It seems like almost everyone is diagnosed with gastroesophageal reflux disease, or at least it did in the last few weeks in my practice. I exaggerate, of course, but the pharmaceutical companies do an excellent job of making it appear that way with advertising. Wherever you look there is an advertisement for the treatment of heartburn or indigestion, both of which are related to reflux disease.
GERD affects as much as 40 percent of the U.S. population (Gut 2005;54(5):710; Gut 2011 Dec 21). Its incidence is on the rise, with an increase of nearly one-third over the last decade (Gut 2011 Dec 21).
Reflux disease typically results in symptoms of heartburn and regurgitation brought on by stomach contents going backward up the esophagus, according to the definition by PubMed Health. For one reason or another, the lower esophageal sphincter, the valve between the stomach and esophagus, inappropriately relaxes. No one is quite sure why it happens with some people and not others. Of course there is a portion of reflux that is physiologic (normal functioning), especially postprandial, that is, after a meal (Gastroenterol Clin North Am. 1996;25(1):75).
The risk factors for GERD are diverse. They range from lifestyle, as in obesity, smoking cigarettes and diet; to medications, such as calcium channel blockers and antihistamines; to other medical conditions, like hiatal hernia and pregnancy (emedicinehealth.com). Diet issues include triggers like spicy foods, peppermint, fried foods, chocolate, etc.
Smoking and salt’s role
A recent study showed that both smoking and salt consumption added to the risk of GERD significantly (Gut 2004 Dec; 53:1730-5). The risk increased 70 percent in people who smoked. Surprisingly, people who used table salt regularly saw the same increased risk as seen with smokers.
Treatments vary, from lifestyle modifications for the “mild” to medications or surgery for the severe, noticeable esophagitis. The goal is to relieve symptoms and prevent complications, such as Barrett’s esophagus, which could lead to esophageal adenocarcinoma. Fortunately, Barrett’s esophagus is not common and adenocarcinoma is even rarer.
The most common and effective medications for the treatment of GERD are H2 receptor blockers (e.g., Zantac and Tagamet), which partially block acid production; and proton pump inhibitors (e.g., Nexium and Prevacid), which almost completely block acid production (Gastroenterology. 2008;135(4):1392). Both classes of medicines have two levels: over the counter and prescription strength. You need to tell your doctor if you have taken these medications, even those that are OTC. There are potential side effects with these drugs, especially proton pump inhibitors.
There are a number of modifications that can improve the situation, such as raising the head of the bed about 6 inches, not eating prior to bedtime and obesity treatment, to name a few (Arch Intern Med. 2006;166:965-971).
In the same study already mentioned with smoking and salt, both fiber and exercise had the opposite effect, that is reducing the risk of GERD (Gut 2004 Dec; 53:1730-5; Gut 2005;54:11-17). This was a prospective (forward looking) trial. The analysis by Journal Watch suggests that the fiber effect may be due to its ability to reduce nitric oxide production, a relaxant for the lower esophageal sphincter (JWatch Gastro. Feb. 16, 2005).
In one study, obesity exacerbated GERD. What was interesting about the study is that researchers used manometry, which measures pressure, to show that obesity increases the pressure on the lower esophageal sphincter significantly (Gastroenterology 2006 Mar; 130:639-49). Intragastric (within the stomach) pressures were higher in both overweight and obese patients on inspiration and on expiration, compared to those with normal BMI. This is yet another reason to lose weight.
Eating prior to bed, myth or reality?
We have all heard that it’s better to avoid eating late. But is this a myth?
Though it may be simple, it is one of the most powerful modifications we can make to avoid GERD. There was a study that showed a 700 percent increased risk of GERD for those who ate within three hours of bedtime, compared to those who ate four hours or more prior to bedtime.
Of note, this is 10 times the increased risk of the smoking effect (Am J Gastroenterol. 2005 Dec;100(12):2633-6). Therefore, it is best to not eat right before bed and to avoid “midnight snacks.”
Although, there are number of ways to treat GERD, the most comprehensive have to do with modifiable risk factors. Drugs have their place in the arsenal of choices, but lifestyle changes are the first and most effective approach in many instances.
Next week, I will discuss the pros and cons of proton pump inhibitors, as more and more studies are published on the role of these drugs.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to www.medicalcompassmd.com and/or consult your personal physician.