gastroesophageal reflux disease: those purple pills are not enough

Heartburn – an uncomfortable burning sensation in the chest or throat due to stomach acid in the esophagus – affects at least 20% of Americans on a regular basis. Frequent heartburn is known as gastroesophageal reflux disease (GERD). A score of 8 points or more on the following questionnaire indicates at least an 80% likelihood that GERD is the correct diagnosis.

GERD symptoms questionnaire

 

what causes gastroesophageal reflux?

The stomach normally sits just below the diaphragm, positioned so the hiatus (opening) of the diaphragm reinforces the LES (lower esophageal sphincter), a muscular ring meant to keep the acidic environment of the stomach separate from the esophagus.

normal stomach vs. hiatal hernia

 
The LES should always remain closed except to allow food into the stomach during meals. Failure of the LES is the most important factor in GERD. Possible reasons for a weak LES include

  • hiatal hernia, where part of the stomach is pushed above the opening in the diaphragm (refer to diagram)
  • obesity due to increased pressure on the stomach
  • stress and sympathetic dominance
  • intestinal malabsorption, including lactose intolerance, which increases gastric distention
  • eating fried fatty foods and other “crap”:
    C = coffee, cigarettes, chocolate, corticosteroids
    R = refined sugars
    A = acidic foods, alcohol, allergens (food sensitivities)
    P = pop (soda), peppermint, packing in food (overeating)

Once the LES is not functioning properly, acid from the stomach and sometimes even bile salts from the duodenum (small intestine) can splash back up into the esophagus; this is the definition of “reflux”. Such chemical irritation causes inflammation and oxidative damage; repeated exposure to duodenal and gastric juice eventually leads to cellular changes in the esophagus called Barrett’s metaplasia, which is a precancerous condition known to increase the risk of dysplasia and esophageal adenocarcinoma (cancer).

proton pump inhibitors

The gold standard in conventional treatment of gastroesophageal reflux are the proton pump inhibitors (PPI) – omeprazole (Prilosec), esomeprazole (Nexium), pantoprazole (Protonix), and lansoprazole (Prevacid). These drugs work by irreversibly blocking the H+/K+ ATPase “proton pump” of parietal cells in the stomach, preventing the release of hydrochloric acid. The rationale for using these drugs in the treatment of GERD is that decreasing the acid content of the refluxate should prevent damage to esophageal tissue. And in fact there is some convincing evidence that PPI therapy can decrease the risk of esophageal adenocarcinoma, as in this 2014 meta analysis:

However, in the twenty-some years that PPIs have been on the market (and wildly popular, the #2 selling drug with over $6 billion in sales in 2013), 10-40% of patients still experience heartburn.

In addition to noncompliance or patient error such as taking the medicine without regard for mealtime, a commonly cited reason for PPI treatment failure is that only 70% of proton pump enzymes are inhibited by the drug at any time.

In my mind a much more important reason is that proton pump inhibitors actually decrease muscle tone of the LES, perpetuating the original reason for gastroesophageal reflux!

pantoprazole may impair gastric and lower esophageal sphincter muscle tone and thus paradoxically exacerbate esophageal reflux – Welsch et al. 2014

Many PPI non-responders are assumed to have the GERD subtype called “NERD” (non-erosive reflux disease) which may involve factors such as impaired esophageal mucosal barrier function, visceral hypersensitivity, and altered esophageal motility rather than acid.

Also consider that 68.7% of nonresponders have bile reflux from the duodenum. Much of the newer research has demonstrated the importance of bile salts in the etiology of heartburn symptoms and pathologic changes in the esophageal mucosa. The following chart shows results from a surgical study performed in rats, where the presence of duodenal juice was the definitive factor in the incidence of esophageal adenocarcinoma:

Clearly, stomach acid is not the only contributing factor to GERD and its symptoms; so perhaps proton pump inhibitors should not be regarded as the only “best” way to manage the issue.

side effects and risks of PPI therapy

There are several major adverse effects caused by proton pump inhibitors. Those discussed below are largely cumulative over time, so the longer the PPI medication is used the greater the risk.

(Although PPIs are officially indicated for only 4-8 weeks at a time, many people diagnosed with GERD end up taking them for the rest of their lives because acid suppression is diminishing the damaging effects of reflux but not really fixing the problem. True safety data for such long-term treatment are lacking; controlled studies do not extend beyond 12 months. The lifelong PPI trend is particularly disturbing as more and more prescriptions are written for children or babies with colic or reflux, despite the fact that clinical trials reveal that PPI therapy is not effective treatment for these common infant GERD-associated symptoms.)

natural alternatives for treating GERD

Just like the causes and triggers of GERD may be different for each person, there is no one-size-fits-all approach for managing the condition without PPIs. However, here are some highlights of the many things I have successfully used with patients:

  • Adjust diet to generally avoid spicy foods, alcohol, carbonated beverages, and other “crap” that triggers heartburn episodes.
  • Support the parasympathetic nervous system (our “rest and digest” mode) to help increase muscle tone of the LES: stress management, taking time to sit down and enjoy meals, etc.
  • Maintain a healthy weight to minimize external pressure on the stomach; eat smaller meals throughout the day to minimize pressure and distention within the stomach.
  • If hiatal hernia is present, find a naturopathic doctor trained in visceral manipulation to readjust the position of your stomach so it sits below the diaphragm again.
  • Soothe and protect the esophagus and stomach lining with healing herbs and nutrients if heartburn still occurs. (A Finnish research group recently published a study using hyaluronic acid and chondroitin sulfate for NERD with this same intent).
  • Improve digestive function with digestive enzymes and probiotics; also assess for and eradicate any overgrowth of pathogenic microbes.

(additional notes)

Other medical and surgical options exist for treating GERD, of course, including H2 blockers, prokinetic agents, various methods of fundoplication, and a fascinating new procedure involving magnetic sphincter augmentation. These are beyond the scope of this post.

My focus here is on proton pump inhibitors because they remain the mainstay of treatment and are often prescribed as empiric therapy without further workup unless found to be ineffective. As a naturopathic doctor my goal is to treat the cause of disease whenever possible; palliative approaches like PPIs may help manage symptoms in the short term but do little to address the underlying problem. Due to the significant downstream effects of acid suppression on digestive function, immune function, and cognitive/neurological function, using proton pump inhibitors indefinitely is not my first choice – especially when there are many alternative methods available that help correct reflux.

antibacterial soap: the dirty truth

You may have heard recently that the FDA issued a proposal to reevaluate the use of antibacterial agents in over-the-counter hand soaps. I can’t say I was disappointed! Although I once took comfort in the idea of antibacterial soap, over the last several years I have chosen to avoid products with the active ingredient triclosan.

My microbiology professor used to say that it takes 30 seconds of skin contact for triclosan to effectively kill bacteria. I don’t know about you, but I rarely see anyone wash their hands for that long — unless maybe they’re scrubbing for surgery. This means that we are flushing millions of gallons of triclosan-contaminated water (not to mention good money) down the drain for virtually no reason.

What happens then? Well, nothing good. Triclosan is poorly biodegradable and not easily removed during waste water treatment, so it enters waterways where it is detrimental to algae, fish, and other aquatic life via acute toxicity as well as disruption of reproductive function. Most municipal water supplies are also heavily chlorinated; triclosan reacts with chlorine to produce chloroform and other toxic metabolites.

Since it remains in the water supply, triclosan eventually makes its way back into our homes — and therefore into our bodies as well. Measurable levels of triclosan are found in the urine of 76% of Americans and evidence increasingly seems to show that triclosan may act as an endocrine disruptor. Estrogenic and androgenic effects may impact fetal development, breast cancer cell growth, obesity, and more. Systemic exposure has also been linked with an increased risk of allergic sensitization to environmental or other inhaled allergens (although skin contact with triclosan does not seem to aggravate eczema, possibly by suppressing mast cell function).

Clearly there are health and safety issues that need evaluation, and hopefully the FDA will take these under serious consideration. But perhaps one of the biggest public health concerns associated with triclosan involves the strong possibility that widespread use of this agent may contribute to antibiotic resistance by several mechanisms (including active efflux from the cell, which is a quite dangerous adaptation).

The presence of triclosan in hand soap (as well as in many, many cosmetics, textiles, and other products as mentioned in the list below) can also give people a false sense of security. Consider a kitchen cutting board made with Microban — are you less likely to wash and/or disinfect the board and counter after use?


Yes, triclosan is pretty much everywhere. I expect that list to change somewhat depending on the FDA’s decision. Antibacterial products are, in my opinion, largely a marketing ploy and used far beyond what is necessary for good hygiene.

So what are the alternatives? I believe the answer is the same as it always has been. Wash your hands — just choose better soap.

Handwashing remains a vitally important public health measure for avoiding the spread of respiratory and fecal pathogens. Washing with plain soap and water is better than water alone, because soap decreases the surface tension of water so that dirt and bacteria can be washed away more easily. Scrub your hands thoroughly (click the icon for detailed instructions). Use water of a comfortable temperature because scalding hot water does not get hands cleaner; tepid or even cold water is okay too. Drying hands with a towel helps brush off additional germs, but avoid hand dryers which actually spew more germs into the air. (See the studies cited by the CDC on handwashing).

And never fear, there are plenty of soap brands out there that have not fallen to the “antibacterial” craze. Some of the popular commercially available brands include Method, Mrs. Meyers Clean Day, Dr. Bronner’s castile soaps, and Avalon Organics. (These affiliate links point to Vitacost.com, which is one of my favorite online retailers for health and beauty products, but of course you can find these and other soaps at most drugstores). An added bonus of triclosan-free soaps is that they are often also free of parabens and synthetic fragrances which have plenty of their own side effects.

If you are interested in doing more of your own research on soap brands that are better for you and for the environment, the Environmental Working Group maintains a great database called “Skin Deep” which rates soaps, cosmetics, sunscreens, and other skincare products based on the current data available. Click here to search for liquid hand soaps free of triclosan and triclocarban. Or try out the new EWG Skin Deep mobile app the next time you’re at the store!

five things to consider when choosing a fish oil

There are many health benefits of omega-3 essential fatty acids, but with so many brands on the market it can seem impossible to know which one to choose. Here are five things to look for:

1. potency

EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) are two long-chain omega-3 fatty acids and the main ingredients in fish oil. Humans can make very small amounts of EPA and DHA from the truly essential ALA (alpha-linolenic acid), but rarely enough to meet the daily requirements. Nutrition experts recommend the following Adequate Intakes for maintaining normal function in healthy adults:
   • 1.1 g (women) to 1.6 g (men) of ALA per day
   • 650 mg of combined EPA and DHA per day
Therapeutic doses of omega-3s for specific health concerns are often 2 times higher than the Adequate Intake. The ratio between the two fats may also be adjusted. DHA is needed for structural integrity of cell membranes and neural tissues, but EPA has more effects on modulating immune function and inflammation (including cardiovascular risk factors) so most targeted therapeutic formulas contain much higher percentages of EPA – up to 3.5 times more. Well-balanced formulas most often contain EPA and DHA in a 3:2 ratio.

2. purity

You want to be sure that your oil is fresh and free of contaminants.
Oxidized (i.e. rancid) oil contributes to those dreaded “fishy burps” and can actually harm your health by increasing LDL cholesterol. Fresh oil should have a light, palatable taste; you can test encapsulated oils by chewing apart the gel capsules. 
Always inspect the packaging. Check for a good expiration date as well as for the presence of any additives. The best companies preserve their oils using natural antioxidants such as vitamin E, rosemary, and lemon. “Filler” ingredients such as soy oil, glycerin, and sorbitol or allergens such as dairy and gluten have no place in quality fish oils.
Heavy metal and chemical testing for mercury, lead, PCBs, dioxins, and other contaminants is also an important consideration. The product should clearly state that it has undergone third-party testing and the manufacturer should not hesitate to provide information about its quality-control procedures.

3. processing

There are several categories of fish oil. First is the natural triglyceride form that is the same as if you ate the fish. Many liquid fish oils are in this form and easily dispensed by the teaspoon. People who prefer the convenience of capsules, however, often find that concentrated formulas are easier to use because there are fewer capsules to take each day. Free ethyl esters are isolated and stabilized omega-3s that are usually 2-3x more concentrated than the original oil. This is the form found in the prescription fish oil Lovaza. Finally, some supplement companies offer their concentrated oils as “re-esterified” triglycerides which take the isolated and purified omega-3s and chemically repackage them into new triglyceride (fat) molecules.
All three of these forms are digestible and all three have been clinically shown to reduce serum triglycerides and cholesterol. Ethyl esters are somewhat more stable against oxidation, but triglycerides (both natural and re-esterified) have better bioavailability.

4. pregnancy status

The specialty pre-natal fish oils are highly recommended during pregnancy because they contain a higher percentage of DHA to aid healthy development of the baby’s brain, eyes, and nervous system. Pre-natal products also make sure to avoid oils that contain vitamin A, which can cause birth defects at high doses. (Cod liver oil, for example, contains a relatively high amount of vitamin A — 1500-3000 IU per tsp — so should usually be avoided during pregnancy).

5. price

Sustainability is a major issue in fish oil production. Species like krill which play such an integral and delicate role in the oceanic food chain are not good choices for harvesting — the environmental price is just too high. By contrast, sardines and anchovies make an excellent choice for fish oil because they are abundantly available, reproduce quickly, and tend to be less contaminated with mercury due to their small size.
Norwegian cod, a major source of cod liver oil, is another good example of fish to use for oil. Norway has extremely strict fishing regulations, which guarantees a sustainable source. An added bonus is that cod livers are considered a “waste” part of the fish after the fillets are cut and sold to eat, so virtually the same number of fish are harvested regardless of whether their livers are used for oil or discarded.

Finally, the bottom line is always an important factor when purchasing supplements. But keep in mind all of the above points and remember that the best value may not always be the same as the cheapest product on the shelf!