Functional Approach and diet for Reflux/GERD
Acid reflux, heartburn, GERD (gastroesophageal reflux disease)… call it what you will, the condition can cause chronic symptoms or mucosal damage due to the abnormal reflux of gastric or duodenal contents into the esophagus, or both.
GERD symptoms are one of the most common complaints to primary care doctors in Western countries, and GERD is a risk factor for erosive esophagitis, and Barrett’s esophagus (associated with an increased risk for cancer of the esophagus).
Because the condition is so common, its treatment has been the target of aggressive pharmaceutical marketing to healthcare professionals and consumers, and it’s worth big bucks. If you haven’t seen commercials for acid blocking and acid reducing medications like Zantac, Prilosec, Tagamet, or Pepcid, you’ve either been living under a rock, or simply don’t watch TV (in either case, I’m not judging!).
While prescription and over the counter acid blocking and acid reducing medications are often considered a first line of defense in the treatment of GERD, beware. Research shows evidence of harm from long term use of these medications including osteoporosis, depression, deficiencies of vitamin B12 and a variety of minerals, small intestinal bacterial overgrowth (SIBO), irritable bowel syndrome (IBS), pneumonia, and an increased risk of a variety of gut pathogens.
Another issue is respiratory reflux. Here, reflux of gastric contents can adversely affect the respiratory structures, and cause symptoms like chronic coughing, feeling like something is stuck in the throat, frequent throat clearing, bitter taste in the back of the throat, and difficulty swallowing. These symptoms can be caused by acid that is coming up, as well as from nonacid contents that are refluxed along with the acid from the gut. If you suffer from such symptoms, and find that acid reducing/blocking medications and the typical reflux treatments don't help much, it might be that the nonacid contents are causing the symptoms you are experiencing.
An approach that limits the use of these harmful medications, and treats the condition by addressing underlying causes of GERD is important. This approach includes diet, lifestyle, and other nutritional therapies that both address root causes, and help to restore normal intestinal function.
Conventional approaches do include diet and lifestyle changes, and these can be helpful for managing symptoms (keep in mind they may not necessarily address the underlying cause of the problem). Elimination of common dietary triggers is recommended as a first line intervention. These common triggers include:
- Spicy foods
- Fried foods
- Fatty foods
- Tomato based products
- Highly processed foods
- Junk food
- Carbonated beverages including fizzy water
If diet is poor, as is the case when following a standard American diet, switching to a diet of whole, real foods, that are low glycemic (don’t spike blood sugar too much), rich in plant foods (phytonutrients including antioxidants), and high in fiber often can result in symptom resolution.
In some people there are other dietary triggers, and these can be identified by using an elimination diet, or by testing for IgE and IgG food allergies and food sensitivities respectively. When removing commonly known dietary triggers doesn’t resolve symptoms, this can be a next step in addressing underlying food triggers for the problem.
Dietary guidelines for reducing reflux symptoms are individualized, so keep in mind some trial and error may be necessary before you determine your unique tolerances. In general, the following recommendations may help:
- Low fat and non fat milk and milk products may be better tolerated than full fat versions
- Choose plain breads and cereals as opposed to those made with high fat ingredients like croissants, doughnuts, and pizza
- Stick to fruit based desserts, or better yet fresh fruit to satisfy your sweet tooth, however citrus fruits and pineapple should be avoided
- Avoid heavy gravies, heavy cream, bacon, drippings from meat, and other high fat foods and condiments
- For protein sources, meats should be well cooked and lean so choose poultry, fish, lean pork, shellfish, dried beans and peas, and eggs
- Broths and homemade soups with lean meat and vegetables (except for tomatoes) are recommended
- Choose vegetables other than tomatoes, onions and garlic, and prepare them without added fat
- Spices are based on individual tolerance so you may need to experiment, however avoid chili, jalapeno, and vinegar and stick to salt, pepper, oregano, and sage for example
- Decaf coffee and teas, and non-mint teas may be tolerated
Lifestyle interventions include:
- Maintain a healthy weight
- Stop smoking
- Elevate the head of your bed when sleeping by 6 to 9 inches
- Don’t lie down after a meal, wait at least 3 hours
- Eat slowly and chew thoroughly
- Avoid tight fitting clothing, which may put pressure on your abdomen and LES (lower esophageal sphincter)
Medication begets medication. If you take multiple medications to treat your symptoms, you may have noticed that once you take one medication that helps with your symptoms, before you know it, new symptoms pop up, and then you are prescribed yet another medication for your new symptoms. Now you find yourself in a state of polypharmacy, making it impossible to determine if your new symptoms are actually new, or the result of drug interactions. There are many medications that can cause a worsening of GERD by altering gastric motility, contributing to dysbiosis, or reducing LES tone (the valve that stops gastric contents from coming back up into the esophagus becomes weakened) for example.
Medications that worsen GERD include:
- Sedative/hypnotics (benzodiazepines)
- Tricyclic antidepressants
- Calcium channel blockers
- Alpha adrenergic blockers
- Beta adrenergic blockers
- Sustained release potassium tables
There are nutritional strategies that can help reduce dose or eliminate the need for a variety of medications that are known to exacerbate GERD.
Low stomach acid, impaired gastric motility, poor diet, and polypharmacy are just some examples of issues that can lead to gut dysbiosis (abnormal gut bacteria). Abnormal gut bacteria and gut infections cause inflammation and increased intestinal permeability (leaky gut), which can cause and aggravate GERD.
The bacterium H. pylori has been identified as a cause of stomach ulcers, but also may be linked to reflux. H. pylori can be a benign cohabitator in the gut, but it can progress to symptomatic infection. Infection with H. pylori can lead to chronic gastritis. Chronic gastritis can progress to cancerous changes in intestinal tissue, and gastric cancer. Chronic gastritis can also lead to decreased production of gastric acid and therefore affect conditions like GERD and Barrett’s esophagus.
Interestingly, Barrett’s may be less common in those with H. pylori infection, and decreased acid production due to H. pylori infection may reduce the risk for Barrett’s esophagus.
Probiotics can be important for supporting the microbiome, and strains researched in Barrett's esophagus that have shown efficacy include B. longum and lactobacillus acidophilus.
Healing the gut and restoring normal gut function are cornerstones of overall health and wellness (70-80% of our immune system is located in our gut microbiome) and for addressing possible root causes of GERD. To accomplish this, we can look at a 5R approach:
- Remove – Identify and remove triggers for symptoms and intestinal malfunction (foods, medications, lifestyle habits, gut dysbiosis, detoxification for environmental toxins, etc.). If you take PPIs or H2 blocker medications to lower stomach acid, weaning may be necessary in that stopping the medications cold turkey can cause GERD rebound.
- Replace – Identify and replace where necessary factors for adequate digestion (enzymes, stomach acid, and prebiotic fiber [which is food for good gut bacteria and often Western style diets are void of this important dietary component]).
- Reinoculate – Add back in good gut bacteria in the form of probiotics from supplements and food sources (yogurt, sauerkraut, kombucha, kimchi, and kefir are examples).
- Repair – Heal the gut lining to protect against leaky gut (seen in autoimmune disease, where if you have an autoimmune condition, you have leaky gut).
- Rebalance – Stress management is an important piece of the puzzle for overall good health. Stress can lead to gut dysbiosis and leaky gut, which can make GERD worse.
If you suffer from GERD, addressing it from a root cause perspective using functional medicine and functional nutritional strategies can help resolve symptoms, and prevent downstream, potentially severe consequences. Functional approaches address the root cause of the problem by using natural means like diet, nutrient supplementation and lifestyle interventions.