Monica revisits acid reflux and why common acid-blocking medications might not be the best long-term solution. She discusses the potential downsides of these drugs, including nutrient deficiencies and increased health risks, and offers practical alternatives like dietary adjustments and lifestyle changes.
Although they are among the most widely prescribed medications and most popular over-the-counter remedies, acid blocking drugs may not be the best way to deal with heartburn or GERD.
References:
Overutilization of proton pump inhibitors: a review of cost-effectiveness and risk
Body weight, lifestyle, dietary habits and gastroesophageal reflux disease.
Check out my special Spotify playlist of episodes dedicated to Gut Health here!
Nutrition Diva is hosted by Monica Reinagel, MS, LDN. Transcripts are available at Simplecast.
Hello and welcome to the Nutrition Diva podcast. I’m your host, Monica Reinagel and in this show–now in its 16th year–I try to help you navigate a sane path through what can be an overwhelming amount of nutrition information, not all of which is totally accurate or helpful!
If you have nutrition questions that you’d like me to tackle in future episodes, you can send them to me by email at nutrition@quickanddirtytips.com or leave me a voice mail at 443-961-6206.
Over the last couple of weeks, I’ve gotten a couple of questions from listeners about acid reflux, sometimes known as GERD (which stands for gastroesophageal reflux disease), or just plain old heartburn.
Reflux occurs when stomach acid flows upward into the esophagus, where it can irritate and damage the cells that line the esophagus, which are not built to withstand a very acidic environment. This can lead to a range of uncomfortable symptoms, including chest pain, burping, sore throat, asthma, coughing, and bad breath.
And there’s an even scarier possibility: chronic reflux can increase your risk of esophageal cancer. So, it’s no wonder that doctors are quick to prescribe acid-blocking medications when their patients report heartburn. These drugs are usually pretty effective at reducing reflux symptoms. Of course, if you stop taking them, the symptoms tend to come back. So, many people—and their doctors—have simply accepted that the medications will need to be taken indefinitely.
I’m not sure that’s such a good idea. Shutting down acid production might reduce your reflux symptoms but your body produces stomach acid for a reason. It helps you digest your food, particularly proteins. It kills harmful bacteria that might otherwise cause food poisoning. It also helps dissolve the chemical bonds that allow your body to absorb calcium, iron, and vitamin B12.
We’re now getting to the point where a significant portion of the population has been taking acid-blockers for decades. And we’re starting to see some negative consequences like upticks in B12 deficiency, diarrhea caused by food-borne pathogens, and increased hip fractures among people taking these drugs.
More recently, a study found that people taking PPIs were about 20% more likely to have a heart attack. PPIs include popular drugs like Nexium, Prevacid, and Prilosec. The exact mechanism isn't clear, but it might be related to how these drugs affect the lining of blood vessels.
The FDA recommends that PPIs shouldn't be taken for more than three two-week periods in a single year. A random survey of the next ten people you meet will reveal that this recommendation is regularly ignored.
So, what are the alternatives? There are other medications like H2-receptor antagonists (think Zantac or Pepcid) that might be safer for long-term use. And good old antacids can provide quick relief for occasional symptoms. But the ultimate goal is to reduce our reliance on these sorts of drugs. That will probably require some ongoing lifestyle dietary modifications. Not quite as easy as popping a pill, but the effort is well worth it.
If you're currently taking PPIs or other reflux medications, don't stop them abruptly. Instead, have a conversation with your healthcare provider about developing a plan to potentially reduce your reliance on these drugs. This might involve gradually stepping down your medication while implementing lifestyle changes.
With all of the reliance on acid-blocking medications, you might conclude that acid reflux is simply about having too much stomach acid, but it's actually more complex than that. Other factors like hiatal hernias or delayed gastric emptying can play a role. But often, the primary issue is a dysfunctional lower esophageal sphincter, or LES. The LES is a sort of one-way valve that sits at the bottom of the esophagus, which (when functioning normally) allows food to pass into the stomach for digestion but prevents stomach acid from going in the opposite direction.
If this sphincter is too relaxed, or when there is just too much pressure on it, problems can arise.
Now, here’s something that might surprise you. When you have more acid in your stomach, it causes your LES to close more tightly. When there’s less stomach acid, the LES tends to relax. Now, just think about that for a minute. Reflux is treated with drugs that reduce stomach acid.
Not to pile it on, but GERD becomes more common with age. You know what else happens when we get older? Stomach acid production tends to decline. In fact, although it sounds counterintuitive, some folks find that drinking a small amount of vinegar in water before meals actually helps prevent reflux, by encouraging the LES to close more tightly.
So, let’s talk about what else we can do to address the root causes of reflux.
The good news is that lifestyle modifications can be remarkably effective in managing GERD symptoms.
First, let's talk about diet. You've probably heard a long list of foods to avoid if you have reflux - chocolate, coffee, alcohol, spicy foods, tomato sauce, and citrus fruits, to name a few. However, what triggers reflux in one individual may not be a problem for others. So, take those lists of foods to avoid with a grain of salt. You may find, through trial and error, that only some of them (or different ones) are personal triggers for you.
But if certain foods, such as tomatoes or coffee, trigger your heartburn, it’s probably not because they are acidic but because they tend to relax the muscle that is in charge of keeping stomach acid in the stomach where it belongs.
You may also find recommendations online for specific diets, such as an “alkalizing” diet. These diets are generally healthy–heavy on the fruits and vegetables, easy on the meat, dairy, refined grains and added sugars. If you find that this approach helps with your symptoms, you’ll get no argument from me on the nutritional merits. But I do feel compelled to point out that these diets don’t really change the pH of your stomach–or your body–in any meaningful way.
Scientists are also beginning to explore the potential role of the gut microbiome in GERD. Studies have shown that patients with reflux often have altered gut microbiota compared to healthy individuals. This dysbiosis may contribute to increased esophageal inflammation and impaired LES function.
While research in this area is still evolving, these findings have potential implications for GERD management. There’s not a lot of data to support general probiotic supplementation as a remedy for GERD, but we may see future GERD treatments that target the microbiome with specialized probiotics. In the meantime, diets that support a diverse and healthy gut microbiome–increasing fiber intake and consuming fermented foods–may indirectly benefit GERD management.
Here are some additional tips that can help you manage symptoms.
And finally, I’ll make one last plea for you to minimize your use of acid-blocking medications. Advertisers try to convince us that we can indulge in heartburn-triggering foods without paying the price. All we need to do is load up on antacids an hour beforehandbefore hand—and have another handful at the ready to put out the fire afterwards!
As we talked about earlier, constantly suppressing stomach acid can have a lot of potential downsides. So, it’s important to do what you can to avoid the foods and habits that give you heartburn.
That said, as I mentioned earlier, chronic exposure to stomach acid can increase your risk of esophageal cancer. So if despite your best efforts, you continue to experience heartburn or other GERD symptoms on a regular basis, you may also need to use medications. Sometimes the benefits outweigh the risks.
I’m just saying that acid-blocking medications should not be our first-line (or only) response to this condition. Ideally, we would turn to them only when lifestyle and dietary modifications are not enough.
I hope you found today’s episode useful!
In addition to this podcast, I also speak about nutrition and behavioral health at conferences, workplaces and other events and if you’d like to find out more about having me present at a live or virtual event, you can learn more at my new website wellnessworkshere.com
Nutrition Diva is a Quick and Dirty Tips podcast. Our team includes Brannan Goetschius, Nathan Semes, Davina Tomlin, Holly Hutchings, and Morgan Christianson. Thanks to all of them and thanks to you for listening! I’ll see you again next week.