Mutation research/Fundamental and molecular mechanisms of mutagenesis. 480: 189-200.
Lightdale JR, et al. 2013. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics. 131 (5): e1684-e1695.
Lukić M, et al. 2012. The impact of the vitamins A, C and E in the prevention of gastroesophageal reflux disease, Barrett’s oesophagus and oesophageal adenocarcinoma. Collegium antropologicum. 36 (3): 867-872.
Martinucci I, et al. 2018. Gastroesophageal reflux symptoms among Italian university students: epidemiology and dietary correlates using automatically recorded transactions. BMC gastroenterology. 18 (1): 1-10.
McKnight G, et al. 1997. Chemical synthesis of nitric oxide in the stomach from dietary nitrate in humans. Gut. 40 (2): 211-214.
Møller M, Dahl R & Bøckman O 1988. A possible role of the dietary fibre product, wheat bran, as a nitrite scavenger. Food and chemical toxicology. 26 (10): 841-845.
Mone I, et al. 2016. Adherence to a predominantly Mediterranean diet decreases the risk of gastroesophageal reflux disease: a cross-sectional study in a South Eastern European population. Diseases of the esophagus. 29 (7): 794-800.
Nafei Z, Behniafard N, Mirzaei M, Karimi M & Akbarian E 2021. Prevalence of allergic rhinitis and eczema in adolescents living in Yazd City: part of Global Asthma Network Survey. Iranian journal of allergy, asthma and immunology. 20 (3): 271-278.
Nandurkar S, et al. 2004. Relationship between body mass index, diet, exercise and gastro‐oesophageal reflux symptoms in a community. Alimentary pharmacology & therapeutics. 20 (5): 497-505.
Nelkine L, Vrolijk MF, Drent M & Bast A 2020. Role of antioxidants in the treatment of gastroesophageal reflux disease-associated idiopathic pulmonary fibrosis. Current opinion in pulmonary medicine. 26 (4): 363-371.
Niu C-Y, et al. 2012. Incidence of gastroesophageal reflux disease in Uygur and Han Chinese adults in Urumqi. World journal of gastroenterology. 18 (48): 7333.
Nocon M, Labenz J & Willich S 2006. Lifestyle factors and symptoms of gastro‐oesophageal reflux–a population‐based study. Alimentary pharmacology & therapeutics. 23 (1): 169-174.
Owen RW, et al. 2000. Olive-oil consumption and health: the possible role of antioxidants. lancet oncology. 1 (2): 107-112.
Pan J, et al. 2019. Alcohol consumption and the risk of gastroesophageal reflux disease: a systematic review and meta-analysis. Alcohol and Alcoholism. 54 (1): 62-69.
Pitsavos C, et al. 2005. Adherence to the Mediterranean diet is associated with total antioxidant capacity in healthy adults: the ATTICA study–. American journal of clinical nutrition. 82 (3): 694-699.
Psaltopoulou T, et al. 2004. Olive oil, the Mediterranean diet, and arterial blood pressure: the Greek European Prospective Investigation into Cancer and Nutrition (EPIC) study. American journal of clinical nutrition. 80 (4): 1012-1018.
Roman S & Kahrilas PJ 2013. Overview of gastroesophageal reflux disease treatments. In Practical Manual of Gastroesophageal Reflux Disease (ed. F. Marcelo, M. Vela, E. Joel and M. Richter).
Salehi B, et al. 2019. Beneficial effects and potential risks of tomato consumption for human health: An overview. Nutrition. 62: 201-208.
Sartorius T, et al. 2012. Monounsaturated fatty acids prevent the aversive effects of obesity on locomotion, brain activity, and sleep behavior. Diabetes. 61 (7): 1669-1679.
Sherman PM, et al. 2009. A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population. journal of the American College of Gastroenterology. 104 (5): 1278-1295.
Silvia C, et al. 2018. Diagnosis of GERD in typical and atypical manifestations. Acta Bio Medica: Atenei Parmensis. 89 (Suppl 8): 33.
Sotos-Prieto M, et al. 2021. Association between the Mediterranean lifestyle, metabolic syndrome and mortality: a whole-country cohort in Spain. Cardiovascular diabetology. 20 (1): 1-12.
Surdea-Blaga T, Negrutiu DE, Palage M & Dumitrascu DL 2019. Food and gastroesophageal reflux disease. Current medicinal chemistry. 26 (19): 3497-3511.
Taraszewska A 2021. Risk factors for gastroesophageal reflux disease symptoms related to lifestyle and diet. Roczniki Państwowego Zakładu Higieny. 72 (1).
Tomita R, Tanjoh K, Fujisaki S & Fukuzawa M 2003. Physiological studies on nitric oxide in the lower esophageal sphincter of patients with reflux esophagitis. Hepato-gastroenterology. 50 (49): 110-114.
Trichopoulou A, et al. 2014. Definitions and potential health benefits of the Mediterranean diet: views from experts around the world. BMC medicine. 12 (1): 1-16.
Tucker KL 2010. Dietary patterns, approaches, and multicultural perspective. Applied physiology, nutrition, and metabolism. 35 (2): 211-218.
Van Dam RM 2005. New approaches to the study of dietary patterns. British journal of nutrition. 93 (5): 573-574.
Van Der Stede WA 2014. A manipulationist view of causality in cross-sectional survey research. Accounting, organizations and society. 39 (7): 567-574.
Wahrburg U, Kratz M & Cullen P 2002. Mediterranean diet, olive oil and health. European journal of lipid science and technology. 104 (9‐10): 698-705.
Widmer RJ, Flammer AJ, Lerman LO & Lerman A 2015. The Mediterranean diet, its components, and cardiovascular disease. American journal of medicine. 128 (3): 229-238.
Wiklund I 2004. Review of the quality of life and burden of illness in gastroesophageal reflux disease. Digestive diseases. 22 (2): 108-114.
Youssef M-J, et al. 2021. Several Components of the Lebanese Mediterranean Diet and Particular Sociodemographic, Medical and Lifestyle Factors may be Associated with Gastroesophageal Reflux Disease in Adults: A Cross-sectional Study in a Middle Eastern Setting. Current Nutrition & Food Science. 17 (1): 82-93.
Zavala-Gonzales MA, Azamar-Jacome AA, Meixueiro-Daza A & De La Medina AR 2014. Validation and diagnostic usefulness of gastroesophageal reflux disease questionnaire in a primary care level in Mexico. Journal of neurogastroenterology and motility. 20 (4): 475.
Zheng Z, Nordenstedt H, Pedersen NL, Lagergren J & Ye W 2007. Lifestyle factors and risk for symptomatic gastroesophageal reflux in monozygotic twins. Gastroenterology. 132 (1): 87-95.
Abbasi B, et al. 2012. The effect of magnesium supplementation on primary insomnia in elderly: A double-blind placebo-controlled clinical trial. Journal of research in medical sciences. 17 (12): 1161.
Azami M, Hafezi Ahmadi M, Karimian M, Salamati M & Nourmohammadi H 2021. Epidemiology of gastroesophageal reflux disease in Iran; a systematic review and meta-analysis. Technology and research information system. 4 (3): 0-0.
Behniafard N, Nafei Z, Mirzaei M, Karimi M & Vakili M 2021. Prevalence and Severity of Adolescent Asthma in Yazd, Iran: Based on the 2020 Global Asthma Network (GAN) Survey. Iranian journal of allergy, asthma and immunology. 20 (1): 24-32.
Cao H, et al. 2019. Association between tea consumption and gastroesophageal reflux disease: a meta-analysis. Medicine. 98 (4): e14173.
Çela L, et al. 2013. Lifestyle characteristics and gastroesophageal reflux disease: a population-based study in Albania. Gastroenterology research and practice. 2013 (1.): 936792.
Choe JW, et al. 2017. Foods inducing typical gastroesophageal reflux disease symptoms in Korea. Journal of neurogastroenterology and motility. 23 (3): 363.
Dahle H 1979. Nitrite as a food additive. NIPH annals. 2 (2): 17-24.
Daneshzad E, Keshavarz S-A, Qorbani M, Larijani B & Azadbakht L 2020. Dietary total antioxidant capacity and its association with sleep, stress, anxiety, and depression score: A cross-sectional study among diabetic women. Clinical nutrition ESPEN. 37: 187-194.
Darvishmoghadam S, et al. 2016. Review of clinical spectrum of gastroesophageal reflux disease in a general population; a study from south-east Iran. Middle East journal of digestive diseases. 8 (4): 310.
El-Serag H, Satia J & Rabeneck L 2005. Dietary intake and the risk of gastro-oesophageal reflux disease: a cross sectional study in volunteers. Gut. 54 (1): 11-17.
Ellwood P, et al. 2020. Global Asthma Network Phase I surveillance: geographical coverage and response rates. Journal of clinical medicine. 9 (11): 3688.
Elmaliklis I-N, et al. 2019. Increased functional foods’ consumption and Mediterranean diet adherence may have a protective effect in the appearance of gastrointestinal diseases: a case–control study. Medicines. 6 (2): 50.
Ferracioli-Oda E, Qawasmi A & Bloch MH 2013. Meta-analysis: melatonin for the treatment of primary sleep disorders. PloS one. 8 (5): e63773.
Garcia-Marcos L, et al. 2007. Relationship of asthma and rhinoconjunctivitis with obesity, exercise and Mediterranean diet in Spanish schoolchildren. Thorax. 62 (6): 503-508.
Gong Y, Zeng Q, Yan Y, Han C & Zheng Y 2019. Association between lifestyle and gastroesophageal reflux disease questionnaire scores: a cross-sectional study of 37 442 chinese adults. Gastroenterology research and practice. 2019 (1): 5753813.
Herregods T, Bredenoord A & Smout A 2015. Pathophysiology of gastroesophageal reflux disease: new understanding in a new era. Neurogastroenterology & Motility. 27 (9): 1202-1213.
Hoffman R & Gerber M 2015. Food processing and the Mediterranean diet. Nutrients. 7 (9): 7925-7964.
Hom C & Vaezi MF 2013. Extra-esophageal manifestations of gastroesophageal reflux disease: diagnosis and treatment. Drugs. 73 (12): 1281-1295.
Hungin APS, Molloy-Bland M & Scarpignato C 2019. Revisiting Montreal: new insights into symptoms and their causes, and implications for the future of GERD. American journal of gastroenterology. 114 (3): 414.
Iriti M & Varoni EM 2015. Melatonin in Mediterranean diet, a new perspective. Journal of the science of food and agriculture. 95 (12): 2355-2359.
Jarosz M & Taraszewska A 2014a. Risk factors for gastroesophageal reflux disease: the role of diet. Przeglad gastroenterologiczny. 9 (5): 297–301.
Jarosz M & Taraszewska A 2014b. Risk factors for gastroesophageal reflux disease: the role of diet. Przeglad gastroenterologiczny. 9 (5): 297.
Jones R, et al. 2009. Development of the GerdQ, a tool for the diagnosis and management of gastro‐oesophageal reflux disease in primary care. Alimentary pharmacology & therapeutics. 30 (10): 1030-1038.
Kant AK 2004. Dietary patterns and health outcomes. Journal of the American Dietetic Association. 104 (4): 615-635.
Keshteli AH, et al. 2017. The relationship between fruit and vegetable intake with gastroesophageal reflux disease in Iranian adults. Journal of research in medical sciences. 22.
Kim J, et al. 2014. Association between coffee intake and gastroesophageal reflux disease: a meta-analysis. Diseases of the esophagus. 27 (4): 311-317.
Kim YM, et al. 2019. Association between skeletal muscle attenuation and gastroesophageal reflux disease: a health check-up cohort study. Scientific reports. 9 (1): 1-8.
Kubo A, Block G, Quesenberry CP, Buffler P & Corley DA 2014. Dietary guideline adherence for gastroesophageal reflux disease. BMC gastroenterology. 14 (1): 1-9.
Lee JS, et al. 2001. Involvement of oxidative stress in experimentally induced reflux esophagitis and Barrett’s esophagus: clue for the chemoprevention of esophageal carcinoma by antioxidants. Mutation research/Fundamental and molecular mechanisms of mutagenesis. 480: 189-200.
Lightdale JR, et al. 2013. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics. 131 (5): e1684-e1695.
Lukić M, et al. 2012. The impact of the vitamins A, C and E in the prevention of gastroesophageal reflux disease, Barrett’s oesophagus and oesophageal adenocarcinoma. Collegium antropologicum. 36 (3): 867-872.
Martinucci I, et al. 2018. Gastroesophageal reflux symptoms among Italian university students: epidemiology and dietary correlates using automatically recorded transactions. BMC gastroenterology. 18 (1): 1-10.
McKnight G, et al. 1997. Chemical synthesis of nitric oxide in the stomach from dietary nitrate in humans. Gut. 40 (2): 211-214.
Møller M, Dahl R & Bøckman O 1988. A possible role of the dietary fibre product, wheat bran, as a nitrite scavenger. Food and chemical toxicology. 26 (10): 841-845.
Mone I, et al. 2016. Adherence to a predominantly Mediterranean diet decreases the risk of gastroesophageal reflux disease: a cross-sectional study in a South Eastern European population. Diseases of the esophagus. 29 (7): 794-800.
Nafei Z, Behniafard N, Mirzaei M, Karimi M & Akbarian E 2021. Prevalence of allergic rhinitis and eczema in adolescents living in Yazd City: part of Global Asthma Network Survey. Iranian journal of allergy, asthma and immunology. 20 (3): 271-278.
Nandurkar S, et al. 2004. Relationship between body mass index, diet, exercise and gastro‐oesophageal reflux symptoms in a community. Alimentary pharmacology & therapeutics. 20 (5): 497-505.
Nelkine L, Vrolijk MF, Drent M & Bast A 2020. Role of antioxidants in the treatment of gastroesophageal reflux disease-associated idiopathic pulmonary fibrosis. Current opinion in pulmonary medicine. 26 (4): 363-371.
Niu C-Y, et al. 2012. Incidence of gastroesophageal reflux disease in Uygur and Han Chinese adults in Urumqi. World journal of gastroenterology. 18 (48): 7333.
Nocon M, Labenz J & Willich S 2006. Lifestyle factors and symptoms of gastro‐oesophageal reflux–a population‐based study. Alimentary pharmacology & therapeutics. 23 (1): 169-174.
Owen RW, et al. 2000. Olive-oil consumption and health: the possible role of antioxidants. lancet oncology. 1 (2): 107-112.
Pan J, et al. 2019. Alcohol consumption and the risk of gastroesophageal reflux disease: a systematic review and meta-analysis. Alcohol and Alcoholism. 54 (1): 62-69.
Pitsavos C, et al. 2005. Adherence to the Mediterranean diet is associated with total antioxidant capacity in healthy adults: the ATTICA study–. American journal of clinical nutrition. 82 (3): 694-699.
Psaltopoulou T, et al. 2004. Olive oil, the Mediterranean diet, and arterial blood pressure: the Greek European Prospective Investigation into Cancer and Nutrition (EPIC) study. American journal of clinical nutrition. 80 (4): 1012-1018.
Roman S & Kahrilas PJ 2013. Overview of gastroesophageal reflux disease treatments. In Practical Manual of Gastroesophageal Reflux Disease (ed. F. Marcelo, M. Vela, E. Joel and M. Richter).
Salehi B, et al. 2019. Beneficial effects and potential risks of tomato consumption for human health: An overview. Nutrition. 62: 201-208.
Sartorius T, et al. 2012. Monounsaturated fatty acids prevent the aversive effects of obesity on locomotion, brain activity, and sleep behavior. Diabetes. 61 (7): 1669-1679.
Sherman PM, et al. 2009. A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population. journal of the American College of Gastroenterology. 104 (5): 1278-1295.
Silvia C, et al. 2018. Diagnosis of GERD in typical and atypical manifestations. Acta Bio Medica: Atenei Parmensis. 89 (Suppl 8): 33.
Sotos-Prieto M, et al. 2021. Association between the Mediterranean lifestyle, metabolic syndrome and mortality: a whole-country cohort in Spain. Cardiovascular diabetology. 20 (1): 1-12.
Surdea-Blaga T, Negrutiu DE, Palage M & Dumitrascu DL 2019. Food and gastroesophageal reflux disease. Current medicinal chemistry. 26 (19): 3497-3511.
Taraszewska A 2021. Risk factors for gastroesophageal reflux disease symptoms related to lifestyle and diet. Roczniki Państwowego Zakładu Higieny. 72 (1).
Tomita R, Tanjoh K, Fujisaki S & Fukuzawa M 2003. Physiological studies on nitric oxide in the lower esophageal sphincter of patients with reflux esophagitis. Hepato-gastroenterology. 50 (49): 110-114.
Trichopoulou A, et al. 2014. Definitions and potential health benefits of the Mediterranean diet: views from experts around the world. BMC medicine. 12 (1): 1-16.
Tucker KL 2010. Dietary patterns, approaches, and multicultural perspective. Applied physiology, nutrition, and metabolism. 35 (2): 211-218.
Van Dam RM 2005. New approaches to the study of dietary patterns. British journal of nutrition. 93 (5): 573-574.
Van Der Stede WA 2014. A manipulationist view of causality in cross-sectional survey research. Accounting, organizations and society. 39 (7): 567-574.
Wahrburg U, Kratz M & Cullen P 2002. Mediterranean diet, olive oil and health. European journal of lipid science and technology. 104 (9‐10): 698-705.
Widmer RJ, Flammer AJ, Lerman LO & Lerman A 2015. The Mediterranean diet, its components, and cardiovascular disease. American journal of medicine. 128 (3): 229-238.
Wiklund I 2004. Review of the quality of life and burden of illness in gastroesophageal reflux disease. Digestive diseases. 22 (2): 108-114.
Youssef M-J, et al. 2021. Several Components of the Lebanese Mediterranean Diet and Particular Sociodemographic, Medical and Lifestyle Factors may be Associated with Gastroesophageal Reflux Disease in Adults: A Cross-sectional Study in a Middle Eastern Setting. Current Nutrition & Food Science. 17 (1): 82-93.
Zavala-Gonzales MA, Azamar-Jacome AA, Meixueiro-Daza A & De La Medina AR 2014. Validation and diagnostic usefulness of gastroesophageal reflux disease questionnaire in a primary care level in Mexico. Journal of neurogastroenterology and motility. 20 (4): 475.
Zheng Z, Nordenstedt H, Pedersen NL, Lagergren J & Ye W 2007. Lifestyle factors and risk for symptomatic gastroesophageal reflux in monozygotic twins. Gastroenterology. 132 (1): 87-95.
Type of article: orginal article |
Subject:
public specific
Received: 2023/10/19 | Published: 2025/02/4 | ePublished: 2025/02/4
Received: 2023/10/19 | Published: 2025/02/4 | ePublished: 2025/02/4
Send email to the article author
| Rights and permissions | |
 |
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
