EXAMINING THE PREVALENCE, PATIENT PROFILES, AND EXPERIENCES OF MODIFIABLE LIFESTYLE BEHAVIOURS IN INDIVIDUALS WITH BARRETT’S OESOPHAGUS: A SCOPING REVIEW PROTOCOL

Background

Barrett’s oesophagus (BO) is a premalignant condition that develops due to chronic exposure to gastro-oesophageal reflux disease (GORD), in which the normal squamous epithelium of the distal oesophagus is replaced by specialised intestinal metaplasia (Coleman et al., 2018; Souza & Spechler, 2022). This metaplastic change represents a key stage in the reflux–dysplasia–adenocarcinoma sequence, conferring an increased risk of progression to oesophageal adenocarcinoma (OAC), which carries one of the lowest five-year survival rates globally (Coleman et al., 2018; Mittal et al., 2021; Walker & Gossage, 2023). OAC is typically diagnosed at an advanced stage when curative treatment options are limited and survival rates are poor, underscoring the importance of identifying and managing BO effectively to interrupt this progression pathway (Mittal et al., 2021). Although the annual risk of progression from non-dysplastic BO to OAC is relatively low, estimated at approximately 0.1–0.5% per year (Sijben et al., 2023; Thrift, 2021), the condition remains clinically significant due to its increasing prevalence and the poor prognosis once diagnosed (Desai et al., 2019). Notably, a systematic review indicates that only 11.8% of patients diagnosed with OAC have a documented prior diagnosis of BO, while underlying BO is detected at the time of cancer diagnosis in 56.6% of cases and in over 90% of early-stage disease (Tan et al., 2020), indicating that most BO remains undiagnosed until cancer develops.

Globally, oesophageal cancer represents a major public health concern, with projections estimating nearly one million new cases and 0.9 million deaths by 2040 (Morgan et al., 2022; Sung et al., 2021). The incidence of OAC continues to rise steadily in Western countries, in parallel with rising obesity rates (Arnold et al., 2017; Elliott & Reynolds, 2021; Sung et al., 2021; Thrift, 2021). Obesity, particularly central adiposity, is a key modifiable risk factor for both GORD and BO (Singh et al., 2013; Xie et al., 2024). These epidemiological trends highlight the pressing need for strategies that address modifiable lifestyle factors to reduce risk, improve symptom management, and enhance quality of life in this population, particularly among those already living with BO (Kahrilas et al., 2025; Mao et al., 2022). Consequently, increasing attention has turned toward behavioural and lifestyle approaches that may help mitigate disease risk, alleviate symptoms, and promote overall health (Garg, 2025; Mao et al., 2022).

In clinical practice, the management of BO focuses on preventing disease progression, alleviating reflux symptoms, and improving quality of life (Fitzgerald et al., 2014; National Institute for Health and Care Excellence, 2023). Reflux symptoms such as heartburn and regurgitation can be distressing (Wickramasinghe et al., 2023), significantly affecting daily functioning and quality of life (van der Ende-van Loon et al., 2022), and, if inadequately controlled, may contribute to mucosal inflammation and neoplastic change (Argüero & Sifrim, 2024). Clinical guidelines recommend a multimodal approach combining pharmacological therapy, endoscopic surveillance, and lifestyle modification (Fitzgerald et al., 2014; National Institute for Health and Care Excellence, 2023). While medication is effective in controlling acid exposure, for many individuals, symptoms are not fully resolved by pharmacological treatment alone (Guadagnoli et al., 2023; Zou et al., 2024). As a result, lifestyle modification has become a recognised key component of conservative management, providing a practical means of reducing symptom severity, improving well-being, and potentially mitigating disease progression through engagement with modifiable lifestyle behaviours (Hungin et al., 2022; Kahrilas et al., 2025).

Modifiable lifestyle behaviours refer to changeable daily habits, including diet, physical activity, smoking, alcohol use, sleep, medication adherence, and weight management, which have the potential to influence both symptom severity and disease-related outcomes in BO (Asreah & Abdullhameed, 2021; Elfanagely et al., 2021; Filiberti et al., 2021; Thiruvengadam et al., 2020; Wan et al., 2024; Zhao et al., 2016). Weight reduction has been shown to improve reflux control (Mukhtar et al., 2022), while smoking cessation and moderation of alcohol intake can reduce mucosal irritation and inflammation (Bishehsari et al., 2017; Muto et al., 2022; Vaishnav et al., 2025). Alongside these changes, adopting regular physical activity and dietary modification can enhance metabolic health, alleviate reflux symptoms, and improve overall well-being (Al-Beltagi et al., 2025; Herdiana, 2023; Severo et al., 2025; Valentini et al., 2023).

Despite the recognised importance of lifestyle modification, engagement among individuals with BO appears inconsistent (Realdon et al., 2016; Zhang et al., 2021). Patients may receive brief, limited, or infrequent lifestyle advice during routine consultations, which often lack sustained support to implement and maintain meaningful behavioural change (Britton et al., 2019; Keyworth et al., 2021; Zhang et al., 2021). There is also uncertainty among healthcare professionals regarding which lifestyle factors are most relevant to disease management, partly due to the limited high-quality evidence supporting non-pharmacological strategies (Kahrilas et al., 2024; Keyworth et al., 2021).

The existing evidence on lifestyle behaviours in BO is fragmented and heavily weighted toward epidemiological research examining behaviours as risk factors for disease onset or progression, rather than as modifiable behaviours within diagnosed populations (Singh et al., 2014; Xu et al., 2015; Zhao et al., 2016). While such studies have clarified the contribution of modifiable behaviours to the development of BO, they provide limited insight into how individuals manage their lifestyle after diagnosis (Realdon et al., 2016; Zhao et al., 2021). Consequently, there is little understanding of how people with BO engage with modifiable behaviours as part of ongoing disease management (Zhang et al., 2021).

To date, no review has comprehensively synthesised evidence on modifiable lifestyle behaviours among individuals with BO. A rapid scoping of Cochrane, PROSPERO and the Open Science Framework in April 2025 did not identify any completed or ongoing reviews with this focus. Given the conceptual breadth, heterogeneity of study designs, and early stage of the evidence base, a scoping review is the most appropriate approach to map what is known, clarify how it has been studied, and identify gaps to inform future research and patient-centred practice.

Without a clear understanding of how people with BO engage with lifestyle change, clinical guidance will continue to rely on generalised rather than evidence-based, tailored recommendations. Integrating these strands of evidence is essential to capture both behavioural patterns and the social, emotional, and practical influences on engagement. This review will systematically map the breadth, range, and nature of available evidence, highlight key themes, and identify areas that warrant further investigation. The findings will contribute to the evidence base informing patient-centred strategies for supporting lifestyle modification and improving symptom management and outcomes in BO.

Aim and research question

The aim of this scoping review is to map and synthesise existing evidence on modifiable lifestyle behaviours among individuals with BO, focusing on their prevalence, lived experience, and variation across patient subgroups. A scoping review was chosen as the most appropriate design for this study, as it allows for a comprehensive overview of the breadth and characteristics of existing research in this area. Scoping reviews are used to map the breadth and nature of existing evidence and identify gaps in the literature. This approach was selected as appropriate to meet the aims and objectives of the current review. The objectives of this review are:

The findings will help to identify evidence gaps and inform future research relating to lifestyle behaviours and disease management in this population. The Population–Concept–Context framework (PCC; (Peters et al., 2020), which guides the construction of clear and focused review questions and inclusion criteria, informed the development of the following review question:

What is known from existing evidence about the prevalence, lived experience, and variation by patient characteristics of modifiable lifestyle behaviours among individuals with Barrett’s oesophagus?

Inclusion criteria

Participants

Adults (≥18 years) with a confirmed diagnosis of Barrett’s oesophagus. Studies that include mixed samples (e.g., individuals with Barrett’s oesophagus and oesophageal cancer) will only be included if findings for the Barrett’s oesophagus subgroup are reported separately. Studies that focus exclusively on patients with oesophageal adenocarcinoma or other gastrointestinal conditions without distinct reporting for Barrett’s oesophagus will be excluded.

Concept

This scoping review will examine the prevalence, variation by patient characteristics, and lived experience of modifiable lifestyle behaviours among individuals with Barrett’s oesophagus. Modifiable lifestyle behaviours include, but are not limited to, diet, physical activity, smoking, alcohol consumption, weight management, sleep, and medication adherence, as these factors are recognised to influence reflux symptoms, disease management, and overall well-being (Asreah & Abdullhameed, 2021; Elfanagely et al., 2021; Filiberti et al., 2021; Thiruvengadam et al., 2020; Wan et al., 2024; Zhao et al., 2016). Studies will be included if they report any of the following:

Studies that examine lifestyle behaviours solely as risk factors for developing Barrett’s oesophagus or progressing to oesophageal cancer will be excluded unless they also report data relevant to prevalence, variation, or lived experience within the Barrett’s oesophagus population.

Context

Studies conducted in either clinical or community contexts will be included. No geographical restrictions will be applied; however, only studies published in English will be included. To ensure the evidence reflects current clinical practice and lifestyle recommendations, only studies published within the last ten years (2015–2025) will be included (Fitzgerald et al., 2014). This timeframe reflects major updates to diagnostic and management guidelines for Barrett’s oesophagus, ensuring inclusion of studies aligned with contemporary practice (Fitzgerald et al., 2014).

Types of sources

Peer-reviewed primary research using quantitative, qualitative, or mixed-methods designs will be included, encompassing randomised controlled trials, cohort studies, cross-sectional studies, case-control studies, and qualitative studies. Reviews, meta-analyses, pooled analyses, commentaries, conference abstracts, and unpublished theses will be excluded; however, reference lists of relevant reviews will be screened to identify additional eligible primary studies. In cases where multiple studies arise from the same dataset, overlapping data will be extracted only once from the primary publication to prevent data duplication. Additional non-overlapping, unique lifestyle data will be extracted from companion publications where reported.

Search strategy

An exploratory search will be initially conducted in PubMed to identify relevant studies and develop a list of preliminary keywords and index terms. The full search strategy will then be developed in consultation with an experienced university librarian and piloted on the EMBASE database. Title and abstract screening of the pilot results will be used to refine the search terms and structure. The final search will be conducted in EMBASE (Ovid), MEDLINE (Ovid), CINAHL (EBSCOhost), and Web of Science.

Reference lists of included studies and relevant reviews will be screened to identify any additional sources, and both forward and backward citation searching will be undertaken to identify any studies that may have been missed through the electronic searches. Grey literature will be searched using Google Scholar, with the first 100 results ordered by relevance screened.

Study selection

Search results from all databases will be collated and imported into Covidence for screening, and duplicates will be removed automatically. Titles and abstracts will then be screened independently by two reviewers (DC and SK) to assess eligibility. Studies that do not meet the inclusion criteria will be excluded at this stage. The full texts of potentially eligible studies will subsequently be retrieved and screened in duplicate by both reviewers. Any disagreements between reviewers at any stage will be resolved through discussion, and where necessary, a third reviewer (EG) will be consulted to reach a consensus. Reasons for exclusion at the full-text stage will be recorded and presented in a flow diagram.

Data extraction

Data will be extracted from included studies using a tool developed by the research team and informed by the Joanna Briggs Institute (JBI) guidance for scoping reviews. The tool will align with the review objectives, focusing on the prevalence, patient characteristics, and lived experience of modifiable lifestyle behaviours among individuals with Barrett’s oesophagus.

The following data will be extracted: study details (author, year, country, design); aims and methods; participant characteristics (sample size, demographics, clinical factors); lifestyle behaviours addressed (e.g. diet, physical activity, smoking, alcohol, sleep, medication adherence, weight management); and key findings relating to:

Data extraction will be conducted by the lead reviewer (DC) using the data extraction tool developed by the research team and piloted to ensure clarity and consistency, any uncertainties will be discussed with a third reviewer (EG). The tool may be refined as necessary, and any modifications will be documented and reported in the final scoping review.

As this review aims to map and synthesise existing evidence rather than assess study quality, a formal critical appraisal will not be conducted. Extracted data will be organised under three overarching domains: prevalence, variation, and lived experience of lifestyle behaviours.

Data synthesis and presentation

Results will be reported in line with the PRISMA-ScR guidelines (Tricco et al., 2018). Extracted data will be summarised in tables and accompanied by a narrative synthesis guided by the JBI framework (Peters et al., 2020). Findings will be organised thematically around three core domains: (1) prevalence of lifestyle behaviours, (2) lived experience of engaging with these behaviours, and (3) variation in engagement across patient subgroups.

This approach will allow for a comprehensive understanding of how lifestyle behaviours are adopted, perceived, and maintained by individuals with Barrett’s oesophagus, highlighting barriers, facilitators, and contextual factors that influence behaviour change. It will also identify subgroups who may require additional support to initiate or sustain lifestyle changes.

Quantitative data will be summarised descriptively and narratively, where applicable, and qualitative findings will be synthesised thematically. Where appropriate, results will be grouped by behaviour type, subgroup, and outcome to identify patterns or discrepancies. Meta-analysis will not be undertaken due to anticipated heterogeneity in study design and outcome measures.