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Most people will feel the “burn” of heartburn at some point. But if you have gastroesophageal reflux disease, or GERD, it’s more than an occasional discomfort. Do you need to avoid coffee? Hot wings? Chocolate? Would a special pillow help? Do drugs for GERD boost the risk of Covid-19? Here’s the scoop.
"While most people think that reflux occurs because of an overproduction in stomach acid, it’s actually the contrary—it’s having low amounts of stomach acid that leads to this problem,” claims mercola.com.
How does low stomach acid cause reflux? Mercola doesn’t say.
“There’s no data to support that theory,” says Scott Gabbard, a gastroenterologist at the Cleveland Clinic. “Reflux isn’t an acid problem. It’s a valve problem.”
A valve called the lower esophageal sphincter (LES), to be precise. It’s the junction between your esophagus and your stomach.
“It’s a ring of muscle that’s supposed to open when you swallow and then close,” Gabbard explains.
“If that valve opens when it’s not supposed to, you’ve got an open conduit for stomach contents to come back up into the esophagus.”
That’s reflux. It happens to everyone occasionally. Most of us don’t even feel it.
“But if the reflux becomes troublesome with symptoms like frequent heartburn, sour taste in the mouth, or regurgitation, we call it gastroesophageal reflux disease,” says Carolyn Newberry, a gastroenterologist and assistant professor of medicine at Weill Cornell Medical College.
And that’s not rare. “Around 20 percent of American adults have GERD symptoms on a weekly basis,” says Joel Rubenstein, research scientist at the Veterans Affairs Center for Clinical Management Research and director of the Barrett’s Esophagus Program at the University of Michigan Medical School.1
What causes the lower esophageal sphincter to relax?
In some cases, drugs like beta-agonists for asthma, calcium channel blockers for blood pressure, and benzodiazepines for anxiety may be to blame.
“And having elevated weight can do it,” notes Gabbard.
“Excess fat increases pressure in the abdomen, and it may actually have some hormonal effects that cause the sphincter to relax.”
GERD Grief
“The vast majority of people who have GERD will not have any long-term consequences,” says Rubenstein. But regularly bathing the esophagus in corrosive stomach acid can lead to serious complications in some people.
“People can develop esophagitis, which is inflammation in the esophagus,” says Newberry. In some cases, that can lead to esophageal ulcers.
Over time, acid exposure can cause the cells that normally line the esophagus to be replaced with cells that resemble the acid-resistant cells of the intestine. That condition—Barrett’s esophagus—occurs in roughly 15 percent of people with GERD.2
Barrett’s has no symptoms, and it can lead to a deadly cancer.
“People with Barrett’s have an estimated lifetime risk of esophageal adenocarcinoma of about 5 to 10 percent,” says Rubenstein.3 “And the fatality rate for adenocarcinoma is very high.” Most patients live for less than a year.
“Many people aren’t diagnosed until that cancer is late stage,” notes Rubenstein. “Most patients with Barrett’s will not progress to cancer,” he adds. “But we do endoscopies to identify those who will. Those who are screened tend to be diagnosed with an earlier-stage cancer and have better survival.”2
Trigger Warning
“There’s this thought that everybody with reflux needs to avoid coffee, chocolate, fatty foods, and all of the trigger foods on the lists that you find online,” says Newberry. (Others include citrus, tomatoes, spicy foods, mint, and carbonated drinks.)
But there’s no good evidence that eliminating those foods extinguishes the flames of heartburn. “And it makes for a pretty bland diet and can give people anxiety about what they’re eating,” says Newberry.
Some spicy or acidic foods may irritate the esophagus, and others—like chocolate, mint, coffee, and alcohol—may relax the lower esophageal sphincter.4 Carbonated drinks can increase bloating, which could also cause the sphincter to relax. But no one has done randomized trials to see if avoiding those foods curbs heartburn.
A few small trials have tested high-fat meals. “Fatty foods don’t drain from the stomach as quickly, which may lead the stomach contents to back up and induce reflux,” says Newberry.
In one study of 15 people with reflux, a meal with 600 calories and 20 grams of fat resulted in less acid in the esophagus and less heartburn than a meal with 1,100 calories and 65 grams of fat.5
“Whether consuming less fat or lower-calorie meals works over the long term hasn’t been well studied,” says Gabbard.
Where does that leave someone with heartburn?
“I don’t want to send the message that diet has no role in reflux, because it does for many people,” says Newberry. “But you need to figure out what your triggers are.”
“I tell people to cut out a food category in that list of triggers for a week or two, then to reintroduce it. If the food bothers you, avoid it. If it doesn’t, it’s probably not a culprit for you.”
Bye Bye, Burn
What else helps?
■ Lose excess weight. “By losing weight, particularly around the midsection, you’re decreasing the pressure in the abdominal cavity, which helps reduce reflux,” says Newberry.
In a study on nearly 30,000 Norwegians with reflux, those who dropped the most weight were twice as likely to report a drop in reflux symptoms as those who dropped the least.6
■ Eat earlier. Not eating for a couple of hours before bedtime may help, though the evidence is limited.
One study had 30 people with reflux eat a Big Mac, fries, and a soda either six hours or two hours before bedtime.7
“Eating within a couple of hours of going to bed increased nighttime reflux,” says Newberry.
■ Elevate your torso. “Nighttime reflux can be quite bothersome,” says Gabbard. “If you lie on your back, the valve is essentially level with the contents of the stomach. And if you lie on your right side, the valve is submerged.”
“Lying on your left side at an incline positions the lower esophageal sphincter straight up,” says Gabbard. “So we studied a pillow that essentially locks patients in that proper position.”
“In an earlier study in people without GERD, sleeping in that position decreased acid in the esophagus by 87 percent compared to lying flat.”8 (The study was funded by the pillow maker.)
In the more recent study, Gabbard instructed 25 patients with nighttime reflux to sleep on a special pillow (provided by the pillow maker) for at least 6 hours a night.9 After two weeks, “their score on a symptom scale improved by about 70 percent.”
But that study had no control group, so people may have felt better because they expected to or because symptoms tend to come and go over time.
Not ready to cough up $280 for a pillow? Try sleeping on your left side or on a bed wedge or setting the head of your bed frame on blocks.
Dropping Acid
“Unfortunately, we don’t have any FDA-approved medications that work on the valve,” says Gabbard.
“Our medicines either neutralize acid or decrease acid production. So you still have things refluxing up. But if there’s less acid in it, it’s not damaging the esophagus.”
■ Antacids like Tums, Alka-Seltzer, Mylanta, and Rolaids neutralize acid in the esophagus. They work quickly, but don’t last long, so they’re best for treating mild, occasional heartburn. (Alka-Seltzer tablets have roughly 600 to 1,200 milligrams of sodium per dose, so consider other antacids instead.)
■ Histamine-receptor antagonists (H2RAs) like Pepcid and Tagamet make the stomach produce less acid, and they last longer than antacids. H2RAs also work more quickly than proton pump inhibitors.
“But they can stop working after two weeks or less,” says Gabbard. “So they may be better for short-term use.”
In April, the Food and Drug Administration asked companies to stop selling the H2RA drug ranitidine (also known as Zantac), and advised consumers to throw out any unused ranitidine.10
Tests found that levels of a contaminant in ranitidine called NDMA increase over time and at higher-than-room temperatures. NDMA is thought to be a human carcinogen.
But if you’ve been taking ranitidine, don’t panic.
“A study presented at a conference this year looked at health records from 65 million patients,” says Gabbard. “It found no link between ranitidine use and cancer compared with people who took another H2RA.” Though the study hasn’t been published yet, its results are reassuring.
■ Proton pump inhibitors (PPIs) like Prilosec, Prevacid, and Nexium are the most potent acid blockers on the market. They not only treat symptoms like heartburn and regurgitation but also heal inflammation in the esophagus. And they may trim the odds that Barrett’s esophagus progresses to cancer.11
What about studies that found a slightly greater risk of kidney disease, dementia, and bone fractures in people who take PPIs?
“The problem is that those studies were observational, so there were many factors you can’t control for,” says Gabbard.
“Take 1,000 people on a PPI compared to 1,000 who aren’t, and the people on PPIs are overall in worse health. They have a worse diet, they’re more likely to have obesity, and so on.”
Researchers try to control for weight and other possible “confounders,” but they can’t eliminate them all.
“So you may conclude that PPIs cause, say, kidney disease when something else is responsible,” says Rubenstein.12 “The way to fix that problem is with a randomized controlled trial.”
In a recent trial, researchers randomly assigned roughly 17,500 people to take a PPI or a placebo every day. After three years, the PPI takers were no more likely than the placebo takers to have broken a bone or be diagnosed with pneumonia, chronic kidney disease, dementia, or a handful of other health problems.13
That’s reassuring to Rubenstein. “It is possible that PPIs have very weak effects on those outcomes, but I don’t think we are ever going to have a larger trial,” he says.
And for many people, the benefits far outweigh a small, unproven risk, says Gabbard. “Some patients, like those with ulcers and Barrett’s esophagus, may need to be on PPIs for life.”
The trial did find a slightly higher risk of gastrointestinal infection in PPI takers than in placebo takers.
“The main reason we have acid in our stomach is to kill the microorganisms that we ingest,” Rubenstein explains. “So decreased stomach acid may predispose a person to contract a GI infection.”
Could that explain the results of an online survey of roughly 53,000 Americans who reported having symptoms like abdominal pain, heartburn, or regurgitation?14
“Those taking a PPI once daily were roughly twice as likely to report having a positive Covid-19 test,” says Rubenstein. “And those who were taking twice daily PPIs were roughly four times more likely to report a positive Covid-19 test.”
“The study was observational, so it can’t prove that PPIs increase your risk of getting Covid-19,” he cautions. And with an online survey, researchers can’t confirm what people report.
While Rubenstein isn’t ignoring the results, “I don’t think they’re a reason for people to just stop taking their PPIs. It’s only one study.”
Covid-19 or not, “patients should make sure that they have a good reason for taking a PPI,” says Rubenstein.
“They are wonderfully effective drugs, especially for people with Barrett’s esophagus. But they are overused. If you don’t have Barrett’s, you can try stopping the PPI or using an H2 blocker, which is less potent. If your symptoms go away, you don’t need to be on the PPI.”
1Gut 63: 871, 2014.
2Am. J. Gastroenterol. 111: 30, 2016.
3Gastroenterology 149: 302, 2015.
4J. Thorac. Dis. 11: S1594, 2019.
5Clin. Gastroenterol. Hepatol. 5: 439, 2007.
6Am. J. Gastroenterol. 108: 376, 2013.
7Am. J. Gastroenterol. 102: 2128, 2007.
8J. Clin. Gastroenterol. 49: 655, 2015.
9Dis. Esophagus 30: 1, 2017.
10 fda.gov/news-events/press-announcements/fda-requests-removal-all-ranitidine-products-zantac-market.
11Lancet 392: 400, 2018.
12Gastroenterology 152: 706, 2017.
13Gastroenterology 157: 682, 2019.
14Am. J. Gastroenterol., in press.