Gastroesophageal reflux disease (GERD) is a common condition in clinical practice and in the community. GERD is characterized by heartburn, regurgitation and chest pain sufficiently severe enough to impair quality of life, or cause esophageal mucosal damage needing medical attention.¹ It results from pathological reflux of gastric contents into esophagus.¹ The risk factors for GERD may include age, higher body mass index, non-vegetarian diet, excessive tea and coffee intake, tobacco, and alcohol consumption as shown in multiple population-based studies.² However, most of these studies merely showed an association between the presence of frequent heartburn and of these risk factors. There are scanty data on therapy of GERD in relation to management of these risk factors.

Metabolic syndrome is known to be associated with several digestive diseases.³ The components of metabolic syndrome include obesity, hypertension, non-insulin-dependent diabetes mellitus, dyslipidemia and metabolic syndrome associated fatty liver disease. Of these components, obesity is particularly known to be a risk factor for GERD.⁴ Obesity may result in increased intra-abdominal pressure. This may be associated with increased intra-gastric and gastro-esophageal pressure gradient, greater frequency of transient lower esophageal sphincter (LES) relaxation, low LES pressure, the presence of hiatus hernia, delayed gastric and esophageal clearing time.^5,6 Mechanistically, it is quite expected that patients treated for GERD with anti-secretory therapy along with management of metabolic syndrome particularly obesity would respond better than those not being metabolically healthy.

In this issue of the journal, the authors of Kangbuk Samsung Health Study reported on erosive esophagitis remission rates in relation to metabolic health and obesity status on a large sample of Korean subjects.⁷ They found that the non-obese group showed higher erosive esophagitis remission than the metabolically un-healthy obese group. Based on these data, the authors suggested that maintaining metabolically healthy state and normal body weight may contribute to erosive esophagitis remission.⁷

Though the findings of this study are quite logical and expected, these may not translate into restoration of metabolic health by bariatric surgery, an effective method of obesity treatment, to treat GERD optimally. In a meta-analysis, the authors found that though metabolic bariatric surgery that reduced body weight improved cardiac, respiratory and metabolic disorders including diabetes mellitus, the risk of cholelithiasis, GERD, and pancreatic exocrine insufficiency increased.⁸ However, it is important to note that bariatric surgery does not only reduce body weight but may also alter gastric capacity, operative damage to the autonomic nerves supplying the proximal gut and gastric motor function.⁸ These anatomical and physiological changes may increase the frequency and severity of GERD after metabolic bariatric surgery despite loss of body weight. In a study, sleeve gastroplasty with fundoplication achieved greater GERD remission despite lesser body weight loss than sleeve gastroplasty alone.⁹ Bariatric endoscopy is another method of treatment for obesity. However, it may not induce greater remission in patients with GERD. For example, in a multicenter study, though endoscopic intra-gastric balloon placement reduced body weight, it did not improve GERD.¹⁰ This is quite expected as endoscopic intra-gastric balloon implantation is associated with increased intra-gastric pressure and transient LES relaxation. Data on effect of body weight reduction by pharmacotherapy and life style modification on GERD remission have not been widely reported. Since these measures to restore metabolic health including body weight reduction do not adversely affect gastric anatomy and motor function, these are more likely to improve GERD in contrast to metabolic bariatric surgery and endotherapy. Since the safety of long-term administration of proton pump inhibitors is being questioned, non-pharmacological measures to improve metabolic health in GERD management cannot be over-emphasized.¹¹

In conclusion, the findings of the current study⁷ showing the contribution of metabolic health to remission of erosive esophagitis are of utmost importance and the authors’ suggestion that metabolically unhealthy subjects, particularly those with obesity should restore their metabolic health is very appropriate. More studies from the other parts of the world are needed on this issue.

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Uday Ghoshal has patents and applications for indigenous radio-opaque markers for colon transit study, double-lumen catheter for upper gut aspirate culture, fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) fermentation chamber, BreathCalc, and FODMAP meal challenge test. He is also an advisory board member of Readystock and served as speaker and advisor of BioQuest Solutions Pvt. Ltd. India. None of the other authors declare any other conflict of interest concerning this paper.

Uday Ghoshal reviewed the paper and wrote the first draft of the paper; and Nikhil Sonthalia, Akash Roy, and Mahesh K Goenka provided critical input and edited the paper.