Diseases

Diseases of
of the
the Esophagus
Esophagus (2016)
(2015) 29, 794–800
••, ••–••
DOI:
DOI: 10.1111/dote.12384
10.1111/dote.12384

Original article

Adherence to a predominantly Mediterranean diet decreases the risk of

gastroesophageal reflux disease: a cross-sectional study in a South Eastern
European population

I. Mone,1,2 B. Kraja,1,2 A. Bregu,3 V. Duraj,2 E. Sadiku,1,2 J. Hyska,1,3 G. Burazeri4

Downloaded from https://academic.oup.com/dote/article/29/7/794/2756843 by guest on 14 July 2023

1
University of Medicine, 2University Hospital Center ‘Mother Theresa’, 3Institute of Public Health, Tirana,
Albania; and 4Department of International Health, School for Public Health and Primary Care (CAPHRI),
Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

SUMMARY. Our aim was to assess the association of a Mediterranean diet and gastroesophageal reflux disease
among adult men and women in Albania, a former communist country in South Eastern Europe with a predomi-
nantly Muslim population. A cross-sectional study was conducted in 2012, which included a population-based
sample of 817 individuals (≥18 years) residing in Tirana, the Albanian capital (333 men; overall mean age: 50.2 ±
18.7 years; overall response rate: 82%). Assessment of gastroesophageal reflux disease was based on Montreal
definition. Participants were interviewed about their dietary patterns, which in the analysis was dichotomized into:
predominantly Mediterranean (frequent consumption of composite/traditional dishes, fresh fruit and vegetables,
olive oil, and fish) versus largely non-Mediterranean (frequent consumption of red meat, fried food, sweets, and
junk/fast food). Logistic regression was used to assess the association of gastroesophageal reflux disease with the
dietary patterns. Irrespective of demographic and socioeconomic characteristics and lifestyle factors including
eating habits (meal regularity, eating rate, and meal-to-sleep interval), employment of a non-Mediterranean diet
was positively related to gastroesophageal reflux disease risk (fully adjusted odds ratio = 2.3, 95% confidence
interval = 1.2–4.5). Our findings point to a beneficial effect of a Mediterranean diet in the occurrence of
gastroesophageal reflux disease in transitional Albania. Findings from this study should be confirmed and expanded
further in prospective studies in Albania and in other Mediterranean countries.
KEY WORDS: Albania, gastroesophageal reflux disease, Mediterranean diet, non-Mediterranean diet, South
Eastern Europe.

INTRODUCTION A number of studies have explored the possible

Gastroesophageal reflux disease (GERD) is a
common and chronic gastrointestinal disorder that
significantly decreases the quality of life.1,2 Since it is
a public health concern affecting up to 28% of the
adult populations in the Western countries, it is
important to recognize the behavioral factors affect-
ing the GERD symptoms.3
Address correspondence to: Dr Iris Mone, MD, PhD, University
of Medicine, Rr. ‘Dibres’, No. 371, Tirana 1001, Albania. Email:
iris_mone@yahoo.com
Authors’ contribution: I. Mone, B. Kraja, A. Bregu and G.
Burazeri contributed to the study conceptualization and design,
analysis and interpretation of the data and writing of the article.
V. Duraj, E. Sadiku and J. Hyska commented comprehensively
on the manuscript. All authors have read and approved the
submitted manuscript.
Financial support: This study was supported by the University of
Medicine, Tirana, Albania.
794
© 2015 International Society for Diseases of the Esophagus
association between lifestyle/behavioral factors
and GERD. Although the evidence indicates that
GERD is associated with various behavioral factors
including body weight, smoking and sleeping posi-
tion, debate remains about the putative role of diet in
development of the GERD symptoms.4 Furthermore,
different and conflicting results appear for the
responsible food items which are related to reflux
symptoms.5–10 However, it has been argued that the
effects of individual dietary items on the risk of
GERD depend on the overall dietary patterns.5,9
From this point of view, it has been shown that
dietary patterns and dietary habits affect the GERD
symptoms.11,12
As a matter of fact, there is a growing interest using
dietary pattern approaches in epidemiological studies
to assess the effects of diet on disease risk.13 Hence, it
C 2015 International Society for Diseases of the Esophagus
V 1
2 Diseases of the Esophagus
has been suggested that a Mediterranean diet that
reflects the dietary pattern in the Mediterranean
European region characterized by a high intake of
vegetables, legumes, fruits, whole grains, fish, and
olive oil, moderate amounts of alcohol and dairy
products, and low amounts of red or processed meat
is healthful and provides beneficial effects especially
on cardiovascular and cancer risk.14–16 To date,
however, the influence of Mediterranean diet in the
GERD symptoms, to our knowledge, has not been
studied in population-based samples.
After the collapse of the communist regime in 1990,
Albania embarked in the complex journey toward a
market-oriented economy. Conventionally, Albanian
diet has consisted of a low consumption of total calo-
ries, meat, and dairy products, but a high intake of
fruit, vegetables, and carbohydrates.17 However, in
the past two decades, Albania has experienced a rapid
transition including substantial dietary changes18
with an emergent ‘Western’ behavior consisting of
processed foods that are higher in sugar, salt and
saturated fats.19 The prevalence of GERD in a repre-
sentative population-based sample of Albanian
adults has been recently estimated at 12%,20 which is
lower than in many Western European countries.21
In this context, our aim was to assess the associa-
tion of GERD with adherence to a Mediterranean
diet among adult men and women in Albania, a post-
communist predominantly Muslim country in South
Eastern Europe, which is currently experiencing
a rapid socioeconomic transition including behav-
ioral changes. We hypothesized that the Mediterra-
nean diet decreases the risk of GERD in this study
population.
MATERIALS AND METHODS
A cross-sectional study was conducted in Tirana, the
Albanian capital, in 2012.
Study population
A simple random sample of 1000 adult individuals
aged ≥18 years was drawn based on family physi-
cians’ lists in Tirana municipality. Study population,
sampling strategy, and sample size calculations have
been described in detail elsewhere.20
Of 1000 people included in the sample, 845 indi-
viduals agreed to participate and were subsequently
examined at primary health-care centers in Tirana
(345 men, mean age: 51.3 ± 18.5 years; 500 women,
mean age: 49.7 ± 18.8 years; overall response rate:
845/1000 = 84.5%).20 Of these, 28 individuals report-
ing use of medications for GERD symptoms (see
‘data collection’ below) were excluded from the
analysis. Hence, the final study population included
817 participants (333 men, mean age: 51.2 ± 18.3
C 2015 International Society for Diseases of the Esophagus
V © 2015 International Society for Diseases of the Esophagus
GERD and Mediterranean diet 795
years; 484 women, mean age: 49.5 ± 18.9 years;
overall response rate: 817/1000 = 81.7%).
Data collection
Following the standard methods of cross-cultural
adaptation of the questionnaires, the Montreal
instrument for assessment of GERD22 was translated
into the Albanian language. Next, the Albanian
version of the instrument was pretested in a small
sample of users of primary health-care services in
Tirana before conducting the current survey.20
Based on the Montreal definition of GERD for
population-based studies,22 individuals were classified
into two groups based on the presence (or, absence)
Downloaded from https://academic.oup.com/dote/article/29/7/794/2756843 by guest on 14 July 2023
of GERD. Participants were considered as having
GERD if, during last year, they reported heartburn
or regurgitation occurring at least once a week, and
having at least moderate problems from such symp-
toms (Table 1). Participants reporting use of medica-
tions for heartburn or regurgitation at least once
weekly23 (n = 28) were excluded from the GERD
group. Heartburn was defined as a burning sensation
in the retrosternal area (behind the breastbone)
(Table 1). Regurgitation was defined as the percep-
tion of flow of refluxed gastric content into the mouth
or hypopharynx (Table 1). Conversely, individuals
with no reflux symptoms and/or those with reflux
symptoms that were not regarded troublesome (mild
symptoms) were classified as non-GERD.
Participants were interviewed about their dietary
habits including frequency of consumption of four
main items of a Mediterranean diet which are consid-
ered typical for Albania (composite/traditional dishes
which are rich in spices, garlic, and herbs, fresh
fruit and vegetables, olive oil, and fish) and for main
items of a non-Mediterranean diet (red meat, fried
food, sweets, and junk/fast food). Answers to each
food item for both the Mediterranean and the non-
Mediterranean dietary patterns consisted of three
categories: frequent consumption (score: 2), moder-
ate consumption (score: 1), and rare/no consumption
(score: 0). A summary score for the Mediterranean
and the non-Mediterranean food items was calcu-
lated for each participant. In the analysis, based on
dietitians’ advice in Albania, the dietary pattern was
dichotomized into: predominantly Mediterranean
(for participants where the Mediterranean dietary
score was higher than the non-Mediterranean score)
versus predominantly non-Mediterranean (for partici-
pants where the Mediterranean dietary score was
lower than the non-Mediterranean score).
In addition, participants were asked whether they
consumed their meals regularly (never, occasionally,
often, or always),11 which in the analysis was dichoto-
mized into: never/occasionally versus often/always.
Eating rate was assessed through the following ques-
tion: ‘How long does it take you to eat your main
796 Diseases of the Esophagus GERD and Mediterranean diet 3

Table 1 Assessment of GERD† in a representative population-based sample of Albanian adults (n = 845)

Heartburn Regurgitation Medication

‘In the past year, did you have heartburn ‘In the past year, did you have regurgitation ‘In the past year, did you take
that is a burning sensation in the that is a perception of flow of refluxed medications for heartburn
retrosternal area (behind the breastbone)?’ gastric content into the mouth or throat?’ or regurgitation?’
No No No
Yes Yes Yes
Frequency of heartburn: Frequency of regurgitation: Frequency of medication:
No heartburn No regurgitation No medication
<1 day/week <1 day/week <1 day/week
1–3 days/week 1–3 days/week 1 day/week
4–6 days/week 4–6 days/week 2–3 days/week
Every day Every day Almost every day
Severity of heartburn: Severity of regurgitation: Type of medication:
No heartburn No regurgitation Antacid
Mild Mild Histamine H2 receptor
Moderate Moderate antagonists

Downloaded from https://academic.oup.com/dote/article/29/7/794/2756843 by guest on 14 July 2023

Severe Severe Proton pump inhibitors

†Definition of gastroesophageal reflux disease (GERD) in this study was as follows: During last year, self-reported heartburn or regurgi-
tation occurring at least once a week, and having at least moderate problems from such symptoms. Participants reporting use of
medications for heartburn or regurgitation at least once weekly (n = 28) were excluded from the GERD group.

meal: <10 minutes, or ≥10 minutes?’. Also, meal-to-
sleep interval was assessed by the following question:
‘How long does it take you to go to sleep in the
evening following your last meal: <30 minutes, or ≥30
minutes?’.
Furthermore, participants were asked about their
smoking habits (categorized into current smoker,
former smoker, never smoker), alcohol intake
(dichotomized into no/occasional intake vs.
moderate/heavy intake), and physical activity (low,
moderate, high).
Demographic data (age and sex) and socioeco-
nomic information (educational attainment [years of
formal schooling, categorized into: 0–8 years, 9–12
years, ≥13 years] and income level [low, middle, high])
were additionally collected.
Physical examination included measurement of
height and weight; subsequently, body mass index
(BMI) was calculated for each study participant
(kg/m2).
The study was approved by the Albanian Commit-
tee of Biomedical Ethics. All individuals who agreed
to participate signed an informed consent after being
explained the aims and procedures of the study.
Binary logistic regression was used to assess the
association of GERD (outcome variable) with the
Mediterranean diet (predictor). Unadjusted (crude)
odds ratios (ORs) and their respective 95% confi-
dence intervals (CIs) were initially calculated. Subse-
quent models included adjustment for age (numerical
variable) and sex. Next, logistic models were addi-
tionally adjusted for socioeconomic characteristics
(educational attainment and income level). Then, life-
style factors (smoking, alcohol intake, physical activ-
ity, and BMI) were also introduced into the logistic
models. Final models included additional adjustment
for eating habits (meal regularity, eating rate, and
meal-to-sleep interval). For all models, multivariable-
adjusted ORs and their respective 95% CIs were cal-
culated. Hosmer–Lemeshow goodness-of-fit test was
used to assess the validity of the logistic models.
The analysis was rerun separately in each BMI
category (that is a stratified analysis conducted
separately for normal weight [BMI < 25.0 kg/m2],
overweight [BMI = 25.0–29.9 kg/m2], and obese indi-
viduals [BMI ≥ 30.0 kg/m2]).
The statistical analysis was conducted in SPSS
(Statistical Package for Social Sciences, version 17.0,
Chicago, IL).

Statistical analysis
Chi-square test was used to compare the distribution
of sex, socioeconomic characteristics (educational
attainment and income level), lifestyle factors
(smoking, alcohol intake, physical activity, and
BMI), eating habits (meal regularity, eating rate,
and meal-to-sleep interval), and GERD between par-
ticipants employing a Mediterranean and a non-
Mediterranean diet. Conversely, Mann–Whitney test
was used to compare the age distribution between the
two groups.
© 2015 International Society for Diseases of the Esophagus
RESULTS
In this study population, the overall prevalence
of GERD based on self-reported symptoms was
73/817 = 8.9%.
Based on our operational definition, overall, 445
(54.5%) participants employed a predominantly
Mediterranean diet compared to 372 (45.5%) partici-
pants who employed a largely non-Mediterranean
diet (Table 2). Women tended to engage more with a
C 2015 International Society for Diseases of the Esophagus
V
4 Diseases of the Esophagus GERD and Mediterranean diet 797

Table 2 Adherence to a Mediterranean diet by socioeconomic Table 3 Association of gastroesophageal reflux disease (GERD)
characteristics, lifestyle factors and gastroesophageal reflux disease with adherence to a predominantly Mediterranean diet; unadjusted
(GERD) status in a population-based sample of Albanian adults and multivariable-adjusted ORs from binary logistic regression
(n = 817)
Model n* OR* 95% CI* P*
Non-
Mediterranean Mediterranean Model 1† <0.001
Variable diet (n = 372) diet (n = 445) P-value* Mediterranean diet 445 1.00 Reference
Non-Mediterranean diet 372 3.06 1.82–5.14
Sex: 0.010 Model 2‡ <0.001
Men 170 (45.7)† 163 (36.6) Mediterranean diet 419 1.00 Reference
Women 202 (54.3) 282 (63.4) Non-Mediterranean diet 359 2.87 1.70–4.86
Age (years) 51.3 (31.0)‡ 49.3 (32.0) 0.121 Model 3¶ <0.001
Educational level: 0.135 Mediterranean diet 379 1.00 Reference
0–8 years 56 (15.7) 76 (18.2) Non-Mediterranean diet 331 3.20 1.84–5.56
9–12 years 153 (43.0) 150 (36.0) Model 4§ 0.024
≥13 years 147 (41.3) 191 (45.8) Mediterranean diet 338 1.00 Reference
Income level: 0.095 Non-Mediterranean diet 304 2.12 1.10–4.07
Low 49 (14.0) 45 (10.9) Model 5†† 0.018

Downloaded from https://academic.oup.com/dote/article/29/7/794/2756843 by guest on 14 July 2023

Middle 235 (67.3) 266 (64.6) Mediterranean diet 338 1.00 Reference
High 65 (18.6) 101 (24.5) Non-Mediterranean diet 304 2.27 1.15–4.47
Smoking: <0.001
Current smoker 93 (25.4) 80 (18.5) *Odds ratios (OR: non-Mediterranean vs. Mediterranean diet),
Former smoker 53 (14.5) 36 (8.3) 95% confidence intervals (95% CIs) and P-values from binary
Never smoker 220 (60.1) 316 (73.1) logistic regression. Discrepancies in the totals are due to missing
Alcohol consumption: 0.229 covariate values. †Model 1: crude (unadjusted) models. ‡Model 2:
No/Occasional 260 (74.5) 324 (78.5) adjusted for age (numerical variable) and sex. §Model 4: adjusted
intake simultaneously for age, sex, socioeconomic characteristics, and
Moderate/Heavy 89 (25.5) 89 (21.5) behavioral factors (smoking [current smoker, former smoker, and
intake never smoker], alcohol intake [no/occasional intake vs. moderate/
Physical activity: 0.062 heavy consumption], physical activity [low, moderate, and high],
Low 96 (27.9) 85 (20.6) and body mass index [<25, 25–29.9 and ≥30]). ¶Model 3: adjusted
Moderate 173 (50.3) 231 (55.9) simultaneously for age, sex, and socioeconomic characteristics
High 75 (21.8) 97 (23.5) (educational attainment [0–8 years, 9–12 years and ≥13 years] and
BMI: <0.001 income level [low, middle, and high]). ††Model 5: adjusted simul-
<25 85 (23.8) 189 (45.5) taneously for age, socioeconomic characteristics, behavioral
25–29.9 178 (49.9) 168 (40.5) factors, and eating habits (meal regularity [never/occasionally vs.
≥30 94 (26.3) 58 (14.0) often/always], eating rate [<10 minutes vs. ≥10 minutes] and meal-
Meal regularity: 0.397 to-sleep interval [<30 minutes vs. ≥30 minutes]).
Never/occasionally 68 (18.8) 69 (16.5)
Often/always 293 (81.2) 350 (83.5)
Eating rate: 0.555
<10 minutes 25 (6.9) 24 (5.7)
≥10 minutes 336 (93.1) 395 (94.3)
In crude/unadjusted models (Table 3), GERD
Meal-to-sleep interval: 0.759 was positively related to employment of a non-
<30 minutes 22 (6.1) 23 (5.5) Mediterranean diet (OR = 3.1, 95% CI = 1.8–5.1)
≥30 minutes 339 (93.9) 396 (94.5)
GERD: <0.001
(model 1). Essentially, adjustment for age and sex
No 321 (86.3) 423 (95.1) (model 2) and further adjustment for socioeconomic
Yes 51 (13.7) 22 (4.9) characteristics (education and income) (model 3)
*Chi-square test for all comparisons, except for the age where
did not affect the findings. On the other hand,
Mann–Whitney test was used. †Numbers and column percent- upon additional adjustment for lifestyle factors
ages (in parentheses). Discrepancies in the totals are due to missing (smoking, alcohol intake, physical activity, and BMI)
covariate values. ‡Median and interquartile range (in parentheses).
(model 4), the positive association between GERD
and a non-Mediterranean dietary type was somehow
attenuated (OR = 2.1, 95% CI = 1.1–4.1). After
Mediterranean diet than men (P = 0.01). Otherwise, further adjustment for eating habits (meal regularity,
there was no evidence of a significant socioeconomic eating rate, and meal-to-sleep interval) (model 5), the
gradient in the distribution of dietary patterns. positive association between GERD and a non-
Smoking was inversely related to employment of a Mediterranean dietary type remained unabated (OR
Mediterranean diet (P < 0.001). There was no evi- = 2.3, 95% CI = 1.2–4.5).
dence of a significant relationship with alcohol intake An additional analysis was conducted separately
or physical activity. On the other hand, participants for each BMI category (Table 4). Employment of a
employing a Mediterranean diet tended to be thinner non-Mediterranean diet was a strong ‘predictor’ of
compared with their counterparts engaging with a GERD – not statistically significant though – among
non-Mediterranean diet (P < 0.001). Meal regularity normal weight participants (multivariable-adjusted
was not significantly associated with the type of diet, OR = 5.6, 95% CI = 0.4–74.5), but less so among
similar to the eating rate, or meal-to-sleep interval. overweight individuals (multivariable-adjusted OR =
Conversely, there was an inverse association between 2.3, 95% CI = 0.8–6.0) and especially in obese coun-
GERD and Mediterranean diet (P = 0.001) (Table 2). terparts (multivariable-adjusted OR = 1.7, 95% CI =
C 2015 International Society for Diseases of the Esophagus
V © 2015 International Society for Diseases of the Esophagus
798 Diseases of the Esophagus GERD and Mediterranean diet 5

Table 4 Association of gastroesophageal reflux disease (GERD) with adherence to a predominantly Mediterranean diet by body mass
index (BMI) status; unadjusted and multivariable-adjusted odds ratios (ORs) from binary logistic regression

BMI < 25.0 kg/m2 (n = 274)* BMI: 25.0–29.9 kg/m2 (n = 346)* BMI ≥ 30.0 kg/m2 (n = 152)*

Model OR (95% CI)† P† OR (95% CI)† P† OR (95% CI)† P†

Model 1‡
Mediterranean diet 1.00 (reference) 0.03 1.00 (reference) 0.01 1.00 (reference) 0.33
Non-Mediterranean diet 4.71 (1.15–19.3) 2.43 (1.19–4.95) 1.61 (0.62–4.15)
P-value of the interaction term between BMI and dietary type: P = 0.46
Model 2¶
Mediterranean diet 1.00 (reference) 0.03 1.00 (reference) 0.02 1.00 (reference) 0.61
Non-Mediterranean diet 4.96 (1.18–20.87) 2.38 (1.16–4.88) 1.29 (0.48–3.44)
P-value of the interaction term between BMI and dietary type: P = 0.34
Model 3§
Mediterranean diet 1.00 (reference) 0.03 1.00 (reference) 0.01 1.00 (reference) 0.43
Non-Mediterranean diet 4.97 (1.17–21.10) 2.70 (1.24–5.88) 1.55 (0.52–4.63)
P-value of the interaction term between BMI and dietary type: P = 0.39

Downloaded from https://academic.oup.com/dote/article/29/7/794/2756843 by guest on 14 July 2023

Model 4**
Mediterranean diet 1.00 (reference) 0.03 1.00 (reference) 0.13 1.00 (reference) 0.60
Non-Mediterranean diet 12.37 (1.27–120.9) 2.08 (0.81–5.37) 1.43 (0.37–5.49)
P-value of the interaction term between BMI and dietary type: P = 0.49
Model 5††
Mediterranean diet 1.00 (reference) 0.19 1.00 (reference) 0.11 1.00 (reference) 0.47
Non-Mediterranean diet 5.66 (0.43–74.5) 2.25 (0.84–6.04) 1.71 (0.40–7.38)
P-value of the interaction term between BMI and dietary type: P = 0.63

*Discrepancies in the total are due to missing BMI values (n = 45). †Odds ratios (OR: non-Mediterranean vs. Mediterranean diet), 95%
confidence intervals (95% CIs) and P-values from binary logistic regression. ‡Model 1: crude (unadjusted) models. §Model 3: adjusted
simultaneously for age, sex, and socioeconomic characteristics (educational attainment [0–8 years, 9–12 years and ≥13 years] and income
level [low, middle, and high]). ¶Model 2: adjusted for age (numerical variable) and sex. **Model 4: adjusted simultaneously for age, sex,
socioeconomic characteristics, and behavioral factors (smoking [current smoker, former smoker and never smoker]), alcohol intake
(no/occasional intake vs. moderate/heavy consumption) and physical activity (low, moderate and high). ††Model 5: adjusted simultane-
ously for age, socioeconomic characteristics, behavioral factors and eating habits (meal regularity [never/occasionally vs. often/always],
eating rate [<10 minutes vs. ≥10 minutes], and meal-to-sleep interval [<30 minutes vs. ≥30 minutes]).

0.4–7.4). Nevertheless, there was no evidence of a
significant interaction between BMI and dietary type
(in multivariable-adjusted models, P-value for the
interaction term between BMI, and dietary type:
P = 0.63).
DISCUSSION
This is one of the few studies reporting on the asso-
ciation of GERD with adherence to a predominantly
Mediterranean diet in a population-based sample of
adults in Albania, a transitional predominantly
Muslim country in the Western Balkans, which has
traditionally engaged with a Mediterranean diet.17 It
should be pointed out that employment of a primarily
Mediterranean diet was more prevalent in women
than in men. In both sexes, however, employment of
a predominantly Mediterranean diet in this study
population was associated with a decreased risk for
GERD upon adjustment for a wide array of demo-
graphic and socioeconomic characteristics and
lifestyle/behavioral factors including also selected
eating habits such as meal regularity, eating rate and
meal-to-sleep interval.
We have previously reported that smoking, physi-
cal inactivity, and obesity are strong predictors of
GERD in the Albanian adult population.20,24 In a
previous study, we have also reported that consump-
© 2015 International Society for Diseases of the Esophagus
tion of fried foods alone was associated with a greater
risk of GERD, whereas meat consumption by itself
was not related to GERD.20
Based on the current evidence, the association of
GERD with the consumption of different food items
is controversial.5–10 For example, consumption of a
high-fat diet has been shown to be associated with
GERD in some studies,5–7 but not in a few other
studies.8–10 Furthermore, El-Serag et al. have demon-
strated that fruits, vegetables, and high-fiber diets
are inversely associated with GERD, whereas Zheng
et al. found that none of these items was associated
with the risk of GERD symptoms.5,9
It has been argued that a potential explanation
for inconsistent findings across studies may be that
specific foods are consumed as part of an overall
diet, and it is plausible that the effects of individual
dietary items on the risk of GERD depend on the
overall dietary patterns.5,9 Therefore, in our study we
assessed the effects of an overall dietary pattern
(predominantly Mediterranean vs. mainly non-
Mediterranean) rather than the role of each food item
on the risk of GERD symptoms. Only one previous
study has revealed a decreased GERD risk detected
by pH-impedance monitoring among Italians
employing a Mediterranean diet.25
In our study, interestingly, no single component of
the Mediterranean dietary score had a significant
influence on GERD risk. Conversely, when these
C 2015 International Society for Diseases of the Esophagus
V
6 Diseases of the Esophagus
components were integrated into a single Mediterra-
nean dietary score, there was evidence of a significant
protective effect which may be explained by the syn-
ergistic and antagonistic interactions between differ-
ent ingredients of the Mediterranean diet.
The Mediterranean diet is characterized by high
levels of components found protective against GERD
and by low levels of components associated with an
increased risk of developing this disease. However,
the composite/traditional Albanian dishes contain a
mix of vegetables and legumes,26 which are rich in
dietary fiber, associated with a reduction of GERD
risk27 and fat, herbs, spices, tomato, garlic, and
onions,26 which are positively associated with GERD
risk through their presumed effects on reducing
lower oesophageal sphincter (LOS) pressure and
slowing gastric emptying.28–30 Nonetheless, the main
source of lipids in the Albanian traditional dishes is
olive oil consumed in large quantities in Mediterra-
nean populations which has been shown to provide
health benefits through its anti-inflammatory and
antioxidant properties.31
As for the eating habits, we obtained evidence of a
positive and significant association between GERD
and meal irregularity or, a short meal-to-sleep inter-
val (<30 minutes), but not so for a fast eating rate
(<10 minutes) (data not shown). Our findings in this
regard are largely compatible with previous reports
on the association between eating habits and
GERD.11
In the current analysis, we provide useful evidence
on the influence of an overall dietary pattern
(predominantly Mediterranean vs. largely non-
Mediterranean) on GERD symptoms – a topic
which, to date, has been under-researched in
population-based studies. Therefore, a remarkable
strength of the current study conducted in transi-
tional Albania consists of the population-based
design including a representative sample of adult men
and women with a satisfactory participation rate
(82%). Furthermore, in our study, all symptoms were
measured with a well-validated instrument fulfilling
the consensus criteria for GERD.22 In any case, we
cannot completely exclude the possibility of informa-
tion bias, given the fact that lifestyle/behavioral
factors including dietary habits were assessed based
on interview. Of important note, the Mediterranean
versus non-Mediterranean dietary scores that we
employed in our analysis based on dietitians’ advice
needs further rigorous refinement and replication in
future studies, and should be also compared with
other Mediterranean prototypes from e.g. the neigh-
boring Greece.32 Also, daily calorie intake was not
assessed in this study, which could provide additional
insight into the association between dietary type and
GERD.
In addition, findings from cross-sectional studies
are not assumed to be causal. Hence, the issue of
C 2015 International Society for Diseases of the Esophagus
V © 2015 International Society for Diseases of the Esophagus
GERD and Mediterranean diet 799
reverse causality, pointing to the possibility of behav-
ioral changes (e.g. changes in dietary patterns) after
the onset of GERD symptoms, remains uncertain
from such cross-sectional designs.
CONCLUSIONS
Our findings point to a beneficial effect of a Mediter-
ranean dietary pattern in the occurrence of GERD in
this South Eastern European largely Muslim popula-
tion undergoing a particularly rapid socioeconomic
transition and behavioral changes. Employment of a
predominantly Mediterranean diet among Albanian
Downloaded from https://academic.oup.com/dote/article/29/7/794/2756843 by guest on 14 July 2023
adults of both sexes was related to a decreased risk of
GERD irrespective of socioeconomic characteristics
and other lifestyle factors. Nevertheless, findings
from this study should be confirmed and expanded
further in prospective studies in Albania and in other
Mediterranean countries.
References
1 Eloubeidi M A, Provenzale D. Health-related quality of life
and severity of symptoms in patients with Barrett’s esophagus
and gastroesophageal reflux disease patients without Barrett’s
esophagus. Am J Gastroenterol 2000; 95: 1881–7.
2 Dean B B, Crawley J A, Schmitt C M et al. The burden of
illness of gastro-oesophageal reflux disease: impact on work
productivity. Aliment Pharmacol Ther 2003; 17: 1309–17.
3 El-Serag H B, Sweet S, Winchester C C et al. Update on the
epidemiology of gastro-oesophageal reflux disease: a systematic
review. Gut 2014; 63: 871–80.
4 Festi D, Scaioli E, Baldi F et al. Body weight, lifestyle,
dietary habits and gastroesophageal reflux disease. World J
Gastroenterol 2009; 15: 1690–701.
5 El-Serag H B, Satia J A, Rabeneck L. Dietary intake and the
risk of gastro-oesophageal reflux disease: a cross sectional
study in volunteers. Gut 2005; 54: 11–7.
6 Shapiro M, Green C, Bautista J M et al. Assessment of dietary
nutrients that influence perception of intra-oesophageal acid
reflux events in patients with gastro-oesophageal reflux disease.
Aliment Pharmacol Ther 2007; 25: 93–101.
7 Meyer J H, Lembo A, Elashoff J D et al. Duodenal fat inten-
sifies the perception of heartburn. Gut 2001; 49: 624–8.
8 Colombo P, Mangano M, Bianchi P A et al. Effect of calories
and fat on postprandial gastro-oesophageal reflux. Scand J
Gastroenterol 2002; 37: 3–5.
9 Zheng Z, Nordenstedt H, Pedersen N L et al. Lifestyle
factors and risk for symptomatic gastroesophageal reflux in
monozygotic twins. Gastroenterology 2007; 132: 87–95.
10 Nandurkar S, Locke G R 3rd, Fett S et al. Relationship
between body mass index, diet, exercise and gastro-
oesophageal reflux symptoms in a community. Aliment
Pharmacol Ther 2004; 20: 497–505.
11 Esmaillzadeh A, Keshteli A H, Feizi A et al. Patterns of diet-
related practices and prevalence of gastro-esophageal reflux
disease. Neurogastroenterol Motil 2013; 25: 831–e638.
12 Yamamichi N, Mochizuki S, Asada-Hirayama I et al. Lifestyle
factors affecting gastroesophageal reflux disease symptoms: a
cross-sectional study of healthy 19864 adults using FSSG
scores. BMC Med 2012; 10: 45.
13 Hu F B. Dietary pattern analysis: a new direction in nutritional
epidemiology. Curr Opin Lipidol 2002; 13: 3–9.
14 Trichopoulou A, Lagiou P. Healthy traditional Mediterranean
diet: an expression of culture, history, and lifestyle. Nutr Rev
1997; 55: 383–9.
800 Diseases of the Esophagus
15 Toledo E, Hu F B, Estruch R et al. Effect of the Mediterranean
diet on blood pressure in the PREDIMED trial: results from a
randomized controlled trial. BMC Med 2013; 11: 207.
16 Couto E, Boffetta P, Lagiou P et al. Mediterranean dietary
pattern and cancer risk in the EPIC cohort. Br J Cancer 2011;
104: 1493–9.
17 Gjonça A, Bobak M. Albanian paradox, another example of
protective effect of Mediterranean lifestyle? Lancet 1997; 350:
1815–7.
18 Burazeri G, Goda A, Sulo G, Stefa J, Kark J D. Financial loss
in pyramid savings schemes, downward social mobility and
acute coronary syndrome in transitional Albania. J Epidemiol
Community Health 2008; 62: 620–6.
19 Mone I, Bulo A. Total fats, saturated fatty acids, processed
foods and acute coronary syndrome in transitional Albania.
Mater Sociomed 2012; 24: 91–3.
20 Cela L, Kraja B, Hoti K et al. Lifestyle characteristics and
gastroesophageal reflux disease: a population-based study in
Albania. Gastroenterol Res Pract 2013; 2013: 936792.
21 Dent J, El-Serag H B, Wallander M A et al. Epidemiology of
gastro-oesophageal reflux disease: a systematic review. Gut
2005; 54: 710–7.
22 Vakil N, van Zanten S V, Kahrilas P et al. The Montreal defi-
nition and classification of gastroesophageal reflux disease: a
global evidence-based consensus. Am J Gastroenterol 2006;
101: 1900–20.
23 Djärv T, Wikman A, Nordenstedt H, Johar A, Lagergren J,
Lagergren P. Physical activity, obesity and gastroesophageal
reflux disease in the general population. World J Gastroenterol
2012; 18: 3710–4.
© 2015 International Society for Diseases of the Esophagus
GERD and Mediterranean diet 7
24 Kraja B, Burazeri G, Prifti S. Anthropometric indices and
gastro-esophageal reflux disease in adult population in Tirana,
Albania. Med Arh 2008; 62: 139–41.
25 Zentilin P, Iiritano E, Dulbecco P et al. Normal values of 24-h
ambulatory intraluminal impedance combined with pH-metry
in subjects eating a Mediterranean diet. Dig Liver Dis 2006; 38:
226–32.
26 Beluli H, Fosa M. Albanian Cuisine: 500 Traditional Recipes.
Tirana: Toena Publisher, 2007.
27 Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle
related risk factors in the aetiology of gastro-oesophageal eflux.
Gut 2004; 53: 1730–5.
28 Roman S, Pandolfino J E. Environmental-lifestyle related
factors. Best Pract Res Clin Gastroenterol 2010; 24: 847–59.
29 Kaltenbach T, Crockett S, Gerson L B. Are lifestyle measures
effective in patients with gastroesophageal reflux disease?
An evidence-based approach. Arch Intern Med 2006; 166: 965–
71.
30 Kubo A, Block G, Quesenberry C P Jr et al. Dietary guideline
adherence for gastroesophageal reflux disease. BMC
Downloaded from https://academic.oup.com/dote/article/29/7/794/2756843 by guest on 14 July 2023
Gastroenterol 2014; 14: 144.
31 Pauwels E K. The protective effect of the Mediterranean diet:
focus on cancer and cardiovascular risk. Med Princ Pract 2011;
20: 103–11.
32 Trichopoulou A, Costacou T, Bamia C, Trichopoulos D.
Adherence to a Mediterranean diet and survival in a Greek
population. N Engl J Med 2003; 348: 2599–608.
C 2015 International Society for Diseases of the Esophagus
V