Lifestyle interventions can reduce the risk of Barrett's esophagus: a systematic review and meta-analysis of 62 studies involving 250,157 participants

Abstract

Background: Barrett's esophagus (BE) is a well-established risk factor for esophageal adenocarcinoma. Our objective was to investigate the effectiveness of lifestyle interventions on BE risk.

Methods: We searched PubMed, Embase, and Web of Science up to 30 September 2020. The summary relative risks (RRs) and 95% confidence intervals (CIs) for the highest versus lowest categories of exposure were assessed. Analyses of subgroup, dose-response, sensitivity, and publication bias were conducted.

Results: Sixty-two studies were included that involved more than 250,157 participants and 22,608 cases. Seven lifestyle factors were investigated: smoking, alcohol, body mass index (BMI), physical activity, sleep time, medication, and diet. We observed statistically significant increased BE risks for smoking (RR = 1.35, 95% CI = 1.16-1.57), alcohol intake (RR = 1.23, 95% CI = 1.13-1.34), body fatness (RR = 1.08, 95% CI = 1.03-1.13), less sleep time (RR = 1.76, 95% CI = 1.24-2.49), and proton pump inhibitors use (RR = 1.64, 95% CI = 1.17-2.29). Reduced risks of BE were found for aspirin (RR = 0.70, 95% CI = 0.58-0.84) and the intake of vitamin C (RR = 0.59, 95% CI = 0.44-0.80), folate (RR = 0.47, 95% CI = 0.31-0.71), and fiber (RR = 0.95, 95% CI = 0.93-0.97). The quality of most included studies was high and the subgroup analysis according to the quality score showed significant results (p < 0.05). There was no publication bias for smoking and alcohol. Although the analysis suggested significant evidence of publication bias for BMI, sensitivity analysis showed that the changes in the recalculated RRs were not significant.

Conclusions: The large meta-analysis revealed that lifestyle modifications could reduce the risks of BE and, consequently, esophageal adenocarcinoma.

Keywords: Barrett's esophagus; esophageal adenocarcinoma; lifestyle; meta-analysis.

FIGURE 1

Forest plot of smoking (current vs. never) and Barrett's esophagus risk. The results demonstrated that smoking is associated with Barrett's esophagus risk

FIGURE 2

Forest plot of alcohol intake (highest vs. lowest category) and Barrett's esophagus risk. The results demonstrated that higher alcohol intake is associated with Barrett's esophagus risk

FIGURE 3

Forest plot of BMI (highest vs. lowest category) and Barrett's esophagus risk. The results demonstrated that high BMI is associated with Barrett's esophagus risk

FIGURE 4

Forest plots of physical activity (highest vs. lowest category) and sleep time (<6 vs. >6 h/night) and Barrett's esophagus risk. (A) Physical activity. (B) Sleep time. The results demonstrated that longer sleep time is associated with Barrett's esophagus risk and there is no association between physical activity and Barrett's esophagus risk

FIGURE 5

Forest plots of medications use (highest vs. lowest category) and Barrett's esophagus risk. (A) NSAIDs. (B) Aspirin. (C) PPIs. (D) Statins. The results demonstrated that aspirin intake may reduce the Barrett's esophagus risk and there is no association between NSAID, PPIs, Statins, and the risk of Barrett's esophagus

FIGURE 6

Forest plots of dietary intakes (highest vs. lowest category) and Barrett's esophagus risk. (A) Vitamin C. (B) Folate. (C) Fiber. (D): Total meat. (E) White meat. (F) Selenium. The results demonstrated that the intake of vitamin C, folate, and dietary fiber may reduce the Barrett's esophagus risk and there is no association between total meat and white meat and the risk of Barrett's esophagus