Is your heart burn (or acid reflux or GERD) getting you down? It really can make every meal miserable. Typically, at least in Western Medicine, this problem is solved with antacids, acid blockers and PPI’s.
In my 3 part series I’m going to teach you about current treatments for heartburn, why you might want to think about some natural alternatives, and most importantly help you get RELIEF.
Part 1: Do I need medication for my heartburn or acid reflux?
Have heartburn or acid reflux? No problem. Just take this medication, and you’ll have zero heartburn! Sounds great right? Until it doesn’t work or you get side effects from the meds.
Contrary to what mainstream media might convey (have you seen the commercial with the fire fighter?), stomach acid is not a bad thing. In fact, stomach acid is a vital part of the digestive process and plays a key role in combatting bad bacteria, and is essential for nutrient absorption.
To understand this, let’s get technical and learn a bit about the digestive process:
For optimal digestion, your stomach has to have a certain level of acid, also known as the pH level. Your food won’t be broken down unless acidity is around a pH of 2. But if you don’t have the right acid level, you get symptoms of undigested food like burping, bloating, gas, bathroom issues, or even leaky gut! For those of you who geek out with the science, read on:
- After you eat your lunch and it enters your stomach, the pH of your stomach begins to rise.
- This increase in pH stimulates the cells in the stomach to produce gastrin. Gastrin is a hormone which triggers the production of protein‐digesting enzymes, or pepsinogens, mucus, and hydrochloric acid.
- The combination of the neurotransmitter acetylcholine and gastrin trigger the production of histamine in the gut.
- The combination of these three elements- acetylcholine, gastrin and histamine, elicit the parietal cells to produce hydrochloric acid via a proton pump system.
- The stomach shifts to the increasingly acidic environment needed to break down protein and carbohydrates contained in the food ingested.
- The food is now ready to continue its journey to the upper part of the small intestine where the acidified contents trigger the pancreas to release pancreatic juice, the liver to secrete more bile and the gallbladder to release stored bile, all of which are crucial for digestion and absorption.
Are you still with me? Now, let’s take a step back. What happens when we take drugs to reduce stomach acid?
- When you take Antacids‐ These medications use an active ingredient to neutralize the stomach acid. Examples might include Tums®, Rolaids®, Maalox® and Alka‐Seltzer®.
- When you take Acid Blockers‐ These medications block the action of histamine (H2 blockers) and their interaction with the parietal cells to reduce the production of stomach acid. Examples include Tagamet®, Zantac® and Pepsid®.
- When you take Proton Pump Inhibitors (PPI’s)‐ These medications block the proton pump within the parietal cells, so that stomach acid is not produced and therefore not transported into the stomach. Examples would include Nexium®, Prevacid®, and Prilosec®.
The most popular of the drugs above are the PPI’s which were noted in the highest‐selling class of drugs for 2012, with sales of $9.5 billion (1). They’re popular because they’re effective. PPIs have the ability to inhibit hydrochloric acid secretion for up to 48‐72 hours and create overall lower hydrochloric acid output over a 24 hour period (2). While this may be good for significant gastrointestinal issues, the lowered stomach acidity can present risks.
So, the big question is, IS IT WORTH THE RISK? Stay tuned next week for Part 2 of this series.
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Part 2:
The Dangers of taking Prescription Medications for Acid Reflux & Heartburn
I hate to tell you this but all of these Rxs that you’re paying for and taking are a band-aid solution. The problem is that they don’t FIX your actual problem. The real issue is your that you aren’t digesting food well. Believe me, I was on them for years!
Even though you get immediate relief by taking a Histamine blocker or Proton Pump Inhibitor (PPIs), these medicines have side effects that harm you long term. Let me explain.
Bacteria Issues
Stomach acid actually acts as a protective mechanism against pathogenic bacteria. Normal stomach acid has pH of 1.5 to 2.5, which declines with age (4). Stomach acid with a pH of less than 3.0 has been found to kill bacteria within 15 minutes (3). However, use of acid‐blocking medications will increase the pH to 3.5 and beyond, thus reducing the effectiveness of this protective mechanism.
In a mice study, E. coli and other bacteria such as Y. enterocolitica, S. enterica serovar Typhimurium, C. rodentium and C. perfringen, were found to survive better in a less acidic environment (6).
In addition, use of PPIs is also associated with a higher instance of C. difficile infection and a higher instance of small intestine bacterial overgrowth (SIBO)(5)(7).
Therefore, when the pH of the stomach is off, there is a higher likelihood that bacteria, or microorganisms which are less helpful, will move through the stomach and into our intestines, possibly replacing the helpful or “good” bacteria.This imbalance in the microbiome could also lead to further impairment of nutrient absorption.
Impaired Nutrient Absorption
Healthy digestion requires stomach acid. However, when stomach acid is under-produced, the cascade of required steps is also impacted. Hydrochloric acid is needed to activate pepsin, a key enzyme for protein digestion. If hydrochloric acid is low, then the activation of pepsin is also impacted. As a result, proteins, which rely on pepsin to break them down, won’t be broken down well.
- VITAMIN B12‐ Vitamin B12 is needed for nerve and brain function and is reliant on pepsin to break it from the animal protein ingested. If pepsin isn’t activated due to a low production of stomach acid, a B12 deficiency could result.
In a review of several case reports and cross‐sectional observational trials there was a correlation between decreased serum B12 levels and PPI use (8)(12). There was also a small study in which a direct correlation between B12 absorption and the PPI dose administered. This study found that B12 absorption decreased to 0.9% from 3.2% (with 20 mg of a PPI) and to 0.4% from 3.4% (with a 40 mg PPI dose)(9).
- VITAMIN C‐ A 2009 review found that intake of PPIs also lowers the concentration of vitamin C‐ specifically in its active form of ascorbic acid (10, 11). This finding is significant because humans must obtain this vital antioxidant from their diets. If taking a PPI lowers the concentration, then it’s possible that a person could not be getting enough bioavailable vitamin C.
- FOLATE‐ Folate (folic acid) plays a key role in regulating homocysteine. Low levels of folate correlate with higher levels of homocysteine, which when elevated, can negatively impact cardiovascular health. Unfortunately, suppressing stomach acid can adversely affect the absorption of folate. In a study of Mylanta II, Tagamet and Zantac, folate absorption was reduced with all three medications, with an overall reduction of 16% (15).
- IRON‐ There are few studies which review the impact of PPI use and iron absorption. However, it should be noted that non‐heme iron absorption increases with improved acidity (11).
- CALCIUM‐ Calcium is needed for strong teeth and bones. It is proposed that a higher acidic environment is needed to make the calcium available for absorption (8). It is also believed that the intake of PPIs can also negatively impact the resorption of calcium from bone since this process is also dependent on proton pumps which are inhibited with the intake of PPIs (8). Additional new research is continuing to establish the link between PPIs, osteoporosis and other lifestyle factors (13, 14). While the mechanism that the PPIs have on calcium is not entirely understood, new studies have further strengthened existing evidence linking the use of PPIs to osteoporosis and osteoporotic fractures (13).
- MAGNESIUM‐ PPI use has been linked directly to magnesium deficiency and the FDA issued associated warnings that PPIs may cause a magnesium deficiency, if taken for more than a year (8).
- ZINC‐ Zinc is a cofactor in many of the body’s necessary enzymatic reactions. In studies utilizing Tagamet and Pepcid to reduce stomach acid, the absorption of zinc decreased by as much as 50% (15).
Dementia and other issues
The use of proton pump inhibitors has been linked to other issues such as chronic kidney disease and end‐stage renal disease (16). Also, in a review of clinical data reports, PPIs were found to be associated with an increase in heart attacks and cardiovascular mortality (17, 18).
A 2014 study of 3,327 persons 75 years or older found 431 of them with dementia and 260 patients with Alzheimer’s disease. Of those reviewed, those patients receiving PPI medications has significantly higher risks of dementia and Alzheimer’s disease (19). In a 2016 published German prospective cohort study during 2004‐2011 of 73,679 individuals aged 75 years or older found that those receiving regular PPI medication had a significantly increased risk of dementia (21). These correlations are further supported by a recent 2017 systematic review of 11 studies of PPI use and either dementia or acute cognitive impairment. The review found a positive association within 3 of the 4 dementia studies and in a majority of the cognitive impairment studies (20). However this review, as well as the 2016 study, both note that further studies to establish an actual cause and effect relationship are needed (20, 21).
I don’t mean to scare you with all this information. I want you to make informed decisions about what type of medicines you take every day. In Part 3, we’ll discuss how we spell R.E.L.I.E.F (and it’s not Rolaids!)
Part 3 How do I get relief?
As you are reading this, you may be thinking, “But wait, I still have heartburn!”
The reality is that even a small amount of acid, refluxing into the esophagus can cause damage over time. But is the root of the problem too much acid or, too little stomach acid.
Dr. Wright, the author of Why Stomach Acid is Good for You, has found that in over thirty years of practice a majority of his heartburn patients are shown to have too little stomach acid, despite having the symptoms of reflux and heartburn. This finding makes sense because as we age, there is a decline in stomach acid (15).
If you don’t have too much acid production (such as seen in the disease Zollinger‐Ellison Syndrome), what are some other reasons why someone may experience heartburn?
- Reduced Lower Esophageal Sphincter (LES) Pressure‐ Normally in a contracted state, the G-E Junction (Gastro-esophageal) protects the esophagus from the contents of the stomach refluxing up into it by constricting, thus avoiding the burning sensation associated with heartburn. However the LES (or G-E junction) can become relaxed in some cases such as:
- Hormonal changes related to pregnancy, progesterone‐containing oral contraceptives, or during the later stage of a normal menstrual cycle (23)
- Hiatal Hernia
- Scleroderma and other diseases
- Certain foods or herbs
- In response to muscle relaxants and NSAIDS
- Increased Intra-abdominal Pressure due to pregnancy, tight clothing, obesity, or chronic respiratory disorders
- Cigarette smoking
- Decreased Gastric Emptying or decreased Motility
- Stress‐ Stress is associated with GERD, and its severity correlates to the degree of stress (22)
What can I do?
Depending on the severity of the issue, several steps could be taken in terms of food, lifestyle, and supplementation.
Food
The following foods should be avoided as they have been associated with a decreased tone of the Lower Esophageal Sphincter (23,24, 25, 26):
- Alcohol
- Chocolate
- Coffee (both caffeinated and decaffeinated, although caffeine itself has been found to be more problematic)
- Tea, particularly black
- Peppermint, spearmint or other mint family plants
- Cows milk
- High‐fat foods
- Orange juice
- Tomato juice
- Onions
- Spicy foods
- Fried foods
There are general categories of foods which can also increase symptoms of reflux:
- Milk and milk products
- Eggs
- Cereals/grains
- Meat and protein sources
- Some vegetables
- Some fruits
Lifestyle
Much of the lifestyle recommendations focus on enhancing the digestive process so that the body is adequately prepared to receive the food and digest it. This begins with preparing yourself for the meal so that it can be eaten without stress, which can in and of itself improve gastric activity, while preparing to receive the food (26). This process begins with taking the time to prepare your eating space and chewing food properly. Chewing food adequately both breaks down the food into more readily digestible pieces, while the saliva produced contains elements which can help protect the esophageal mucosal barrier (25).
- Eat slower, beginning with increasing the number of times food is chewed
- Avoid large meals
- Avoid eating 3‐4 hours before lying down to allow time for the stomach to empty
- Avoid vigorous activity after eating
Additional lifestyle steps which can be taken include:
- Elevate the head of the bed for sleeping 4‐6 inches
- Avoid tight fitting clothing
- Lose weight if overweight
- Avoid stress
- Cease Smoking
Supplementation
There are a variety of herbal remedies which can assist with GERD (24):
- Relieves mucous membrane irritation: licorice, slippery elm and marshmallow**
- Anti‐inflammatory‐ Chamomile**
- Anti‐anxiety‐ valerian and skullcap**
There are also steps which can be taken to increase stomach acid including (15, 25);
-
Intake of bitters, such as Swedish Bitters before a meal to stimulate the digestive system**
-
Intake of 1‐2 tablespoons of lemon juice or apple cider vinegar in 4 ounces of water 10 minutes or less before a meal
-
Betaine HCl or Glutamic Acid HCl (with or without pepsin)**
If currently on a PPI it is suggested that you work with your physician or medical professional to attempt to taper off of it because rebound hyperacidity can result (24).
Before beginning any supplementation regimen, it is advised that you do so under the direction of your integrative physician or healthcare professional to determine appropriate supplementation, dosing, and possible interactions.
References:
(1)Consumer Reports. (2013). Best Buy Drugs: Using proton pump inhibitors to treat heartburn and stomach acid reflux (pp. 1–18). Consumer Reports. Retrieved from https://consumerhealthchoices.org/wp‐content/uploads/2012/01/BBD‐PPIs‐Full.pdf
(2)Ksiądzyna, D., Szeląg, A., & Paradowski, L. (2015). Overuse of proton pump inhibitors. Pol Arch Med Wewn, 125, 289–98.
(3)Giannella, R. A., Broitman, S. A., & Zamcheck, N. (1972). Gastric acid barrier to ingested microorganisms in man: studies in vivo and in vitro. Gut, 13(4), 251–256.
(4)Lipski, E. (2012). Digestive wellness: strengthen the immune system and prevent disease through healthy digestion (4th ed.). New York, NY: McGraw‐Hill
(5)Reducing Adverse Effects of Proton Pump Inhibitors ‐ American Family Physician. (n.d.). Retrieved October 5, 2016, from https://www.aafp.org/afp/2012/0701/p66.html
(6)Tennant, S. M., Hartland, E. L., Phumoonna, T., Lyras, D., Rood, J. I., Robins‐Browne, R. M., & Driel, I. R. van. (2008). Influence of Gastric Acid on Susceptibility to Infection with Ingested Bacterial Pathogens. Infection and Immunity, 76(2), 639–645. https://doi.org/10.1128/IAI.01138‐07
(7)Lombardo, L., Foti, M., Ruggia, O., & Chiecchio, A. (2010). Increased Incidence of Small Intestinal Bacterial Overgrowth During Proton Pump Inhibitor Therapy. Clinical Gastroenterology and Hepatology, 8(6), 504–508. https://doi.org/10.1016/j.cgh.2009.12.022
(8)Heidelbaugh, J. J. (2013). Proton pump inhibitors and risk of vitamin and mineral deficiency: evidence and clinical implications. Therapeutic Advances in Drug Safety, 4(3), 125. https://doi.org/10.1177/2042098613482484
(9)Marcuard, S. P., Albernaz, L., & Khazanie, P. G. (1994). Omeprazole Therapy Causes Malabsorption of Cyanocobalamin (Vitamin B12). Annals of Internal Medicine, 120(3), 211– 215. https://doi.org/10.7326/0003‐4819‐120‐3‐199402010‐00006
(10)McColl, K. E. L. (n.d.). Effect of Proton Pump Inhibitors on Vitamins and Iron. Am J Gastroenterol, 104(S2), S5–S9.
(11)Henry, E. B., Carswell, A., Wirz, A., Fyffe, V., & Mccoll, K. E. L. (2005). Proton pump inhibitors reduce the bioavailability of dietary vitamin C. Alimentary Pharmacology and Therapeutics, 22(6), 539–545. https://doi.org/10.1111/j.1365‐2036.2005.02568.x
(12)Ito, T., & Jensen, R. T. (2010). Association of Long‐Term Proton Pump Inhibitor Therapy with Bone Fractures and Effects on Absorption of Calcium, Vitamin B12, Iron, and Magnesium. Current Gastroenterology Reports, 12(6), 448–457. https://doi.org/10.1007/s11894‐010‐0141‐ 0
(13)Andersen, B. N., Johansen, P. B., & Abrahamsen, B. (2016). Proton pump inhibitors and osteoporosis: Current Opinion in Rheumatology, 28(4), 420–425. https://doi.org/10.1097/BOR.0000000000000291
(14)Khalili, H., Huang, E. S., Jacobson, B. C., Camargo, C. A., Feskanich, D., & Chan, A. T. (2012). Use of proton pump inhibitors and risk of hip fracture in relation to dietary and lifestyle factors: a prospective cohort study. BMJ, 344. https://doi.org/10.1136/bmj.e372
(15)Wright, J. V., & Lenard, L. (2001). Why stomach acid is good for you: natural relief from heartburn, indigestion, reflux, and GERD. New York: M. Evans.
(16)Proton Pump Inhibitors and Risk of Incident CKD and Progression to ESRD. (n.d.). Retrieved October 10, 2016, from https://jasn.asnjournals.org/content/early/2016/04/13/ASN.2015121377
(17)Juurlink, D. N., Dormuth, C. R., Huang, A., Hellings, C., Paterson, J. M., Raymond, C., … Mamdani, M. M. (2013). Proton Pump Inhibitors and the Risk of Adverse Cardiac Events. PLoS ONE, 8(12), e84890. https://doi.org/10.1371/journal.pone.0084890
(18)Shah, N. H., LePendu, P., Bauer‐Mehren, A., Ghebremariam, Y. T., Iyer, S. V., Marcus, J., … Leeper, N. J. (2015). Proton pump inhibitor usage and the risk of myocardial infarction in the general population. PLoS One, 10(6), e0124653.
(19)Haenisch, B., Holt, K. von, Wiese, B., Prokein, J., Lange, C., Ernst, A., … Scherer, M. (2015). Risk of dementia in elderly patients with the use of proton pump inhibitors. European Archives of Psychiatry and Clinical Neuroscience, 265(5), 419–428. https://doi.org/10.1007/s00406‐014‐ 0554‐0
(20)Batchelor, R., Gilmartin, J. F.‐M., Kemp, W., Hopper, I., & Liew, D. (2017). Dementia, cognitive impairment and proton pump inhibitor therapy – a systematic review. Journal of Gastroenterology and Hepatology. https://doi.org/10.1111/jgh.13750
(21)Gomm, W., Holt, K. von, Thomé, F., Broich, K., Maier, W., Fink, A., … Haenisch, B. (2016). Association of Proton Pump Inhibitors With Risk of Dementia: A Pharmacoepidemiological Claims Data Analysis. JAMA Neurology, 73(4), 410–416. https://doi.org/10.1001/jamaneurol.2015.4791
(22)Song, E. M., Jung, H.‐K., & Jung, J. M. (2013). The Association Between Reflux Esophagitis and Psychosocial Stress. Digestive Diseases and Sciences, 58(2), 471–477. https://doi.org/10.1007/s10620‐012‐2377‐z
(23)Mahan, L. K., Escott‐Stump, S., Raymond, J. L., &. Krause’s food & the nutrition care process. St. Louis, MO: Elsevier/Saunders.
(24)Rakel, D. (2012). Integrative medicine (3rd ed.). Philadelphia: Elsevier.
(25)Gaby, A. (2011). Nutritional medicine. Concord, N.H: Fritz Perlberg Publishing.
(26)Nahikian‐Nelms, M. (2016). Nutrition therapy and pathophysiology. Belmont, CA: Wadsworth, Cengage Learning.
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