EXAMINING THE PREVALENCE, PATIENT PROFILES, AND EXPERIENCES OF MODIFIABLE LIFESTYLE BEHAVIOURS IN INDIVIDUALS WITH BARRETT’S OESOPHAGUS: A SCOPING REVIEW PROTOCOL

Background: Although Asian Americans only make up about 6% of the total U.S. population, they comprise almost 60% of individuals living with chronic hepatitis B (CHB). Asian Americans are disproportionately affected by CHB; and are more likely to develop Hepatitis B Virus (HBV)-related cirrhosis and hepatocellular carcinoma (HCC). Mental health may impact patient adherence to long-term management and treatment of chronic conditions such as CHB. Increased likelihood to report depressive symptoms and lower health-related quality of life (HRQOL) has been established among patients with CHB compared to the general population. Physical inactivity and smoking have also been associated with lower HRQOL among U.S. adults with depression. This study aims to examine the association between modifiable lifestyle behaviors (physical activity, smoking, alcohol use) and depression among Asian Americans with CHB by medication status. Methods: Chinese- and Vietnamese-Americans with CHB were recruited through outpatient clinics and community-based organizations to participate in an in-person assessment at baseline, as part of an ongoing intervention trial aimed at improving long-term adherence to monitoring/treatment. Participants were asked to report on their socio-demographic characteristics, health-related behaviors, depression symptoms, and modifiable lifestyle behaviors, among others. Bivariate analyses (two sample t- test, chi square test of independence) and multivariable logistic regression were conducted to examine association between exposures to modifiable lifestyle behaviors and outcomes of depression. Results: The study analysis sample consists of 289 participants (219 Chinese- and 70 Vietnamese-Americans). Bivariate analyses showed that there is no statistically significant difference in mean depression scores among those on CHB medication vs. those not (4.73 vs. 4.78, p 0.94), with 38.71% and 39.39% reporting mild to severe depression, respectively. In terms of lifestyle behaviors, when controlling for socio-demographic factors, multivariable logistic regression showed that while none of the three lifestyle behaviors (physical activity, smoking, alcohol use) were significantly associated with depression (p > 0.05) among participants not on medication, being physically inactive was significantly associated with a higher risk of depression (OR = 5.10, 95% CI = 1.72-15.10, p < 0.01) among participants currently on CHB medications, with other covariates held constant. Conclusion: Our study found a significant association between physical inactivity and depression among Asian Americans currently on CHB medication. Our findings suggest a need to incorporate physical activity, as part of a mental health intervention for patients with CHB, particularly for those on medication. Larger studies are needed to determine the association between depression and smoking and/or alcohol use among Asian Americans with CHB. Citation Format: Winterlyn Gamoso, Lin Zhu, Timmy R. Lin, Yin Tan, Grace X. Ma. The association between modifiable lifestyle behaviors and depression among Asian Americans with chronic hepatitis B by medication status [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-137.

Review question/objective Public health interventions are often implemented directly by government and so have an observational, rather than experimental, evidence base that may not be captured in traditional academic published sources. There is, therefore, a need to determine whether this grey literature is being actively sought when evaluating the effectiveness of public health interventions through systematic literature review; and also whether the inclusion of this grey literature has an impact on the conclusions of systematic literature reviews (SRs) evaluating public health interventions. This is particularly important as the findings of systematic literature reviews are increasingly used to inform public health policy decisions. Where possible, the sources used to obtain the grey literature in the included SRs will be categorised. As the prevention of childhood obesity is a major emerging public health issue in developed countries, this has been chosen as the topic for this methodological systematic review. The review question is: What is the impact of findings from grey literature on the outcomes of systematic reviews on interventions to prevent obesity among children? Primary Review Objective is to evaluate the impact of findings from grey literature on the results of systematic reviews on prevention of childhood obesity. Secondary Review Objective is to determine the ratio of black to grey literature (definitions are provided in Background) included in the eligible systematic reviews; to determine the study design of the grey literature included in SRs. Background By 2025 obesity rates are predicted to rise in Australia by 65% despite the myriad substantial efforts of a multiplicity of interventions and strategies from the public health sector, particularly those at the community or small unit level.1 Childhood obesity often persists into adulthood, and these strongly established links to adult obesity along with all the attendant risks and consequences make childhood a natural starting point for a closer examination of prevention literature.2,5-6 It also provides a logical focus for early intervention and therefore an abundance of literature exists in the field. Recent literature increasingly supports the argument that high level policy, regulation and legislation is required to prevent childhood obesity, and that whole-of-population, whole-of -environment approaches need to be developed and implemented.7-8 However while policy: “a set of plans to establish and achieve the desired performance goals of a group or organisation”9 abounds, and often confounds10 successes remain generally elusive. To be genuinely evidence-informed, policy needs to access systematic reviews which provide summary conclusions derived from their critical assessments and syntheses of the relevant evidence base. To be comprehensive and representative this base should include, or at least consider, “grey literature and unpublished studies”.11There are two types of literature which could be included in systematic reviews and are known colloquially as black and grey. Black literature is that which is published in academic, scholarly journals. Grey literature, which is usually defined as “Information produced on all levels of government, academia, business and industry in electronic and print formats not controlled by commercial publishing i.e. where publishing is not the primary activity of the producing body”12, takes many different forms13 but is essentially documents that have not been formally published, and have commonly not been peer-reviewed.14 Research institutes for example, produce working papers, technical and consensus reports, issues papers and policy briefs which have valuable content to impart and constitute grey literature. In addition the Joanna Briggs Institute, the Cochrane Collaboration and the Campbell Collaboration stipulate that, in addition to black literature, searches for grey and unpublished literature must be conducted by their systematic reviewers in order to avoid publication bias.15 While systematic reviews sum up the best available research on a specific question by “synthesizing the results of several studies”16 decision makers are now often faced with numerous systematic reviews on the same health issue. The next logical and appropriate step is an overview of systematic reviews, to synthesise and summarise the findings17 and if the overview is itself a systematic review, then the end result should provide stronger and even more comprehensive evidence. A recent dialogue of Australian public health professionals and dietitians emphasised the advocacy approach to obesity prevention, settling on the tripartite strategy of “political commitment, multi-sectoral support and community engagement.”18 It is this complexity of approach that may benefit from an examination of the grey literature (GL) supporting these policies. Simkhada's view19 that GL is needed to fill the information gap as “an essential part of the evidence base for practice in complex interventions, which may have multi-stakeholders, have multi-variables, have a lack of predictability and robust data and require a broad literature approach”, is held by many others20-23. Currently the Australian government is investing in research into the access and preservation of GL in light of its relevance to the development of health policy24. Similarly in 2006 the U.S. National Library of Medicine, aware that policymakers, more than any other research group, found GL especially relevant for context, and for its ability to reflect and map “how debate changes over time on a particular topic”25 commissioned AcademyHealth26 to conduct a research project into the scope and status of this literature. Often the strength of GL lies in the way it can reflect the lay voice, the voice from the field, public opinion: what people think. How can policy succeed when individuals' beliefs and behaviours are at odds with the underlying principles and truths of achieving healthy weight?27-28 Baum and others suggest that we need to look below the surface, focusing on the underlying social determinants of heath rather than “immediate and visible causes” and that the role of public policy should be to shape the social environment so that it is more conducive to good health.29-30 As Australian obesity prevalence continues to rise (in fact no country has managed to reverse obesity trends)31-32, it is reasonable to suggest that policy associated with obesity prevention is at best flawed or limited and possibly under- or ill-informed. As Badger et al argue “it is irresponsible to interfere in the lives of other people on the basis of theories unsupported by reliable empirical evidence”11. Community engagement is a challenging but well-supported aspect of behavioural change in public health. Community receptiveness needs to be gauged and substantiated in creative ways so that it can feed into the information that underpins our policies and supports implementations.33-34. To achieve a greater degree of success in regard to childhood obesity prevention, there is a need to tap into evidence from the widest variety of sources, so as to reflect the complexities of the issue and perceptions of end-users.35 Grey literature is where community attitudes, beliefs, values and opinions might be reasonably expected to be found, and also where pilot programs and case studies assessing the feasibility of public health interventions will have been reported. The degree to which this literature has been accessed and incorporated into the evidence that informs policy may have an impact on the ultimate success or sustained “take-up” of an intervention. To determine the extent to which systematic reviews in the field of child obesity prevention identify and include grey literature in their collated evidence-bases, a comprehensive search of the literature will be undertaken. The resultant systematic reviews will be retrieved and examined for inclusion. Those that do not match the selection criteria will be excluded. The ratio of black to grey literature in the included systematic reviews will be calculated and the proportion of systematic reviews that are grey will be briefly discussed. A comparison of results from grey versus black systematic reviews, and of those systematic reviews with high versus low ratios of included grey literature, will be undertaken to determine whether grey literature changes the findings or interpretation of the outcomes that are assessed. Inclusion criteria Types of studies Systematic reviews of interventions to prevent obesity among children, where there is either meta-analysis or narrative summary or tabular presentation of results. Types of reviews will include those where the primary literature consists of experimental or observational literature. Traditional literature reviews, or narrative reviews not based upon an a-priori protocol and rigorous methodology will be excluded. Qualitative synthesis or mixed methods reviews will also be included. Types of participants The reviews of interest will only include studies on children aged two to 18 years without (at baseline) a diagnosis of obesity, or eating disorders, or co-morbid conditions that pre-dispose to obesity. Types of intervention(s) Public health interventions aimed at obesity prevention that may be applied at the population, community (including schools) or primary care level. Types of outcomes Primary - Obesity prevention will be measured according to body mass index (weight/height2) as calculated against a suitable growth reference e.g. relevant age and .sex growth classification standards, with classification into underweight, healthy weight, overweight, and obese categories.36-37 Outcomes will be grouped according to the type of prevention program implemented. Secondary - Ratio of black to grey eligible systematic reviews; ratio of black to grey studies included in eligible systematic reviews; study designs of grey literature included in eligible systematic reviews; sources used in eligible systematic reviews to obtain grey literature Search strategy The search strategy aims to find both published and unpublished systematic reviews. A three-step search strategy will be utilised in this review. An initial limited search of MEDLINE, EMBASE, CINAHL and the Cochrane Library will be undertaken to “scope” the literature followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reviews, reports and articles will be searched for additional systematic reviews. Systematic reviews published in English will be considered for inclusion in this review, with no date limitation. The databases to be searched include: ARIF (Aggressive Research Intelligence Facility): Reviews database & Methodology database; Biological Abstracts; Campbell Library; CINAHL; Cochrane Library; EMBASE; ERIC; Google Scholar; INFORMIT: Education, Health and Social Science databases; Medline/PubMed; PAIS; Proquest; PsycInfo; Scopus; Sociological Abstracts; TRIP (Turning Research into Practice) database. The search for unpublished systematic reviews will include: DIPEx - Database of Individual Patient Experiences; EPPI Centre (particularly Obesity and Sedentary Behaviour Database); Google Advanced Search; Google Books; GreyNet; Mednar; Scirus; Social Care Online (SCIE); TROVE (for theses, books); WHOLIS. Major international institutional repositories will also be searched. Journals which will be hand searched include Childhood Obesity, International Journal of Pediatric Obesity, Obesity and Obesity Reviews. Initial search keywords to be used will be: (Obesity OR obese) AND (Child or paediatric or pediatric or adolescent or youth or infant) AND (prevent* or intervent*) AND (systematic review or meta-analys* or meta analys*). Where a thesaurus of descriptors or index terms exists, or the ability to “explode” headings, or limit to years of publication and/or document type, full advantage will be taken of these database-specific features. Searches will comprise of a combination of keywords and other available options designed to maximize the chances of retrieval of eligible studies. An example of a completed reproducible search strategy will be appended to the systematic review report. (Appendix I) All study titles and abstracts will be imported into reference management software, duplicates removed, and each title/abstract reviewed according to the inclusion criteria. The full text paper of each potentially relevant study will then be retrieved and again reviewed for eligibility according to the inclusion criteria. Reasons for exclusion will be documented. In cases where study eligibility is uncertain, a consensus decision will be reached by the co-authors. A final database of included systematic reviews will be produced. A PRISMA flowchart38 will be constructed so that the article selection process is transparent and can be replicated. Assessment of methodological quality Systematic reviews selected for retrieval will be assessed by two independent reviewers for methodological validity using the Joanna Briggs Institute (JBI) critical appraisal checklist for systematic reviews prior to inclusion in the review (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Data will be extracted using the JBI standardised extraction tool for systematic reviews (Appendix III). The data extracted will include specific details about the phenomenon of interest, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis The unit of interest is the pooled body mass index results from the eligible systematic reviews (whether presented as a mean difference in BMI or difference in proportions of underweight, healthy, overweight or obese), grouped according to type of obesity prevention program. As the eligible systematic reviews are likely to include studies presented in other eligible systematic reviews in the evidence base (ie duplicated data), it would not be appropriate to meta-analyse the pooled body mass index results for the same interventions reported in these systematic reviews as it would result in double-counting. As the objective of this systematic review is to determine the impact of grey literature on review results, for each type of childhood obesity prevention program an assessment of the concordance of pooled results between grey and black systematic reviews will be undertaken. ie overlapping confidence intervals of the pooled results, and evaluating the agreement of findings/discrepancy in findings. It will also be determined whether there are patterns or trends in pooled results according to the increasing levels/ratios of grey literature in the included systematic reviews. Potentially, sensitivity analysis will be undertaken and publication bias39 will be examined, both as tests of the impact of Grey Literature if there are a sufficient number of studies A narrative meta-synthesis (i.e. meta-synthesis and narrative summary) of the results for each pre-specified outcome will be presented within subheadings appropriate to each type of obesity prevention program identified and assessed in the included systematic reviews. In the event that any systematic reviews compare results from grey and black literature, these will be presented narratively and potentially meta-analysed if the data are homogenous and not duplicated between systematic reviews. Conflicts of interest No conflicts of interest Acknowledgements This review will form part of a submission for the Masters of Clinical Science and therefore a secondary reviewer Lisa Heuch (LH) will only be used for critical appraisal. LH is a Masters of Clinical Science Candidate, The Joanna Briggs Institute, The University of Adelaide.

Alcohol Drinking and the Risk of Barrett's Esophagus and Esophageal Adenocarcinoma

What are the pre-existing medical conditions and lifestyle behaviours of women with and without PCOS during the preconception period? During the preconception period, medical conditions of obesity, depression, anxiety, and a history of infertility were more highly prevalent in women with than without PCOS, and more women with than without PCOS were engaged in unhealthylifestyle behaviours. Women with PCOS are predisposed to infertility and pregnancy complications. Optimizing preconception medical health and lifestyle behaviours can improve maternal and pregnancy outcomes but, to the best of our knowledge, no study has examined the preconception medical conditions and lifestyle behaviours of women with PCOS. This is a cross-sectional study on 942 women with PCOS and 7024 women without PCOS, aged 24-30 years from the Australian Longitudinal Study of Women's Health, an ongoing, national survey-based prospective cohort study. The current study analysed self-reported data from Survey 6 collected in 2019 of the cohort of women born between 1989 and 1995. Explored outcomes included BMI, pre-existing medical conditions, and modifiable lifestyle behaviours, including smoking, recreational drug use, alcohol intake, and physical activity level, during the preconception period. Differences between subgroups were tested using Student's t-test, χ2 test, or Fisher's exact test as appropriate. The associations of pregnancy intention with medical conditions and lifestyle behaviours were examined using logistic regression. Obesity, depression, anxiety, and infertility were highly prevalent in women actively planning for pregnancy. Among women with PCOS, the prevalence of obesity was 47.02%, followed by depression at 32.70%, anxiety at 39.62%, and infertility at 47.17%. Conversely among women without PCOS, the corresponding prevalence was lower, at 22.33% for obesity, 18.98% for depression, 23.93% for anxiety, and 16.42% for infertility. In women actively planning for pregnancy, only those without PCOS demonstrated a lower prevalence of unhealthy lifestyle behaviours compared to non-planning women. The prevalence of unhealthy lifestyle behaviours was similar in women with PCOS regardless of their pregnancy intentions. Multivariable logistic regressionrevealed that only moderate/high stress with motherhood/children (adjusted odds ratio (OR) 3.31, 95% CI 1.60-6.85) and history of infertility (adjusted OR 9.67, 95% CI 5.02-18.64) were significantly associated with active pregnancy planning in women with PCOS. The findings were based on self-reported data. The cohort of women surveyed may have a higher level of education than women in the community, therefore our findings may underestimate the true prevalence of pre-existing medical conditions and lifestyle challenges faced by the broader population. A higher proportion of women with than without PCOS had pre-existing medical conditions and engaged in potentially modifiable unhealthy lifestyle behaviours during preconception despite their risk for subfertility and pregnancy complications. Healthcare professionals play a pivotal role in guiding this high-risk group of women during this period, offering counselling, education, and support for the adoption of healthy lifestyles to improve fertility, pregnancy outcomes, and intergenerational health. C.T.T. holds a seed grant from the National Health and Medical Research Council (NHMRC) through the Centre of Research Excellence in Women's Health in Reproductive Life (CRE WHiRL) and Royal Australasian College of Physician Foundation Roger Bartop Research Establishment Fellowship. H.T. holds an NHMRC Medical Research Fellowship. C.L.H. holds an NHMRC CRE Health in Preconconception and Pregnancy Senior Postdoctoral Fellowship. A.E.J. holds a CRE WhiRL Early to Mid-career Fellowship. The authors have no conflicts of interest to declare. N/A.

Lifestyle modification behaviors are a key strategy for controlling hypertension. Understanding the causal model of lifestyle modification behaviors would shape the behaviors which are necessary for controlling blood pressure levels among Thai adults with hypertension. The purpose of this study was to examine the proposed relationships between psychosocial variables, such as desire, attitude, perceived behavioral control (PBC), intention, trying, social support, illness identity, self-efficacy, and lifestyle modification behaviors (LMB). This study was a path analytic study using a self-administered questionnaire which was responded to by 240 selected Thai adults with hypertension at the out-patient clinic in 5 hospitals throughout Thailand. A set of questionnaires was used for collecting data and the internal consistency was between 0.75 - 0.95. Data were analyzed by path analysis. The results found that PBC and social support had positive and direct influences on LMB (β = 0.31, p < 0.001; β = 0.36, p < 0.001, respectively). Desire and PBC had positive and direct influences on intention (β = 0.55, p < 0.001; β = 0.19, p < 0.01, respectively). Self-efficacy, intention, and PBC had positive and direct influences on trying (β = 0.46, p < 0.001; β = 0.19, p < 0.01; β = 0.15, p < 0.05, respectively). The revised model accounted for 47, 30, and 39 % of the variance in intention, trying, and lifestyle modification behaviors, respectively. Knowledge about the factors influencing lifestyle modification behaviors in Thai adults with HTN will assist a nurse in developing interventions/programs to promote lifestyle modification behaviors in this population.

Osteoarthritis, as a common type of degenerative joint disease, puts older adults at high risk. It could impact the wellbeing of older adults, including physical, psychological, social, and economic factors. The aim of this study was to examine the effect of group support enhancing a self-management program on lifestyle modification behaviors among Indonesian older adults with knee osteoarthritis. Seventy-nine participants who met the inclusion criteria were recruited and assigned into the experimental group and the control group. Lifestyle modification behavior was measured during the first week, and after 6 weeks, of the program by using a Lifestyle Modification Behaviors Questionnaire (LMBQ). The internal consistency reliability coefficient of the LMBQ was 0.84. An independent t-test was conducted to examine the between group effect of the program. There was a statistically significant difference in lifestyle modification behaviors between the experimental group and the control group after receiving the program (t = 18.19, p = < 0.05). The group support enhancing self-management program effectively improved lifestyle modification behaviors among Indonesian older adults with knee osteoarthritis.

Living a healthy lifestyle is one of the safest and most cost-effective ways to improve one's quality of life and prevent and/or manage chronic disease. As such, current CKD management guidelines recommend that patients adhere to a healthy diet, perform ≥150 minutes per week of physical activity, manage their body weight, abstain from tobacco use, and limit alcohol. However, there are limited studies that investigate the relationship between these lifestyle factors and the progression of CKD among people with established CKD. In this narrative review, we examine the reported frequencies of health lifestyle behavior engagement among individuals with non-dialysis-dependent CKD and the existing literature that examines the influences of diet, physical activity, weight management, alcohol consumption, and tobacco use on the progression of CKD, as measured by decline in GFR, incident ESKD, or elevated proteinuria or albuminuria in individuals with CKD. Many of the available studies are limited by length of follow-up and small sample sizes, and meta-analyses were limited because the studies were sparse and had heterogeneous classifications of behaviors and/or referent groups and of CKD progression. Further research should be done to determine optimal methods to assess behaviors to better understand the levels at which healthy lifestyle behaviors are needed to slow CKD progression, to investigate the effect of combining multiple lifestyle behaviors on important clinical outcomes in CKD, and to develop effective techniques for behavior change. Despite the lack of evidence of efficacy from large trials on the ability of lifestyle behaviors to slow CKD progression, maintaining a healthy lifestyle remains a cornerstone of CKD management given the undisputed benefits of healthy lifestyle behaviors on cardiovascular health, BP control, and survival.

The skinny on obesity and reflux

This is the second WGO guideline published to complement World Digestive Health Day themes. WGO guidelines are intended to highlight appropriate, context-sensitive and resource-sensitive management options for all geographical regions, regardless of whether they are considered to be “developing,” “semi-developed,” or “developed.” There is a concern that guidelines from developed countries, by emphasizing high-tech investigations and Barrett esophagus (BE) surveillance, for example, may divert research and clinical resources from more urgent problems in developing and semideveloped countries. However, one could argue that there are similar problems in developed countries and that an overemphasis on complications or “proposed GERD associations” (as in the Montreal Consensus1) is leading to inappropriate investigations and resource utilization even in developed regions. It is also important to emphasize to health care insurers and funding bodies that appropriate, effective therapy is both therapeutic and diagnostic and that conducting mandatory investigations [eg, esophagogastroduodenoscopy (EGD) to permit proton-pump inhibitor (PPI) therapy is not patient-centered and, more importantly, is likely not to be cost-effective. WGO Cascades are thus context-sensitive, and the context is not necessarily defined solely by resource availability. Neither the epidemiology of the condition, nor the availability of resources for the diagnosis and management of gastroesophageal reflux disease (GERD), is sufficiently uniform throughout the world to support the provision of a single, gold-standard approach. WGO Cascades: a hierarchical set of diagnostic, therapeutic, and management options for dealing with risk and disease, ranked by the resources available. GERD is now widely prevalent around the world (Table 1), with clear evidence of increasing prevalence in many developing countries. Prevalence estimates show considerable geographic variation, but it is only in East Asia that they are currently consistently lower than 10%.2 The high prevalence of GERD, and hence of troublesome symptoms, has significant societal consequences, impacting adversely on work productivity3 and many other quality-of-life aspects for individual patients.4,5TABLE 1: GERD Symptoms: Range of IncidencePractice recommendations should be sensitive to context, with the goal of optimizing care in relation to local resources and the availability of health care support systems. The expression of the disease is considered to be similar across regions, with heartburn and regurgitation as the main symptoms. For initial management, the patient may purchase over-the-counter (OTC) medication for heartburn relief or seek further advice from a pharmacist. When patients perceive that their symptoms are more troublesome, they may seek a doctor’s advice; depending on the patient’s circumstances and the structure of the local health care system, patients may seek advice at the primary care level or they may consult a gastroenterology specialist or surgeon, directly or by referral. The WGO Cascade approach aims to optimize the use of available health care resources for individual patients, based on their location and access to various health care providers. CLINICAL FEATURES Predisposing and Risk Factors GERD is a sensorimotor disorder associated with impairment of the normal antireflux mechanisms (eg, lower esophageal sphincter function, phrenicoesophageal ligament), with changes in normal physiology (eg, impaired esophageal peristalsis, increased intragastric pressure, increased abdominothoracic pressure gradient) or, very rarely, excess gastric acid secretion (Zollinger-Ellison syndrome). Eating and Lifestyle An increase in GERD symptoms occurs in individuals who gain weight.6 A high body mass index (BMI) is associated with an increased risk of GERD.7 High dietary fat intake is linked to a higher risk of GERD and erosive esophagitis (EE).8 Carbonated drinks are a risk factor for heartburn during sleep in patients with GERD.9 The role of coffee as a risk factor for GERD is unclear; coffee may increase heartburn in some GERD patients,10 but the mechanism is unknown and it may be due to caffeine, rather than coffee per se. Coffee is not a dominant risk factor. The role of alcohol consumption as a risk factor for GERD is unclear. Excessive, long-term use may be associated with progression to esophageal malignancy, but this may be independent of an effect of alcohol on GERD.11,12 The role of smoking as a risk factor for GERD is unclear, although like alcohol, it is associated with an increased risk of malignancy.13,14 Medication—Certain Medications May Affect GERD See the Patient history and physical examination section. The treatment of comorbidities (eg, with calcium channel blockers, anticholinergics, and nonsteroidal anti-inflammatory drugs (NSAIDs) may negatively affect GERD and its treatment.15 Some medications (eg, potassium supplements, tetracycline, bisphosphonates) may cause upper gastrointestinal (GI) tract injury and exacerbate reflux-like symptoms or reflux-induced injury. Pregnancy Heartburn during pregnancy usually does not differ from the classic presentation in the adult population, but it worsens as pregnancy advances. Regurgitation occurs with approximately the same frequency as heartburn, and GERD in the first trimester is associated with a number of altered physiological responses.16,17 Factors that increase the risk of heartburn18 are: heartburn before pregnancy, parity, and duration of pregnancy. Maternal age is inversely correlated with the occurrence of pregnancy-related heartburn.19 Symptomatology GERD has a wide spectrum of clinical symptom-based and injury-based presentations, which may manifest either separately or in combination. Symptom evaluation is key to the diagnosis of GERD, particularly in the evaluation of the effectiveness of therapy. Heartburn and regurgitation are the most common symptoms, but atypical symptoms of GERD may occur, with or without the common symptoms. Atypical symptoms may include epigastric pain20 or chest pain,1,21 which may mimic ischemic cardiac pain, as well as cough and other respiratory symptoms that may mimic asthma or other respiratory or laryngeal disorders. Dysphagia may also occur. A minority of GERD patients have multiple unexplained symptoms, which may be associated with psychological distress22 (Table 2).TABLE 2: GERD Symptoms23,24Natural History Most cases of GERD are mild and are not associated with a significant increase in morbidity or mortality in comparison with the general population. In most GERD patients, the severity of the condition remains stable or improves over a 5-year observation period during current routine clinical care.26 There is a relationship between GERD and obesity: a higher BMI or larger waist circumference and weight gain are associated with the presence of symptoms and complications of GERD, including BE.27 Complicated GERD is characterized by stricture, BE, and esophageal adenocarcinoma. The Montreal consensus includes EE as a complication of GERD (recognizing that the definition of “mucosal breaks” used in the Los Angeles classification includes esophageal ulceration in the range of reflux esophagitis).28 Nonerosive reflux disease (NERD) may progress to EE in approximately 10% of GERD patients,29 and EE may therefore be considered as a manifestation of more severe reflux disease. EE is associated with BE and is a major risk factor for BE. In comparison with patients who were free of GERD at follow-up, those with EE had a 5-fold increased risk of BE after 5 years, in a cohort of the general population in Sweden.30 Globally, BE is rare in patients with GERD. It is more common in western populations. It is not known when BE develops relative to the onset of GERD; however, it appears to be more prevalent in older individuals and is strongly associated with an increased risk of esophageal adenocarcinoma.31 There is a well-documented association between BMI and adenocarcinoma of the esophagus and gastric cardia, although the risk of malignancy in a given individual with GERD is very low.32 Alarm Features Most alarm features are not specific for GERD; many are associated with alternative diagnoses that are unrelated to GERD. In most countries, many of these features relate to gastric cancer, complicated ulcer disease, or other serious illnesses. Dysphagia.33 Odynophagia (painful swallowing). Recurrent bronchial symptoms, aspiration pneumonia. Dysphonia. Recurrent or persistent cough. GI tract bleeding. Frequent nausea and/or vomiting. Persistent pain. Iron-deficiency anemia. Progressive unintentional weight loss. Lymphadenopathy. Epigastric mass. New-onset atypical symptoms at age 45 to 55 years (a lower age threshold may be appropriate, depending on local recommendations). Family history of either esophageal or gastric adenocarcinoma.34 The WGO Global Guideline on common GI symptoms may also be consulted: http://www.worldgastroenterology.org/guidelines/global-guidelines/common-gi-symptoms and http://journals.lww.com/jcge/Fulltext/2014/08000/Coping_With_Common_Gastrointestinal_Symptoms_in.4.aspx. DIAGNOSIS Diagnostic Considerations The presence of heartburn and/or regurgitation symptoms 2 or more times a week is suggestive of GERD.35 Clinical, endoscopic, and pH-metric criteria provide a comprehensive characterization of the disease, although investigations are usually not required to establish a diagnosis of GERD—with the caveat that the pretest probability of GERD varies markedly between geographical regions. The initial evaluation should document the presence, severity, and frequency of heartburn, regurgitation (acid or otherwise), and alarm features; atypical esophageal, pulmonary, otorhinolaryngological, and oral symptoms should also be sought. It may be helpful to evaluate precipitating factors such as eating, diet (fat), activity (stooping), and recumbence; and relieving factors (bicarbonate, antacids, milk, OTC medications). At this point, it is important to rule out other GI diagnoses, particularly upper GI cancer and ulcer disease, especially in areas in which these are more prevalent. It is also important to consider other, non-GI diagnoses, especially ischemic heart disease. Diagnostic questionnaire tools for GERD (reflux disease questionnaires, RDQs) have been developed for epidemiological studies. However, RDQs did not perform particularly well in the Diamond study.36 In fact, diagnosis by a physician such as the family practitioner or GI specialist showed better sensitivity and specificity for the diagnosis of GERD than did the RDQ. Questionnaires are generally difficult to use in clinical practice. A careful history is the basis for symptomatic diagnosis, with EGD being reserved for identifying or excluding significant structural lesions in selected cases. A region-based assessment of the local “pretest probability” may provide some guidance with regard to the choices and sequence of diagnostic tests needed, given the relatively poor predictive value of most symptoms. PPI Treatment as an Aid to Diagnosis “PPI trial.” It is no longer recommended to administer an empirical short-term (1 to 2 week) course of high-dose PPI treatment to determine whether or not the patient’s symptoms are acid related,36 since this is neither sensitive nor specific. Nonetheless, this is commonly done in practice. A formal course of PPI therapy, of adequate duration (usually 8 weeks) is required to assess the treatment response in GERD patients. Weakly acidic reflux episodes may be a substantial proportion of all reflux episodes. If this is the case, such patients may not respond well to PPI therapy (20% to 40% of GERD patients may not respond to PPI treatment).20 In addition, genuinely alkaline reflux may comprise up to 5% of all reflux episodes. In a subset of PPI nonresponders, reflux-like symptoms may be due to functional heartburn, rather than GERD.20 Alternative diagnoses, including peptic ulcer disease, upper GI malignancy, functional dyspepsia, eosinophilic esophagitis, achalasia of the cardia, and cardiovascular disease should also be considered. In patients with cases that are refractory to PPI treatment, ambulatory 24-hour esophageal pH/impedance monitoring, with the patient off PPI therapy, may be considered to help characterize symptoms.37 If there has been complete failure to respond to PPI treatment, the PPI should be stopped at least 1 week before 24-hour pH monitoring is performed (rescue antacid may be allowed when necessary), to assess for acid reflux. If the refractory reflux symptoms have responded partially, 24-hour pH monitoring (with or without esophageal impedance monitoring) should be performed with PPI administration being continued, to assess for acid reflux that is persistent despite treatment. Occasionally, 24-hour pH monitoring with esophageal impedance monitoring may be required, with the patient both on and off PPI therapy.38 Helicobacter pylori Infection39 In many countries with a high prevalence of H. pylori infection, peptic ulcer and gastric cancer continue to be more common than GERD and cause much higher morbidity and mortality.40 In this setting, any approach to the diagnosis and management of upper gut symptoms must include an assessment of the risks of infection with H. pylori and an awareness of the overlap among, and difficulty of discriminating between, symptoms of GERD, peptic ulcer disease, and functional symptoms—with a decision regarding the relative merits of a test-and-treat approach in comparison with EGD to test for H. pylori and related diseases before empirical antireflux therapy. Although epidemiological studies show a negative association between the prevalence of H. pylori infection and the presence and severity of GERD, this is not proof of causation. H. pylori infection should be sought and eradication therapy given when indicated in accordance with international, national, or local guidelines.41 Although there may be an inverse correlation between H. pylori infection and GERD prevalence and severity, this may well reflect differing effects of a separate, distinct factor or factors on the 2 conditions, rather than a causal relationship between H. pylori and GERD. Physiological studies using pH monitoring have shown that abnormal esophageal acid exposure, which is the hallmark of esophageal reflux, is not influenced by the presence or absence of H. pylori infection. In most patients, H. pylori status has no effect on symptom severity, symptom recurrence, or treatment efficacy in GERD. H. pylori eradication does not exacerbate preexisting GERD or affect treatment efficacy.42 Indeed, in patients with H. pylori-positive uninvestigated dyspepsia, eradication therapy is associated with a lower prevalence of reflux-like symptoms (36%) than control therapy (49%).43 A subgroup of patients infected with more proinflammatory strains of H. pylori (virulence factors vacA and cagA) may be less likely to have severe esophagitis or BE. This may be because infection in these patients more often causes severe corpus gastritis with atrophy, resulting in reduced acid output. However, these patients are at much greater risk of developing gastric cancer. Eradication therapy in these patients has the potential to reduce the risk of gastric malignancy.41 PPIs and H. pylori PPIs are associated with a worsening of the histologic grade of gastritis in H. pylori-infected patients, accompanied by an increased prevalence of gastric mucosal atrophy and intestinal metaplasia44 that occurs earlier, as well as more frequently, than in H. pylori-infected patients who do not take PPIs. As gastric mucosal atrophy and intestinal metaplasia are known to be the major risk factors for the development of gastric adenocarcinoma, most expert guidelines recommend testing and treating for H. pylori before long-term PPI therapy, particularly in younger patients. Endoscopy EGD is usually performed for new-onset upper GI symptoms, almost irrespective of age, in regions where it is available and affordable and where both the frequency of ulcer disease and the concern about malignancy are high, as in most of Asia.45 The Cascades given below address the limited availability of endoscopy in less well-resourced areas by suggesting the use of empiric H. pylori eradication therapy as a first-line strategy. If EGD is performed in regions where the prevalence of GERD is low, the majority of GERD patients will have NERD; in these circumstances, the sensitivity of EGD for the diagnosis of GERD will be low and the main outcome will therefore be the exclusion of other upper GI diagnoses. Endoscopy is particularly recommended for patients with alarm features suggestive of GERD with complications or of other significant upper GI disease such as dysphagia, bleeding, odynophagia, or weight loss. Patients with dysphagia should undergo investigation for a potential complication or for an underlying motility disorder, achalasia, stricture, ring, eosinophilic esophagitis, or malignancy.25 In several Asian countries, the preference for EGD is driven by the risk of malignancy at an early age and by the availability of “affordable, direct-access” endoscopy—an “endoscopy first” approach. Additional investigations other than EGD are rarely needed; furthermore, they have variable accuracy and are often unavailable. Patient History and Physical Examination The goals of patient evaluation include the assessment of symptoms and risk factors for the diagnosis of GERD and the prediction of long-term sequelae. In this regard, it is important to consider the regional epidemiology of upper GI disease and the pretest probability of GERD relative to other conditions. In Asia, for instance, BE is uncommon and it is not therefore an important risk for esophageal adenocarcinoma, which is itself uncommon. The prevalence of peptic ulcer and gastric cancer are the greater drivers of endoscopy in Asia where, unlike in the west, esophageal adenocarcinoma is less common. Personal and Family History Features The following features may be helpful in making a diagnosis and assessing the severity of GERD: Predisposing factors and risk factors, including family history. Duration of symptoms. Daytime symptoms, including time of day and relationship to meals. Nocturnal symptoms, including impact on sleep and the effects of a recumbent position and large, late evening meals. Treatments and remedies tried, including symptomatic response to therapy; symptom improvement with acid-lowering medications including antacids supports a diagnosis of GERD. Periodic dysphagia or food bolus impaction may suggest reflux-related esophageal injury, stricture or malignancy, as well as eosinophilic esophagitis or esophageal dysmotility.46 Drug History The patient should be asked about any medications that may contribute to upper gut symptoms (not necessarily GERD): Aspirin/NSAIDs, iron, potassium, quinidine, tetracycline, bisphosphonates. Zidovudine, anticholinergic agents, α-adrenergic antagonists, barbiturates. β2-adrenergic agonists, calcium channel blockers, benzodiazepines, dopamine. Estrogens, narcotic analgesics, nitrates, progesterone, prostaglandins, theophylline. Tricyclic antidepressants, chemotherapy. Dietary History In some patients, bloating or constipation may be associated with an increased risk of GERD or gastroesophageal reflux symptoms (GERS).47 Several studies suggest that stopping smoking and some physical measures, as well as modification of meal size and timing, be but there is limited evidence for the of alcohol and dietary including caffeine, and In those who are weight may be associated with improvement in GERD or may increase the for Physical There are usually no physical of GERD. and BMI are to of rarely, be and to other problems such as cardiac disease, and cancer. Diagnostic for GERD A diagnosis of GERD be in the of heartburn and In pregnancy, GERD be on the basis of symptoms If the dominant or most troublesome symptoms are atypical for GERD, other diagnoses should be including H. diseases and disease. In regions with a high prevalence of H. pylori infection, an initial H. pylori test-and-treat or endoscopy should be considered. are pH or monitoring and esophageal be performed but are required to assess structural (eg, in patients with dysphagia symptoms. reflux symptoms or GERD complications be using (Table Diagnostic for Diagnosis ulcer disease. gut and functional heartburn on the basis of a clinical response to therapeutic acid pH monitoring, or impedance pH ring, of the body motility esophageal heart disease, disease. chest Cascades for the Diagnosis of GERD For perform esophageal in regions or for selected patients in regions with features suggest eosinophilic For consider this only there is a high prevalence of BE in the local population and there are For most EGD will not the management, in the absence of alarm features or access to antireflux There is no role for upper GI in the investigation of routine upper GI symptoms (Table Cascades for the Diagnosis of Although the severity and frequency of symptoms between GERD patients, reflux symptoms do not the criteria for a diagnosis of GERD and are with and as or severe symptoms with of and therapy to their of the management of GERD a both with to the and to the health care who or provide therapy. The of GERD management are and of esophageal acid either by local acid or by of gastric acid secretion using or, rarely, antireflux The primary goals of treatment are to symptoms, the patient’s of esophagitis, symptom recurrence, and or complications in the most heartburn less than per week will respond to with an antacid or a week or less medications are very to have any are and are to antacids in this of patients, of or that symptoms and of late at may be in those who are may also reduce the frequency of symptoms. Patients who have more symptoms should be for therapy. A diagnosis of troublesome symptoms 2 or more times per empirical therapy with an acid inhibitor or, may also be used PPIs or are or for symptom relief in patients a If OTC or patients will often to a or primary care The definition of treatment failure to a on the treatment being In treatment may because the patient does not have GERD; in it may be that the treatment is to address the severity of the GERD. In the case, there may be a response to treatment, and management will be by the availability and of more may to care initial management to reflux should on clinical with treatment of the symptoms being the It is to the effective of For patients with mild symptoms, and some patients with PPI therapy is a management in many cases. At the primary care PPIs or a of and therapy be at the for therapy, which may be more than therapy For better symptom patients should be about to use PPI treatment therapy may be defined as the PPI to before and in the of to before the meal of the day as Patients in PPI treatment with or without may from a of therapy to a PPI therapy may not work for a proportion of patients, either because the symptoms are not due to acid an alternative diagnosis should be because the of acid is to control the symptoms. to care should be considered for patients. OTC antacids show in patients with weight in the and is an important of the long-term management of GERD and should not be as a therapeutic as it may reduce the frequency and of symptoms and the grade of of late of precipitating factors, use of a sleep OTC or the most but usually symptom relief and be as Alarm features the Alarm features for patients in the of OTC treatment by the diagnosis, patients with alarm symptoms to and patients on the use of their OTC in some may include the availability of treatment choices varies between countries. for short-term or antacids gastric and these include acid with of for short-term to available than OTC Patients advice for reflux symptoms may from OTC PPI treatment. which have OTC availability in individual the of the OTC PPIs may be available in other Alarm features the Alarm features medication without investigation should be in the presence of the following Heartburn or regurgitation symptoms Duration with severe or after 2 of treatment with an OTC or when a or New-onset heartburn or regurgitation at age 45 to 55 age in several Asian regions. Dysphagia or or of GI and anemia. or of or weight loss. and/or suggestive of chest to or of In or below years of age for or below years for PPIs. The goals of are that the patient should and to an of with the most therapy. If and complete symptom relief is not patients should be recommended to a health care for diagnostic PPI who gastric acid should have an for long-term PPI the long-term for PPIs should be

Growing evidence suggests that healthcare provider advice may reduce alcohol use, increase physical activity, and improve the adoption of other desirable lifestyle behaviors among patients. However, how brief interventions and other provider–patient interactions can shape the cumulative adoption of multiple modifiable behaviors is less well studied for diabetes prevention and control. Using weighted Internet panel survey data from a large socio-demographically diverse urban population in the United States (n = 1003), the present study describes differences in group characteristics among those who ‘had been ever diagnosed’ with prediabetes/diabetes versus those who had not. It also examines the associations between the cumulative adoption of lifestyle behaviors and each of the following: (a) lifetime prediabetes/diabetes diagnosis; (b) brief lifestyle intervention exposure (i.e., ever received provider encouragement to modify lifestyle behaviors); and (c) recent provider–patient communication about diabetes. There were several group differences among those who ‘had been ever diagnosed’ with prediabetes/diabetes versus those who had not, by age, employment status, health status, nutrition knowledge, blood pressure/hypertension diagnosis, and diabetes-related health behaviors (p < 0.05). Each of the three provider–patient interactions of interest were positively associated with a higher cumulative sum of adopted modifiable lifestyle behaviors for diabetes prevention and management. The results suggest that provider advice/provider–patient interactions of any type can have a salutary impact on whether individuals with prediabetes or type 2 diabetes will engage in recommended lifestyle behavior modifications.

Alternative Therapeutic Approaches to Chronic Proton Pump Inhibitor Treatment

Influence of Socioeconomic Status on Lifestyle Behavior Modifications Among Survivors of Acute Myocardial Infarction

AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review

Whistler Summary: “The Slow Rate of Rapid Progress”

BackgroundPromoting positive changes in lifestyle behavior in the whole population may be a feasible and effective approach to reducing type 2 diabetes burden, but the impact of population shifts of modifiable risk factors remains unclear. Currently most of the evidence on modifiable lifestyle behavior and type 2 diabetes risk on a population level comes from studies of between-individual differences. The objective of the study was to investigate the association and potential impact on disease burden for within-individual change in lifestyle behavior and diabetes risk.MethodsPopulation-based prospective cohort study of 35,680 participants aged 30–50 at baseline in 1990–2003 in Västerbotten County, Sweden (follow-up until 2013). Five self-reported modifiable lifestyle behaviors (tobacco use, physical activity, alcohol intake, dietary fiber intake and dietary fat intake) were measured at baseline and 10 year follow-up. Lifestyle behaviors were studied separately, and combined in a score. Incident diabetes was detected by oral glucose tolerance tests. Multivariate logistic regression models and population attributable fractions (PAF) were used to analyze the association between change in lifestyle behavior between baseline and 10 year follow-up, and risk of incident diabetes.ResultsIncident diabetes was detected in 1,184 (3.3%) participants at 10 year follow-up. There was a reduced diabetes risk associated with increase in dietary fiber intake, odds ratio (OR) 0.79 (95% confidence interval (CI) 0.66, 0.96) for increase of at least one unit standard deviation (3.0 g/1,000 kcal) of the baseline distribution, PAF 16.0% (95% CI 4.2, 26.4%). Increase in the lifestyle behavior score was associated with reduced diabetes risk, OR 0.92 (95% CI 0.85, 0.99) per unit increase of the score.ConclusionsThese results support a causal link between lifestyle behavior and type 2 diabetes incidence. A small shift in lifestyle behaviors, in particular intake of dietary fiber, has the potential to reduce diabetes burden in the population and might be a suitable target for public health intervention.