Heartburn is not just an acid problem
By Dr. Martin Gleixner, MSc, ND
Heartburn is a burning sensation in the chest related to digestive upset.
Note that the term heartburn is a misnomer. In reality, it has nothing to do with heart health. Rather, this symptom is associated with the return of food from the stomach back into the esophagus (a process called regurgitation or reflux).
In medicine, the diagnosis refers to gastroesophageal reflux disease (GERD). This common disease affects an estimated 14-20 per cent of all U.S. adults. The symptom of heartburn is estimated to occur daily in 7 per cent of the U.S. population. We can only assume that statistics are similar in Canada.
In my practice, heartburn comes up frequently. It can be a patient's primary concern, or is simply mentioned in passing because their symptoms of GERD are managed with either over-the-counter antacids or prescribed medications.
As doctors, educating our patients and promoting preventative medicine is one of our most important duties. Because of this, I encourage patients to address the underlying causes of GERD even in cases when the symptoms are managed with medications. GERD is not only associated with troublesome symptoms such as heartburn, but it can lead to complications that include esophageal stricture and esophageal cancer. Fixing the underlying problem(s) therefore, is recommended.
I would like to take this opportunity to highlight the importance of taking a dual approach in the treatment of any disease. This topic was discussed in great detail in a previous column entitled "Address underlying problem, not just symptoms". Let's do a quick review of this approach so that we can better understand the reasoning behind a multifaceted treatment plan for GERD.
To understand this concept, let’s look at the following flow chart diagram entitled "A Dual Approach". Generally speaking our conventional medical system focuses mainly on the left side. Most of today's modern pharmaceutical medications to treat GERD are designed to control symptoms, usually by changing the biochemistry in the body. The first-line therapy for GERD is the use of medications called proton pump inhibitors (PPIs) such as Nexium, Prevacid, Tecta and Pariet.
PPIs medications block the acid pump of parietal cells in the stomach thereby stopping the release of hydrochloric acid (ie stomach acid).
Concerns associated with the use PPI for GERD include failure to work (about 25-40 per cent of patients continue to have symptoms), inflammation of the stomach (gastritis), rebound excessive acid secretion (if/when the medication is stopped), increase risk of serious infections (Helicobacter pylori or Clostridium difficile), and increase osteoporotic fracture risk (possibly due to decreased calcium absorption). Blocking stomach acid can lead to the inability to properly breakdown protein and therefore lead to nutritional deficiencies. Improperly digested proteins can promote immune system reactions in the intestines thereby leading to an increased risk of food allergies/intolerances.
Despite these concerns, PPIs can provide quick relief, and can also save lives over the short-term as there is good evidence for healing esophageal erosion (including Barrett's esophagus, a condition that can lead to esophageal cancer).
The treatment approach that suppresses stomach acid however, does not promote true health because ultimately it does not address the underlying problem (i.e. the causes of one's health condition). When the symptom of heartburn is masked with a medication, the reflux of food in the stomach still occurs, but the symptoms are lessened or resolved because the acid was completely neutralized.
This raises important questions:
- If reflux is still occurring despite a reduction in heartburn symptoms does it mean that GERD was cured?
- If the stomach acid was completely neutralized what happens to our ability to digest (especially to digest proteins which relies strongly on stomach acid)?
- How can it be that most middle-aged people and seniors commonly have low stomach acid (as our stomach often decrease the secretion of acid with age), but still experience acid reflux (and heartburn)?
Perhaps then, the problem is not necessarily that there is too much stomach acid, but rather a dysfunction with the sphincter (a type of valve) between the stomach and the esophagus. This valve (also known as the lower esophageal sphincter or LES) may not properly close or can be forced open by an over-distended stomach.
- Is GERD therefore, more of a valve (LES) problem versus a stomach acid problem?
- If stomach acid isn't the problem then why do acid-blocking medications help GERD symptoms (such as heartburn)?
Because when you stop ALL production of stomach acid, you stop any possibility of acid irritation at all. Therefore, this means that those treated with GERD using acid-blocking medications don't necessarily have higher levels of stomach acid compared to those without GERD.
Wow. These questions provide food for thought.
- The final question is therefore: if stomach acid isn't the underlying problem, then what is?
This brings us to the right side of the flow chart.
The goal is to look for the reasons why your body has developed symptoms. Within this philosophy, symptoms are used as a guide to discover the underlying imbalances in your health. The true causes of GERD are numerous.
A good review article published in journal Alimentary Pharmacology & Therapeutics, by Boechxtaens (2007), provides a good summary of the multifactorial causes of GERD. These include:
- The delayed emptying of the stomach (after the ingestion of food);
- The reduced ability of the valve (LES) to remain closed;
- The inability of the esophagus to clear reflux once it comes upwards from the stomach; and finally,
- A fragile mucus membrane of the esophagus (i.e. lining of the esophagus) that is more easily damaged by the reflux of food.
Fixing these problems can take place when we look into the root causes. These can include:
- Overeating or eating too close before bedtime.
- Doing intense exercise (especially cardio) too soon after eating.
- Eating too much fatty foods or complex meals that sit in the stomach for longer.
- Eating foods that you may be intolerant to. This varies between patients; some being more sensitive to caffeine or alcohol, while others it may be orange juice or tomatoes, etc...
- Eating foods that you may be allergic to. This cause is harder for patients to determine and can be any type of food. The most common food allergies that I see in my practice (and seen by my colleagues) involved with GERD are dairy and gluten. Talk to your naturopathic doctor about different options to determine your food allergies. An elimination/challenge assessment or a blood test for IgG antibodies against many common foods are some of the methods that can be used.
- Side-effects of certain medications and smoking (tobacco or marijuana) can be important causes of GERD in susceptible individuals.
- Lack of antioxidants, vitamins and other nutrients in our foods as well as eating refined processed foods or other irritating foods can lead to an unhealthy lining of the esophagus and stomach.
- Lower than optimal levels of stomach acid. As it turns out, the presence of stomach acid appears to be an important trigger in closing the valve between the stomach & esophagus (i.e. the LES). Numerous naturopathic treatments exist to allow for more appropriate secretions of acid in the stomach.
- The presence of bile acids in reflux indicates that dysfunction can also occur between the liver/gallbladder and the small intestine/stomach. This is the reason why some patients with GERD respond well to individualized herbal formulas that help the appropriate release of bile by the liver/gallbladder.
- The lack of saliva (often caused by insufficient chewing) that normally protects the lining of the esophagus.
- Pregnancy or weight gain (especially abdominal obesity) can increase pressure inside the abdominal cavity thereby increasing the risk of GERD. Weight loss strategies were discussed in great detail in previous articles.
By determining the root cause(s) of your health condition, treatment can be more individually prescribed to re-balance bodily systems and offers better long-term success.
Because many symptoms are often uncomfortable especially with severe GERD, I maintain the importance to palliate symptoms (whether via pharmaceutical medications or natural means). This provides increased comfort in a patient's life while the underlying causes are addressed.
The key, especially in chronic illness is to always incorporate not only the left side of the flow chart, but also the right side.
This new vision aims to take your health further than symptom management. Adopting the right side of the flow chart moves a patient towards a long-term cure.
Published by Dr. Gleixner on Wednesday September 14th, 2011 in Times & Transcript.
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