EEE _§_§ Heartburn Risk Factors, Knowledge, and Prevention Strategies A Population-Based Survey of Individuals With Heartburn Susan A. Oliveria, SeD, MPH; Paul J. Christos, MPH, MS: Nicholas J. Talley, MD, PRD; Andrew J. Dannenberg, MD Background: Twenty-five million adults exp. hhearthurn daily. To target individuals for prevention pro- ‘grams, characteristics of persons with heartburn and the associated causes of this condition must first be identi- fied, Methods: We conducted a population-based tele- phone survey of 2000 individuals with heartburn to de- scribe the cause of the disease, knowledge of risk fac- tors, and prevention strategies. Results: Lifestyle and work habits, and certain food and beverage consumption, were associated with heartburn, Women reported the onset of heartburn about 5 years later than men. Survey respondents were unaware of the risk factors for heartburn, and sex-dependent differ- ences in knowledge were apparent, Logistic regression, modeling identified increasing age, female sex, higher level ‘of education, and frequent vs infrequent heartburn as sig nificant (P<02) predictors of whether patients told a phy- sician about their heartburn symptoms. Increasing age, higher body mass index, and reduced level of edueation, ‘were significant (P<.02) predictors of frequent vs infre- {quent heartburn in this study population, Conelusion: The findings ofthis study provide a frame- work for the development of a heartburn prevention pro- ‘gram based on lifestyle modification, Arch Intern Med. 1999;159:1592-1598 From the Strang Cancer Prevention Center (Drs Olivera ‘and Dannenberg and Mr Christos) and the Departments of Public Health (@r oliveri and Mr Christos) and Medicine (Dr Dannenberg) ‘Weill Medical College, Cornell University, New York, NY; and the Department of Medicine University of Syduey, Nepean Hospital, Sydney, Australia (@r Talley). Dr Oliveriais now withthe Department of Medicine, Memorial Slown-Ketering Cancer Center, New York, NY. WENTV-FIVE MILLION adults experience heartburn daily, and more than one third of adults experience heartburn at least once ‘a month in the United States." Heart burn, a burning sensation behind the breast bone, is the most common sym tom of gastroesophageal reflux disease Although not life threatening, gastro- esophageal reflux can cause complica tions, including esophagitis, ulceration, and stricture formation. Moreover, gas” troesophageal reflux is a risk factor for Barrett esophagus, a premalignant condi- tion of the esophagus.°° The high preva lence and associated long-term discom- fort of heartburn affeets quality of life and 4s costly to society. In 1999, more than $1 billion was spent on nonprescription heartburn remedies, including hydrogen, receptor antagonists and antacids (AC Nielsen marketing company, unpub- lished data, September 1996). Hearthurn occurs when the esopha- {gus is exposed to gastric acid. Ordinarily the lower esophageal sphineter, which sepa rates the esophagus from the stomach, pre- vents acid from entering the esophagus. At ‘appropriate times, ansient lower esoph- ageal sphincter relaxation occurs, rest ing in gastroesophageal reflux and heart burn." Heartburn results when sensory nerve endings are stimulated by acid re flus or esophageal distention" Consump- tion of certain foods and beverages has been reported to induce heartburn ** Body po- sition, including recumbency, bending ove and the postprandial state, hasalso been as- sociated with hearthurn."® Lifestyle fae- tors, such as stress, cigarette smoking, al cohol consumption, obesity, medication use, and certain exercises, may also pre- cipitate heartburn. specific factors may be responsible for heartburn, but it ap- pearsas though these factors are nique for cach individual. For instance, some pa- tients report that cofleeconstumption causes theirheanburn, while other patients are not allected by the consumption ofthis be age. Furthermore, itis unclear whether in- dividuals can identity the factors that cause their heartburn symptoms, Recommends- tions are generally made by physicians for dlictary modification, weight los, lifestyle Ibchaviers and body postion, eventhough they may not know the specifie cause of Iheartbura in an individual patient" (©1999 American Medical Association. All rights reserved,SUBJECTS AND METHODS 4 cross-sectional survey of 2000 individuals with iearburn was conducted The study population in- cluded adults aged 18 yeas or older in the United States who repotted having heartburn inthe past 8 months. all eligible study participants were re- tired to have (dlephone sve. A survey ins them was developed and pio tested and included a Screening question oidenifyindvidhals with heart intr as well as questions related to sociodemo- ipephic heaciertcnieency ofsoptora, olf ported cans of hearthurn, knowledge of actors Contributing to heartburn, and prevention strategies The survey lildwork was done bythe MEDSEAT Group, Ann Arbor, Mich, Random digit dang was teed fo select household stated By state ene sure thatthe study population was grogphicaly ep- sentative Person aged 18 yon older who at Sere the telephone were denied as individuals svar the bad experienced erm di ing the past 6 months, Heartburn was defined as" ‘Mtningsenston nthe chest behind the breastbone which may or may not be associated withthe sensa- Tomaf food coming back into the mouth oran ack or biter ste All cligible individuals were re- ried forthe td Trained interviewers adminis tered the standerdized survey using compater- tssisted telephone tncrviewing. Recaliment as going unt! 2000 individuals sucessuly com pleted the env survey. Random eis (N= 10559) were made to com- plete 2000 surveys, About one fourth (or 2377) of the telephone mubers were ineligible because they tee the wrong miner «cll or sina mer Sracotplter ot fx umber Seven ced wen four respondents were ineligible forthe study: 467 didnot speak English or were dal, and 257 ded not fave heartburn. lgilty was unknown for 3130 por {ental survey respondents who ether could nt be reached by telephone (n= 1160) of refsed to an- Ser the sereening question (a= 3970) Othe 2328 lige subjects, 338 (14.1) refed a complete the Descriptive statis. inclding means, SDs, and percentage, wer calculated to characterize the t= Fey population for sociodemographic vores, fe- gqeneyof heartburn symptoms, causes of heat Burn, and knowledge of risk factors. Logistic regresion modeling was aed w ely predictors efitequentheanburtandinforminga physi about heartburn symptoms. A commercially available sta {sical progr was used forall analyse. Odds a> tios (ORS). confidence interval (Cl): es ai ties snd Plies ald) are presente. ‘Characteristics of individuals with heartburn, causes of heartburn, patient knowledge, and prevention stral- egies have not been described previously in the general population. Recently, there has been an increase in the ‘number of nonprescription medications available to pre- vent heartburn, To target individuals for prevention pro- mographe Characteristics of Indvduals crates (ose) (sti) 1g, SDP Siiat58 73.148 (o=a0)) (n=iten Wig, mean «0, 0.%66 714.150 (0-44) (n= i118) Soy mass indocmeanaSO}} 275448 2705615 (28) (n= 11) Angry 1620 s71108) 107003) sna weg) 18505 0 2o0jeta) 260(28) so ‘si i06) 223189) ena 103,026) 187059) inn ise) tsar) 20 wig) 3781) Ephesus airs sion) ssa ans) Partie las) 125(108) Satterploed 26) Zen Hamermlarorbuse rbd 405) 16,124) Fated 18,10) 26024) Stir ey 13t11) Unompoed, dab orabur 51162) 147(125) it tate Sing ocomvrmacred ——12(173)119(05) Maridor ig with someone 527.0) 770 (83) Dore or spr owes) 22103) Widowed ea trots) aor Lassa caligesdosted 265,445) 62282 Coleg std auet) 54461) Tm ey se rare ty cua) ogi) 26 Meopltan oan W523) 26(102) 27 “ates ac en smb fia, ns tereie eae anes donot 200 ois ease of msg espa. npc exe ay isn esposs ear mero espondets gen in pueeses este teh ogame ly ag tes squse ‘grams that include dietaty modification, lifestyle and be- havior modification, and treatment remedies, individuals and the associated causes of their heartburn must first bbe identified. The assessment of an individual's knowl- ‘edges erucial wo successfully implement prevention strat egies. We conducted 4 population-based survey to de- scribe the sociodemographic characteristics, frequency of symptoms, self-reported causes of the condition, and, knowledge of heartburn risk factors in individuals with, heartburn, We also collected information on the diffe centapproaches used by individuals with heartburn to pre vent the onset of symptoms. Ls} Sociodemographic characteristics of the 2000 individu als with heartburn representing all 50 states are pre- sented in Rable ¥. The age range of the survey respon- dents was 18 10 91 years, Women made up 59% of the study population. Most survey respondents were whit (87%) and married or living with someone (68%). About (©1999 American Medical Association. All rights reserved,half of the men and women were college educated, and ‘more than 70% of survey respondents lived in small ci- {es oF rural towns. The self-reported frequency of heartburn was as fol- lows: daily (21.596), afew times a week (244%), once a week (11.3%), few times a month (16.5%), once a month (11.5%), and less than once a month (13.8%). We clas- sified individuals with heartburn as persons with fre- quent (daily or a few times a week) vs infrequent (once aweek, a ew times a month, once a month, or less than once a month) heartburn. Forty-six percent of the sur- vey respondents had frequent heartburn. Approxi- rately 38% of the survey respondents reported that the frequency of their heartburn was increasing with age, while 18% reported a decrease of heartburn frequency with age. The trend of increasing heartburn with age is presented in the Figure. ‘Table 2 presents the prevalence of heartburn symp- toms by sociodemographic characteristics. Women Were somewhat more likely to report daily heartburn than men. Women reported the onset of heartburn about 5 years ada Wi aT a insu Win ot ttt Tha Ot” se sed Toe (esa 5365) (de) aD) 28} es) baer. ‘Assocation betwee aging and hertbura equncy. eqn eau Inaetes heanbum once a week ae tines & month once a month, o ess ‘an oncea mon equent heartburn clo ew esa eek (P= 03, P= 1879) Categois dont ata 2000 beauseo ising responses. i om later than men (mean 4 SD age, 34.7 416.6 vs 20.9.4 14.2 years; P<.001). Survey respondents who were not col- lege educated were more likely to report frequent symp- toms compared with individuals with heartburn who wer college ediscated (OR, 1.45; 95% Cl, 1.21-1.73) (P= 001). ‘We asked survey respondents to report when they experienced heartburn using achecklistof potential tig- ger situations (Table 3). Respondents were allowed 10 respond toall questions that applied. Heartburn was ex- perienced alter or during a broad range of activities and events. Men and women reported heavy mealsand high- fat foods, acidic foods, and lying down as causes of heart- burn; 23% 10 52% of the respondentsattributed their hear burntothese situations. Women reported heartburn caused, bya hectic day at home, stressful family situations, eat- ing « heavy meal, and lying down more often than men. ‘Women were 70% more likely than men to report stress ful family situations (OR, 1.70; 95% Cl, 1.40-2.0' 559% more likely than men to report alhectic day at home (OR, 1.55;95%6 Cl, 1.25-1,92) as causes of heartburn. In contrast, men were 24% more likely than women to re- porta week of long work hours (OR, 1.24; 95% Cl, 0.09- 1.55) and 50% more likely than women to Feport business travel (OR, 1.50; 95% Cl, 1.08-2.07) as eases of heart- burn, Weasked specifically about the frequency of heart- burn after eating, during sedentary activities, and during, sportsand exercise. Men and women reported similar {quencies ofexercise-related heartburn although about 75% ‘of those surveyed did not experience heartburn associated, with exercise. As was expected, specific foods and bever ages were reported to cause heartburn (Table 4). Men ‘were 64% more likely than women to report drinking al- coholic beverages asa cause of heartburn (OR, 1.64; 95% 1, 1.29-2.09). Women reported eating higher percent- age of heartburn-promating foods, including fatty foods, chocolate, peppermint, citrus fruitsor juices, and tomato products, No other predominant male-female differences ‘were observed. In preliminary analyses, we explored the relation ship between age groups, Irequent vs infrequent hear and Table 2. Prevalence of Heartburn Symptoms by Sotlodemographlc Characteristics 1 Wearbar symptoms” cnaracteatiee| ty woe Monin Monte ont Ser Wen (0 398192) 100242) to (t22) a5 (16s) tats) ©1013) Warn (a 2230) BAA) (107) 19588) ©1700) HA) ge group. (134) 45) 251134) 116) kt) att) 7520s) ta) aaitog) © si 67) ata) t6 a) 05209) 122,350) S5(117) gag) do(t0A) © (109), 85221) 0258) ata) gut) 38(00) 5a(ia1) 737252) 7559) © 35/124) 3013) © 8(tom) ea) 4237) 2 pt6) 19/08) 3475) 30155) 18003) 18,248) (173) aan 8154) 47) i113) Lessthan calle eGucted(n=987) 720232) 267 271) T09(t10) 84GB) 95005) 10(111) Cologe educated (n= 988) 105 (197) 213216) Hatt) te1(63) 30182) 65167) ~Values are gh as number percentage of indus. Categories do 0 otal 2000 or 10O% Because of missing responses (©1999 American Medical Association. All rights reserved,Table. Setrepoted Causes of Heartburn Table A. Seiteparted Food Related Cases of Heartburn uestons qoseey esi ‘aur enim ite ou aera ar? Grohe orpem 508) OEE.) (ceo ding Tomprehes 58149) 501 601) Wes y ak reqs) 059) 37 Sy nis sas) e704) Buses tel aon mE) ot Goce fea) alan) Wekotinghousatvek 17512) 211179) te Peppermint S65) 1313) Weskwthounaauscadines 120(182) 220003) 20 fay onde eesig 776) ss yt ae tenes) 20073) <0 Fatale sous) S772) Srslfony stuns 200257) 47280) <0 Ctensedbewoges 21042) 60053) Oinngatsosieg” 48) Zales) 8 Gatoniedbownps 201278) 314288) Vacant! cos) 208) 14 Nestleboergie 217068) 205(174) Esingataay malt 308479) 61423) 5 Aone bor ean 35172) oh oie ‘sings de 5403) eau) 8 laa asd aloeng putin Dea a a ol Dirge bewroges 164(200) 156(131) <001 | fadsarevrges ne jouearbur? Ths asa mathe one ton Satin meen dering 22 (nat arsert és oreo each question WikstiogandvacingTv, 125(164) 2079) 2 tates ae pena amber pena) a dia. reading niga is eomtom ced ay sng poe ering oon ote 100281) 2073) a4 re rf mse Ayngdomisinpx 218087) sue? | wasreported more frequently as.aeause of heartburn by ing the younger age groups, Furthermore, smoking and drink Aonectheatoveortee ——99(124) 118(100) 16 the younger age groups, Furthermore, smoking and drink: eee ing alcoholic beverages were reported less by the older aac tee age groups as causes of heartburn. No other important Mere? trends were observed, Consumption of fast foods, ca aye 460 9502 feinated beverages, and alcoholic beverages were r Freqanty sosc2m) s8498) ported less by the older age groups as causes of hear- Sonate re burn, Those with frequent heartburn reported a higher — frequency for all the causes of heartburn listed in Tables ‘Never 169(206) 213 (18.1) quency Wert dma wing — UGRO) ZR Salt Nesly alle comparisons ruched stata Doyo exerci significance (P=.05) ete red. yg ds Obesity was associated with an increased fr sntininga smc ra quency of self-reported heartburn, We calculated body ca anon sua ay | MnnitesCaetoted a weigh i blo died a ence height in meters squared) and categorized those wit ease weit) users) at | heartburn into quartiles. Individuals in the highest quar- rary ross) mola tiles of body mass index were more likely to report dal er 1728) 28718 ‘st | heartburn compared with those in thelovwest quartile (re ‘Do you ser experience arthur erent) of body mass index; ORs ranged from 1.30 to 2.19. Ca ‘Adose-response relationship was apparent, withan ove — CesT ll trend test that was statistically significant (P=02). ong Zoq ino > Most survey respondents were unable to dently Inmet B10) 1043) 14 | known causes of heartburn, Table & presents the 1 Depends neercseacivy §— 11022) 15785) 98 | spondents’ knowledge of heartburn risk factors. To ob Ps 0) 948) at tain valid responses to the questions on heartburn knowl- usp nl a ons Gps cls, weil questions on ctor hat arent ko can gen ante pea to be associated with heartburn, Although the survey “newts map swe quston (tat anime a0 population was composed of 2000 individuals with he cathaesi) burn, most of them were unaware ofthe risk factors for far men, = 349 fr women, n= 42. The question wasnt appa (ant exercise fr 472 men and 747 women. burn status, and the factors listed in Tables 3 and 4. Sta- Listical esting was not accomplished for age comparisons because of the small numbers available after stratifics- tion by age groups, but was done for analyses compar- ing frequent vs infrequent heartburn status. hectic day at work, business travel, a week of long work hours, and week with numerous deadlines were reported less by the older age groups as causes of heartburn, Heartburn before, during, and immediately after exercise or sports| hheartburn. The findings revealed that men and women differ in their knowledge about risk factors for heart- bburn, which may reflect sex-dependent differences in life- style. For example, men were more likely than women to identify the following risk factors for heartburn: work schedule or conditions, alcohol consumption, smoking, and exercise. Conversely, women were more likely than men to identify the following factors as risk factors for heartburn: age, citrus juice consumption, weight, stress, and wearing tight clothes around the stomach, Although all of the respondents surveyed had heart burn, with almost 50% having weekly symptoms, only: (©1999 American Medical Association. All rights reserved,Table 5. Factors identilid by Survey Respondents, as Contributing to Heartburn Factors conttoutng ‘aon (oHeatoum ‘ Pe ae T7108) 286,243) OF Sex 4362) 7564) ot Smoking wweeia215(182) oF ductal lvl 3108) 415) a Faty foods 388470) 505,605) 14 Work schedule orcondtons 256(312) 505(259) 09 Trael sched orconions 131(160) 181(154) 78 (vacation ar business) arise 1011123) 11608) 08 Catena consumption 704358) 4175.4) 80 Cir juice consumption 307(37.4) S17(489) 4 ‘cant consmption 216063) | 206174) <00 No.of daily meals A717) 224190) 15 Ting of mals 250 (315) 350,04) 8h Sanat meal 322392) ois) 22 Lying down ater meats «305(37:1) 31266) 8 Stas 20 (612) 656,655) 05 Weigh 207052) S71(318) 002 Height ‘ei M2) at Wenig tht lotes around 108(132) 267(226) <001 tha etomch Spiny foods 580 (670) 72655) 52 None of th above ‘ait) (9) a? ~ India were asked he folowing question, “Which ofthe flowing ‘actors do you think combo the coin of hearbum?” Tas 8 ‘mult ansver uesion (nial ansvered yes rr each quest0n {lates are gen as number (ecentae) of nds. 4 computation exuded any masing responce. 55i6 of men and 66% of women informed their physi- cian, Survey respondents with frequent heartburn were 4.14 times more likely (95% Cl, 3.41-5.02) to have told their physician that they had symptoms compared with survey respondents with infrequent heartburn (P<.001). Of the 916 respondents with frequent heartburn, 716 (78.2%) informed their physician vs 199 (21.7%) who did not inform their physician; of the 1061 respondents, with infrequent heartburn, 402 (46.4%) informed their physician vs 566 (53.3%) who did not inform their phy- sician. Women were more likely to have told their phy- ian about their heartburn symptoms compared with ‘men, Regression modeling identified increasing age, fe- male sex, higher level of education, and frequent vs in- frequent heartburn as significant predictors of whether patients told their physician about their heartburn symp- toms (Table 6). “Approaches used to prevent and treat heartburn are presented in Table 7 and Table 8. Forty-five percent of the survey respondents used a nonprescription medi- cation to prevent the onset of heartburn symptoms. Other approaches to heartburn prevention included taking pre- scription medication and avoiding spicy foods. Women were more likely to take a prescription medication and avoid fatty foods and citrus juices, while men were more likely to do nothing to prevent heartburn. More than 75% of male and female respondents reported taking a non- prescription medication to teat heartburn. Although cer tain foods and lifestyles have been identified as poten- ual causes of heartburn, most individuals did not report ‘Table 6, Multivariate Relationship of Demographic. Variables With Informing a Physician About Heartburn (es vs No)" Odes Falog varabet (92% contidence treat) . Baw 1.082 (1025-140), =a01 So, 149 (1188-1757) =a01 aucatonal vl 1.276 (1081-1585), oe face 082 (0652-1107) a2 Heartburn requeny 4321 (35125336) 90 Tarestor seep id ty tots S7(140) 90(189) 05 rod cis juices tad) a3(a2) oe Dc pc ods sorta) 1221232) 70 ‘rid ates 1102) 2(04) > 90 Bcd emokng 820) eit) 0 ‘rd avy as mois) 20(78) 6 Do rahing ssn 9(1n 06 ter 50(t45) 73,139) 87 “Indias were ated te foowingqueston: "What do youd to avid prevent heartburn?” Tis was amt arse question (habia arsed Ses nat each questo). “Hates are gen as number (percentage of aida. Te question was ‘ot appeal (nda io coud not ays quent aa preven fl eartbur)for 14 men and 84 women + Computtns ecu any missing responses. that they modified these behaviors to avoid or prevent heartburn. Fable 9 presents the results of mulivariate analyses. Increasing age, higher body mass index, and re duced level of education were statistically significant pre- dictors of frequent vs infrequent heartburn in this study population, —1 znd __ This is the first population-based study to characterize individuals with heartburn for cause, knowledge of risk factors, and prevention strategies. Lifestyle and work hab- (©1999 American Medical Association. All rights reserved,Table 8. Pharmacological Approaches and Lifestyle Behaviors to Treat Heartburn ogroashes omen Sha Benavlre* (este Pt Tile anonpreccipion mediation, 622058) 917778) 2 sich earns Tala apresarpon medzaton 120(148) 262(223) <0 Dink ater eis) 6162) 08 Dinka e073) 706) SF Dinkcalaorcattnaedbewrages 1721) 7(40) (Chew gum or suckzenges 607) 1815) a8 Have somaing oat 94) 1412) 09 Sup in bod or eat hat mes en 18 anche Getupand stand sai 18015) a? Donating watunlthehearhumn 60(73) 5(58) 18 oe 8) bee men 07s) 71 dias were ated he flowing ueson: When youe arta, wat oyu usualy dof ete Sma? Th nasa maple arse ueston (nia ashe je orf eich ues. "lau ae gen as number (eres of aca 4 Computations excluded any ising responses. ts, in addition to certain food and beverage consump- lion, were associated with heartburn. Most survey re- spondents were unaware of the risk factors for heartburn, and sex-dependent differences in knowledge were ap- parent. Women reported the onset of heartburn symp- toms about 5 years later than men, which is likely to re- flect differences in lifestyle. Obesity was associated with aan increased frequency of self-reported heartburn, and ‘dose-response relationship was evident, Many survey respondents did not inform their physician about their symptoms, and nonprescription medication was the ap- proach used most often to prevent or reat heartburn, Col- lege educated individuals were less likely to report heart- burn symptoms compared with those without a college education. This may reflect differences in access to care and knowledge about prevention and treatment strate- ies. Thus, those respondents with less than a college edi cation were about 20% less likely to use a prescription ‘oF nonprescription medication to prevent heartburn. ln- creasing age was an important predictor of frequent heart burn. Itis unclear, however, whether heartburn was as- sociated with aging because of a change in esophageal physiological characteristics, lifestyle, or increased use fof medications that predispose to gastroesophageal reflux. This study used a telephone survey and, thus, ex- cluded individuals who had no telephone service or who did not answer the telephone. Fifty-nine percent of the respondents were women, which probably reflects the greater likelihood of women to answer the telephone. Al- though we used random digit dialing (conducted dur- ing various times of the day), stratified by state, to en- sure geographic representativeness, our study population was predominantly white individuals (87%) who lived in small cities or rural towns (72%), which may limit the generalizability ofthe findings. Another limitation of the study was our inability to collect information on use of medications oF medical conditions, such as pregnancy’ ‘Table 9, Multivariate Relationship of Demographic. Variables With Heartburn Frequency (Frequent vs Infrequent Heartburn)* ‘Os alloy varabet oxecontsene tena) Baw 71007 (009-1013), 2 se. ‘096 (0907-1228) 34 Body masindox (BM) 1.024 (1007-1082) 08 sucabaal vl o7i9(oso7-o866) =< oot face 76 (osse-1.155) 38 Frequent indeates daly oF afew tnes a week: infequent (leet) once a ek, 2 ines month cea mona ess than once 2 mt “Ag ince a continuous vara ithe logistic model ex Tis mae (retrent and 2s ema a (auld as fe weg hogan | ‘ded by the hag in meters squared), a coonuous variable the logs ‘model educational vel isles than colee educated (referent) and 25 ale educated or area and ace, tis hie (efeend) and 2 eal otters "Asta for al ater variables in alge egression model. diabetes mellitus, and hiatal hernia, that predispose 10 heartburn.” Physicians often recommend lifestyle changes in ad dition to medications to prevent heartburn. Decreasing, consumption of spicy foods and caffeinated beverages, for example, has been suggested to improve symptoms. ‘Weight loss is recommended for obese patients, Avoid- ing the supine position alter eating may decrease gastro- ‘esophageal reflux and thereby prevent heartburn. The re- sults of this study support these recommendations and, show a relationship between certain lifestyle factors and heartburn. Puture studies are needed, however, to con- lirm that behavior modification is useful in preventing and treating heartburn, The findings of this study are important for the development of a heartburn prevention program, which incorporates lifestyle modification. It is apparent that most individuals with heartburn have lute insight into the factors that cause heartburn, Lifestyle modification strategies necessarily must fist begin with education so that dietary modification, behavior modification, and treatment remedies can be implemented. This is espe- cially true for individuals who are reluctant to use medi- ccalions. The results of this study need to be considered, in the context of medications that are used to prevent of treat hearthurn, Whether the need for medical interven- tion can be decreased by simple changes in lifestyle needs to be tested in the general population, Alterna- lively, many individuals are unlikely to be willing to modify their lifestyles because of easy access to safe and cllective therapy’ Accepted for publication November 2, 1998. This study was supported by Whitchall-Robins Health- care, Madison, NJ We thank Deborah Plutzer and Bridgette Bayliss for their assistance with manuscript preparation Reprints: Susan A. Oliveria, ScD, MPH, Memorial ‘Sloan-Kettering Cancer Center, 1275 York Ave, Box 99, New York, NY 10021 (e-mail: oliveri1@mskec.org) (©1999 American Medical Association. All rights reserved,Es 1. Thali Organization ln A al Suey an Her Aas Ania Pins tan: Te Gal roan ne 86, ows Lud Praalene of sympa of dyspepsia inte communi. ‘ut 19020820. abel OT, Fras MF, Casal 0. Syptomate pastoeophael ef nc (Gece and precptang tc. Og is Se 197521 958. Sasroesophagel Ret Disease HaHa and Heir) Bes, Ma Natoal tite of Diabetes and Digestive ad Keay Deas, 1084 Na nal iets of Heth pubicton 4282 Bartow R thar A, a. Te Merck Maga f Dagnai and Tray. 1h aay A March Rasch abrtres 1992708, Mars lO, Rta SE Gasresaphogsl ref ease. Zaki, Damer- rg Al, es. Ppt cer sae and Ota Ace Aad Disorders Aran, I: deadem Research esate: WOT.247-214 ala DR, Darina People of asrossepogel ax se: 0 ® ” u 6 LES inate ard eophagil crac. I: Castel 0, e,The soph gus 2nd Bosto, Mas Lie ron & Co; 05-43-84 oes CML Digestive Tat Pan New Yr, HY: azrln abhi Oo Ie 158720, hero Cast OO. it and eau. JAMA 1679241200720, (Gk, Kas 88 Sire Cstel D0 Gasssephage fx ced by ‘arc n heathy umes, AWA. 1085261350036 Brady LA, Re Pall, Hale, Senin The retin be tween ses and symptoms ot gaeresophgel ct fens oy holga tacrs A. Gastoetal 1058811 Densh GW, Case DO. nity tf saing on he ver esophageal phi Weg Me, 172841261137 Xa BB, Sel JW, Cstal 0. Gasrasopage ruin runners: chars fais ara. on nara Med 1029412420. Xa DA Cast Consonabe Brgy phase) for gesasophagel ‘hota. Cs D0, The Esophapus 2d. Boston, Ms: itl Bron eo: m6 05513, AS lett ne. Logie gression Examples Ung SAS Sta, Version (Cay, MO- SAS stn Ie; 1295 SRGTINTERTWED VOL, OLS (©1999 American Medical Association. All rights reserved, ‘Downloaded From: https:/jamanetwork.com/ on 03/24/2021