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.