Gastroesophageal reflux disease (GERD) is a chronic medical condition in which the stomach acid frequently flows from the stomach to the esophagus. From time to time many people experience isolated reflux, but this is not GERD, it is termed gastroesophageal reflux (GER).
GERD is a serious medical condition that can lead to scaring of the lower esophagus and with repeated exposure may lead to Barrett’s esophagus which may increase a person’s rate for esophageal adenocarcinoma (“Definition & Facts for Barrett’s Esophagus,” 2017). More recently it has been posited that exercise-induced GERD is associated with atrial fibrillation [AFib] (Swanson, 2008) a condition that effects the atrial electrical conduction pathways and subsequent ability to contract synchronously (“What Is Atrial Fibrillation (AFib or AF)?”, 2017). AFib raises the risk for stroke if left untreated (“What Is Atrial Fibrillation (AFib or AF)?”, 2017). Other data has linked GERD with heart rate variability suggesting alterations in neurocardiac function via autonomic reflexes (Cuomo et al., 2006; Milovanovic et al., 2015).
GERD is a complex condition and exercise may help or hurt
GERD is a complex condition with physiological, environmental, and psychological causes.
Exercise can be a trigger and treatment for GERD dependent on mode and intensity.
Some data suggests that the physiological mechanisms may be related to dysfunction at the esophagogastric junction (McArdle, Katch, & Katch, 2013; Pandolfino, Bianchi, Lee, Hirano, & Kahrilas, 2004). There is conflicting evidence on the influence of mode of exercise and GERD. A study of asymptomatic volunteers was evaluated for exercise-induced reflux with vigorous cycling, running, and weight training. The group with the highest incidence of reflux was the running group. The authors attributed the lower rate of reflux in the cycling group to the absence of jarring (Clark, Kraus, Sinclair, & Castell, 1989). In this study weight training only precipitated reflux “in some participants” according to the authors.
It is known that reflux can be influenced by body position. For example, with nocturnal GERD being associated with the supine position. Interestingly, the weight training group performed exercise both in an upright and supine position with no association found with induced-reflux (Clark, Kraus, Sinclair, & Castell, 1989). Other data find no correlation with ambulation or straining activity but suggest transient lower esophageal sphincter dysfunction as the cause (Schoeman, Tippett, Akkermans, Dent, & Holloway, 1995). Other sources have determined that 60% of athletes and healthy subjects experience GERD and evidence suggests that weight training causes the most severe symptoms with running, and cycling milder (McArdle, Katch, & Katch, 2013).
The rates of gastrointestinal problems and exercise are highest among elite athletes, with rates 3-times higher than recreational exercisers (Oliveira & Burini, 2009). A kaleidoscope of factors for exercise-induced GERD has been proposed including, as mentioned above, dysfunction at the esophagogastric junction and bouncing of organs of gastrointestinal system. Additionally, retrograde pressure gradient between the stomach and esophagus, gastric distention, delayed gastric emptying in dehydrated state, and increased intra-abdominal pressure have been posited. (McArdle, Katch, & Katch, 2013).
Symptoms of exercise induced gastroesophageal reflux disease
Given the complexity of GERD and its potential harm the athlete and exercise professional should be aware of the symptoms of GERD, prevention and lifestyle related factors to help the condition. It should be noted that symptoms of GERD can mimic other conditions such as evolving myocardial infarction (chest pain, nausea, near-vomiting or vomiting). Regardless of the origin an individual should initiate protocols for seeking medical attention for persons with these symptoms.
Exercise-related GERD symptoms include substernal chest pain/pressure, sour taste, eructation, nausea, and vomiting (McArdle, Katch, & Katch, 2013). Some athletes may present with cough, wheezing, or hoarseness (McArdle, Katch, & Katch, 2013). However, by themselves these symptoms may be indications of exercise-induced inspiratory stridor or exercise-induced asthma which has been demonstrated in adult and child athletes (Lee, Kim, Yu, & Hong, 2009).
Management of exercise induced GERD
As in GERD treatment for the non-athlete population lifestyle modification is recommended. Recommendations include avoiding sleep within a 4-hour window of an evening meal, reducing provoking foods such as chocolate, peppermint, onions, high-fat foods, alcohol, coffee, and citrus (McArdle, Katch, & Katch, 2013). Additionally, refraining from smoking and having knowledge of medications that may worsen the condition (McArdle, Katch, & Katch, 2013) is important especially as exercise professionals encounter increasing numbers of master-athletes (Bergquist, 2009). Other possible solutions are selection of activities that minimize bending or being supine as these positions may trigger exercise-induced GERD (Sodhi, Javid, Zargar, & Shoukat, 2008). Finally, there is evidence that diaphragmatic bio-feedback training can reduce symptoms (Sun et al., 2015).
Bergquist, L. (2009). Second wind: The rise of the ageless athlete. Champaign, IL: Human Kinetics.
Clark, C. S., Kraus, B. B., Sinclair, J., & Castell, D. O. (1989). Gastroesophageal reflux induced by exercise in healthy volunteers. JAMA: The Journal of the American Medical Association, 261(24), 3599. doi:10.1001/jama.1989.03420240113036
Cuomo, R., Giorgi, F. D., Adinolfi, L., Sarnelli, G., Loffredo, F., Efficie, E., . . . Budillon, G. (2006). Oesophageal acid exposure and altered neurocardiac function in patients with GERD and idiopathic cardiac dysrhythmias. Alimentary Pharmacology and Therapeutics, 24(2), 361-370. doi:10.1111/j.1365-2036.2006.02987.x
Definition & Facts for Barrett’s Esophagus. (2017, March 01). Retrieved from https://www.niddk.nih.gov/health-information/digestive-diseases/barretts-esophagus/definition-facts
Lee, S., Kim, H., Yu, J., & Hong, S. (2009). Differential diagnoses of EIA. Retrieved from https://www.medscape.com/viewarticle/589918_5
McArdle, W. D., Katch, F. I., & Katch, V. L. (2013). Sports and exercise nutrition (4th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.
Milovanovic, B., Filipovic, B., Mutavdzin, S., Zdravkovic, M., Gligorijevic, T., Paunovic, J., & Arsic, M. (2015). Cardiac autonomic dysfunction in patients with gastroesophageal reflux disease. World Journal of Gastroenterology, 21(22), 6982-6989. doi:10.3748/wjg.v21.i22.6982
Oliveira, E. P., & Burini, R. C. (2009). The impact of physical exercise on the gastrointestinal tract. Current Opinion in Clinical Nutrition and Metabolic Care, 12(5), 533-538. doi:10.1097/mco.0b013e32832e6776
Pandolfino, J. E., Bianchi, L. K., Lee, T. J., Hirano, I., & Kahrilas, P. J. (2004, August 01). Esophagogastric junction morphology predicts susceptibility to exercise-induced reflux. Retrieved from https://www.nature.com/articles/ajg2004284
Schoeman, M. N., Tippett, M. D., Akkermans, L. M., Dent, J., & Holloway, R. H. (1995). Mechanisms of gastroesophageal reflux in ambulant healthy human subjects. Gastroenterology, 108(1), 83-91. doi:10.1016/0016-5085(95)90011-x
Sodhi, J., Javid, G., Zargar, S., & Shoukat, A. (2008). Effect of bending exercise on gastroesophageal reflux in symptomatic patients. Indian Journal of Gastroenterology, 27(6), 227-231.
Sun, X., Shang, W., Wang, Z., Liu, X., Fang, X., & Ke, M. (2015). Short-term and long-term effect of diaphragm biofeedback training in gastroesophageal reflux disease: An open-label, pilot, randomized trial. Diseases of the Esophagus, 29(7), 829-836. doi:10.1111/dote.12390
Swanson, D. R. (2008). Running, esophageal acid reflux, and atrial fibrillation: A chain of events linked by evidence from separate medical literatures. Medical Hypotheses, 71(2), 178-185. doi:10.1016/j.mehy.2008.02.017
What is atrial fibrillation (AFib or AF)? (2017, February 6). Retrieved from http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsp