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This is the final article of a four part series on acid reflux and GERD. Read the first article on the underlying cause, the second article on the myths of H. pylori and low stomach acid being the major causes and the third article on the main stream medical treatments.

Online dietary advice for GERD is often characterized by the following statement:

“Avoid fatty or fried foods, coffee, tea, alcohol, spicy foods, oranges and other citrus fruits, tomatoes, onions, carbonated beverages, chocolate and mint.”

This anecdotal advice is based on the idea that there is a link between specific “trigger foods” and acid reflux. Yet a common thread that explains how and why trigger foods cause symptoms has proved elusive. Even worse, diets that limit trigger foods have proven ineffective resulting in soaring sales of acid-reducing medicines.

Throwing the baby out with the bathwater

The American Medical Association’s Continuing Medical Education (CME) program for doctors and gastroenterologists no longer supports any type of dietary intervention for treating GERD.[1] Here’s a quote:

“Routine global elimination of food that can trigger reflux is not recommended in the treatment of GERD.”

This is a recommendation published in 2013 based on a systematic review of lifestyle modifications for GERD in 2006. This review was an evaluation of clinical studies conducted from 1975 through 2004. Their conclusions:

“There is no evidence supporting an improvement in GERD measures after cessation of tobacco, alcohol, or other dietary interventions.”

The fact that trigger food diets didn’t work doesn’t mean that dietary intervention won’t work, but it does mean going back to the drawing board.

Why trigger food diets failed?

While the American Medical Association no longer recommends dietary modification for GERD, people recognize that there is a connection between GERD and diet. But two challenges have hampered a refinement of the trigger food approach, which made the cause and effect relationship difficult to identify.

1st challenge: There is a delay between when a food is consumed and the onset of symptoms.

Was your heartburn and other reflux-related symptoms caused by something you ate one hour ago, or 10 hours ago?

2nd challenge: People seldom consume individual foods in isolation.

Most meals and snacks combine different food types belonging to all three food groups:

  • Proteins
  • Fats
  • Carbohydrates

If you got heartburn from pizza, was it the peperoni, tomato sauce or wheat flour dough?

I believe uncertainty from these two challenges has plagued diet studies on GERD and presented a roadblock in identifying exactly which foods cause symptoms. And like a bad murder investigation, if you can’t figure out who the murderer is, it’s tempting to build your case around any suspect who happened to be near the scene of the crime.

Some of the best examples of innocent bystanders involve coffee, alcohol, fatty or fried foods, and spicy foods. I want to take a closer look at these examples, but I want to do so looking through a different lens.

A new lens for dietary GERD treatment

In my first article, I talked about making a connection between carbohydrates and my own GERD symptoms. After confirming my own observations with clinical proof, I proposed a novel, evidence-based mechanism of acid reflux and developed a dietary solution, Fast Tract Diet described in the Fast Tract Digestion Heartburn book

The premise is:

Specific types of carbohydrate such as lactose, fructose, resistant starch, fiber and sugar alcohols are difficult to digest and absorb into the bloodstream. As a result, they can build up in the small intestine and over-feed intestinal bacteria.

Over-fed bacteria grow and produce excessive amount of gas including hydrogen, carbon dioxide and methane. These gases drive acid reflux because they create pressure in the small intestine and stomach, which forces the lower esophageal sphincter (LES) to open allowing stomach contents to enter the esophagus. I.e. Mentos in a coke bottle.

The defining feature of the book is a mathematical formula to measure symptom potential in every day foods. This formula is called Fermentation Potential (FP). The lower the FP points, the lower the symptom potential. The book includes 16 tables with the FP values for over 350 foods, so that you do not have to do the math yourself. Also, you can use the Free Online FP Calculator for foods that are not listed in the book.

Also, the Fast Tract Diet was presented at Digestive Disease Week in 2013 to provide gastroenterologists a new dietary solution for GERD and Small Intestinal Bacterial Overgrowth (SIBO) related conditions.

Debunking trigger food diet myths

In light of this new theory and the Fermentation Potential (FP) calculation, let’s take a look at some examples of trigger foods and see if we can spot the real culprits (difficult-to-digest carbohydrates).

Fried or fatty foods: I agree that many fried foods can cause acid reflux, but not because of oil or fats in the foods, or used to fry the foods.

Clear evidence now exists in the scientific literature that fats themselves do not cause reflux,[2],[3],[4] and there is no factual basis for clinicians recommending a low fat diet for people with GERD.[5]

Where I would focus instead is the wheat or corn flour-based batter often used to coat fried foods. Wheat flour or corn flour contain lots of resistant starch which in my opinion, is more likely to cause symptoms than fats, oils or butter in fried foods. Depending on the type of flour, one ounce can present some 8 to 10 grams of fermentable carbohydrate to gut bacteria. To put this in perspective, gut bacteria can turn 30 grams of carbohydrate into 10 liters of intestinal gas. That means that 10 grams of unabsorbed carbohydrates can yield approximately 3 liters of symptom-causing gas. Imagine three balloons filled with gas in your intestines.

Alcohol: Though many studies have been done on the role of alcohol in GERD symptoms, the results are conflicting.[6]

A large case control study involving 3153 people concluded that alcohol “did not seem to be risk factor for reflux”.[7]

All alcoholic drinks are not created equal. A shot of whiskey, vodka, rum, gin, etc. has no carbohydrates and is not likely to drive symptoms. But many mixed drinks (or sweet wines) contain lots of sucrose which is one half fructose. Fructose is hard to absorb and has a high FP value. And non-light beer has lots of resistant starch. According to this theory, sugar in sweet drinks and resistant starch in non-light beer are more likely than the alcohol to drive symptoms. Check out this article on SIBO and Alcohol.

Coffee: Many people report GERD symptoms from coffee but in the study cited above,[8] the authors concluded that neither coffee nor tea was a risk factor for GERD. Though coffee contains a small amount of soluble fiber, I would first suspect the lactose-containing milk, or the sugar often added to coffee. Milk also contains hard-to-digest oligosaccharides (short sugar chains) which may also drive symptoms.

Pizza: I can’t tell you how many times people have told me that peperoni, spices and tomato sauce on pizza gives them heartburn. While commercial tomato sauce does have some added sugar, I think the chief suspect is the wheat-based pizza crust which contains lots of resistant starch. An average slice of pizza has an FP value of 11 grams mostly due to the crust. An FP of 11 is considered moderate, but if you have two slices, the FP jumps to 22 grams which is considered high and likely to cause symptoms. If you add a can of regular coke, the total FP jumps to 36 grams.

Spicy foods: There is no clear evidence that spicy foods exacerbate GERD,[9] yet many people report a connection. One explanation I can think of is that some spicy foods may irritate the esophagus creating a burning sensation which mimics symptoms of acid reflux.

There are three basic issues limiting the effectiveness of trigger-food diets

  1. They fail to limit all of the difficult-to-digest carbohydrates that I believe are the real triggers for GERD.
  2. They limit innocent bystander foods that don’t cause symptoms such as coffee, alcohol, spices and fats.
  3. Trigger food diets don’t include practices and techniques that minimize carbohydrate malabsorption.

Holistic dietary strategy for GERD

Dr. Norm's consultation for digestive healthBased on my research over the years, I developed a 3 Pillar Strategy outlined in the Fast Tract Digestion series for reliving symptoms without drugs:

Diet: limit foods containing the most difficult to digest carbohydrates such as lactose, fructose, resistant starch, fiber and sugar alcohols.

Behavioral modification: select fully ripened fruits and vegetables, cook starchy foods well and consume them fresh, employ pro-digestion strategies for starches such as eating slowly and chewing well for maximum salivary amylase function.

Identify and address any additional underlying causes of small intestinal bacterial overgrowth (SIBO) or dysbiosis: lactose intolerance, celiac disease, low stomach acid, etc. (case by case).

In addition, you may also want to examine your medications and / or supplements for side effects and / or symptom causing ingredients. I have seen many clients who are on certain medications and / or taking supplements, which end up being the source of their symptoms.

With your doctor’s consent, wean yourself off of acid reducing medicines ASAP while reducing fermentable carbohydrates in your diet. Many people have successfully weaned off PPIs and 2H blockers with the Fast Tract Diet.

Ready to start the Fast Tract Diet?

1. Read the Fast Tract Digestion Hearburn book

2. Get the Fast Tract Diet Mobile App for Android or iPhone/iPad

3. Call for individual consultation at 844-495-1151 US or send an e-mail to rhea.tanaka@digestivehealthinstitute.org

Fast Tract Digestion Heartburn - GERD diet that works without drugs  Fast Tract Diet App for Gut Health

Not sure if the Fast Tract Diet is for you?

Read the professional reviews and genuine experiences | testimonials of the Fast Tract Dieters and decide for yourself.

Looking for a community of Fast Tract Dieters?

Fast Tract Diet Group on FacebookJoin the Fast Tract Diet Discussion Group on Facebook for questions, support and inspiration. Great recipes are also posted there.

 

Your comments and questions are welcome.

Read the first article, “What Really Causes Acid Reflux and GERD?”. 

Read the second article,Is GERD caused by H. pylori & Low Stomach Acid?”.

Read the third article,GERD – Why standard treatments are ineffective“.

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[1] Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013 Mar;108(3):308-28; quiz 329.

[2] Penagini R, Mangano M, Bianchi PA. Effect of increasing the fat content but not the energy load of a meal on gastro-oesophageal reflux and lower oesophageal sphincter motor function. Gut. 1998 Mar;42(3):330-3.

[3] Pehl C, Waizenhoefer A, Wendl B, Schmidt T, Schepp W, Pfeiffer A. Effect of low and high fat meals on lower esophageal sphincter motility and gastroesophageal reflux in healthy subjects. Am J Gastroenterol. 1999 May;94(5):1192-6.

[4] Ruhl CE, Everhart JE. Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization: the NHANES I Epidemiologic Followup Study. First National Health and Nutrition Examination Survey. Ann Epidemiol. 1999 Oct;9(7):424-35.

[5] Penagini R. Fat and gastro-oesophageal reflux disease. Eur J Gastroenterol Hepatol. 2000 Dec;12(12):1343-5.

[6] Chen SH, Wang JW, Li YM. Is alcohol consumption associated with gastroesophageal reflux disease? J Zhejiang Univ Sci B. 2010 Jun;11(6):423-8.

[7] Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J.Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux. Gut. 2004 Dec;53(12):1730-5.

[8] Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J.Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux. Gut. 2004 Dec;53(12):1730-5.

[9] Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med. 2006 May 8;166(9):965-71.