Original Article

19

The Role of Diet in the Management of Non-Ulcer Dyspepsia

Mohsen Akhondi-Meybodi1*, Mohammad Ali Aghaei1, Zahra Hashemian1

1.

Department of Gastroenterology,
Shahid Sadoghi Hospital, Yazd, Iran

ABSTRACT
BACKGROUND
Dyspepsia is a common symptom with an extensive differential diagnosis and
a heterogeneous pathophysiology. Many studies have reported that dyspeptic
symptoms are associated with ingestion of some foods. Current treatments for
functional dyspepsia have generally ignored the potential role of diet.

METHODS
This cross-sectional study was done at the Gastroenterology Department of
Shahid Sadoughi Hospital, Yazd, Iran from September 2008 to March 2009.
Based on the diagnostic criteria for functional dyspepsia symptoms presented
to outpatient gastroenterology clinics, adult patients were invited to participate
in this study. Upper GI endoscopy was performed in all the patients so as to
rule out any gross pathology. The patients were asked about a list of nutrients
including 114 foods which is commonly used in our area. Then, the effects of
specific foods were identified on the relief or aggravation of the symptoms
with four degrees: low, medium, high, and very high.

RESULTS
Of 384 patients, 152 were men and 231 were women with a mean SD
age of 39.1614 years (range: 13-80 years). The foods that caused the highest aggravation of symptoms were sausage and bolognas, pickles vinegar, soft
drinks, grain, tea, salt, pizza, watermelon, red pepper, and macaroni. However,
the most frequent foods that led to the alleviation of symptoms were apples,
rice, rock candy, bread, caraway seed, dates, honey, yogurt, quince, and walnut.

CONCLUSION
This study shows that some foods, especially spicy, pickled, and high-fat foods,
strongly induced dyspepsia and aggravated the symptoms in dyspeptic patients.
*

Corresponding Author:
Mohsen Akhondi-Meybodi, MD
Associate Professor of Medicine, Department of Gastroenterology, Shahid Sadoghi
Hospital, Safeia Ave., Sina Boulevard,
Yazd, Iran. Postal cod: 8915887857
Tel: + 98 353 8224000
Fax: +98 353 8224100
Email: akhondei@yahoo.com
Received: 25 Aug. 2014
Accepted: 18 Nov. 2014

KEYWORDS
Non-ulcer dyspepsia; Diet; Management
Please cite this paper as:
Akhondi-Meybodi M, Aghaei MA, Hashemian Z. The Role of Diet in the Management of
Non-Ulcer Dyspepsia. Middle East J Dig Dis 2015;7:19-24.

INTRODUCTION
Dyspepsia, defined as pain or discomfort centered in the upper ab-

Middle East Journal of Digestive Diseases/ Vol.7/ No.1/ January 2015

20

Role of Diet in NUD

domen, is a common symptom with an extensive

differential diagnosis and a heterogeneous pathophysiology. It occurs in approximately 25% (ranging from 13% to 40%) of the population annually.
However, most affected people do not seek medical
care. The most important causes are non-ulcer (functional) dyspepsia and peptic ulcer.1,2
There is evidence that people with functional dyspepsia have a reduced quality of life. Many patients
report their symptoms are related to food ingestion.3,4
Previous studies have made inconsistent observations with regard to eating patterns in functional dyspepsia. Furthermore, none of these studies has evaluated the relationship between symptoms and eating
patterns concurrently.5 Many studies have reported
that dyspeptic symptoms are associated with ingestion of some foods such as onions, peppers, fried and
fatty foods, alcohol, citrus fruits, and spicy foods.5
Treatment of functional dyspepsia can be frustrating for physicians and patients. This is because
few treatment options have proved effective so far.
While patients need continued reassurance and support from their physicians, treatment is generally
aimed at one of the presumed underlying etiologies
of functional dyspepsia.6 Besides, current treatments
for functional dyspepsia generally ignore the potential role of diet.
In some studies,7 the effect of fatty foods or carbohydrates has been evaluated on dyspepsia in general,
but, in our study, we have evaluated the effect of 114
foods individually on alleviating or aggravating nonulcer dyspepsia. The purpose of this study is to determine specific diets that aggravate the disease and
to show that avoidance of certain food items plays
an important role in managing functional dyspepsia.
MATERIALS AND METHODS
This cross-sectional study was conducted at
the Gastroenterology Department of Shahid Sadoughi Hospital, Yazd, Iran, from September 2008
to March 2009. Based on the diagnostic criteria of
functional dyspepsia symptoms set by Rome III
and reference to outpatient gastroenterology clinics, adult patients were invited to participate in the
Middle East Journal of Digestive Diseases/ Vol.7/ No.1/ January 2015

study.
The inclusion criteria for patients with functional
dyspepsia were symptoms of postprandial fullness,
bloating, epigastric pain, nausea, or vomiting of at
least a moderate severity for more than 3 months.
According to the Rome III criteria, upper GI endoscopy was performed for all the patients so as
to rule out any organic cause. Patients with irritable
bowel syndrome, previous abdominal surgery, and
coronary artery diseases were excluded. Only patients with normal endoscopy or mild gastritis were
included in the study, and those with ulcers, erosive
gastritis, or cancer were excluded.
A questionnaire was prepared to elicit data about
the patients demographic features, duration of
dyspepsia symptoms, precedence of performed endoscopy, as well as a list of 114 commonly used
foods and their aggravating or alleviating effect.
Also, the relieving or aggravating effects of specific
foods were identified in terms of four degrees: low,
medium, high, and very high.
Other than 114 choice-controlled items on the
questionnaire, there were three open-response
questions about the types of food that would trigger symptoms and three types of food that would
alleviate symptoms.
The sample size was calculated to be 384
(=%0.5, p=%0.5, d=%0.5). Also, data were analyzed using Chi-square test and SPSS software,
version 11.5.
RESULTS
Of 384 patients, 152 (39.6%) were men and 231
(60.4%) were women with a mean SD age of
39.16 14 years (range: 13-80 years). Of these, 296
(77.1%) lived in urban areas and 88 (22.9%) lived
in rural areas. With regard to education, 54 (14.1%)
patients were illiterate, 105 (27.3%) had primary
school degrees, 55 (14.3%) had a postgraduate diploma, and 46 (12%) had a higher education degree.
In this study, the patients with functional dyspepsia
were evaluated on 114 nutrients. Thirty nine patients
were ulcer-like, 189 were dysmotitlity-like, and the
others were in unspecified categories. The patients

Akhondi-Meybodi et al.
opinions were collected regarding 114 edibles and
their influence on dyspepsia and its symptoms.
According to figure 1 and table 1, the foods that
aggravated the symptom the most were sausage and
bolognas, pickles, foods and fruits, vinegar, soft
drinks, grains, tea, salty foods, pizza, watermelon,
red pepper, and macaroni (pasta).
According to figure 2 and table 2, the foods that
alleviated the symptoms the best were apples, rice,
rock candy, bread, caraway seeds, dates, honey, yogurt, quinces and walnuts. In this study, the items in
the fatty group, especially oily ones, exacerbated the
symptoms in 57% of the patients, but walnuts and
almonds alleviated them (table 1).
In the fruit group, watermelon was the most aggravating food and aggravated the symptoms in 74.5% of
the patients, followed by cucumber (59.7%), orange
(48.3%), and citrus juice (42%). However, some fruits
also had some relieving effects (figures 3 and 4).
In the beverage group, citrus juice had the most
adverse effect on non-ulcer dyspepsia. It could especially exacerbate the symptoms in 42% of the patients. Also, carbonated drinks induced symptoms in
86.7% of the patients. As shown in table 1, coffee
aggravated the symptoms in 60% of the patients, but
it was had no effect in 38% of the patients. The studied participants rarely drank alcohol because of the
strict religious beliefs in our country.
Sedative effects were reported by the patients.
Rice had a good effect in 15.7% of the patients but
had no effect on dyspepsia in 60% of the patients.
Other nutrients like rock candy, bread, caraway
seeds, dates, honey, yogurt, quinces, and walnuts
were the most common foods having alleviating effects in this study (table 3).
The patients were also asked three open questions
about aggravating and alleviating effects of specific
food items that may not have been mentioned in the
forum. Many of their answers were correlated with
the answers mentioned in the forum.
DISCUSSION
Questions regarding diets are common questions a physician encounters in managing patients
Middle East Journal of Digestive Diseases/ Vol.7/ No.1/ January 2015

21

Fig. 1: The 10 most common nutrients that aggravate symptoms

in dyspeptic patients

Fig. 2: The 10 most common nutrients that alleviate symptoms in

dyspeptic patients

Fig. 3: The 10 most common fruits that aggravate symptoms in

dyspeptic patients

with dyspepsia, and every physician recommends a

certain diet or avoidance of certain foods. Over the
past years, internists have recommended to avoid
raw fruits. Patients also say their symptoms are
related to ingestion of a variety of food items and
food groups, including fatty foods, carbohydrates,

22

Role of Diet in NUD

Table 1: Foods that aggravate and alleviate symptoms in dyspeptic patients
N (%) Reporting symptoms

Food item

N (%) Reporting symptoms

Aggravate

Alleviate

Aggravate

Alleviate

Carbonated drinks

325 (86.7)

6(1.6)

Apple

74(19.5)

65(17.2)

Legumes

266(65.1)

13(3.4)

Beans

330(86.4)

4(1)

Bell pepper

240(71.4)

2(0.5)

Bread

33(8.6)

56(14.6)

Sausage

315(89.2)

1(0.3)

Orange

153 (48.3)

2-0/6

Bolognas

313(89)

(0.1)

Peanut

82(24.5)

10(3)

Coffee

125(60.1)

3(1.4)

Eggs

93(24.7)

6(1.6)

Red meat

45(11.8)

28(7.4)

Cakes

109(30)

16(4.3)

Beef

104(32.8)

8 (2.7)

Yogurt

59(15.6)

44(11.6)

Pasta

263(70.9)

1(0.3)

Honey

44(11.9)

30(8.2)

Pineapple
Milk
Cheese
Cucumber
Sweets

Food item

Tea

13(4.6)

25(8.8)

Rock candy

55(14.7)

9.6

59(15.6}

13(3.4)

Onions

141(40.1)

6(1.7)

29(7.6)

15(3.9)

Mayonnaise

128(36.3)

2(0.6)

225 ( 59.7)

9(2.4)

Watermelon

281(74.5)

8(2.2)

16(4.3)

109(30)

Cabbage

187(54.4)

6(1.7)

Grains

162(44.1)

5(1.4)

309(80.9)

5(1.3)

Table 2: Alleviating and aggravating nutrients

Nutrients

Table 3: Food items that alleviate symptoms

Alleviation

Aggravation

Alleviate

Aggravate

Sausage and Bolognas

0.3

89.2

Apple

17.2

19.5

Pickles -Vinegar

0.5

88.5

Rice

15.7

23.8

Soft Drinks

1.6

86.7

Rock candy

14.7

9.6

86.4

Bread

14.6

8.6

1.3

80.9

Caraway seeds

13.6

4.2

78.3

Dates

12.3

19.4

Pizza

0.3

77.3

Honey

11.9

8.2

Watermelon

2.2

74.5

Yogurt

11.6

15.6

71.4

Quince

11.2

7.2

1.6

70.9

Walnut

11

10.5

Grains
Tea
Salty foods

Pepper
Macaroni

Fig. 4: The most common fruits that alleviate symptoms in dyspeptic patients

Middle East Journal of Digestive Diseases/ Vol.7/ No.1/ January 2015

Food item

certain fruits and vegetables, coffee, and carbonated drinks. In gastroenterology textbooks and articles, the role of diet in these patients is questioned,
and they recommend larger studies in this area. The
exact mechanism by which diet induces dyspepsia symptoms has not been clarified yet. However,
Feinle-Bisset et al.7 have suggested a few probable
factors including gastric acid hypersecretion, alterations in the secretion of gastrointestinal hormones,
gastric or small intestinal hypersensitivity, gastric
emptying, and intragastric meal distribution.
The present study evaluated the opinion of patients regarding aggravating and alleviating effects

Akhondi-Meybodi et al.
of specific foods on their symptoms. These opinions can help physicians manage the disease better.
In this study, the patients with functional dyspepsia
were evaluated on 114 nutrients. The data analysis
revealed a significant exacerbation of symptoms
particularly by fats and oils.
The foods that caused the highest aggravation
of the symptoms were sausage and bolognas, sour
foods, vinegar, soft drinks, grains, tea, salty foods,
pizza, watermelon, red pepper, and macaroni. This
finding agrees with the limited amount of research
ever done. The list of the food articles is almost
the same as the one studied in Brazil, where it was
found that foods strongly associated with dyspepsia were carbonated drink, pepper, fried foods, red
meat, sausage, coffee, and pasta.7
As compared to the research reported in the literature, our study was conducted on a larger group
(384 patients) and more diverse food items (114
items). These foods had either an effect or no effect or a bad effect. In case there were effects, they
were grouped into mild, moderate, and severe. The
sedative effects reported by the patients were not
significant except for walnuts and almonds. The intensifying effect of beverage was significant. This
finding is in agreement with Feinl et al.s study
which showed that people with functional dyspepsia have the ability to handle less volume of liquids
and beverages.7 In our study, however, beverages,
especially citrus juice and fuzzy beverage, induced
symptoms in many patients. Coffee worsened the
symptoms in many of our patients. In one study,
coffee was found to promote reflux but did not affect dyspepsia.8 Coffee may aggravate dyspepsia
symptoms in some cases9 and, if implicated, should
be avoided.8-9
Tea, one of the most commonly used beverages in the world, aggravated the symptoms in over
80% of the patients in this study, but Chen et al.
and Mahadva et al. showed that tea had an alleviating effect on dyspepsia. They reported that tea
users suffer from dyspepsia less frequently.10-11 In
contrast; our patients said that tea aggravated their
symptoms. One reason for this discrepancy is that
many patients with dyspepsia automatically learn
Middle East Journal of Digestive Diseases/ Vol.7/ No.1/ January 2015

23

to omit nutrients that do not suit them.

Pepper is one the items that mostly aggravated
the symptoms in many patients. Pepper and pickles
serve as a base for many nutrients. They are considered as one of the top 10 stimulating nutrients that
adversely affect dyspepsia.
Previous studies have demonstrated that red
pepper consumed in diets taken not chronically
stimulates the TRPV1 receptor, which increases
the sensitivity of the patient. Capsaicin can mediate a painful, burning sensation in the human gut
via the transient receptor potential vanilloid-1
(TRPV1). Chronic consumption of red pepper diets
via TRPV1 receptors can decrease dyspeptic symptoms.12
Another question that is very common is what
food is good for dyspepsia? Alleviating effects of
the above-mentioned foods are not as prominent as
their aggravating effects, but many patients agree
that rice, apple, caraway seeds, quince and rock
candy had alleviating effects on dyspepsia. Other
studies also show that rice is well tolerated and
should be recommended, as a source of carbohydrate for patients with dyspepsia.12-13
In this study, the fatty group of nutrients proved
to have significant aggravating effects on the symptoms in dyspeptic patients. The results of some
other studies agree with ours.7,14-18 They all point
out that the detriment may come through altered
secretion of cholecystokinin (CCK), peptide-YY
(PYY), and ghrelin and via the increased size of the
antrum. Because the presence of lipid in the duodenum causes gastric sensitivity, avoidance of highfat meals is advisable.18,19 This is of more relevance
to dysmotitlity like dyspepsia that causes bloating.
Alleviating effect of this group is not significant,
expect for walnuts and almonds.
This study had several strengths. First of all, the
number of patients included in the study was rather
great. Secondly, the food items that were investigated constituted a wide variety of commonly used
food items. Thirdly, the questions that the patients
were asked were inclusive in that they seem to have
covered all the important aspects of the research;
they bore upon such matters as whether each and

24

Role of Diet in NUD

every of those specific foods was effective or not,

the effect was favorable or adverse, and to what extent. The limitation of the study is that the patients
opinions are largely influenced and preconditioned
by their culture. Another limitation was that we
could not exclude the cases with GERD which may
have overlapped with functional dyspepsia.
This study shows that some foods can strongly
increase dyspepsia symptoms. One may especially
refer to spicy, pickles, and high-fat foods. In order
for patients to realize whether or not dietary changes
are effective in reducing dyspepsia symptoms, they
can eliminate specific foods and then resume using
those eliminated items. But because of induction
symptoms, many patients avoid of certain edibles
especially fruit. Many patients also omit some food
items because of fear or cultural preconditions. So,
further research is needed to establish the role of
diet therapy in functional dyspepsia and logical use
of diets.
CONFLICT OF INTEREST
The authors declare no conflict of interest related to
this work.
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