GERD evidence for the solution #2

A diet restricting carbohydrates (particularly complex carbohydrates such as bread, pasta, cereal) and sugar resolved the severe reflux my daughter had been experiencing for years.  Her modified diet–which emphasizes fruits, vegetables, lean meat, fish, eggs, yogurt, cheese and nuts–sounds like the healthy diet recommended by health experts for years, but is in fact quite different from the USDA’s food pyramid dietary recommendations (which include a heavy dose of breads and grains).

To date, there is support in the scientific literature to support this approach to the treatment of GERD.  In 2006, Shaheen et al conducted a study which demonstrated that a very low carbohydrate diet (<20g/day) resolved reflux symptoms in obese patients.  Similarly, Westman and colleagues in 2001 described relief of reflux in patients who restricted carbohydrates, though this was a small observational report.  Another study from 2002 (Troncone et al) demonstrated endoscopic and histologic resolution of reflux esophagitis in neurologically impaired children who were changed to an amino acid based formula.  These findings are not conclusive, but certainly support the idea that diet (specifically carbohydrates) may play a role in the development of GERD.

The question remains:  why?  Some researchers believe that the gastrointestinal dysfunction resulting in GERD may have to do with lower esophageal sphincter (LES) dysfunction and small intestinal bacterial overgrowth (SIBO).  Despite the fact that physicians are currently treating reflux with acid reducing medication, the scientific community seems to be looking into the complex relationship between hormones, obesity, gastrointestinal flora, diet and LES dysfunction–not high acid in the stomach.  In theory, ingestion of large amounts of carbohydrates can alter the population of gastrointestinal (GI) microflora, resulting in malabsorption and production of gas.  This bacterial overgrowth is often observed in patients with irritable bowel syndrome (IBS),  those who have undergone GI surgery or who have GI motility disorders from diabetes or scleroderma, for example.  This SIBO can result in bloating, fullness, diarrhea and possibly reflux as a result of LES dysfunction partly due to excess pressure from gas producing bacteria.  This relationship is still under investigation, and further research is necessary to support this theory.

for sources, please see REFERENCES

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GERD evidence for the solution #1

When I mentioned my daughter’s issues with reflux to a friend of mine, who happens to be a speech pathologist, she said, “Oh, a low carb diet–that’s a basic principle in treating patients with reflux.  We learned that early on.”  Why then, does the medical community not prescribe this “well known” approach to their patients with reflux?  My theory is that most physicians (1) are unaware, (2) lack the time and energy to provide dietary counseling, and (3) we are accustomed to prescribing medications.

The usual lifestyle changes recommended for reflux/ GERD include weight loss and avoiding alcohol & tobacco, coffee/caffeine, spicy foods, chocolate, mint and carbonated beverages.  To date, only weight loss and head of bed elevation (for nocturnal reflux) have been shown to reduce reflux in randomized controlled trials.  Studies investigating the other lifestyle changes did not demonstrate any improvement in reflux symptoms, though it is generally recommended that patients monitor their own response to different foods and tailor their diet accordingly.  For many people with reflux, weight loss may effectively treat the condition, eliminating the need for medication–though this is not easily accomplished.  Obesity/overweight is thought to cause reflux by increasing intra-abdominal pressure, increasing the likelihood of a hiatal hernia (where part of the stomach pouches above the diaphragm), and affecting hormonal factors, which may reduce lower esophageal sphincter tone (LES, the muscle that keeps stomach contents from refluxing back into the esophagus).  In a study by Jacobson and colleagues, it was shown that losing just 10-15 pounds decreases heartburn symptoms by 40%, and the converse is true–if a normal weight patient gains 10-15 pounds, their likelihood of reflux symptoms is expected in increase by about 40%.  So it should be no surprise that since 20-30% of the US population is considered obese, the sales of proton pump inhibitors have reached $13.9 billion in 2008, making them the 3rd largest selling class of drugs in the United States.  According to their website (www.prilosecOTC.com), as of 2008, over 11 million patients have used Prilosec alone to treat heartburn.  There have been concerns voiced by physicians about the overuse of these drugs, particularly the length of treatment (the FDA has only approved use of Prilosec OTC for 14 consecutive days).  Unfortunately (but fortunately for the pharmaceutical companies), these drugs are being prescribed by physicians and taken by patients over the counter indefinitely for a symptoms that will not resolve after 14 days of acid suppression.

Drugs should not be considered a “cure” for reflux–the causes must be addressed in every patient.  In the case of my daughter, a very low carbohydrate diet was the solution.  For other patients, a modest amount of weight loss may provide resolution of their heartburn symptoms.  Based on my own research, I believe that a trial of a “specific carbohydrate diet” (avoiding bread, pasta, sugars and focusing on vegetables, fruits, meat, poultry, fish, eggs, yogurt, cheese, nuts) may prove helpful for many GERD sufferers.  If followed properly, this diet would not only promote weight loss in those who may need to lose a few pounds, but also improve their reflux symptoms–for reasons I discuss in GERD evidence for the solution #2.

for recipe ideas, please see RECIPES

for sources, please see REFERENCES

GERD why acid suppression is wrong

When the powerful gastric acid reducing class of drugs known as proton pump inhibitors (PPIs) were introduced to the world of modern medicine, they were used primarily as short term treatment of patients with severe peptic ulcer disease.  These “PPIs” were considered wonder drugs—they had an extremely safe profile, few drug interactions and were well tolerated (or so we thought at the time).  Once they were made available in pill form, I witnessed firsthand how they blossomed to become one of the most widely prescribed medicines on earth.  These potent drugs were no longer reserved for the very ill, but were being prescribed as a prophylactic medicine—given to a healthy patients to prevent complications such as gastritis during a hospital admission or in the outpatient setting for those with even mild reflux (with the hopes of preventing esophageal cancer).   As physicians we were blinded by the popularity of these drugs, believing that they could do no harm since they seemed so well tolerated by patients.  It was not until my daughter had to take one of these drugs that I began to think about the implications and widespread reach of these drugs on our population as a whole.

Why is stomach acid so bad?  It can be harmful in rare circumstances in which the body produces too much acid (e.g. Zollinger-Ellison Syndrome) or if a patient has an ulcer that needs to heal.  As humans, the complex and finely tuned physiology of our bodies has evolved over millions of years to include the protective and vital acidic environment in our stomachs.  This is not accidental—our body needs these acidic juices produced by parietal cells in the lining of our stomach to digest food, protect us from potentially harmful microbes and communicate via complex feedback mechanisms with the rest of our digestive tract to optimize gut motility and nutrient absorption.  In fact, treatment with a PPI has been associated with infections (pneumonia, c. difficile colitis, possibly common viruses), nutritional deficiencies (such as magnesium, iron, B12), osteoporosis, interstitial nephritis, gastric polyps and possibly small intestinal bacterial overgrowth (SIBO).  Small intestinal bacterial overgrowth has been implicated in the development of irritable bowel syndrome, lower esophageal sphincter (LES) dysfunction (which causes reflux) as well as interfering with intestinal permeability—which itself has been linked in several studies to the development of autoimmune diseases such as Celiac Disease, Type 1 Diabetes and inflammatory bowel disease.

Since the pharmaceutical companies have initiated direct to consumer marketing of these agents and convinced both physicians and patients that PPIs are unquestionably safe for long term use, we will soon observe the negative effects of our flippant use of these powerful drugs globally.  Both physicians and patients should exercise caution and common sense when using these acid reducing medications, and frequently reassess the need to continue these medications.

NOTE:

FDA urges healthcare providers and patients to report any adverse events or side effects that may be associated with the use of proton pump inhibitors to FDA’s MedWatch adverse event reporting program by phone at 1-800-F-D-A-ten-88 or by the Internet at  www.FDA.gov/medwatch        

To read more about how to treat reflux effectively, read the entries: GERD the solution and GERD evidence for the solution.

To read about why I believe that acid reducing drugs may not have any impact on your risk of developing esophageal cancer, read GERD drugs no help at all?

 for sources, please see REFERENCES

GERD the solution

Desperate parents take desperate measures if their children are suffering.  My daughter who had gastroesophageal reflux disease (GERD) for years was truly suffering, mostly as a result of the medical treatment she had been receiving—namely the PPIs (proton pump inhibitors Prilosec and Prevacid).  She had not been sleeping, she could barely focus in school, was experiencing daily headaches, caught every virus that went through school, had a poor appetite and then developed diarrhea.  After discontinuing the PPI, she became a new person—full of life, color in her cheeks, cheerful mood and had a healthy appetite once again.  I decided to never, ever give anyone in my family that class of medication again!

But what about the reflux?  I became a dietary tiger mom and took away her precious pasta, bread and sugar.  Within four days, her gastrointestinal symptoms were gone—no more bloating, gas, abdominal discomfort, and no reflux.  Her energy was also improved.  I kept track of all that she ate in a diet journal, tracking her emotions, energy, GI symptoms and clearly noticed that when she ate pasta, bread or sugar her reflux symptoms returned.  She has maintained the reflux free diet quite well and has only complained a few times when birthday cake or another special occasion arises.  She knows very well at the age of 9 that if she were to eat these foods, she will suffer the consequences.  Of course, I changed the way our entire household ate—pretty much eliminating pasta and bread (and both mom and dad have lost a few pounds as a result of that change alone!).  Large piles of fruit and vegetables have taken over our kitchen and smoothies have become a regular treat for all of the kids.

As a result of my attempts to adopt a mostly vegetarian diet in our family (for health and environmental reasons), I had accidentally shifted my daughter’s diet to include primarily pasta and whole grains. In order to set things right, I acted in defiance of the USDA’s food pyramid schema—and prioritized fruit, vegetables, fish, meat and some dairy while minimizing grains.  This worked like a charm for her and she continues to feel healthy and happy, reporting no reflux at all!  I’m not certain why this approach worked, but based on what I’ve read in recent scholarly medical articles on the subject, I believe that she had a perfect storm:  excess refined carbohydrates (daily pasta, bread, sugar) and acid suppression.  This may have resulted in overgrowth of unfavorable bacteria in her gut and malabsorption, and possibly vitamin/mineral deficiency exacerbating matters.  Luckily, these all seemed to resolve with elimination of certain carbohydrates (specifically breads, pasta, crackers) and probiotics to repopulate her gut with favorable microflora.

Of note, my daughter did have negative tests for gluten sensitivity (Endomysial IgA, Transglutaminase IgA)–but she may have Celiac Disease or non- Celiac gluten sensitivity…we’ll see.

To read more, look for GERD evidence for the solution and a future entry on PROBIOTICS.


GERD my daughter

My daughter has suffered from severe gastroesophageal reflux disease (GERD) since she was born.   We thought that the infantile spitting up and the constant vomit smell on her clothes would eventually go away as she grew older.  So it was not until last year, at the age of 9, that we finally brought her to a gastroenterologist for further evaluation.  The physician started her on omeprazole (Prilosec), a proton pump inhibitor (PPI)—a potent gastric acid suppressing medication.  My husband and I (also a physician) were quite hesitant to start a growing child on a medication that would significantly suppress her gastric acid production with no end point.  In the adult world, I had no problem prescribing this class of medication (with the hope of ultimately preventing esophageal cancer), but in a child it somehow seemed wrong.

While taking the PPI, my daughter improved with regard to her reflux symptoms, but began experiencing other problems, in particular difficulty sleeping (which we thought was due to the reflux itself), lethargy, and a depressed mood (which is difficult to tease out the cause in a 9 year old girl!).  We decided to stop the medication, and noticed these side effects disappear.  We wanted to know why she was experiencing the reflux, and treat that, as opposed to treating the symptoms.  She underwent an upper endoscopy as well as a gastric emptying study, which were both normal.  So we were stuck—do we continue the medication indefinitely or let her suffer and see what happens?   After enduring a few months of severe reflux off medication, we brought her to her pediatrician, who recommended we try a different PPI, lansoprazole (Prevacid).

Again, the reflux resolved but newer, more severe side effects cropped up.  This time she experienced daily headaches, insomnia, depressed mood and diarrhea after a few weeks on Prevacid.   I stopped the medication immediately after my daughter informed me that she was having diarrhea.  In the medical literature, there were warnings about clostridium difficile colitis and use of PPI’s, so clearly I was alarmed.   Within 2-3 days of discontinuing the medication, her diarrhea, headaches, insomnia and poor mood completely resolved.  She returned to being a normal happy 9 year old girl.  After realizing that these medications were causing significant morbidity in my otherwise healthy child, I decided to look for a cure to her gastroesophageal reflux…and I think I have found it (at least for my dauthter)!

To read more, see GERD the solution