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Abstract

Objective

The role of lifestyle habits in patients with laryngopharyngeal reflux disease (LPRD) is comparatively underexplored. We aim to examine the specific lifestyle habits in patients with LPRD.

METHODS

Systematic sampling was applied to select respondents aged 18 through 80 years in otorhinolaryngology-head and neck surgery (OHNS) clinics in Nan Fang Hospital during August 2017–July 2018, 1658 eligible participants were included by a systematic sampling method. Subjects with RSI score>13 were considered as LPRD patients. The risk of reflux symptoms was estimated and multivariate calculated as odds ratios in relation to exposure to tobacco smoking, alcohol, coffee, tea, carbonated drinks, chocolate, spicy food, night sleep time, dinner-to-bed time, subjective sleep quality, and physical exercise.

Results

There was a significant dose-response association between carbonated beverage and LPRD. Among people who had drinking carbonated drinks the odds ratio was 1.76 (OR 1.77, 95% CI 1.24–2.50, P = .002) compared with non-carbonated drinker. A similar positive association was found for poor subjective sleep quality and shorter night sleeping time, the odds ratio for reflux was 1.58 (95% CI 1.14 to 2.18) among those who always have poor subjective sleep quality compared with those whose have good subjective sleep quality. The odds ratio for reflux was 2.29 (95% CI 1.23–4.28, P = .015) among those who always sleep 3–5 hours every night compared with those who sleep more than 8 hours every night. Beyond that, we found high BMI may have a negative correlation with LPRD, the odds ratio for reflux was .61 (95% CI 0.39 to .95, P = .054) among those whose BMI >25 kg/m2 compared with those BMI ≤ 20 kg/m2.

Conclusions

Patients with LPRD may have certain lifestyle habits, avoid carbonated beverage, poor subjective sleep quality, and lack of sleep should be advised in treatment of LPRD.

Keywords

laryngopharyngeal reflux disease lifestyle-related risk factors epidemiology gastroesophageal reflux disease

Introduction

It is generally assumed that certain behavioral or dietary habits, such as alcohol consumption or smoking, induce LPRD.¹ Lifestyle modifications have been a first-line therapy for patients with LPRD. According to the treatment used in the UK District General Hospital, lifestyle behavior modification is considered to be very effective for the management of LPRD.² Much of the lifestyle modification suggestions came from guidelines for gastroesophageal reflux disease (GERD) because of a scarcity of published evidence on lifestyle habits of patients who suffer from LPRD. Although LPRD and GERD both involve retrograde reflux of the gastric contents, the two disorders have been found to have different pathophysiologies, symptomatology, and patient characteristics.³ Lifestyle modification suggestions from the guidelines of GERD may not be suitable for LPRD patients, and lifestyle-related risk factors in patients with LPRD are largely unexplored. The need to cover this gap of knowledge has been recently emphasized.

The LPRD development may be associated with weight,⁴ high-protein diet,⁵ or alcohol, tobacco,^6,7 exercise,⁸ or depression,⁹ anxiety. The overweight and obesity are well-known favoring factors of GERD, while the results were conflicting in research of LPRD.^4,10 Indeed, the customs, eating habits, and climate in are varied in different country, such as tea consumption, lifestyle-related risk factors other than carbonated drink, spicy food, chocolate and tea consumption, as well as poor subjective sleep quality have not been investigated in previous research.

Epidemiological data of LPRD represent an important reference for clinical diagnosis and treatment. Recently, a multi-center cross-sectional study with 72 tertiary comprehensive hospitals in China using the Reflux Symptom Index (RSI) suggested that the incidence of LPRD-related symptoms in outpatients at the ENT department was up to 10.15%.⁶ Using the RSI in 2012, Athanasia et al showed that the prevalence of LPRD in Greek is 8.5%,⁷ In 2002, Belafsky et al developed the RSI, a self-administered nine-item questionnaire designed in an attempt to standardize patient symptoms and improve initial diagnoses.¹¹ This tool is now widely used clinically in the management of LPRD and in epidemiological studies. The scale for each individual item ranges from 0 (no problem) to 5 (severe problem), with a maximum total score of 45. A RSI >13 is considered abnormal and strongly indicative of LPRD. Since its introduction, the RSI has been translated into several languages, the Chinese version of the RSI had confirmed its good reliability and validity.¹²

This study aimed to analyze the lifestyle habits of patients with LPRD and whether the frequent consumption of potential reflux-provoking food and habits such as smoking, alcohol, tea, coffee, chocolate, carbonated drink, and spicy food consumption, night sleep time, dinner-to-bed time, and physical exercise may be associated with the risk of LPRD in outpatients at the otorhinolaryngology department.

Methods

Ethics approval was obtained from the Nan Fang Hospital Research Ethics Committee (REGISTRATION NUMBER: NFEC-2017-104). In the Nan Fang Hospital of China, an extensive public health survey was performed in OHNS clinics of Nan Fang Hospital during August 2017–July 2018, from August 2017 to July 2018. The survey questionnaire was administered by trained interviewers in the clinic’s temporary research center. The total amount of the exact questionnaires is 1751 respondents and 1658 eligible participants were included by a systematic sampling method. The method yielded a sample that was self-weighted to provide an estimated yearly number of clinical patients.

Those whose registration number ended in five were selected to fill out questionnaires during the second week of every month in the OHNS clinics of Nan Fang Hospital. Those excluded were patients outside the age range, patients with upper respiratory tract surgery or tumors and any acute illness, patients with severe mental disorders, and patients who refused to fill out the informed consent.

For the purpose of this study, LPRD diagnosis was based on an RSI score > 13, as proposed by Belafsky et al.

Sleep status was defined according to Pittsburgh sleep quality index (PSQI),¹³ for item of subjective sleep quality, each asking “During the past month, how would you rate your sleep quality overall?” Subjects were allowed to choose either one of the following answers: (1) Very good, (2) Fairly good, (3) Fairly bad, and (4) Very bad.

Smoking status was defined according to World Health Organization classifications¹⁴ (Table 1): general or ever-smokers included persons who had ever smoked for at least 6 months; current smokers were those who smoked tobacco products at the time of the survey; former smokers were those who reported smoking at least 100 cigarettes during their lifetime but currently did not smoke; and heavy smokers were those who smoked at least 20 cigarettes daily.

Table 1.

Definitions of smoking and drinking in WHO.

Type	Definition
General or ever-smokers	Who had ever smoked for at least 6 months
Occasional smoker	Anyone who smoked, but less than once a day
Current smokers	Who smoked tobacco products at the time of the survey
Former smokers	Who reported smoking at least 100 cigarettes during their lifetime but currently did not smoke
Heavy smokers	Who smoked at least 20 cigarettes daily
Abstainers	Who reported no drinking in the reference period
General or ever-drinkers	Who had ever consumed at least one alcoholic drink of any kind
Current drinkers	Who consumed one or more alcoholic drinks in the year preceding the interview
Former drinkers	Who had not drank an alcoholic beverage during the past 12 months

Drinking status was defined according to World Health Organization classifications¹⁵ (Table 1): abstainers were defined as those who reported no drinking in the reference period; general or ever-drinkers included persons who had ever consumed at least one alcoholic drink of any kind; current drinkers were defined as persons who consumed one or more alcoholic drinks in the year preceding the interview; and former drinkers were persons who had not drank an alcoholic beverage during the past 12 months. Beverage type was that which was typically drunk, and volume was estimated by the frequency method.

The definition of physical exercise was at least 30 min of moderate physical activity a week.¹⁶

Questionnaire

The questionnaire was developed to evaluate the risk factor of OHNS clinics with LPRD. The survey questionnaire was administered by trained interviewers in the clinic temporary research center. All participants completed extensive written questionnaires covering a wide variety of exposures. In our study, we specifically analyzed variables that were related to lifestyle. These variables included tobacco smoking, alcohol consumption, coffee (caffeinated) intake, tea (total types) beverage, chocolate beverage, carbonated beverage, spicy food intake, night sleep time, subjective sleep quality, dinner-to-bed time, as well as physical exercise. In addition, age, sex, ethnic education, and body mass index (BMI; body weight in kilograms divided by the square of body height in meters) were assessed as potential confounders. The dietary habits of lifestyle habits contained 6 items, each asking the number of days per week one certain kind of food or beverage was consumed within the prior 3 months.

Another estimated amount of beverage use was defined as at least one cup of coffee or tea, one bottle of carbonated drinks each time, and one occasion for consuming chocolate, carbonated drinks, and spicy foods. Subjects were allowed to choose either one of the following answers: 1) none, 2) 0–1 time/week, 3) 1–3 times/week, 4) 4–6 times/week, 5) ≥7 times/week. In addition to this, when assessed tea beverage by type of tea consumption and daily tea beverage other than outlined above. Regular physical exercise of at least 30 minutes’ duration was categorized into never (reference), 1 times/week, 1–3 times/week, and >3/week. Other than this, the tobacco smoking year, average cigarette and tea beverage per day, type of alcohol and tea were also be asked. The data were checked, analyzed, and discussed by the team, including the statistical experts. (Table 2)

Table 2.

Items of lifestyle habits in the questionnaire.

Lifestyle items	Options
Smoking	Never	Occasionally	Constantly	Everyday
Daily smoking (years)	None	0–5	6–10	>10
Number of daily cigarettes smoked	None	0–5/day	6–10/day	11–30/day	≥31/day
Alcohol drinking	Never	Occasionally	Constantly	Every day
Year of drinking (years)	No	1–5	6–10	≥11
Number of drinking (times/week)	No	<1	1–3	4–6	Everyday
Alcohol type	None	Spirit	Wine	Brandy	Beer
Coffee use	Never	Occasionally	Constantly	Everyday
Number of coffee (times/week)	No	<1	1–3	4–6	Everyday
Tea use(total types)	Never	Occasionally	Constantly	Everyday
Number of tea (times/week)	No	<1	1–3	4–6	Everyday
Cups of tea (total types) per day	No	<1bei/day	1–3bei/day	≥4bei/day
Type of tea	No	Black tea	Green tea	Others
Carbonated beverage	Never	Occasionally	Constantly	Everyday
Number of carbonated drink (times/week)	No	<1	1–3	4–6	Everyday
Chocolate use	Never	Occasionally	Constantly	Everyday
Number of Chocolate (times/week)	No	<1	1–3	4–6	Everyday
Spicy food use	Never	Occasionally	Constantly	Everyday
Spicy food consumption (times/week)	No	<1	1–3	4–6	Everyday
Dinner-to-bed time (hours)	<1	1–2	2–3	>3
Night sleep time (hours)	<3	3–5	6–8	>8
Poor subjective sleep quality	No		Yes
Physical exercise (time/week)	No	<1	1–3	4–6	Everyday

The questionnaire was pretested amongst 25 randomly selected hospital staff members before the study commenced, to identify any problem areas in the questionnaire and to make appropriate alterations, as adjudged necessary. The questionnaire was usually completed within five min.

Statistical Analyses

Some study variables were categorized to facilitate analysis. The categories for the number of years of tobacco smoking (cigarette, pipe, or cigar) were none (reference), 1–5 years, 6–10 years, and ≥11 years. The daily number of cigarettes smoked was categorized as 0 cigarettes (reference), 0–5, 6–10, 11–30, and ≥31 cigarettes. The categories for the number of years of alcohol drinking were none (reference), 1–5 years, 6–10 years, and ≥11 years. The categories for BMI were classified as ≤20 kg/m², 20–22 kg/m², 22–25 kg/m², and >25 kg/m². The categories for age were 18–20 years, 21–34 years, 35–49 years, 50–64 years, and 65–79 years.

All data including demographic data (age, sex, BMI, education) and lifestyle habits (smoking; alcohol, coffee, tea, carbonated drink, chocolate, and spicy food consumption; poor subjective sleep quality; and physical exercise) were compared between subjects with and without LPRD. The chi-square test was used to analyze categorical data, and Student’s t test was used to analyze continuous data. Using unconditional logistic regression, we calculated the odds ratios (ORs) as estimates of the relative risk and related 95% confidence intervals (CIs) to measure the association between frequent lifestyle habits and LPRD. Variables with a P <.25 in the univariate analysis were entered as candidate risk factors in the multivariate logistic regression analysis to identify independent risk factors of LPRD. Potential confounding effects such as age, sex, and BMI were tested by introducing them one by one into the model. All analyses were performed with IBM SPSS version 20. A 2-sided probability value of less than .05 was considered statistically significant.

Results

The demographic data and lifestyle habit characteristics of the patients are shown in Table 3. In the total of 1658 adults, the mean ages were 39 years (LPRD group) and 39 years (Control group). There were no pronounced age differences between the sexes.

Table 3.

Age and sex distribution among cases with LPRD and control subjects.

Types	Total (%)	Male (%)	Female (%)
Number of subjects
LPRD group	243 (15.2)	212 (15.3)	121 (15.1)
Control	1355 (84.8)	671 (84.7)	680 (84.9)
Mean age (years)
LPRD group	39	40	40
Controls	39	39	40
Age range (years)
LPRD group	18–80	18–80	19–75
Control	19–75	19–68	18–76

Subjects with LPRD were more likely to have a lower BMI (P = .031), a higher daily smoking number (P = .015), a higher carbonated drink consumption rate (P = .01), a higher chocolate consumption rate (P=.004), a shorter night sleeping time (P = .02), a shorter dinner-to-bed time (P = .023), and an poor subjective sleep quality (P < .01) than subjects without LPRD (Table 4). There was no difference in age, education, or the remaining lifestyle habits between the two groups.

Table 4.

Demography and lifestyle habits of subjects with or without laryngopharyngeal reflux.

Types	Control (n = 1355)	LPRD group (n=243)	χ²	*P
Sex (Male/Female)	671/680	121/121	.001	.980
Mean age ± SD	39.94±13.09	39.42±13.19	.563	.574
BMI(kg/m2)	22.54±3.38	22.03±3.37	2.17	.031
Age(years)
18–20	20	5	1.3000	.861
21–34	513	99
35–49	465	77
50–64	298	53
65–79	50	9
BMI(kg/m2)
≤20	320	75	6.776	.079
20–22	303	52
22–25	421	71
>25	303	43
Education
Primary school or below	247	42	5.123	.163
Junior high school	371	62
High school	298	46
University and above	383	87
Smoking
Never	1019	176	1.049	.789
Occasionally	156	31
Constantly	43	10
Everyday	136	25
Daily smoking (years)
None	1036	181	1.714	.634
0–5 years	116	18
6–10 years	54	13
>10 years	143	29
Number of daily cigarettes smoked
0	1020	176	12.402	.015
0–5/day	65	4
6–10/day	87	13
11–30/day	152	36
≥31/day	15	7
Alcohol drinking
Never	850	148	1.500	.769
Occasionally	442	87
Constantly	51	7
Everyday	10	1
Year of drinking
No	851	148	3.000	.394
1–5 years	149	34
6–10 years	115	23
≥ 11 years	167	24
Number of drinking
No
<1 times/week	1065	191	1.335	.859
1–3 times/week	169	32
4–6 times/week	60	13
Everyday	25	4
Alcohol type
None	845	150	.732	.981
Spirit	110	21
Wine	100	15
Brandy	8	2
Beer	150	28
Mixed	130	24
Coffee use
Never	917	155	2.554	.516
Occasionally	412	82
Constantly	20	5
Everyday	5	0
Number of coffee use
No	1135	199	.880	.876
<1 times/week	156	30
1–3 times/week	35	8
4–6 times/week	17	4
Everyday	7	1
Tea use
Never	308	59	1.579	.664
Occasionally	662	124
Constantly	179	27
Everyday	203	32
Number of tea use
No	445	88	3.334	.504
<1 times/week	346	65
1–3 times/week	212	36
4–6 times/week	113	13
Everyday	223	38
Cups of tea
No	450	89	2.799	.424
<1 bei/day	365	69
1–3 bei/day	257	36
≥4 bei/day	248	44
Type of tea
No	297	60	4.652	.199
Black Tea	422	80
Green Tea	494	84
Others	65	5
Carbonated beverage
Never	647	83	16.868	.001
Occasionally	654	146
Constantly	44	12
Everyday	5	2
Number of carbonated drink
No	843	126	16.234	.003
<1 time/week	347	87
1–3 times/week	127	20
4–6 times/week	25	9
Everyday	6	0
Chocolate use
Never	732	106	8.715	.033
Occasionally	604	132
Constantly	16	3
Everyday	1	0
Number of chocolate use
No	986	167	5.051	.282
<1 times/week	281	62
1–3 times/week	61	8
4–6 times/week	11	4
Everyday	1	0
Spicy food use
Never	359	64	3.452	.327
Occasionally	632	102
Constantly	219	50
Everyday	141	27
Number of spicy food use
No	496	91	1.162	.884
<1 times/week	348	61
1–3 times/week	223	44
4–6 times/week	111	16
Everyday	166	28
Dinner-to-bed time
<1 hour	53	14	9.577	.023
1–2 hours	84	26
2–3 hours	207	29
>3 hours	1001	172
Night sleep time
<3 hours	10	2	9.871	.020
3–5 hours	125	33
6–8 hours	1014	187
>8 hours	202	21
Subjective sleep quality
Good	1064	164	14.368	<.001
Bad	285	78
Physical exercise
No	632	118	4.342	.362
<1 times/week	267	47
1–3 times/week	221	45
4–6 times/week	67	14
6 Everyday	164	19

In the multivariate logistic regression analysis model, carbonated drink consumption (OR 1.76, 95% CI 1.24–2.50, P=.002), a short night sleep time (3–5 hours every night) (OR 2.29, 95% CI 1.23–4.28, P = .015) and an irregular sleep–wake pattern (OR 1.58, 95% CI 1.14–2.18, P=.006) were all independently associated with LPRD (Table 5).

Table 5.

Lifestyle habits and risk of LPRD.

	Number		Univariate		Multivariate†
	Cases	Controls	OR 95% Cl	*p	OR 95% Cl	*P
BMI(kg/m2)
≤20	75	319	1.00 (reference)		1.00 (reference)
20–22	52	303	.73 (.50–1.08)	.111	.72 (.49–1.08)	.110
22–25	71	422	.72 (.50–1.02)	.065	.75 (.51–1.10)	.142
>25	43	303	.60 (.40–.91)	.015	.61 (.39–.95)	.028
Carbonated beverage
No	647	83	1.00 (reference)		1.00 (reference)
Yes	703	160	1.77 (1.33–2.36)	<.001	1.76 (1.24–2.50)	.002
Night sleep time
>8 hours	202	21	1.00 (reference)		1.00 (reference)
6–8 hours	1014	187	1.92 (.40–9.37)	.418	1.65 (.32–8.50)	.548
3–5 hours	125	33	2.54 (1.41–4.59)	.002	2.29 (1.23–4.28)	.009
<3 hours	10	2	1.77 (1.10–2.85)	.018	1.85 (1.13–3.03)	.015
Sleep–wake pattern
Regular	1067	165	1.00 (reference)		1.00 (reference)
Irregular	282	77	1.78 (1.32–2.40)	<.001	1.58 (1.14–2.18)	.006
Chocolate
No	732	106	1.00 (reference)		1.00 (reference)
Yes	621	135	1.50 (1.14–1.98)	.004	1.31 (.95–1.81)	.106
Dinner-to-bed time
<1 hour	53	14	1.00 (reference)		1.00 (reference)
1–2 hours	84	26	1.54 (.84-2.83)	.168	1.54 (.81–2.91)	.187
2–3 hours	207	29	1.80 (1.13–2.88)	.014	1.56 (.94–2.59)	.084
>3 hours	1001	172	.82 (.54–1.24)	.342	.75 (.49–1.16)	.199

In the multivariate logistic regression analysis model, carbonated drink consumption (OR 1.76, 95% CI 1.24–2.50, P = .002), a short night sleep time (3–5 hours every night) (OR 2.29, 95% CI 1.23–4.28, P = .015), and an poor subjective sleep quality (OR 1.58, 95% CI 1.14–2.18, P = .006) were all independently associated with LPRD (Table 5).

In the multivariate analysis, there was a negative association between night sleeping time and LPRD, with an approximate 129% increase in risk among people who sleep 3-5 hours every night compared with those who sleep more than 8 hours (OR 2.29, 95% CI 1.23–4.28, P = .015). Similarly, a poor subjective sleep quality was associated with an increased risk of LPRD (P value for linear trend <.01). The risk of LPRD was 58% higher among people who had poor subjective sleep quality than among those who had good subjective sleep quality (OR 1.58, 95% CI 1.14–2.18, P = .006) (Table 5). Dinner-to-bed time was not associated with any change in the risk of reflux. This finding differed from the univariate analysis of dinner-to-bed time, which showed a decrease in the risk of reflux when comparing the same groups as above (OR .75, 95% CI 0.49 to 1.16, P = .199). The analyses revealed that the decreased risk of reflux identified in the univariate data could be entirely explained by confounders. No strong confounding effects were identified in the analyses of night sleeping time and poor subjective sleep quality (Table 5).

There was a moderately strong and dose-dependent association between an increasing frequency of carbonated beverage consumption and the risk of LPRD (Table 5). The multivariate analysis revealed that among individuals who drink carbonated drinks, the risk of reflux was significantly increased by 76% compared with those who did not drink any carbonated drinks (OR 1.76, 1.76, 95% CI 1.24–2.50, P = .002). Chocolate consumption was not associated with any change in the risk of reflux. This finding differed from the univariate analysis of chocolate consumption, which showed an increase in risk of reflux when comparing the same groups as above (OR 1.31; 95% CI 0.95 to 1.81, P = .106). The analyses revealed that the increased risk of reflux identified in the univariate data could be entirely explained by confounders.

There was a negative association between BMI and LPRD, with an approximate 39% (OR .61, 95% CI 0.39-.95, P = .054) decreased risk among people with a BMI>25 kg/m² compared with those with a BMI < 20 kg/m² (Table 3). No strong confounding effects were identified in the analyses of BMI.

Discussion

This study explored the risk factors of laryngopharyngeal reflux disease (LPRD) among ENT clinic outpatients, focusing on their lifestyle habits. We discovered that lack of sleep, poor subjective sleep quality, and carbonated beverage consumption were associated with an increased risk of reflux, and the frequent consumption of carbonated drinks was independently associated with an increased risk of LPRD with an apparent dose-response relationship. Additionally, LPRD is not associated with increasing BMI or obesity.

It is generally agreed that obesity and GERD are strongly associated, in our study, patients with LPRD were not obese. Controversy exists as to the effect of obesity on LPRD as results of different studies are diverse and contradictory.^4,10 Although, there is no prospective study have shown a positive correlation between increasing BMI and LPRD. More prospective studies are needed to identify mechanisms and causes.

Cessation of carbonated beverage consumption is commonly recommended as a lifestyle modification for patients with LPRD.² Several studies have suggested that carbonated beverages may exacerbate GERD.¹⁷ Similarly, increased carbonated beverage consumption in our study was significantly different between the LPRD and non-LPRD groups. In our multivariate analysis, there was a consistent dose-response relation between levels of carbonated beverage consumption (OR 1.76, 95% CI 1.24–2.50, P = .002), suggesting that a frequent carbonated beverage consumption is indeed a risk factor for LPRD. Carbonated beverages have been shown to increase postprandial esophageal acid and have been associated with promoting GERD symptoms by decreasing the lower esophageal sphincter (LES) pressure; beverage consumption was also found to predict GERD symptoms in a multivariate analysis.¹⁷ Presently, there are very few studies supporting the role of carbonated beverages in LPRD.

Sleep disturbance and poor quality of sleep have been shown in a significant portion of patients with GERD.18,19 The hypothesis is that LPRD and sleep disturbance create a “vicious cycle” whereby sleep disturbance enhances throat and esophageal acid sensitivity, which in turn further enhances sleep disturbance. In our multivariate analysis, patients with a lack of night sleeping time (3-5hours) were characterized with high rick of LPRD than those have more than 8 hours sleeping time (OR 2.29,95% CI 1.23–4.28, P = .015). Patients with shorter night sleeping time have been linked to the poor subjective sleep quality. Poor subjective sleep quality has in turn been associated with increased incidence of LPRD-related symptoms. In our study, multivariate analysis showed that patients with irregular sleep wake pattern was associated with LPRD, with an odds ratio for reflux of 1.58 (95% CI 1.14–2.18, P = .006).

Tea and coffee are generally thought to be potent stimuli of gastric acid secretion and thus have been associated with heartburn.²⁰ However, the results of the effects of coffee and tea on LES pressure and postprandial acid reflux time, or the number of acid reflux episodes, were conflicting.^21-23 In a population-based cross-sectional study, coffee exposure data showed a reduced risk of reflux symptoms among coffee drinkers compared with non-coffee drinkers, with an approximate 40% decrease in risk among people who drank more than seven cups of coffee per day compared with those who drank less than one cup (OR .6, 95% CI 0.4 to .7). A recent survey in Taiwan described no association between coffee drinking and GERD incidence,²¹ multivariate analysis from the study showed that drinking tea ≥4 days/week (OR 1.6, 95% CI 1.1–2.3) was an independent risk factor of asymptomatic erosive esophagitis (AEE) in men. A large epidemiologic study found that tea drinking was not associated with any effect on the risk of reflux symptoms.²² Our study showed no relation between tea consumption, type of tea consumption, frequency of tea consumption, coffee consumption, frequency of coffee consumption and LPRD incidence. Other foods, including chocolate and spicy foods, have also been found to be associated with acid regurgitation or heartburn among patients with GERD; however, no association has been reported with LPRD.

Alcohol consumption and habitual smoking have been reported to be putative risk factors for LPRD.⁶ Hence, the recommendation of lifestyle modifications for the treatment of LPRD include smoking cessation and limiting alcohol intake.² Previous studies, though limited in sample size and lacking multiple factor analysis, have still been controversial regarding the associations of smoking and alcohol consumption with LPRD symptoms. A case series study suggested that some items of the RSI were significantly associated with smoking or drinking.²³ Nikolaos Spantideas et al pointed out that alcohol drinkers have higher RSI scores than nondrinkers, and smokers have higher RSI scores than nonsmokers (t test, P < .001 and P = .006, respectively).⁷ Controversially, pseudorandom sampling performed in an English population found no association between LPRD and smoking or alcohol consumption.⁸ Our present cross-sectional study, which included smoking, duration of smoking, daily smoking, alcohol consumption, duration of alcohol consumption, daily alcohol consumption and alcohol type, found no association between the factors above and LPRD.

This study focused on the lifestyle-related risk factor of patients with LPRD, which has rarely been researched. Moreover, we collected a wide range of exposure data our questionnaire, making it possible to evaluate a wide range of potential confounding factors in the multivariate analyses. The present study indicated an important role for lifestyle-related factors in the etiology of LPRD. However, few robust data have been published.

There are several limitations in our study. First, the main tool of the epidemiological survey-RSI scale was not an objective diagnostic tool of LPRD, without any objective methods, such as pH measurements. However, there is not an easy and generally accepted diagnostic method available for large-scale outpatient studies in otorhinolaryngology clinics, and those that are available are invasive and costly. Another potential source of error in our study was confounding; however, this was thoroughly evaluated in our multivariate analyses. Third, we could not identify any causal relationship due to the cross-sectional design of the study. Finally, we examined dietary habits using self-reported questionnaires, which might have resulted in some level of inaccuracy in classifying participants into different categories.

In conclusion, our study on the lifestyle habits of outpatients with LPRD provides evidence that poor lifestyle habits, such as carbonated beverage consumption, a short night sleep time, and poor subjective sleep quality may contribute to LPRD. Future research to corroborate our hypotheses is warranted for these common lifestyle habits, which have been strongly embedded in our dietary culture.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study received support by the Gungdong Basic and Applied basic Research Foundation, grant number 2020A1515110638.

Statement of Human and Animal Rights

All procedures in this study were conducted in accordance with the Nan Fang Hospital Research Ethics Committee ( REGISTRATION NUMBER: NFEC-2017-104 ) approved protocols.

Informed Consent

Written informed consent was obtained from a legally authorized representatives for anonymized patient information to be published in this article.

ORCID iD

Meigui Wang

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Risk Factor-Related Lifestyle Habits of Patients With Laryngopharyngeal Reflux

Abstract

Objective

METHODS

Results

Conclusions

Keywords

Introduction

Methods

Questionnaire

Statistical Analyses

Results

Discussion

Footnotes

Declaration of conflicting interests

Funding

Statement of Human and Animal Rights

Informed Consent

ORCID iD

References