A Burning Epidemic
Acid reflux is a lifestyle disease – plain and simple!
Yet an astounding 15% of North Americans suffer from acid reflux and 11 million antacid prescriptions are filled annually in Canada alone! Clearly acid reflux is a problem we don’t have a good grasp on without using strong medications.
It doesn’t have to be this way!
Today we’ll take a closer look at conditions like gastro-esophageal reflux disease (GERD) and their symptoms; Spoiler: it’s not always heartburn! I’ll be answering all your burning questions on the topic of acid reflux including causes and how natural treatment options can provide safe and effective relief.
What is acid reflux or GERD?
In case there is any confusion…
Heartburn is simply the sensation of burning in the chest, specifically behind the sternum (breastbone).
Acid reflux is when stomach acid passes back up into the esophagus. This may or may not cause symptoms such as heartburn and regurgitation of food to occur. It can be the result of several processes, some physiological and some anatomical.
Why is it important to distinguish the difference? Because heartburn can be a symptom of many things – including a heart attack! So it’s important to know when we’re dealing with acid reflux and when we may be dealing with something else.
What are the symptoms of GERD:
- Heartburn
- Regurgitation
- Chronic cough
- Frequent throat-clearing (especially after eating or drinking)
- Voice changes
- Dental erosion (enamel wearing down)
- Bitter or sour taste in the mouth
- Sore throat
- Trouble swallowing*
- Painful swallowing*
*These are alarm symptoms and require prompt evaluation by your doctor
It’s a problem with stomach acid right?
It’s important to discuss how the body naturally protects us from acid reflux so that we can have an understanding of how to effectively navigate the condition.
First, we have a mechanical barrier known as the reflux barrier which consists of the lower esophageal sphincter (LES) and part of the diaphragm – that giant fan-shaped muscle that allows for our lungs to expand so we can breathe. The diaphragm wraps tightly around the LES to form this reflux barrier which prevents stomach (and even intestinal) fluids from making their way back up into the esophagus. (See Below)
Beyond the mechanical reflux barrier we just described, there are also chemical, microbial, and neurological factors at play.
Known mechanisms of acid reflux development:
Without a doubt too much stomach acid is a problem, and the strongest factor in determining the severity of acid reflux events is the length of time your esophagus is exposed to acidic fluid.
That being said, it’s a bit more complex than that!
The following section explores some of the mechanisms behind acid reflux development.
Decreased LES tone
After all, the lower esophageal sphincter is a muscle. This type of muscle, known as smooth muscle, responds almost completely to the input of our autonomic nervous system. And like all muscles, the LES has the ability to contract and relax. It should relax and open when we swallow and contract and close after we finish eating. Like any pressure valve though, exceed the threshold and the valve snaps open allowing acid reflux to occur.
Again, It’s not as simple as the on/off switch that I’ve made it seem like above. In fact, it’s perfectly normal for our LES to relax after meals for small periods of time. It becomes a problem when the LES relaxes too frequently and stays open for too long. These are called transient lower esophageal relaxations (TLERs) and they cause issues when they occur frequently after eating.
Alcohol, smoking, stress, peppermint and certain medications (like muscle relaxants) are just a few agents that relax the LES and open the doors for acid reflux. Identifying and minimizing these agents (if possible) is a great treatment strategy for this scenario.
Hiatal hernia
Hiatal hernia is one of the leading causes of acid reflux. Most often it’s when the stomach slides up through the acid reflux barrier putting the acidic contents of the stomach in direct and frequent contact with the esophagus.
Obesity is a leading cause of hiatal hernia and up to 40% of those who are obese will have a hiatal hernia.
Weight loss may be the only necessary treatment for this group. For severe cases surgery may be required.
Gastric emptying
This is quite simply the time it takes or the speed at which food empties(exits) the stomach and is a measure of motility. Some people with acid reflux have slower gastric emptying which increases the volume and pressure in the stomach. It gets backed up, so to speak. When this happens, the LES is overcome and stomach contents are free to reflux into the esophagus and beyond. Certain fatty foods like that juicy burger can also slow down gastric emptying which is why these foods are often acid reflux triggers.
Treatments for these people should involve addressing the motility of the stomach and reducing or removing processed fatty foods from your diet. Naturopathic doctors have great treatments like electroacupuncture and specific herbal medicines that can stimulate gastric emptying. In fact, acupuncture and electroacupuncture can improve both gastric emptying and acid reflux – go figure!
Visceral hypersensitivity
I’ve spoken at length about visceral hypersensitivity here and how it can influence the sensation of pain to non-irritating stimuli in the digestive tract. As it turns out, the esophagus is equally prone to sensitivity. That means that some of you may experience heartburn to normal reflux events while the rest of you wouldn’t even know it’s happening.
This is the case in non-erosive reflux disease (NERD), where the esophagus remains completely undamaged yet symptoms of reflux can make you feel like your chest is on fire. You see it doesn’t matter whether it’s acidic or non-acidic reflux, if the nervous tissue in your esophagus is sensitive than you’re going to feel it!
We know of at least one major receptor that contributes to visceral hypersensitivity. The transient receptor potential vanilloid-1 (TRPV-1) receptor – or the the much easier to remember “chilli pepper” receptor – can contribute to heartburn after consumption of spicy foods like cayenne peppers. When you trigger these receptors by eating spicy foods it can cause discomfort along the entire digestive tract, including in the esophagus.
Now we’d be missing a large piece of the puzzle if we didn’t talk about the effects of chronic stress on acid reflux development.
In fact, chronic stress increases visceral hypersensitivity directly. It also leads to overeating, poor food choices, and weight gain which can all worsen acid reflux. Stress also switches off our parasympathetic or “rest & digest” program which doesn’t bode well for our digestive system in general.
As you can imagine, addressing stressors can make a big difference in treatment outcomes. For example, deep breathing before a meal and practicing mindful eating can be a game-changer for some. Going for walks with friends or loved ones, attending a Tai Chi class or meditating quietly can be very useful strategies for others. Herbs can also be used to modify how your body responds to chronic stress and can reduce visceral hypersensitivity.
What does spit have to do with anything?!
When it comes to acid reflux, we don’t talk about the role of saliva nearly enough.
We should!
Along with kicking off the digestive process and wetting and mixing our food, saliva has protective super powers as well! Saliva contains enzymes and substances that protect the esophagus. When saliva is compromised it can lead to worsening reflux. It’s simple: less saliva production means less protection for the esophagus, which means it’s more prone to acid-related damage. A great example of this is in those who have a condition called Sjogren’s syndrome, an autoimmune condition that attacks the tear and saliva glands. These people are just more prone to acid reflux.
Optimizing saliva is a great strategy for anyone suffering with chronic acid reflux, not just those with Sjogren’s!
How can you do this?
- Eat in a relaxed state – saliva output is under parasympathetic control
- Chew your food thoroughly – the more thoroughly you chew your food the longer time you give the salivary glands to make the good stuff
- Chew gum after meals – Studies show gum-chewing can reduce acid reflux after meals.
- Various herbs like Echinacea and prickly ash can support saliva healthy saliva production.
The “acid pocket”
So researchers have recently discovered this thing they call an “acid pocket”. Like the name implies, it is a pocket of acid that forms above the mixing of foods and digestive juices in close proximity to the reflux barrier. Those with acid reflux have a larger acid pocket, which you can imagine makes things worse.
What do we do about this?
So it turns out that algae contains compounds that can form over the acid pocket like a raft floating on top of water (or lava!). This ensures that the acid pocket doesn’t proceed upwards to damage the esophagus – Seaweed for the win!
This next one is a popular theory, but does it actually hold its weight?
The low stomach acid theory?
Sounds counter-intuitive, doesn’t it??
The idea behind this is that the LES is primarily controlled by stomach acid and if we just have enough of it then the LES will stay shut, preventing us from getting acid reflux altogether. It’s a nice thought, the only problem with this idea is that there are numerous factors affecting the LES, not just stomach acid.
The vagus nerve on the other hand, holds all the cards when it comes to the function of the LES. It has the greatest effect on whether it remains closed or open, not stomach acid.
The second problem is the antacid conundrum. Let me explain.
If low stomach acid were the true cause of most cases of acid reflux then wouldn’t proton pump inhibitors (PPIs) – strong prescription antacids – worsen acid reflux?
Actually, the opposite is true. In fact, PPIs are incredibly effective at lowering stomach acid and controlling the symptoms of acid reflux. But just because they work doesn’t mean you should take them forever! And they certainly don’t work for everyone.
For a discussion on some of the dangers of PPIs read this.
Lastly, withdrawing PPIs causes the stomach to release a large amount of stomach acid. This is driven by an increase in the hormone gastrin during PPI treatment, which, when withdrawn allows the high amounts of gastrin to stimulate large increases in stomach acid. This is known as rebound hyperacidity. Again, this results from high, not low stomach acid.
But Hold On!
Before we toss this out let’s look at how it could make sense with the following exceptions:
Digestive enzyme deficiencies and dysbiosis (bacteria out of whack), which are common in people who lack stomach acid, will both increase gas in the intestines. This gas can travel upwards and increase the pressure on the LES. And like a pressure valve that has reached its threshold, the LES gives way allowing stomach juices to travel upward resulting resulting in belching and acid reflux. In this particular group of people, replacing digestive enzymes or stomach acid could provide a logical treatment for acid reflux. I have certainly seen this scenario in my practice and have had good success approaching each case differently.
But again it’s just a theory – not one that research supports.
Until then, I’d suggest consulting an expert before turning towards increasing stomach acid as a strategy for acid reflux. And please, if you have esophagitis, Barrett’s esophagus or an ulcer, absolutely do not try this – you’ll pay for it!
Heartburn…Not Just NERD & GERD!
As I mentioned earlier, chronic heartburn isn’t always acid reflux disease. Heartburn is also a common symptom in the following conditions:
- Functional Dyspepsia
- Peptic ulcer disease (& H. pylori infection)
- Eosinophilic esophagitis
- Esophageal spasm
- Scleroderma
- SIBO (what’s this?)
- Sjogren’s Syndrome
- Achalasia
- Chronic bronchitis
- Asthma
- Post-nasal drip
That’s why it’s important to get a thorough evaluation, especially if your symptoms aren’t going away. Your treatments should be personalized based on your own unique biochemistry and risk factors. Strategies like weight loss, quitting smoking, learning to manage your stressors, chewing your food more often and making healthier choices can go a long way!
But If you’re tired of trying things that haven’t worked, let’s talk about how we can get you relief!
References:
Che, Fredrick, et al. “Prevalence of hiatal hernia in the morbidly obese.” Surgery for Obesity and Related Diseases 9.6 (2013): 920-924.
Ong, Andrew Ming-Liang, et al. “Diaphragmatic breathing reduces belching and proton pump inhibitor refractory gastroesophageal reflux symptoms.” Clinical Gastroenterology and Hepatology 16.3 (2018): 407-416.
Zhu, Jiajie, et al. “Acupuncture for the treatment of gastro-oesophageal reflux disease: a systematic review and meta-analysis.” Acupuncture in Medicine 35.5 (2017): 316-323.
Dickman, R., et al. “Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn.” Alimentary pharmacology & therapeutics 26.10 (2007): 1333-1344.
Kim, Jie-Hyun, et al. “The Clinical Efficacy of a Pure Alginate Formulation (Lamina G) for Controlling Symptoms in Individuals with Reflux Symptoms: A Randomized Clinical Study.” Gut and liver (2019).
Manabe, N., et al. “Efficacy of adding sodium alginate to omeprazole in patients with nonerosive reflux disease: a randomized clinical trial.” Diseases of the Esophagus 25.5 (2012): 373-380.
Saifullah, A. M., et al. “Comparative Study of Alginate and Omeprazole in Symptomatic Treatment of Non-erosive Gastroesophageal Reflux Disease.” Mymensingh medical journal: MMJ 27.4 (2018): 771-775.