Statistical methods
Statistical analyses were performed with the Statistical Package for the
Social Sciences for Windows (SPSS version 24.0; IBM Corp, Armonk, NY,
USA). The pre- to post-lockdown clinical and diet outcome evolutions
were investigated with Wilcoxon rank test. The relationship between
patient features, symptoms and findings, and response to the pandemic
questionnaire was investigated with Spearman analysis. A level of
significance of p<0.05 was used.
Results :
Thirty-two patients met the inclusion criteria and completed the
evaluations. The mean age of cohort was 50.5 ± 16.4 yo. There were 22
females and 10 males. The clinical features of patients are described in
Table 1. The initial RSS-12 of untreated patients before the lockdown
significantly improved from baseline (66.6±49.1) to 3- (47.6±39.2;
p=0.008) and 6-month posttreatment (38.5±38.6; p=0.002). The mean RSS-12
at the end of the lockdown period was 52.2±55.4. From the end of the
treatment period and the end of the lockdown period, the mean RSS-12 did
not statistically change. The pre-treatment RSA (24.2±11.2)
significantly improved at 3- (20.3±9.5; p=0.031) and 6-month (17.2±8.3;
p=0.001) posttreatment. Twenty-five patients (78.1%) reported
significant symptom reduction after 3- or 6-month posttreatment and were
considered as responders (Table 1). The mean PSS at the end of the
lockdown was 28.3±8.8, which corresponded to high stress level regarding
normative data (threshold=12.8±6.2).8
The pre- to post-lockdown evolution of patient consumption of
‘refluxogenic’ foods and beverages is reported in Table 2. According to
the Wilcoxon rank test, patients significantly decreased most foods and
beverages associated with a high risk of reflux event.
Eleven patients (34.4%) reported that the adherence to antireflux diet
was better than initially presumed thanks to lockdown period, while 14
(43.8%) believed that the lockdown did not impact the adherence to diet
(Figure 1A). Three patients (9.4%) thought that the lockdown period was
associated with a better decrease of stress than initially presumed
thanks to lockdown period. Eleven patients (34.4%) believed that the
lockdown period increased the stress level, while there was no influence
of lockdown on stress in 18 patients (56.3%; figure 1B). Overall, 6
patients (18.8%) reported that the lockdown had a negative impact of
their LPR.
The PSS and RSS-12 scores at the end of the pandemic were significantly
correlated (rs=0.681; p<0.001). There was a
positive association between the stress increase and the lack of
adherence to diet at the end of the pandemic (rs=0.367;
p=0.039)
Discussion :
The adherence to antireflux diet and the management of stress and
related autonomic nerve dysfunction are both important issues in the
success of LPR treatment.9
In the present study, we observed that LPR patients who were diagnosed
just before the lockdown periods adequately adhered to antireflux diet,
and mainly reported favorable or no impact of lockdown on their
antireflux diet. The positive or neutral impact of lockdown on diet
habits of patients corroborated the findings of some previous
studies,3,10 while other authors reported mitigated
impact of lockdown on diet habits.4 In a recent
meta-analysis of 42 studies, Della Valle et al . reported that
85% of studies measuring changes in Mediterranean diet adherence
before-during lockdown reported an increase rate of change of
high-adherence to diet ranged from +3.3% to +21.9%.3Similar findings were observed by Alverez-Gomez et al . who found
that the confinement period was associated with better healthy lifestyle
and dietary habits of the Spanish population, including adequate
consumption of fruits, vegetables and legumes, as well as adequate time
to prepare meals.10 The pre- to posttreatment specific
analysis of diet changes in the present study supports that patients had
significantly decreased high-fat, high-quick-release sugar, and
refluxogenic foods and beverages, which was associated with symptom
relief or significant reduction in LPR patients.9
The occurrence of pharyngeal reflux events is related to esophageal
sphincter dysfunction, which may be influenced by autonomic nerve
dysfunction.1 In that way, Wang et al . reported
that patients with anxiety or stress may have more severe LPR symptoms
compared with those without significant autonomic nerve dysfunction. In
the present study, 34% of patients reported a negative impact of
lockdown on stress level, while 56% did not report lockdown influence.
Interestingly, the stress score was significantly associated with RSS-12
at the end of the lockdown, which supports the influence of stress on
LPR disease.
The main limitation of the study remains the low number of patients,
which was related to the short period of study (lockdown periods) and
the need to include patients with an objective LPR diagnosis (HEMII-pH).
The lack of evaluation of stress during the consultation is an
additional limitation.