Hiatus hernia diet: what to eat and how to have dinner

What is a hiatus hernia and why does it cause heartburn?

When we eat, food goes down the oesophagus, in the chest, to the stomach, in the abdomen. Between the two lies the diaphragm, and the oesophagus passes through it by an opening called the hiatus.

In a hiatus hernia, part of the stomach rises through that opening. The junction between the oesophagus and the stomach closes less well, and what is in the stomach comes back up more easily. That is gastro-oesophageal reflux.

The oesophagus is not designed to withstand digestive acid. It becomes irritated, and heartburn, pain behind the sternum and a dry cough appear. That is why the size of the hernia matters less than it seems. What determines how you feel is how much reflux there is and how long the acid stays up there. See “Heartburn in pregnancy”.

Why do I have a hiatus hernia?

There is almost never a single cause. It is associated with excess weight, smoking, strong coughing or repeated vomiting over a long time, and weakening of the diaphragm with age. It is common and often causes no symptoms. Endoscopy finds many more hernias than cause discomfort.

None of this is your fault. From that list there are two factors you can act on: weight and smoking. The American reflux guideline recommends acting on both [1].

Is a hiatus hernia the same as reflux?

No. A hernia promotes reflux and the two often go together. But reflux also occurs without a hernia when pressure inside the abdomen increases, as with excess weight or in pregnancy.

The symptoms are the same (heartburn, dry cough, discomfort) and this advice works equally in both cases. If yours is reflux without a hernia, there is the diet for gastro-oesophageal reflux.

It is best not to leave it unchecked. If it goes on over time, the irritation can end in oesophagitis, and scarring can narrow the oesophagus. Your doctor monitors that. We work on the part that depends on what you eat and how you eat it.

Weight, habits and food

The reflux guideline of the American College of Gastroenterology ranks lifestyle measures by the strength of their evidence. Only one carries a strong recommendation: losing weight if you are overweight or obese, with moderate-quality evidence [1].

Less abdominal fat means less pressure pushing the stomach upward. You do not need to reach a specific number to start noticing it.

The other measures come with a conditional recommendation and low-quality evidence [1]. They include not eating dinner in the two or three hours before going to bed, stopping smoking, raising the head of the bed and avoiding the foods that trigger your symptoms.

Food is similar. A review of 21 studies on diet, supplements and probiotics concluded that the evidence is limited in scope, quality and applicability [2]. What makes sense is an individualised plan maintained over time, one that looks at what is removed as well as what is added [2].

Do not restrict your diet more than necessary.

How do I organise my meals if I have a hiatus hernia?

During the day, spread your food over four or five moderate meals. Include breakfast: having it matters more than the time. If it disagrees with you or does not fit your day, adjust it. Eat slowly and chew well. The less volume the stomach holds each time, the less pressure there is against the junction with the oesophagus.

Dinner is the meal that makes the most difference, because you lie down afterwards. Besides the time, what is on the plate counts.

• Small amounts. A large dinner keeps the stomach full and under pressure for hours, just when you are about to lie down.
• Acidic and fatty foods are better at lunchtime. At that hour you have many hours ahead before going to bed.
• Nothing right before getting into bed, not even liquids.

For sleeping, besides raising the head of the bed, it is better to lie on your left side. Lying on the right side there is more reflux, at night and after eating [1]. A review of studies that measured acid during sleep found less reflux on the left side than on the back or the right side [3].

For the same reason, for a nap, it is better to sit in an armchair than to lie down in bed right after eating.

Do I have to give up coffee, tomato and citrus?

Coffee, yes. With tomato and citrus fruit, it depends on your symptoms. The British reflux guideline advises avoiding the triggers that you associate with your symptoms, and it names smoking, alcohol, coffee, chocolate and fatty food [4]. Note the “you”. Avoiding trigger foods is also among the recommendations of the other major guideline, but without a universal list [1].

In the laboratory, coffee, caffeine, citrus and spicy food barely change the pressure of the lower oesophageal sphincter [1]. It is the valve that closes the passage between the oesophagus and the stomach. It is another matter whether they irritate by another route. Mint, alcohol, tobacco, chocolate and fat do lower that pressure [1].

With coffee there are figures. An analysis of 40 observational studies found reflux in 34.9% of coffee drinkers versus 30.7% of non-drinkers, an association that does not establish that coffee causes reflux [5]. Its authors see the difference as small and of uncertain clinical significance [5]. Even so, we recommend avoiding coffee.

With tomato, citrus fruit and other suspects, you try removing them for one or two weeks. Afterwards, they are reintroduced one at a time, and only those that cause you trouble stay out. Removing them all just in case impoverishes the diet and does not improve heartburn.

Tobacco, coffee, alcohol and fizzy drinks are avoided from the start. There is no safe amount of alcohol for health (WHO): the less, the better. Avoid it during pregnancy and breastfeeding, in childhood, if you are going to drive or if your medication does not allow it. For fizz and tea there is less data, although one study associated drinking a lot of coffee, tea or soft drinks with more reflux symptoms [1].

The coffee analysis does not apply to tea, because it deliberately left out studies that mixed coffee with other drinks [5]. So stop tea for one or two weeks and try it again separately. If it disagrees with you, do not drink it.

Does exercise help with reflux?

Everything suggests it does. An analysis of 33 studies found less reflux among physically active people, with the clearest benefit from 150 minutes of activity a week [6].

The detail to consider is the timing. Avoid moving right after eating, lower the intensity if it gives you heartburn and be careful with exercises that compress the abdomen.

What mistakes do we see in consultations?

• Eating dinner late and compensating by eating less. It is not so much the amount as the time.
• Using two pillows instead of raising the head of the bed. They bend the neck and do not raise the chest.
• Living on boiled rice and chicken breast for months. The diet becomes poor, the heartburn continues and there is no longer any way to know what disagrees with you.
• Stopping the antacid as soon as you feel better, without telling anyone. Your doctor manages that medication. In addition, some common drugs may be behind the symptoms, such as calcium channel blockers, nitrates, bisphosphonates, corticosteroids and anti-inflammatories. That is why it is worth reviewing your medication with your doctor before going round in circles with the diet [4].
• Confusing gastritis with reflux. If what burns is the stomach and not the chest, see the gastritis diet. They look alike, but they are not the same thing.