Acid reflux, commonly called heartburn – are you prone to it? If so, you’ll probably recognise some of the typical symptoms: a feeling of burning in the upper chest area after eating, worsening symptoms with fatty or spicy meals, burping, a chronic cough, and perhaps a feeling that you have a lump in your throat. It’s not pleasant and it can be very anxiety-inducing.
I’ve found that the number of clients I see in clinic with acid reflux symptoms seems to have been increasing. I have some thoughts as to why that might be, which I’ll share later.
Common Acid Reflux Medications
When someone first experiences heartburn, they may seek help from a pharmacist and be given an over-the-counter antacid such as Gaviscon. However, many people with persistent acid reflux are prescribed proton pump inhibitors (PPIs). These have names such as omeprazole, lansoprazole, pantoprazole and esomeprazole. PPIs are extremely effective at blocking production of stomach acid for up to 24 hours at a time. By blocking stomach acid production so effectively, PPIs can provide good symptomatic relief and may at first seem to be the perfect solution – and they definitely have their place. PPIs are a key medication used to treat stomach ulcers, and they can reduce the risk of stomach bleeds in patients taking medications that make them prone to bleeds. However, for people with simple acid reflux, PPIs come with some serious downsides.
In order to understand the potential problems with PPIs, we need to first understand a little bit about how the digestive system works.
When we swallow our food, it heads down a tube called the oesophagus and enters the stomach. Gravity helps this process, but there is also a valve between the oesophagus and the stomach called the lower oesophageal sphincter (LOS for short) which prevents food from moving in the reverse direction, from the stomach up into the oesophagus.
The presence of food in the stomach makes it produce acid – hydrochloric acid to be precise. This is an essential and very normal part of our digestive process. We need an acid environment in the stomach for the following reasons:
- To break our food apart so that it is ready to be digested. In particular, stomach acid is important for breaking apart the complex, three-dimensional structures of proteins. Stomach acid triggers the release of an enzyme called pepsin, which then gets to work chemically on the broken apart proteins.
- To kill off pathogens such as bacteria and fungi that may be present on our food. This is a key protection against food poisoning, and also helps to keep our gut microbiome balanced.
- The production of stomach acid acts as a signal for the pancreas to produce a hormone called secretin, which in turns triggers the release of digestive enzymes into the duodenum. This is really important: if there is not enough stomach acid, not enough digestive enzymes will be produced. We need digestive enzymes in order to break down our food in the small intestine so that we can absorb the nutrients. If we can’t break down the food, not only can we not absorb optimum goodness from our food, but a host of other digestive problems such as bloating, constipation or diarrhoea can occur.
- Vitamin B12 (essential for blood cells and the nervous system) requires adequate stomach acid for its absorption(1).
- Stomach acid ionises minerals so that they can be absorbed into the bloodstream. Low stomach acid can result in deficiencies in calcium, magnesium and iron(2). Because calcium and magnesium are needed for mineralising bones, low stomach acid has been linked to an increased risk of fractures(3).
- Stomach acid prompts the valve between the stomach and the small intestines to open, allowing food through. Without adequate stomach acid, food may stay in the stomach for longer, resulting in a feeling of fullness after meals.
Problems of Insufficient Stomach Acid
Now that you can see how important it is to have adequate stomach acid, it shouldn’t be too much of a surprise to learn that shutting down stomach acid production can cause some problems. It is PPIs in particular that are problematic; antacids such as Gaviscon are not so well absorbed and generally do not have the same adverse effects. PPIs suppress stomach acid extremely effectively, with 90% blockage for up to 24 hours.
Because stomach acid protects against pathogenic microbes, people using PPIs are more prone to having overgrowths of potentially pathogenic species such as Clostridia difficile, Listeria and Salmonella in their guts, as well as a general imbalance to the normal gut flora.(4),(5) People taking PPIs have a high incidence of IBS symptoms(6), which might be due to the resulting imbalances in the gut microbiome, or the knock-on effect that low stomach acid has on digestive enzyme production.
However, the effects of PPIs are not limited to the digestive system. PPI use is also associated with an increased risk of heart attacks(7), kidney disease(8) and dementia(9).
Acid in the Wrong Place
You might find this disturbing, yet there is no doubt that PPIs provide symptomatic relief from acid reflux. And if left unchecked, acid reflux can cause damage to the oesophagus which over time can lead to cancerous changes. Simply stopping PPIs is not a good idea, as this results in rebound reflux, and doesn’t address the underlying problem. And the underlying problem is not that the stomach is producing too much acid; as we’ve seen, it’s meant to do that. No, the problem is that the acid is in the wrong place – the oesophagus.
Lifestyle Measures to Reduce Acid Reflux
What can be done to prevent the acid getting into the oesophagus? Remember that one-way valve, the LOS, that’s meant to stop acid flowing up into the oesophagus? It can become weak and not function properly. When this is happening, there are several diet and lifestyle steps that can help to avoid putting pressure on the LOS. If you are currently taking a PPI and would rather not, it would be a good idea to follow these guidelines so that you get into a better position to talk to your GP about being able to wean off it. It never ceases to amaze me how even very painful acid reflux can reduce significantly just by eating better!
- Avoid overeating – several small meals per day may be more comfortable than 2 or 3 large meals.
- Remain upright (standing or sitting straight) for 1-2 hours after eating, and avoid eating within 3 hours of bedtime. If you do occasionally have to go to bed sooner after eating, it may help to raise your pillow.
- Avoid caffeine, alcohol and peppermint, as these all relax the LOS.
- Certain foods can be triggers. Whilst this can be a personal thing, common culprits include fatty fried foods, spicy foods, tomatoes and citrus fruit.
- Eating mindfully and in a relaxed state is incredibly important. For a thorough overview of this topic, see this talk that I gave to a local arthritis charity on the subject.
- The vagus nerve runs from the brain to the gut, and is responsible for enervating the entire digestive system. Exercises which strengthen the vagus nerve can improve digestion in the stomach. Singing, gargling and laughing all stimulate the vagus nerve – try some every day.
I have also recently been introduced to another tool for getting to one root cause of the problem of acid reflux. The IQoro device is a small plastic device which you insert into your mouth to “train” with for just a few minutes each day. This gradually strengthens the muscles of the upper digestive system, making the LOS less likely to allow acid through into the oesophagus.
I said that I’d share my thoughts on possible reasons behind the increase in prescriptions of acid blocking medications. Reading through the list of lifestyle measures to adopt should give you some clues, as these are the polar opposites of what goes on in many people’s lives. Junk food laden with inflammatory fats, eating too much at a time and eating late at night all play a part. Just as significantly perhaps is the fact that many of us eat quickly and in a state of stress, perhaps while checking emails or even on the go. How many times have you eaten lunch at your desk, or fitted it in between work phone calls? When we are stressed, our body diverts resources away from the digestive system and food can stay in the stomach for longer, increasing the likelihood of reflux. The importance of finding ways to relax while eating can’t be overstated.
Once you have put all the diet and lifestyle measures in place, you may be tempted to try to reduce your PPI use. I don’t, however, advise that you try to do this unsupported, as rebound reflux will happen, and this can damage the lining of the oesophagus. There are various soothing herbs and supplements which can help to protect the mucous membranes of the oesophagus from damage and pain caused by the rebound effect.
If you would like support and a comprehensive plan to improve your digestion, relieve acid reflux and safely reduce your PPI use (with your GP’s consent), then do get in touch.
- Thong, B.K.S., Ima-Nirwana, S and Chin, K.-Y. (2019). ‘Proton Pump Inhibitors and Fracture Risk: A Review of Current Evidence and Mechanisms Involved’, International Journal of Environmental Research and Public Health, 16(9), 1571. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6540255/ (Accessed 11 March 2021).
- Annibale, B., Capurso, G. and Delle Fave, G. (2003). ‘The stomach and iron deficiency anaemia: a forgotten link’, Digestive and Liver Disease: official journal of the Italian Society of Gastroenterology and the Italian Association for the study of the Liver, 3594), pp288-295. Available at https://pubmed.ncbi.nlm.nih.gov/12801042/ (Accessed 11 March 2021).
- Ito, T. and 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), pp448-457. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2974811/ (Accessed 11 March 2021).
- Leonard, J., Marshall, J.K. and Moayyedi, P. (2007). ‘Systematic review of the risk of enteric infection in patients taking acid suppression’, The American Journal of Gastroenterology, 102(9), pp2047-2056. Available at https://pubmed.ncbi.nlm.nih.gov/17509031/ (Accessed 25 March 2021).
- Ortigão, R., Pimentel-Nunes, P., Dinis-Ribeiro, M. et al. (2020). ‘Gastrointestinal Microbiome − What We Need to Know in Clinical Practice’, GE Portuguese Journal of Gastroenterology, 27(5), pp336-351. Available at https://pubmed.ncbi.nlm.nih.gov/32999906/ (Accessed 25 March 2021).
- Schmulson, M.J. and Frati-Munari, A.C. (2017). ‘Bowel symptoms in patients that receive proton pump inhibitors. Results of a multicenter survey in Mexico’, Revista de Gastroenterologia de Mexico, 84(1), pp44-51. Available at https://reader.elsevier.com/reader/sd/pii/S2255534X18300598?token=A8612674B546BDFA2396AE36F08847233E567F1754565769D1167C88435B0B196AB55A7BAE82C91E14C7D6B57EE915DC (Accessed 25 March 2021).
- Shah, N.H., LePendu, P., Bauer-Mehren, A. et al. (2015). ‘Proton Pump Inhibitor Usage and the Risk of Myocardial Infarction in the General Population’, PLoS One, 10(6), e0124653. Available at https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0124653 (Accessed 25 March 2021).
- Xie, Y., Bowe, B., Li, T. et al. (2016). ‘Proton Pump Inhibitors and Risk of Incident CKD and Progression to ESRD’, Journal of the American Society of Nephrology, 27(10), pp3153-3163. Available at https://jasn.asnjournals.org/content/27/10/3153 (Accessed 25 March 2021).
- Gomm, W., von Holt, K., Thomé, F. et al. (2016). ‘Association of Proton Pump Inhibitors With Risk of Dementia: A Pharmacoepidemiological Claims Data Analysis’, JAMA Neurology, 73(4), pp410-416. Available at https://jamanetwork.com/journals/jamaneurology/fullarticle/2487379 (Accessed 25 March 2021).