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acid reflux

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PPIs may affect vitamin absorption and increase fracture risk

By David Dunaief, M.D.

Dr. David Dunaief

Who hasn’t had “reflux” or “heartburn” after a meal? Most of us have experienced these symptoms on occasion. When they are more frequent, you should see a physician to rule out serious causes, like Gastroesophageal reflux disease (GERD).

GERD is estimated to affect between 18.1 and 27.8 percent of U.S. adults, although the real number might be higher, since many self-treat with over-the-counter (OTC) medications (1).

Proton pump inhibitors (PPIs), first launched in 1989, have become one of the top-10 drug classes prescribed or taken OTC. Familiar OTC brands include Prilosec (omeprazole), Nexium (esomeprazole), and Prevacid (lansoprazole), among others. They are also available by prescription.

PPIs are not intended for long-term use, because of their robust side effect profile. The FDA currently suggests that OTC PPIs should be taken for no more than a 14-day treatment once every four months. Prescription PPIs should be taken for 4 to 8 weeks (2).

However, their OTC availability can lead patients to take them too long or too often to manage reflux rebound effects when PPIs are discontinued without physician oversight.

Among potential associations with long-term use are chronic kidney disease, dementia, bone fractures, increased cardiac and vascular risks, vitamin malabsorption issues and Clostridium difficile, a bacterial infection of the gastrointestinal tract.

Do PPIs affect the kidneys?

In two separate studies, results showed that there was an increase in chronic kidney disease with prolonged PPI use (3). All patients started the study with normal kidney function, based on glomerular filtration rate (GFR). In the Atherosclerosis Risk in Communities (ARIC) study, there was a 50 percent increased risk of chronic kidney disease, while the Geisinger Health System cohort study found there was a 17 percent increased risk.

The first study had a 13-year duration, and the second had about a six-year duration. Both demonstrated modest, but statistically significant, increased risk of chronic kidney disease. But as you can see, the medications were used on a chronic basis for years. In an accompanying editorial to these published studies, the author suggests that there is overuse of the medications or that they are used beyond the resolution of symptoms and suggests starting with diet and lifestyle modifications and a milder drug class, H2 blockers (4).

Do PPIs increase dementia risk?

A German study looked at health records from a large public insurer and found there was a 44 percent increased risk of dementia in the elderly who were using PPIs, compared to those who were not (5). These patients were 75 or older. The authors surmise that PPIs may cross the blood-brain barrier and potentially increase beta-amyloid levels, markers for dementia. With occasional use, meaning once every 18 months for a few weeks to a few months, there was a much lower, 16 percent, increased risk.

The researchers also suggested that PPIs may be significantly overprescribed in the elderly. The research was not perfect. For example, researchers did not consider high blood pressure, excessive alcohol use or family history of dementia, all of which can influence dementia occurrence.

Do PPIs increase fracture risk?

In a meta-analysis of 18 observational studies, results showed that PPIs can increase the risk of hip fractures, spine fractures and any-site fractures (6). Interestingly, when it came to bone fractures, it did not make a difference whether patients were taking PPIs for more or less than a year.

They found increased fracture risks of 58, 26 and 33 percent for spine, hip and any-site, respectively. It is not clear what may potentially increase the risk; however, it has been proposed that it may have to do with calcium absorption. PPIs reduce acid, which may be needed to absorb insoluble calcium salts. In another study, seven days of PPIs were shown to lower the absorption of calcium carbonate supplements when taken without food (7).

PPIs & vitamin absorption

In addition to calcium absorption issues, PPIs may have lower absorption effects on magnesium and B12. In one observational study, PPIs combined with diuretics caused a 73 percent increased risk of hospitalization due to low magnesium (8). Diuretics are commonly prescribed for high blood pressure, heart failure and swelling.

Another study’s results showed long-term use of over two years increased vitamin B12 deficiency risk by 65 percent (9).

The bottom line

It’s best if you confer with your doctor before starting PPIs. You might benefit from a milder medication, such as an H2 blocker (Zantac, Pepcid). In addition, PPIs can interfere with other drugs you are taking, such as Plavix (clopidogrel).

Even better, start with lifestyle changes. Try not eating later at night, raising the head of the bed, losing weight and stopping smoking, if needed, before you consider medications (10).

If you do need medication, recognize that PPIs don’t give immediate relief and should only be taken for a short duration to minimize their side effects.

References:

(1) nih.gov. (2) fda.gov. (3) JAMA Intern Med. 2016;176(2). (4) JAMA Intern Med. 2016;176(2):172-174. (5) JAMA Neurol. online Feb 15, 2016. (6) Osteoporos Int. online Oct 13, 2015. (7) Am J Med. 118:778-781. (8) PLoS Med. 2014;11(9):e1001736. (9) Mayo Clinic Proceedings. 2018 Feb;93(2):240-246. (10) Am J Gastroenterol 2015; 110:393–400.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Long-term PPI use increases serious risks. Stock photo

By David Dunaief, M.D,

Dr. David Dunaief

Reflux is common after a large meal. This is when stomach contents flow backward up the esophagus. It occurs because the valve between the stomach and the esophagus, the lower esophageal sphincter, relaxes for no apparent reason. Many incidences of reflux are normal, especially after a meal, and don’t require medical treatment (1).

However, gastroesophageal reflux disease (GERD) is a more serious disorder. It can have long-term health effects, including erosion or scarring of the esophagus, ulcers, and increased cancer risk. Researchers estimate it affects as much as 28 percent of the U.S. adult population (2). No wonder pharmaceutical firms line drug store shelves with over-the-counter and prescription solutions.

GERD risk factors range from lifestyle — obesity, smoking and diet — to medications, like calcium channel blockers and antihistamines. Other medical conditions, like hiatal hernia and pregnancy, also contribute (3). Dietary triggers, such as spicy, salty, or fried foods, peppermint, and chocolate, can also play a role.

One study showed that both smoking and salt consumption increased GERD risk significantly, with increases of 70 percent in people who smoked or who used table salt regularly (4). Let’s examine available treatments and ways to reduce your risk.

What medical options can help with GERD?

The most common and effective medications for treating 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 (5). Both classes of medicines have two levels: over-the-counter and prescription strength. Let’s focus on proton pump inhibitors (PPIs), for which just over 90 million prescriptions are written every year in the U.S. (6).

The most frequently prescribed PPIs include Prilosec (omeprazole) and Protonix (pantoprazole). Studies show they are effective with short-term use in treating Helicobacter pylori-induced peptic ulcers, GERD symptoms, and gastric ulcer prophylaxis associated with NSAID use (aspirin, ibuprofen, etc.) as well as upper gastrointestinal bleeds.

Most of the data in the package inserts is based on short-term studies lasting weeks, not years. The landmark study supporting long-term use approval was only one year. However, maintenance therapy usually continues over many years.

Concerns about long-term usage effects and overprescribing have led to calls among pharmacists to take an active role in educating patients about their risks – along with educating patients about the need to take them before eating for them to work (7).

What are PPI risks?

Side effects after years of use can include increased risk of bone fractures and calcium malabsorption; Clostridium difficile (C. difficile), a serious bacterial infection in the intestines; potential vitamin B12 deficiencies; and weight gain (8).

The FDA has amplified its warnings about the increased risk of C. difficile, which must be treated with antibiotics. Unfortunately, it only responds to a few antibiotics, and that number is dwindling. Patients need to contact their physicians if they develop diarrhea when taking PPIs and the diarrhea doesn’t improve (9).

Suppressing stomach acid over long periods can also result in malabsorption issues. In a study where PPIs were associated with B12 malabsorption, it usually took at least three years’ duration to cause this effect. While B12 was not absorbed properly from food, PPIs did not affect B12 levels from supplementation (10). If you are taking a PPI chronically, have your B12 and methylmalonic acid (a metabolite of B12) levels checked and discuss supplementation with your physician.

Before you stop taking PPIs, consult your physician. Rebound hyperacidity can result from stopping abruptly.

What non-medical options can improve GERD?

A number of modifications can improve GERD, such as raising the head of the bed about six inches, not eating prior to bedtime and obesity treatment, to name a few (11). 

Fiber and exercise. The study that quantified the increased risks of smoking and salt also found that fiber and exercise both had the opposite effect, reducing GERD risk (4). An 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 (12).

Manage weight. In one study, researchers showed that obesity increases pressure on the lower esophageal sphincter significantly (13). Intragastric (within the stomach) pressures were higher in both overweight and obese patients on inspiration and on expiration, compared to those with a “normal” body mass index.

Avoid late night eating. One of the most powerful modifications we can make to avoid GERD is among the simplest. A study 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 before bedtime (14).

While drugs have their place in the arsenal of options to treat GERD, lifestyle changes are the first, safest, and most effective approach in many instances. 

References:

(1) Gastroenterol Clin North Am. 1996;25(1):75. (2) Gut. 2014; 63(6):871-80. (3) niddk.nih.gov. (4) Gut 2004 Dec; 53:1730-1735. (5) Gastroenterology. 2008;135(4):1392. (6) Kane SP. Proton Pump Inhibitor, ClinCalc DrugStats Database, Version 2022.08. Updated August 24, 2022. Accessed October 11, 2022. (7) US Pharm. 2019:44(12):25-31. (8) World J Gastroenterol. 2009;15(38):4794–4798. (9) FDA.gov. (10) Linus Pauling Institute; lpi.oregonstate.edu. (11) Arch Intern Med. 2006;166:965-971. (12) JWatch Gastro. Feb. 16, 2005. (13) Gastroenterology 2006 Mar; 130:639-649. (14) Am J Gastroenterol. 2005 Dec;100(12):2633-2636.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Joel Gonzalez, right, with his wife Amanda, daughter Isabella and son Julian. Photo courtesy Gonzalez

Joel Gonzalez was waking up in the middle of the night, gasping for air. During the day, if he ate too quickly, he felt like food was getting stuck in his throat.

In 2018, Gonzalez, who lives in Coram and is a high school counselor, was diagnosed with gastroesophageal reflux disease, or GERD. A small hiatal hernia, in which part of his stomach bulged through an opening in his diaphragm and into his chest, caused the condition.

Gonzalez started taking medications, which helped relieve the symptoms and enabled him to sleep without experiencing discomfort or waking up suddenly.

In August 2022, after learning that his hiatal hernia had gotten slightly larger and deciding he didn’t want to continue taking reflux medicine for the rest of his life, he met with Dr. Arif Ahmad, director of the St. Charles and St. Catherine of Siena Acid Reflux and Hiatal Hernia Centers of Excellence, to discuss the possibility of surgery.

Gonzalez was so convinced that the surgery would help and confident in Dr. Ahmad’s experience that he scheduled the procedure during that first meeting. Since his November surgery, which took about an hour, he hasn’t had any GERD symptoms and is not taking any medication for the condition.

Gonzalez said he would “absolutely” recommend the surgical procedure, which became a “simple decision” after consulting with Dr. Ahmad.

Caused by a mechanical problem with a valve at the bottom of the esophagus called the lower esophageal sphincter that allows stomach acid to enter the esophagus, GERD affects over 20% of the population.

Symptoms of GERD vary, which means doctors can and do take a range of approaches to treatment.

Hospitals, including St. Charles, St. Catherine of Siena, Stony Brook and Huntington Hospital, have been ramping up their efforts to evaluate and treat GERD.

Port Jefferson-based St. Charles and Smithtown-based St. Catherine of Siena, both part of the Catholic Health system, have been expanding these services at the Acid Reflux and Hiatal Hernia Centers of Excellence.

“There is a big need” for this increasingly focused effort to help patients dealing with the symptoms of GERD, said Dr. Ahmad.

At St. Charles and St. Catherine, Dr. Ahmad, who has been doing hiatal hernia and GERD-correcting surgery for over 25 years, created the center to ensure that the nurses on the floor, the people who do the testing, and the recovery staff are aware of the specific needs of these patients.

Dr. Ahmad has done presentations for the staff to ensure they have “the highest level of expertise,” he added.

Dr. Ahmad, also the director of the Center of Excellence in Metabolic and Bariatric Surgery at Mather Hospital, said he could perform surgery, if a patient needs it, at any of the hospitals, depending on a patient’s request.

Stony Brook’s efforts

At the same time, Stony Brook recently created a multidisciplinary Esophageal Center at Stony Brook Medicine, designed to provide a collaborative care model for diagnosing and treating GERD.

The center provides minimally invasive endoscopic treatments as well as surgical options.

Dr. Lionel D’Souza, chief of endoscopy, said the center provides a cohesiveness that “allows an evaluation by a group of people who are experts and can communicate with each other” to provide a patient-specific plan.

Dr. D’Souza suggested people seek medical attention from their primary care physician or gastroenterologist if they experience any of the following conditions: heartburn every day or severe heartburn several times a week, trouble swallowing, food getting stuck in the throat, anemia, blood in the stool or weight loss without another explanation.

Other partners in the Stony Brook GERD Center include Dr. Olga Aroniadis, chief of the division of gastroenterology, Dr. Alexandra Guillaume, director of the gastrointestinal motility center, and Dr. Konstantinos Spaniolas, chief of the division of bariatric, foregut and advanced GI surgery at Stony Brook Medicine and director of Stony Brook’s bariatric and metabolic weight loss center.

“When someone has a lot of excess weight, the chance of developing GERD is a lot higher,” Dr. Spaniolas said. “Sometimes, getting patients through a program to facilitate with weight loss can help [people] avoid GI symptoms, such as heartburn.”

Stony Brook will see patients in different parts of its network and then, depending on the needs, will determine who is best-suited to start their work up and treatment, Dr. Spaniolas added.

While a potential option, surgery is among a host of choices for people who have ongoing heartburn.

Huntington Hospital, meanwhile, will begin offering esophageal motility testing starting in June. Patients can call Northwell Health’s Heartburn and Reflux Center to schedule an appointment.

A team of gastroenterologists, surgeons and dietitians will work with patients at Huntington to determine the cause of GERD and possible treatments, according to Dr. David Purow, chief of gastroenterology.

Soft foods

Those who have surgery return to solid foods gradually.

Marlene Cross, a resident of St. James who struggled with GERD for about a decade, had the procedure in March.

For the first few weeks, she ate primarily liquids, with some protein drinks and puddings. She added Farina and oatmeal to her diet and then could eat flaky fish.

At 83, Cross, who lost sleep because of GERD-induced heartburn, said the surgery was a success.

“I’m not running a marathon, but I’m definitely feeling a lot better,” said Cross, who is a retired teacher’s assistant for special education students.

Cross urged others who might benefit from surgery to “see a specialist and ask questions and do it” if the doctor recommends it. “The younger you do it, the better.”

St. Charles Hospital
Dr. Arif Ahmad

Do you suffer from acid reflux/GERD? St. Charles Hospital’s Wisdom Conference Center, 200 Belle Terre Road, Port Jefferson will host a free community lecture on acid reflux on Thursday, Nov. 10 from 6 to 7:30 p.m.

Presented by Arif Ahmad, MD, FRCS, FACS Director, Acid Reflux and Hiatal Hernia Centers of Excellence at St. Charles Hospital and St. Catherine of Siena Hospital, topics will include why PPI drugs are not always the answer as a treatment option and permanent solutions with minimally invasive anti-reflux surgery procedures.

Followed by a Q&A. Light refreshments will be served and masks are required. To register, please call 631-474-6797.

Cut down on late night snacking to avoid GERD. METRO photo
Increased fiber and exercise improve symptoms

By David Dunaief, M.D.

Dr. David Dunaief

After a large meal, many people suffer from occasional heartburn and regurgitation, where stomach contents flow backward up the esophagus. This reflux happens when 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. Many incidences of reflux are physiologic (normal functioning), especially after a meal, and doesn’t require medical treatment (1).

Gastroesophageal reflux disease (GERD), on the other hand, is long-lasting and more serious, affecting as much as 28 percent of the U.S. population (2). This is one reason pharmaceutical firms give it so much attention, lining our drug store shelves with over-the-counter and prescription solutions.

GERD risk factors range from lifestyle — obesity, smoking and diet — to medications, like calcium channel blockers and antihistamines. Other medical conditions, like hiatal hernia and pregnancy, also contribute (3). Dietary triggers can also play a role. They can include spicy, salty, or fried foods, peppermint, and chocolate.

One study showed that both smoking and salt consumption added to the risk of GERD significantly (4). Risk increased 70 percent in people who smoked. Surprisingly, people who used table salt regularly saw the same increased risk as seen with smokers.

Let’s examine available treatments and ways to reduce your risk.

Evaluate medication options

The most common and effective medications for treating 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 (5). Both classes of medicines have two levels: over-the-counter and prescription strength. Let’s focus on proton pump inhibitors (PPIs), for which just over 90 million prescriptions are written every year in the U.S. (6).

The most frequently prescribed PPIs include Prilosec (omeprazole) and Protonix (pantoprazole). Studies show they are effective with short-term use in treating Helicobacter pylori-induced peptic ulcers, GERD symptoms, and gastric ulcer prophylaxis associated with NSAID use (aspirin, ibuprofen, etc.) as well as upper gastrointestinal bleeds.

Most of the data in the package inserts is based on short-term studies lasting weeks, not years. The landmark study supporting long-term use approval was only one year. However, maintenance therapy usually continues over many years.

Side effects that have occurred after years of use include increased risk of bone fractures and calcium malabsorption; Clostridium difficile, a bacterial infection in the intestines; potential vitamin B12 deficiencies; and weight gain (7).

Understand PPI risks

The FDA warned that patients who use PPIs may be at increased risk of a bacterial infection called C. difficile. This is a serious infection that occurs in the intestines and requires treatment with antibiotics. Unfortunately, it only responds to a few antibiotics and that number is dwindling. In the FDA’s meta-analysis, 23 of 28 studies showed increased risk of infection. Patients need to contact their physicians if they develop diarrhea when taking PPIs and the diarrhea doesn’t improve (8).

Suppressing stomach acid over long periods can also result in malabsorption issues. In a study where PPIs were associated with B12 malabsorption, it usually took at least three years’ duration to cause this effect. While B12 was not absorbed properly from food, PPIs did not affect B12 levels from supplementation (9). If you are taking a PPI chronically, have your B12 and methylmalonic acid (a metabolite of B12) levels checked and discuss supplementation with your physician. Before stopping PPIs, consult your physician. Rebound hyperacidity (high acid produced) can result from stopping them abruptly.

Increase fiber and exercise

A number of modifications can improve GERD, such as raising the head of the bed about six inches, not eating prior to bedtime and obesity treatment, to name a few (10). In the study that quantified the risks of smoking and salt, fiber and exercise both had the opposite effect, reducing GERD risk (5). An 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 (11).

Manage weight

In one study that examined obesity’s role in GERD exacerbation, researchers showed that obesity increases pressure on the lower esophageal sphincter significantly (12). Intragastric (within the stomach) pressures were higher in both overweight and obese patients on inspiration and on expiration, compared to those with normal body mass index.

Avoid late night eating

One of the most powerful modifications we can make to avoid GERD is among the simplest. A study 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 (13). Therefore, it is best to not eat right before bed and to avoid “midnight snacks.” While drugs have their place in the arsenal of options to treat GERD, lifestyle changes are the first, safest, and most effective approach in many instances. 

References: 

(1) Gastroenterol Clin North Am. 1996;25(1):75. (2) Gut. 2014 Jun; 63(6):871-80. (3) emedicinehealth.com. (4) Gut 2004 Dec; 53:1730-1735. (5) Gastroenterology. 2008;135(4):1392. (6) Kane SP. Proton Pump Inhibitor, ClinCalc DrugStats Database, Version 2022.08. Updated August 24, 2022. Accessed October 11, 2022. (7) World J Gastroenterol. 2009;15(38):4794–4798. (8) www.FDA.gov. (9) Linus Pauling Institute; lpi.oregonstate.edu. (10) Arch Intern Med. 2006;166:965-971. (11) JWatch Gastro. Feb. 16, 2005. (12) Gastroenterology 2006 Mar; 130:639-649. (13) Am J Gastroenterol. 2005 Dec;100(12):2633-2636.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.

GERD is a common condition in which the esophagus becomes irritated or inflamed because of acid backing up from the stomach. Stock photo
You may avoid medications by making simple changes

By David Dunaief, M.D.

Dr. David Dunaief

Wherever you look there is an advertisement for the treatment of heartburn or indigestion, both of which are related to reflux disease.

Reflux typically results in symptoms of heartburn and regurgitation, with stomach contents going backward up the esophagus. For some reason, 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, a portion of reflux is physiologic (normal functioning), especially after a meal (1). As such, it typically doesn’t require medical treatment.

Gastroesophageal reflux disease (GERD), on the other hand, differs in that it’s long-lasting and more serious, affecting as much as 28 percent of the U.S. population (2). Can you understand why pharmaceutical firms give it so much attention?

GERD risk factors are diverse. They range from lifestyle — obesity, smoking cigarettes and diet — to medications, like calcium channel blockers and antihistamines. Other medical conditions, like hiatal hernia and pregnancy, also contribute (3). Diet issues include triggers like spicy foods, peppermint, fried foods and chocolate.

Smoking and Salt

One study showed that both smoking and salt consumption added to the risk of GERD significantly (4). Risk increased 70 percent in people who smoked. Surprisingly, people who used table salt regularly saw the same increased risk as seen with smokers.

Medications

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 (5). Both classes of medicines have two levels: over-the-counter and prescription strength. Here, I will focus on PPIs, for which more than 100 million prescriptions are written every year in the U.S. (6).

The most frequently prescribed PPIs include Prilosec (omeprazole), Protonix (pantoprazole), Nexium (esomeprazole), and Prevacid (lansoprazole). They have demonstrated efficacy for short-term use in the treatment of Helicobacter pylori-induced (bacteria overgrowth in the gut) peptic ulcers, GERD symptoms and complication prevention and gastric ulcer prophylaxis associated with NSAID use (aspirin, ibuprofen, etc.) as well as upper gastrointestinal bleeds.

However, they are often used long-term as maintenance therapy for GERD. PPIs used to be considered to have mild side effects. Unfortunately, evidence is showing that this may not be true. Most of the data in the package inserts is based on short-term studies lasting weeks, not years. The landmark study supporting long-term use approval was only one year, not 10 years. However, maintenance therapy usually continues over many years.

Side effects that have occurred after years of use are increased risk of bone fractures and calcium malabsorption; Clostridium difficile, a bacterial infection in the intestines; potential vitamin B12 deficiencies; and weight gain (7).

Bacterial infection risks

The FDA warned that patients who use PPIs may be at increased risk of a bacterial infection called C. difficile. This is a serious infection that occurs in the intestines and requires treatment with antibiotics. Unfortunately, it only responds to a few antibiotics and that number is dwindling. In the FDA’s meta-analysis, 23 of 28 studies showed increased risk of infection. Patients need to contact their physicians if they develop diarrhea when taking PPIs and the diarrhea doesn’t improve (8).

B12 deficiencies

Suppressing hydrochloric acid produced in the stomach may result in malabsorption issues if turned off for long periods of time. In a study where PPIs were associated with B12 malabsorption, it usually took at least three years’ duration to cause this effect. B12 was not absorbed properly from food, but the PPIs did not affect B12 levels from supplementation (9). Therefore, if you are taking a PPI chronically, it is worth getting your B12 and methylmalonic acid (a metabolite of B12) levels checked and discussing possible supplementation with your physician if you have a deficiency.

Lifestyle modifications

A number of modifications can improve GERD, such as raising the head of the bed about six inches, not eating prior to bedtime and obesity treatment, to name a few (10). In the same study already mentioned with smoking and salt, fiber and exercise both had the opposite effect, reducing the risk of GERD (5). 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 (11).

Obesity

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 (12). Intragastric (within the stomach) pressures were higher in both overweight and obese patients on inspiration and on expiration, compared to those with normal body mass index. This is yet another reason to lose weight.

Eating close to bedtime       

Though it may be simple, it is one of the most powerful modifications we can make to avoid GERD. 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 (13). Therefore, it is best to not eat right before bed and to avoid “midnight snacks.”

Although there are a 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. Consult your physician before stopping PPIs, since there may be rebound hyperacidity (high acid produced) if they are stopped abruptly.

References:

(1) Gastroenterol Clin North Am. 1996;25(1):75. (2) Gut. 2014 Jun; 63(6):871-80. (3) emedicinehealth.com. (4) Gut 2004 Dec.; 53:1730-1735. (5) Gastroenterology. 2008;135(4):1392. (6) Proton Pump Inhibitor, ClinCalc DrugStats Database, Version 20.0. Updated December 23, 2019. Accessed June 23, 2020. (7) World J Gastroenterol. 2009;15(38):4794–4798. (8) www.FDA.gov/safety/medwatch/safetyinformation. (9) Linus Pauling Institute; lpi.oregonstate.edu. (10) Arch Intern Med. 2006;166:965-971. (11) JWatch Gastro. Feb. 16, 2005. (12) Gastroenterology 2006 Mar.; 130:639-649. (13) Am J Gastroenterol. 2005 Dec.;100(12):2633-2636.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.