Tuesday, February 26, 2013

This post might give you Heartburn.

Where I work we have a lot of patients taking medicines for Gastroesophageal Reflux Disease (GERD), more coloquially known as "heartburn."  The usual prescription for said problem is a medicine called a Proton Pump Inhibitor (PPI), usually sold under the names which include esomeprazole (Nexium), lansoprazole (Prevacid), and omeprazole (Prilosec).   These medications are meant to be given in the short term only (like maybe 4-8 weeks), but a lot of our patients have been on a PPI of some type or another for years.  Unfortunately, these medications can have long term side effects as listed here, and since I work with a mostly elderly population healthy bones and healthy B12 levels are a major concern.  Also unfortunately (and understandably) there are plenty of people who don't want to stop taking the medication because they don't want to resume the pain and nausea, etc of their pre-medication days.  There are, however, some people who wish to attempt to treat this by lifestyle changes, which is where my part, and the fun part, begins, as people will usually find more than one way of treating it, not all of it evidence based.

Let's start with what we know, and that is that GERD is caused by intra-adominal pressure--bloating of the stomach that puts pressure on the lower esophageal sphincter (LES) and/or lifestyle habits that weaken the LES.  Having extra abdominal fat (aka being obese) can cause this pressure, and lifestyle habits like smoking can cause your LES to be weak.  Other common triggers seem to be alcohol, spicy foods, deep fried foods, peppermint, garlic, and onions, caffeine beverages, and coffee of all types.  (My friends who are pregnant have also complained of GERD)  I always remind people that what triggers each person is going to be different, and I have encouraged people to keep a diary of what seems to exacerbate their symptoms--some people have no trouble with raw tomatoes but they have trouble with tomato sauce, for example.  For people with active symptoms they also need to leave a gap of anywhere from 1-3 hours between eating and going to sleep and need to sleep with the head of the bed elevated.  I also remind them that even though giving up coffee, etc might be tough for some of us, you don't need it to survive.

Now we come to the more murkier part of the lake.  One of the things that people have been told to do when they have GERD is to severely lower their fat intake--as in all fat.  Fat does have a tendency to slow down the emptying of the stomach, which could cause more pressure, so I can see where this recommendation comes from.  Unfortunately, however, over the years I have seen food lists that tell people to completely stay away from red meat and encourages the use of processed foods like "fat free" cheeses, etc.   That's enough to make me want to ignore dietary advice and just take medicine right there.  I think a more balanced approach would be to eliminate deep fried foods and other foods high in trans fats and all the unnecessary vegetables oils that people add to their food.  Stick with leaner cuts of beef and pork at first, and use olive oil, butter, and nitrite-free bacon sparingly until you figure out what your tolerance is.

One other problem piece of advice is "eat six smaller meals per day."  I think maybe what those who give this advice really mean to say is "try eating less at a meal" or "quit pigging out until you'rencomfortable."  If you are someone that that gastric bypass surgery or you are trying to gain weight, you might have to spread your nutrition over six meals a day, but if you are overweight or trying to maintain your weight, six meals per day might result in weight gain or inability to lose weight.  I have also had some people that experienced nausea if they didn't eat every two hours--in that case you better keep a closer eye than usual on your calorie intake and/or consider taking a PPI temporarily so that you don't gain fifty pounds.

And then there's the people who find relief by restricting their carbohydrate intake as was done in this study (Link), and I have heard some anecdotal reports of this happening as well.  Keep in mind that the people in this study did lose a significant amount of weight in a two week period of time, likely reducing their abdominal pressure, as the authors pointed out.  Since this was a small study and only done in obese women, the authors can't state that everyone who reduces their carbohydrate intake will have a relief of symptoms (and it sounded like the weight loss just benefitted them period).    There are some other theories out there though, and since I did experience one of these myself, permit me to get all anecdotal on you for a moment.  Remember this post where I talked about the elimination diet I did to improve my IBS symptoms?  Remember what those foods that contain FODMOPS do (like wheat, garlic, onions, etc)?  That's right, they can cause gas, bloating, and our nemesis the intra-abdominal pressure again.  I stopped eating the things that were causing me to bloat and compress my stomach and I got stop dealing with daily nausea/GERD symptoms. (Some of the other anecdotes I saw involved people specifically pointing to avoiding gluten as a "cure" for their problems--if the gluten was causing flatulence and bloating, as is the case with celiac/gluten intolerance, then it probably did relieve the pressure and symptoms.)

So, what do you do if you would like to avoid medication for GERD?
1) If you are overweight/obese and most of that extra body fat appears to be in your abdomen, losing weight will often improve symptoms.  If you have been overeating on carbohydrates (you probably need to cut way back to lose weight).
2) Eat just enought of the "good fats" at each meal to help things taste good, you might have to experiment with how much olive oil, etc you can put on your salad.
3) Keep a diary for at least two weeks of foods eaten and symptoms.
4) Consider going on a low FODMOPS diet (see link above), especially if you also have trouble with belching, feeling bloated, or flatulence.
5) Quit smoking if you smoke.
6) Avoid caffeine, alcohol, and spicy foods for at least two weeks, and consider adding small amounts back in to see if you tolerate it (I used to not be able to have coffee, but since I eliminated the other problem foods I can drink it now).

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