The consumption of snacks and soft drinks between meals may contribute to the development and to persistence of gastro-esophageal reflux disease.

THE HYPOTHESIS: The habit of snacking and drinking soft beverages between breakfast, lunch and dinner, which is very widespread in the western world, could be a primum movens, thereby contributing to the development and subsequent persistence of gastroesophageal reflux disease (GERD). WHAT DOES THE PROPOSED HYPOTHESIS BASED ON?: The high prevalence of GERD suggests that it is very probably caused by factors, which are intrinsic and widespread in a western lifestyle. Ingesting snacks or imbibing soft drinks between breakfast, lunch and dinner causes additional gastric acid secretion, acid pocket formation, and additional transient lower esophageal sphincter relaxations (TLESRs) with acid reflux; the latter are proportional to the number of ingestions. Moreover, there is increased esophageal acid exposure, which can last up to several hours in a 24-h period. The majority of patients with GERD do not have a hiatal hernia, and TLESRs are the main pathophysiological factor, resulting in an increase in esophageal acid exposure and, therefore, symptoms and the disease. Overweight/obese people very frequently consume snacks and imbibe soft drinks between breakfast, lunch and dinner and they would, therefore, share according to the hypothesis of the authors of this paper. That is, the same eating habit can cause the two conditions obesity and GERD.

THE HYPOTHESIS UNFOLDED: Every time a snack is ingested or a soft drink imbibed between the three daily meals, gastric acid is re-secreted, the acid pocket reforms, the TLESRs are triggered again and acid reflux events recur. The greater the number of snacks and/or soft drinks consumed, the greater the esophageal engagement of the cleaning system with, over time, increasing impairment. This mechanism may account for disease onset. According to the hypothesis outlined in this paper, GERD patients should consume moderate portions constituting three meals a day, thereby limiting the quantity of acid reflux from TLESRs.