Dear Mr. President: You can Treat Acid Reflux without Drugs

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Dear President Obama,

I’m hoping your recent diagnosis of acid reflux might be a teachable moment for you, your team of doctors, and for some of the 60 million Americans who suffer from reflux. The symptoms include heartburn, abdominal pain, cough, sore throat, hoarseness, laryngitis and sinus irritation. Persistent damaging reflux is referred to as gastroesophageal reflux disease (GERD).

I am a Boston-based microbiologist who also struggled with acid reflux, in my case for 20 years. It all changed when I accidentally made a connection between acid reflux and carbohydrates. I decided one day to go on a low-carb diet to lose weight — and my reflux symptoms vanished in a matter of days without drugs of any kind. That was ten years ago.

Since then, I’ve promoted these findings and a modified carbohydrate diet — no drugs, no gimmicks — wherever I can, including at the Digestive Disease Week (2013) annual meeting for gastroenterologists. Doctors habitually prescribe drugs for this condition, and a diet that has little in common with my own, and may not be effective in treating reflux. The drugs they promote are proton pump inhibitors (PPIs), such as Nexium or Prilosec. PPIs can reduce the absorption of vitamins and minerals including vitamin B12 and iron (anemia risk), calcium (bone fracture risk) and magnesium (cardiovascular, neurological and bone health risk). PPIs have also been linked to Clostridium difficile infections and pneumonia.

Why do PPIs work on this problem – at least for certain periods of time? The drugs eliminate stomach acid, even though stomach acid is essential for health and digestion. While they literally shut down acid production and may improve symptoms, they are not recommended for long term use because of side effects and health risks. And they allow us to evade answering the important question: how to keep acid in the stomach where it belongs?

The standard dietary advice for acid reflux includes avoiding fatty or fried dishes, coffee, tea, alcohol, spicy foods, oranges and other citrus fruits, tomatoes, onions, carbonated beverages, chocolate and mint. Unfortunately, according to the American Medical Association’s Continuing Medical Education (CME) program for doctors and gastroenterologists, “Routine global elimination of food that can trigger reflux is not recommended in the treatment of GERD.”

In other words, after reviewing the research, they concluded that trigger food diets are not effective. The fact that these diets didn’t work doesn’t mean that dietary intervention won’t work, but it does mean that the medical establishment needs to go back to the drawing board. The modified carb diet I have developed and promoted over the last ten years might be a good place for them to start looking.

Let’s start with why cutting carbs can eliminate acid reflux. I believe the answer involves the 100 trillion or so bacteria that live in our intestines.

Did you know that certain types of dietary carbohydrates are difficult to digest and absorb into the bloodstream compared to other carbs, proteins and fats? This is especially true as we get older. As a result, they can build up in the small intestine and over-feed intestinal bacteria. These over-fed bacteria grow and produce excessive amount of gas which, I believe, drives acid reflux as a result of the pressure created in the small intestine and stomach.

As little as 30 grams of unabsorbed carbohydrate can produce more than ten liters of hydrogen gas in the small intestine. It’s like the “Mentos in a coke bottle” effect. The gas pressure forces the lower esophageal sphincter (LES) to open allowing stomach contents to enter the esophagus.

This perspective is new and subject to additional testing in the clinical setting, but there is considerable scientific evidence supporting this explanation.  And since this idea is simply a variation on low carb dieting, there’s not much harm giving it a try before reaching for the purple pill bottle.

Here’s the diet:  Limit foods containing the most difficult to digest carbohydrates, such as lactose, fructose, fiber, resistant starch, and sugar alcohols. These include some dairy, sugar, honey, most starches, whole grain products and fruits. There are no limits on proteins and fats.

Jasmine rice and white bread in moderation are easier to digest and less likely to provoke symptoms. For fruits, watermelon, cantaloupe and strawberries are good choices.  If you are eating pizza, enjoy the toppings but not the dough. Most cheeses are ok because most of the lactose sugar is already fermented. If you are preparing a fried food, fry it without the flour-based batter. Yogurt is OK as long as it’s plain (you can use stevia). Coffee is fine as long as you don’t add sugar and milk, instead use cream and stevia. Fruit juices are problematic because of their sugar content. Alcoholic drinks are OK as long as they don’t contain much sugar.

When you do consume carbs, select fully ripened vegetables and fruits, cook starchy foods well and consume them fresh (not cooled and reheated), employ pro-digestion strategies for starches, such as eating slowly and chewing well to allow amylase enzyme in your saliva time to digest starches.

It’s also important to identify and address any additional underlying causes of small intestinal bacterial overgrowth (SIBO) or dysbiosis: motility issues, lactose intolerance, low stomach acid, antibiotics, etc., on a case by case basis. You can be tested for SIBO with a breath test.

In addition, you may also want to examine any medications and/or supplements you are taking for side effects and/or symptom-causing ingredients. Many medications and supplements can exacerbate acid reflux. Taking digestive enzymes such as lactase or amylase can also help.

Feel free to give me a holler if you want to know more. We can talk over a light beer — regular beer has too much resistant starch. Dry, not sweet wine is another option. How does that sound?

Most respectfully,

Norm Robillard, Ph.D.