Acid reflux can become a vicious cycle

For someone with a high-pressure lifestyle and suffering from acid reflux, the condition can become a vicious cycle.

A morning looks like something like this: you wake with a calm stomach. Then you think about the challenges of the day, the difficult people/situations you have to deal with, and the calm feeling goes. You shower, get ready, get to work.

You’re trying to do intermittent fasting, so you leave breakfast until 10am, then nip out for a coffee and a toasted something. While you bolt it down you’re thinking about a work problem and you race back to the office to apply a solution that came to mind. Then acid reflux strikes — heartburn, a feeling you can’t breathe, chest pain, even some backwash into your mouth — and your stomach feels bloated.

Maybe you take an antacid, or remember you were supposed to take a proton pump inhibitor (PPI) medication like esomeprazole or omeprazole an hour before your meal, to stop your stomach producing too much acid. Whichever route you choose, acid reflux is extremely uncomfortable and the symptoms can take anything from a few minutes to hours to go.

When acid reflux becomes serious and chronic, it can turn into gastroesophageal reflux disease (GERD). When you have this condition, the constant backflow of stomach acid into the oesophagus is irritating the lining, leading to complications.

Sphincter valve

Ria Catsicas, a registered dietitian practising in Johannesburg, explains the process of GERD: “The valve on the sphincter, which keeps the acid in the stomach, stops functioning properly and there is acid reflux into the oesophagus. If that becomes more serious it can develop into Barrett’s oesophagus, a type of cancer.”

The Institute for Functional Medicine (IFM) says GERD is estimated to affect 20% of the Western world, “with a prevalence range believed to be between 18.1% to 27.8% in the US”. Johannesburg specialist and anti-ageing physician Dr Craige Golding says “there is no direct study showing the prevalence in SA, yet it could be as high as 40%”.

He adds: “With dietary changes that have been happening over the years, we see that more and more people are suffering from GERD.”

The IFM concurs that among the factors that are associated with an increased risk for developing GERD symptoms, include obesity, tobacco use, older age, and lower socioeconomic status. “Increased stress may also be a contributor to GERD symptoms, and clinical studies have suggested a relationship between GERD and anxiety as well as depression.”

People who develop GERD may be genetically predisposed or have a hiatus hernia, says Catsicas. But diet and lifestyle play a big role. “When people are overweight, the fat can be pressing on the abdomen area, in turn pressing on the lower oesophagus, and the sphincter slips acid to the oesophagus. If they lose weight, the pressure goes down, and the valve functions better.”

Meals that are high in fat have a bad effect on the sphincter, she says. “Fried foods, takeaway meals like a burger and chips are likely to lead to acid reflux and GERD. Avoid low-fibre foods like sugar and refined white flour — rather have health or seed bread or oats in the morning. Alternate starches are rice and quinoa, and eat more fresh fruit and vegetables.”

“Alcohol such as beer and wine is also likely to make GERD worse. Caffeine will make your stomach produce more acid. I tell my patients with acid reflux to have decaff tea and coffee. And smoking can irritate the lining of the oesophagus.”

In addition, says Catsicas, don’t eat two to three hours before bed as this will worsen the condition.

Intermittent fasting

Intermittent fasting isn’t for everyone, and especially if you are struggling with acid reflux or GERD, says Catsicas. “People wait too long to eat, they get too hungry and then they have large meals. Rather have more frequent, smaller meals. And eat slowly, never rush a meal.”

In some cases, she recommends taking a probiotic to encourage the growth of friendly bacteria in the gut.

But PPIs and antacids may give symptomatic relief but don’t fix the problem in the long run: “They may inhibit the stomach from producing acid but they won’t help the long-term condition; they will not heal the colon or help you lose weight.”

Seeing a dietitian can help you find a way of eating that is healthy and practical, and that suits your budget. “I provide patients with menus for each meal, and advise them to keep a food diary and make a once-a-month follow-up visit to help them keep on track.”

Similarly, the IFM does not set much store by the drugs and over-the-counter products sold for acid reflux and GERD.

“The most popular GERD treatments, stomach acid reducers, are a booming business, with both H2 blockers [histamine H2-receptor antagonists] and PPIs used widely,” it says.

“Prescription PPIs are used by an estimated 15 million Americans. Taking an over-the-counter acid blocker for occasional heartburn symptoms may not be a big issue, but in practice, many patients with chronic reflux are prescribed acid blockers indefinitely. A significant number of researchers have independently linked PPIs to adverse health problems such as bone fractures, chronic kidney disease, and pneumonia, among others.”

Golding says: “Studies indicate that one should not use PPIs long term, since it can contribute to calcium malabsorption — which could contribute to osteoporosis, vitamin B12 deficiency, Clostridium difficile-associated disease and community-acquired pneumonia, and poor protein digestion.”

He says the only time that ongoing or long-term PPI use is indicated is for Barrett’s oesophagus.

“Contrary to popular belief,” Golding adds, “it is not always high stomach acid that is to blame. High stomach acid is known as hyperchlorhydria. Hypochlorhydria, on the other hand, is something that we see happening more and more. This is where there is too little stomach acid, with very much the same symptoms. Many sources suggest that nine out of 10 patients with reflux in fact have a lower stomach acid, rather than higher.

“Hyperchlorhydria is usually treated through the prescription of a PPI or by taking over-the-counter antacids. It is important to point out that if one has low stomach acid, the use of antacids or PPIs will bring short-term relief, but make the problem more pronounced in time.”

He adds: “To help us find out if we are working with too high or too low stomach acid, we usually do what we call the ‘burp test’. This test will help us see if you have too much or too little stomach acid. Please try to refrain from taking anything for acid reflux from the evening before the test until after you have written down the results the next morning. Before going to bed, mix the following in a glass: 2.5ml bicarbonate of soda and 125ml water. Put the glass next to your bed. As soon as you wake up the next morning, drink the mixture and start a timer. Write down how long it takes for you to burp. If the burp is under three minutes, it points to having too much stomach acid. Results: 3-5 minutes — normal levels. Burp after more than 5 minutes points to too little stomach acid.

“One of my favourite nutraceuticals for low stomach acid is called betaine hydrochloride. We work out a protocol that works for the patient to help normalise the levels of stomach acid.”

Betaine hydrochloride is a type of digestive enzyme that Golding says is a better treatment than PPIs in many cases. According to PMR Nutrition, a local company that produces betaine hydrochloride, it should be taken with meals to increase the hydrochloric acid in the stomach to increase the digestion of food.

That GERD can be a vicious cycle is upheld by a study done by neurogastroenterologist Nicholas Talley of the University of Newcastle, Australia, and published in the American Journal of Gastroenterology.

Depression

Writing this month (October 23) in Medscape Medical News, Liam Davenport says: “Anxiety and depression are prevalent in patients with ... GERD, according to a large-scale analysis that also found evidence for a possible underlying causal link between GERD and the common psychiatric conditions.

“In a systematic review and meta-analysis, researchers found that anxiety and depressive symptoms were more than twice as likely in patients with GERD than in healthy controls. Among individuals with GERD, up to one-third and one-fourth were affected by anxiety and depressive symptoms, respectively.”

Talley’s study found that a genetic predisposition seems to underlie GERD and anxiety or depression.

He told Medscape Medical News: “Scientifically, the possible underlying link ‘suggests there are different disease subsets within reflux that probably have a different pathogenesis, and these relationships are an expression of whatever the underlying causal pathways are.

“If you’ve got a patient with reflux, you should be asking one or two questions about anxiety and particularly depression... because it may impact on how well patients respond to therapy, and how well they do in the longer term.”