Reflux sucks! Now what?

A few weeks ago, I saw a patient in the hospital who had been losing weight drastically because of her acid reflux. It was so bad that she couldn’t eat at all. Her meds had stopped working, and none of her usual tricks were helping. That same day, I spoke with a potential client about her struggles with reflux and, later that week I noticed a pile of antacids on my friend’s table. I took that week as a sign that people are really struggling with acid reflux, aka gastroesophageal reflux disease or GERD. If you have GERD, you know the burning radiation of stomach acid going the wrong way up the esophagus. That feeling is what we call heartburn. My own experience with acid reflux was awful; I once had to pull over while driving because I thought that I was having a heart attack. Thankfully, I wasn’t having a heart attack at 32, but I realized that I needed to do something about my reflux. Ugh! It’s the worst.

The details: GERD is what happens when the muscle at the base of the esophagus (the lower esophageal sphincter or LES), just above the stomach, opens when it’s not supposed to and lets the extremely acidic fluid from the stomach up and out. It burns (hence the term heartburn), and can end up doing some serious damage, including changing cells enough to turn cancerous.

The current approach: There are lifestyle approaches that have been helpful for many: wearing loose clothing, avoiding trigger foods, eating upright and staying upright after eating, among many. In addition, almost every one of my patients with GERD is on a proton pump inhibitor (or PPI). It’s a very common method of treating acid reflux. PPIs trigger the acid-producing cells lining the inside of the stomach to decrease acid production. The theory being that if you produce less acid in your stomach, the fluid that may go back up into the esophagus will be less damaging and painful. And it works. For the most part.

There are a few problems with this approach. First, PPIs tend to be addictive, in that, once you start using them, it’s hard to stop. They also trigger those acid-producing cells to produce MORE acid if you stop taking the PPIs. And most interesting to me, is that when you reduce the stomach acid, you leave the body susceptible to dangerous bacteria that would normally have been destroyed by the very low pH of an acidic stomach.

Now it gets really interesting. What if acid reflux isn’t always related to too much acid? There is research that connects bacterial overgrowth in the small intestine with GERD. But how does that make sense? It turns out that some of this bacteria that colonizes in the small intestines produce carbon dioxide (CO2) or gas.

Gas that is produced in the large intestine, further down the gastrointestinal tract, produces farts (go ahead, you can giggle). Usually gas in the upper gastrointestinal tract comes out as burbs. BUT if there is excessive gas production from excessive bacterial growth in the small intestine, the air can push open the muscle the protects the esophagus from stomach acid. Then, when we treat the burning pain with a PPI, we reduce the pH of the stomach and the contents that empty from the stomach into the small intestine, allowing renegade bacteria to flourish even more, creating more gas, and so on. Around and around in a vicious cycle.

If we’re just treating the symptoms with meds that may cause more issues and perpetuate the problem, the source of the problem is left to make things worse!

So, if not PPIs, what options do we have?

First, it’s worth figuring out if you have a bacterial issue. Signs that you have small intestinal bacterial overgrowth (SIBO), in addition to heartburn, include bloating, cramping, flatulence or diarrhea. Rosacea, IBS, and restless leg syndrome have also been linked to SIBO. Your doctor offers a variety of tests to identify the presence of bacterial overgrowth in the small intestine like, the 14C d-xylose breath test, the hydrogen breath test, stool studies looking for fatty stools, and direct quantitative culture. Because the field still requires more research, the tests aren’t perfect, but they can definitely point you in the right direction. It is also possible to have some sort of physical malfunction that prevents normal movement of food through the GI tract, which can allow bacteria to settle in the wrong place. Imaging studies (like a CT scan) can help find those issues.

The dietary approach: Research on the dietary approaches to treating GERD is still fairly new and incomplete. The basic idea though, is that carbohydrates, especially simple sugars and starches, feed the rogue bacteria. So if you can make simple, temporary changes to your diet that stop feeding the bacteria, you can reduce the gas build-up, lower the pressure, and prevent the release of stomach fluid into the esophagus.

I’m not saying that PPIs should never be used, but it’s worth experimenting with your diet to see if you can fix the actual problem before moving on to treating the symptoms. If it works, you can skip the meds. If not, the meds are there as a last resort. If you’re already taking PPIs, it’s still worth trying a dietary approach, with your doctor’s guidance.

So, if you’re interested in giving it a try, focus on eating lean protein, healthy fats, and less starchy vegetables. Avoid dairy and simple carbs like sugar, potatoes, bread, and rice. The role of fiber is controversial. Some theories highlight that moving the bowels with insoluble fiber and/or medication is necessary to decrease bacterial colonies in the small intestine. Sufficient water intake and exercise help move things along, as well. Other theories suggest that fiber is important to prevent bacterial overgrowth, but when treating overgrowth that is already present, holding back on soluble fiber helps to starve out the bacteria. These theories aren’t contradictory.

With my patients and clients, I recommend avoiding soluble fiber from (grains, oats, carrots, beans and peas) temporarily, and loading up on foods that provide bulky insoluble fiber (leafy greens, green beans, vegetables with skins like zucchini, and nuts). After a couple of weeks, if you notice relief in symptoms, you can start introducing soluble fiber back to your daily routine.

Be prepared for a temporary reaction. If there is a bacterial build-up present and you make dietary changes to starve out the colonies, you may experience some issues related to the “die-off” of those bacteria. Headaches, digestive issues, fatigue, skin reactions and more, are common. These symptoms may last a few days or so, but it is normal.

I’ve personally done this with fantastic results. I did experience the “die-off” reaction for about 4 days, but the end result was undeniably positive. I rarely have reflux issues now. My experience is only anecdotal evidence though, so you’ll have to be open to assessing your own body’s response. My patients and clients have had wonderful improvements in their GERD symptoms using this approach. I recommend talking to your doctor and working with a dietitian to make sure that you don’t have any other major issues going on and that you’re getting all of the nutrients that you need throughout the process.

I hope this helps!!

I’d love to hear from you! Do you have GERD? What have you tried to relieve your symptoms?

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