Integrative Approaches to Acid Reflux

Now that I’m in my later years (insert sarcasm here), I find myself having bouts of gastric reflux symptoms with certain lifestyle indiscretions (think: alcohol and dietary deviations). I’m grateful my symptoms are only transient, as it was one of the most common and troublesome things I saw in my primary care rotation. And lots of patients are on heartburn medications, usually in the form of PPIs (proton pump inhibitors) like Omeprazole, aka Prilosec.

Starting from the basics, let’s first cover what reflux is. There isn’t a one size fits all definition, as there can be different reasons for the same symptoms. It can arise from excessive stomach acid, but can also take flight in the form of a relaxed gastroesophageal sphincter, meaning the valve that keeps your stomach contents in your stomach becomes a little wobbly and the acid moves into the esophagus, creating a burning sensation. Feelings of “heartburn” also come in all different sizes. They can range from stomach pain to coughing, wheezing, asthma, difficulty swallowing, voice hoarseness, pain with swallowing, and sometimes (though less commonly) recurrent pneumonia ( 2).

As mentioned briefly above, there are a variety of treatments for reflux. Here are the common ones:

• Tums (calcium carbonate): buffer and neutralize gastric acid in the stomach / esophagus
• Maalox (aluminum hydroxide + magnesium hydroxide): bind and neutralize excess acid in the stomach
• Ranitidine (zantac) – an H2 blocker: blocks a receptor in the stomach called H2, which stops cells from producing excessive stomach acid (efficacy decreases with long-term use)
• Omeprazole (Prilosec) – a protein pump inhibitor (PPI): bind to and block acid producing pumps in the stomach (no change in efficacy with duration of usage)

            For run of the mill heartburn, the order of intervention usually ranges from lifestyle changes –> H2 blockers –> PPIs. PPIs are meant to be used as a short-term treatment to quell the symptoms of severe heartburn as lifestyle interventions are used alongside it. The goal is to eventually taper off this drug. The literature has demonstrated that all things considered it’s a pretty safe drug, though it does come with side effects. Their intended use is to reduce the production of stomach acid, which can have some negative effects with overuse, something called hypochloridria (reducing stomach acid to the point of having too little). Some studies suggest this can lead to small intestine bacterial overgrowth, or SIBO, because the acid that was meant to be protective has been decreased, leading to the opportunity for bacteria to overpopulate where they shouldn’t be ( 1 ). Further, there are some studies that link B12 deficiency with long term use of PPIs in older adults, as well as other nutrient deficiencies, though the data on this is pretty shaky. There are also a few studies that link long-term use with hip fracture in the elderly, though again this is quite rare and there is no overall consensus in the literature ( 8 ). Others adverse events include increased “community-acquired pneumonia; Clostridium difficile colitis; microscopic colitis; vitamin/mineral/electrolyte deficiencies; fundic gland polyps in the stomach; and rebound acid secretion.” Most of these reports, however, were population-based, rather than carefully designed prospective trials. They lacked clear evidence of cause and effect and many showed only modest risk ( 6 ). Other side effects include constipation, headache, nausea, and diarrhea, which aren’t common but can occur ( 2 ).

In addition to side effect profile, these medications sometimes just don’t work for all patients. In a multicenter, randomized, double-blind, placebo-controlled study (meaning the gold standard for how studies should be performed), omeprazole 20 mg once daily was compared with placebo for controlling symptoms of 209 patients with non esophageal reflux. At week four, 57% of patients in the omeprazole group were free of heartburn, 75% were free of acid regurgitation, and 43% were completely asymptomatic. ( 6 ) These stats look pretty good, but on the flip side (hate to play the pessimism card), if only 43% were completely asymptomatic, then 57% still had symptoms in some shape or form.

Being a champion of realism, these drugs serve a purpose for severe symptoms, or for individuals with diagnoses like Barrett’s esophagus or ulcer related diseases on NSAIDs. They can act as a bridge while other interventions are put in place to get to the root cause of the issue. And are 100% necessary for certain patients with the above listed diagnoses to help prevent stomach ulcers.

There are a few case studies in the literature for patients who took more integrative approaches to resolution of heartburn symptoms.

In one case study, a patient presented with constipation, reflux, wheezing, burping, and upper stomach pain. The provider tested for SIBO, which was positive. The patient was then started on rifaximin (an antibiotic for SIBO) as well as a low FODMAP diet with good results. Low FODMAP is typically started for those with IBS symptoms like bloating and constipation, which this patient also had. A nutrition consultant prescribed some gut healing modalities for the patient as well, including L-glutamine supplement in smoothies, B12 and magnesium supplementation, stress management tools, aloe vera juice, and increasing fiber in the diet. The patient experienced good results with resolved symptoms ( 1 ).

While there was a positive outcome, this study comes with many limitations. For one, the sample size was 1, so it doesn’t translate to the general population. The patient in the study also wasn’t consistent with some of the interventions, so compliance was an issue. Furthermore, the patient had symptoms of both constipation and heartburn, so it’s possible that the constipation was the causative factor of the heartburn and resolution of this led to resolution of heartburn-like symptoms. Finally, most of the interventions were introduced together, so it’s impossible to know which (if any) were the most effective, or if all of them together did the trick in a synergistic way.

            In another case study, an 11 year old child was treated for reflux, accompanied with symptoms of constipation, abdominal pain, and chronic nausea. She was started on a PPI (lansoprazole), miralax (a laxative), with dairy restriction and increased her physical activity. She also had an endoscopy at this time (a camera that goes down the esophagus to rule out any gross abnormalities) which revealed normal anatomy. After a trial of lansoprazole for one month, this medication was discontinued due to limited efficacy. She underwent acupuncture and gut-directed hypnosis sessions as well as incorporated ginger chews, ginger tea, and licorice supplementation into her diet. After acupuncture, hypnotherapy and dietary changes, she experienced resolution of symptoms ( 2 ). Obvious limitations mimic the above study. It was a case study without any randomized control with sample size of one and questionable compliance to interventions.

I include both case studies above because I love the marriage of eastern and western medicine modalities. Starting with pharmaceuticals to help tackle the immediate and very troublesome symptoms, followed by making lifestyle changes and slowly transitioning off of medicine. Obviously this is a very personal choice and there is no “right” choice, but I’ve included a few more research backed diet and lifestyle changes that can be trialed when heartburn strikes.

Dietary interventions

• Avoid fatty foods, spicy, acidic, chocolate, tea, mint, carbonated / caffeinated beverages ( 3 )
  • I’d like to note that “fatty” foods are usually mentioned as synonymous to processed / fast foods. NOT good fats like salmon and avocado. Those can stay.
• Some patients experience reflux as a response to food sensitivities, so it may be useful to try an elimination diet of the top allergens (i.e. dairy, wheat, egg, nuts, and fish). Celiac screening may also prove beneficial. ( 3 )
• Treating constipation can improve symptoms. ( 3 )
• There is equivocal evidence for: exercise, alcohol reduction, smoking reduction, weight loss and fiber rich foods to reduce heartburn ( 3 )
• There is weak evidence for avoiding individual foods, alkaline water, and upper esophageal sphincter devices ( 3 )
  • This may be because of difficulty conducting controlled individual food avoidance trials. Because of these limitations, avoiding common trigger foods like those listed above is still highly recommended ( 3 )
• Timing of meals: avoid eating 2-3 hours before bed, and try eating larger meals fewer times per day rather than multiple meals per day. Furthermore, avoid fasting and skipping meals.
• It’s advised to eat >3 meals per day rather than one big meal in the evening ( 7 )

Lifestyle interventions

• Psychosocial stressors may exacerbate symptoms (mind-gut connection), and therefore mindfulness meditation, guided imagery, biofeedback, clinical hypnosis, and yoga have shown some efficacy ( 2 )
  • Interestingly, patients who respond less well to PPIs are more likely to suffer from psychological distress, so it may prove more useful to tackle psychological disturbances than to make drastic changes in diet ( 4 )
    • In a randomized controlled trial, patients with nonerosive GERD were assigned diaphragmatic breathing exercises for 30 min per day. At the end of 4 weeks, those practicing had decreases in esophageal acid exposure by esophageal manometry testing in addition to improvements in quality of life. At 9 months, those still practicing had a decreased usage of a PPI. ( 4 )
  • CBT, hypnotherapy, biofeedback and muscle relaxation have been shown to improve GERD solely or in combination with medical / surgical anti-reflux treatment ( 5 )
• Weight loss may also help with symptoms, as increased intragastric pressure can cause decreased lower esophageal sphincter pressure, therefore increasing esophageal acid exposure ( 2 )
• There is strong evidence for head of bed elevation 6-10 inches before sleep ( 3 )
• Some report wearing looser fitting clothing can be helpful
• Acupuncture is useful:
  • 2 studies from China suggested that acupuncture reduced esophageal acid and bile reflux. Interestingly those that were on a PPI and added in acupuncture had more successful results than those who simply doubled their PPI usage ( 4 ) ( 5 )

I also included a few researched supplements I found in the literature. I would like to first issue out the disclaimer that supplements are definitely not a one size fits all approach. They are not FDA regulated and not all are sourced with integrity. Definitely talk to your healthcare provider prior to starting any of the below and be judicious with brand choice.

Supplements / herbs to avoid

• Peppermint: Some studies report it can lower esophageal sphincter pressure, which can allow gastric acid to rise into the esophagus, creating reflux symptoms ( 2 )

Helpful supplements / herbs

• Ginger and licorice root have been show to help with gastric inflammation ( 2 )
• Melatonin may have gastroprotective effects to “regulate GI motility, modulate visceral sensation and produce anti-inflammation response” ( 2 )
  • One study found 3mg melatonin at bedtime was effective in treating GERD symptoms over placebo, though not as effective as omeprazole (a PPI). This herb can help with lower esophageal sphincter pressure. (side effects include early morning grogginess, somnolence, dizziness, headaches) ( 2 )
• Aloe vera, licorice root, marshmallow root, and slippery elm root are commonly used demulcent herbs, meaning they coat the lining of the stomach similar to the mechanism of Maalox. They repair the mucosa by reducing irritation of the bowel and decreasing sensitivity to gastric acid ( 3 )
• Other herbs, including Iberogast, ginger, and D-limonene, have been found in clinical studies to reduce gastric acidity, improve gastric emptying, and promote gastric healing ( 3 )
• I couldn’t find any evidence based research for this, but have heard anecdotal stories about apple cider vinegar having positive effect
• While the data is most certainly not sound (in fact many studies conflict each other on this), some researchers suggest prolonged PPI therapy can result in poor absorption of essential nutrients, including calcium, iron, magnesium, and vitamins. Supplementation of these nutrients may be necessary to prevent long-term adverse sequelae ( 3 )

Have you tried any of these interventions? Leave it in the comments below!

Always consult your provider when going on or off a medication. There is oftentimes a tapering process needed in order to manage symptoms and side effects. And if symptoms persist despite interventions, work with your physician to consider endoscopy or other screening mechanism.

Sources

( 1 ) Kines, K. and Krupczak, T. (2016). Nutritional Interventions for Gastroesphageal Reflux, Irritable bowel syndrome, and hypoclorydria: A case report. Integrative Medicine, 15(4), 49-53.

( 2 ) Yeh, A.M and Golianu, B. (2014). Integrative treatment of reflux and functional dyspepsia in children. Children, 1(2), 119-133. Doi: 10.3390/children1020119

( 3 ) Jamal, N. and Wang, B. 2019 (ed.). Laryngopharngeal reflux disease: Integrative approaches. doi: 10.1007/978-3-030-12318-5

( 4 ) Dossett, M.L, Cohen, E.M., & Cohen, J. (2017). Integrative medicine for gastrointestinal disease. Integrative Medicine, 44(2), 265-280.

( 5 ) Maradey-Romero, C., Kale, H., & Fass, R. (2014). Nonmedical therapeutic strategies for nonerosive reflux disease. Journal of Clinical Gastroenterology, 48(7), 584-589. Doi: 10.1097/MCG.0000000000000125

( 6 ) Fass, R. (2012). Alternative therapeutic approaches to chronic proton pump inhibitor treatment. Clinical Gastroenterology and Hepatology, 10(4), 338-345. Doi: 10.1016/j.cgh.2011.12.020

( 7 )  Jarosz, M. & Taraszewska, A. (2014). Risk factors for gastroesphageal reflux disease: the role of diet. PRz Gastroenterology, 9(5), 297-301. Doi:  10.5114/pg.2014.46166

 

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