Professional Documents
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Dote 0794
Dote 0794
Dote 0794
Diseases of
of the
the Esophagus
Esophagus (2016)
(2015) 29, 794–800
••, ••–••
DOI:
DOI: 10.1111/dote.12384
10.1111/dote.12384
Original article
SUMMARY. Our aim was to assess the association of a Mediterranean diet and gastroesophageal reflux disease
among adult men and women in Albania, a former communist country in South Eastern Europe with a predomi-
nantly Muslim population. A cross-sectional study was conducted in 2012, which included a population-based
sample of 817 individuals (≥18 years) residing in Tirana, the Albanian capital (333 men; overall mean age: 50.2 ±
18.7 years; overall response rate: 82%). Assessment of gastroesophageal reflux disease was based on Montreal
definition. Participants were interviewed about their dietary patterns, which in the analysis was dichotomized into:
predominantly Mediterranean (frequent consumption of composite/traditional dishes, fresh fruit and vegetables,
olive oil, and fish) versus largely non-Mediterranean (frequent consumption of red meat, fried food, sweets, and
junk/fast food). Logistic regression was used to assess the association of gastroesophageal reflux disease with the
dietary patterns. Irrespective of demographic and socioeconomic characteristics and lifestyle factors including
eating habits (meal regularity, eating rate, and meal-to-sleep interval), employment of a non-Mediterranean diet
was positively related to gastroesophageal reflux disease risk (fully adjusted odds ratio = 2.3, 95% confidence
interval = 1.2–4.5). Our findings point to a beneficial effect of a Mediterranean diet in the occurrence of
gastroesophageal reflux disease in transitional Albania. Findings from this study should be confirmed and expanded
further in prospective studies in Albania and in other Mediterranean countries.
KEY WORDS: Albania, gastroesophageal reflux disease, Mediterranean diet, non-Mediterranean diet, South
Eastern Europe.
has been suggested that a Mediterranean diet that years; 484 women, mean age: 49.5 ± 18.9 years;
reflects the dietary pattern in the Mediterranean overall response rate: 817/1000 = 81.7%).
European region characterized by a high intake of
vegetables, legumes, fruits, whole grains, fish, and
Data collection
olive oil, moderate amounts of alcohol and dairy
products, and low amounts of red or processed meat Following the standard methods of cross-cultural
is healthful and provides beneficial effects especially adaptation of the questionnaires, the Montreal
on cardiovascular and cancer risk.14–16 To date, instrument for assessment of GERD22 was translated
however, the influence of Mediterranean diet in the into the Albanian language. Next, the Albanian
GERD symptoms, to our knowledge, has not been version of the instrument was pretested in a small
studied in population-based samples. sample of users of primary health-care services in
After the collapse of the communist regime in 1990, Tirana before conducting the current survey.20
Albania embarked in the complex journey toward a Based on the Montreal definition of GERD for
market-oriented economy. Conventionally, Albanian population-based studies,22 individuals were classified
diet has consisted of a low consumption of total calo- into two groups based on the presence (or, absence)
‘In the past year, did you have heartburn ‘In the past year, did you have regurgitation ‘In the past year, did you take
that is a burning sensation in the that is a perception of flow of refluxed medications for heartburn
retrosternal area (behind the breastbone)?’ gastric content into the mouth or throat?’ or regurgitation?’
No No No
Yes Yes Yes
Frequency of heartburn: Frequency of regurgitation: Frequency of medication:
No heartburn No regurgitation No medication
<1 day/week <1 day/week <1 day/week
1–3 days/week 1–3 days/week 1 day/week
4–6 days/week 4–6 days/week 2–3 days/week
Every day Every day Almost every day
Severity of heartburn: Severity of regurgitation: Type of medication:
No heartburn No regurgitation Antacid
Mild Mild Histamine H2 receptor
Moderate Moderate antagonists
†Definition of gastroesophageal reflux disease (GERD) in this study was as follows: During last year, self-reported heartburn or regurgi-
tation occurring at least once a week, and having at least moderate problems from such symptoms. Participants reporting use of
medications for heartburn or regurgitation at least once weekly (n = 28) were excluded from the GERD group.
meal: <10 minutes, or ≥10 minutes?’. Also, meal-to- Binary logistic regression was used to assess the
sleep interval was assessed by the following question: association of GERD (outcome variable) with the
‘How long does it take you to go to sleep in the Mediterranean diet (predictor). Unadjusted (crude)
evening following your last meal: <30 minutes, or ≥30 odds ratios (ORs) and their respective 95% confi-
minutes?’. dence intervals (CIs) were initially calculated. Subse-
Furthermore, participants were asked about their quent models included adjustment for age (numerical
smoking habits (categorized into current smoker, variable) and sex. Next, logistic models were addi-
former smoker, never smoker), alcohol intake tionally adjusted for socioeconomic characteristics
(dichotomized into no/occasional intake vs. (educational attainment and income level). Then, life-
moderate/heavy intake), and physical activity (low, style factors (smoking, alcohol intake, physical activ-
moderate, high). ity, and BMI) were also introduced into the logistic
Demographic data (age and sex) and socioeco- models. Final models included additional adjustment
nomic information (educational attainment [years of for eating habits (meal regularity, eating rate, and
formal schooling, categorized into: 0–8 years, 9–12 meal-to-sleep interval). For all models, multivariable-
years, ≥13 years] and income level [low, middle, high]) adjusted ORs and their respective 95% CIs were cal-
were additionally collected. culated. Hosmer–Lemeshow goodness-of-fit test was
Physical examination included measurement of used to assess the validity of the logistic models.
height and weight; subsequently, body mass index The analysis was rerun separately in each BMI
(BMI) was calculated for each study participant category (that is a stratified analysis conducted
(kg/m2). separately for normal weight [BMI < 25.0 kg/m2],
The study was approved by the Albanian Commit- overweight [BMI = 25.0–29.9 kg/m2], and obese indi-
tee of Biomedical Ethics. All individuals who agreed viduals [BMI ≥ 30.0 kg/m2]).
to participate signed an informed consent after being The statistical analysis was conducted in SPSS
explained the aims and procedures of the study. (Statistical Package for Social Sciences, version 17.0,
Chicago, IL).
Statistical analysis
Chi-square test was used to compare the distribution RESULTS
of sex, socioeconomic characteristics (educational
attainment and income level), lifestyle factors In this study population, the overall prevalence
(smoking, alcohol intake, physical activity, and of GERD based on self-reported symptoms was
BMI), eating habits (meal regularity, eating rate, 73/817 = 8.9%.
and meal-to-sleep interval), and GERD between par- Based on our operational definition, overall, 445
ticipants employing a Mediterranean and a non- (54.5%) participants employed a predominantly
Mediterranean diet. Conversely, Mann–Whitney test Mediterranean diet compared to 372 (45.5%) partici-
was used to compare the age distribution between the pants who employed a largely non-Mediterranean
two groups. diet (Table 2). Women tended to engage more with a
© 2015 International Society for Diseases of the Esophagus C 2015 International Society for Diseases of the Esophagus
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4 Diseases of the Esophagus GERD and Mediterranean diet 797
Table 2 Adherence to a Mediterranean diet by socioeconomic Table 3 Association of gastroesophageal reflux disease (GERD)
characteristics, lifestyle factors and gastroesophageal reflux disease with adherence to a predominantly Mediterranean diet; unadjusted
(GERD) status in a population-based sample of Albanian adults and multivariable-adjusted ORs from binary logistic regression
(n = 817)
Model n* OR* 95% CI* P*
Non-
Mediterranean Mediterranean Model 1† <0.001
Variable diet (n = 372) diet (n = 445) P-value* Mediterranean diet 445 1.00 Reference
Non-Mediterranean diet 372 3.06 1.82–5.14
Sex: 0.010 Model 2‡ <0.001
Men 170 (45.7)† 163 (36.6) Mediterranean diet 419 1.00 Reference
Women 202 (54.3) 282 (63.4) Non-Mediterranean diet 359 2.87 1.70–4.86
Age (years) 51.3 (31.0)‡ 49.3 (32.0) 0.121 Model 3¶ <0.001
Educational level: 0.135 Mediterranean diet 379 1.00 Reference
0–8 years 56 (15.7) 76 (18.2) Non-Mediterranean diet 331 3.20 1.84–5.56
9–12 years 153 (43.0) 150 (36.0) Model 4§ 0.024
≥13 years 147 (41.3) 191 (45.8) Mediterranean diet 338 1.00 Reference
Income level: 0.095 Non-Mediterranean diet 304 2.12 1.10–4.07
Low 49 (14.0) 45 (10.9) Model 5†† 0.018
Table 4 Association of gastroesophageal reflux disease (GERD) with adherence to a predominantly Mediterranean diet by body mass
index (BMI) status; unadjusted and multivariable-adjusted odds ratios (ORs) from binary logistic regression
BMI < 25.0 kg/m2 (n = 274)* BMI: 25.0–29.9 kg/m2 (n = 346)* BMI ≥ 30.0 kg/m2 (n = 152)*
Model 1‡
Mediterranean diet 1.00 (reference) 0.03 1.00 (reference) 0.01 1.00 (reference) 0.33
Non-Mediterranean diet 4.71 (1.15–19.3) 2.43 (1.19–4.95) 1.61 (0.62–4.15)
P-value of the interaction term between BMI and dietary type: P = 0.46
Model 2¶
Mediterranean diet 1.00 (reference) 0.03 1.00 (reference) 0.02 1.00 (reference) 0.61
Non-Mediterranean diet 4.96 (1.18–20.87) 2.38 (1.16–4.88) 1.29 (0.48–3.44)
P-value of the interaction term between BMI and dietary type: P = 0.34
Model 3§
Mediterranean diet 1.00 (reference) 0.03 1.00 (reference) 0.01 1.00 (reference) 0.43
Non-Mediterranean diet 4.97 (1.17–21.10) 2.70 (1.24–5.88) 1.55 (0.52–4.63)
P-value of the interaction term between BMI and dietary type: P = 0.39
*Discrepancies in the total are due to missing BMI values (n = 45). †Odds ratios (OR: non-Mediterranean vs. Mediterranean diet), 95%
confidence intervals (95% CIs) and P-values from binary logistic regression. ‡Model 1: crude (unadjusted) models. §Model 3: adjusted
simultaneously for age, sex, and socioeconomic characteristics (educational attainment [0–8 years, 9–12 years and ≥13 years] and income
level [low, middle, and high]). ¶Model 2: adjusted for age (numerical variable) and sex. **Model 4: adjusted simultaneously for age, sex,
socioeconomic characteristics, and behavioral factors (smoking [current smoker, former smoker and never smoker]), alcohol intake
(no/occasional intake vs. moderate/heavy consumption) and physical activity (low, moderate and high). ††Model 5: adjusted simultane-
ously for age, socioeconomic characteristics, behavioral factors and eating habits (meal regularity [never/occasionally vs. often/always],
eating rate [<10 minutes vs. ≥10 minutes], and meal-to-sleep interval [<30 minutes vs. ≥30 minutes]).
0.4–7.4). Nevertheless, there was no evidence of a tion of fried foods alone was associated with a greater
significant interaction between BMI and dietary type risk of GERD, whereas meat consumption by itself
(in multivariable-adjusted models, P-value for the was not related to GERD.20
interaction term between BMI, and dietary type: Based on the current evidence, the association of
P = 0.63). GERD with the consumption of different food items
is controversial.5–10 For example, consumption of a
high-fat diet has been shown to be associated with
DISCUSSION GERD in some studies,5–7 but not in a few other
studies.8–10 Furthermore, El-Serag et al. have demon-
This is one of the few studies reporting on the asso- strated that fruits, vegetables, and high-fiber diets
ciation of GERD with adherence to a predominantly are inversely associated with GERD, whereas Zheng
Mediterranean diet in a population-based sample of et al. found that none of these items was associated
adults in Albania, a transitional predominantly with the risk of GERD symptoms.5,9
Muslim country in the Western Balkans, which has It has been argued that a potential explanation
traditionally engaged with a Mediterranean diet.17 It for inconsistent findings across studies may be that
should be pointed out that employment of a primarily specific foods are consumed as part of an overall
Mediterranean diet was more prevalent in women diet, and it is plausible that the effects of individual
than in men. In both sexes, however, employment of dietary items on the risk of GERD depend on the
a predominantly Mediterranean diet in this study overall dietary patterns.5,9 Therefore, in our study we
population was associated with a decreased risk for assessed the effects of an overall dietary pattern
GERD upon adjustment for a wide array of demo- (predominantly Mediterranean vs. mainly non-
graphic and socioeconomic characteristics and Mediterranean) rather than the role of each food item
lifestyle/behavioral factors including also selected on the risk of GERD symptoms. Only one previous
eating habits such as meal regularity, eating rate and study has revealed a decreased GERD risk detected
meal-to-sleep interval. by pH-impedance monitoring among Italians
We have previously reported that smoking, physi- employing a Mediterranean diet.25
cal inactivity, and obesity are strong predictors of In our study, interestingly, no single component of
GERD in the Albanian adult population.20,24 In a the Mediterranean dietary score had a significant
previous study, we have also reported that consump- influence on GERD risk. Conversely, when these
© 2015 International Society for Diseases of the Esophagus C 2015 International Society for Diseases of the Esophagus
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6 Diseases of the Esophagus GERD and Mediterranean diet 799
components were integrated into a single Mediterra- reverse causality, pointing to the possibility of behav-
nean dietary score, there was evidence of a significant ioral changes (e.g. changes in dietary patterns) after
protective effect which may be explained by the syn- the onset of GERD symptoms, remains uncertain
ergistic and antagonistic interactions between differ- from such cross-sectional designs.
ent ingredients of the Mediterranean diet.
The Mediterranean diet is characterized by high
levels of components found protective against GERD
and by low levels of components associated with an CONCLUSIONS
increased risk of developing this disease. However,
the composite/traditional Albanian dishes contain a Our findings point to a beneficial effect of a Mediter-
mix of vegetables and legumes,26 which are rich in ranean dietary pattern in the occurrence of GERD in
dietary fiber, associated with a reduction of GERD this South Eastern European largely Muslim popula-
risk27 and fat, herbs, spices, tomato, garlic, and tion undergoing a particularly rapid socioeconomic
onions,26 which are positively associated with GERD transition and behavioral changes. Employment of a
risk through their presumed effects on reducing predominantly Mediterranean diet among Albanian
15 Toledo E, Hu F B, Estruch R et al. Effect of the Mediterranean 24 Kraja B, Burazeri G, Prifti S. Anthropometric indices and
diet on blood pressure in the PREDIMED trial: results from a gastro-esophageal reflux disease in adult population in Tirana,
randomized controlled trial. BMC Med 2013; 11: 207. Albania. Med Arh 2008; 62: 139–41.
16 Couto E, Boffetta P, Lagiou P et al. Mediterranean dietary 25 Zentilin P, Iiritano E, Dulbecco P et al. Normal values of 24-h
pattern and cancer risk in the EPIC cohort. Br J Cancer 2011; ambulatory intraluminal impedance combined with pH-metry
104: 1493–9. in subjects eating a Mediterranean diet. Dig Liver Dis 2006; 38:
17 Gjonça A, Bobak M. Albanian paradox, another example of 226–32.
protective effect of Mediterranean lifestyle? Lancet 1997; 350: 26 Beluli H, Fosa M. Albanian Cuisine: 500 Traditional Recipes.
1815–7. Tirana: Toena Publisher, 2007.
18 Burazeri G, Goda A, Sulo G, Stefa J, Kark J D. Financial loss 27 Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle
in pyramid savings schemes, downward social mobility and related risk factors in the aetiology of gastro-oesophageal eflux.
acute coronary syndrome in transitional Albania. J Epidemiol Gut 2004; 53: 1730–5.
Community Health 2008; 62: 620–6. 28 Roman S, Pandolfino J E. Environmental-lifestyle related
19 Mone I, Bulo A. Total fats, saturated fatty acids, processed factors. Best Pract Res Clin Gastroenterol 2010; 24: 847–59.
foods and acute coronary syndrome in transitional Albania. 29 Kaltenbach T, Crockett S, Gerson L B. Are lifestyle measures
Mater Sociomed 2012; 24: 91–3. effective in patients with gastroesophageal reflux disease?
20 Cela L, Kraja B, Hoti K et al. Lifestyle characteristics and An evidence-based approach. Arch Intern Med 2006; 166: 965–
gastroesophageal reflux disease: a population-based study in 71.
Albania. Gastroenterol Res Pract 2013; 2013: 936792. 30 Kubo A, Block G, Quesenberry C P Jr et al. Dietary guideline
21 Dent J, El-Serag H B, Wallander M A et al. Epidemiology of adherence for gastroesophageal reflux disease. BMC
© 2015 International Society for Diseases of the Esophagus C 2015 International Society for Diseases of the Esophagus
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