A Nutritionist’s Approach To Acid Reflux

Reflux is a common gastrointestinal condition in which the contents of the stomach flows back up the oesophagus, causing uncomfortable and painful side effects. 

A 2014 study revealed that the prevalence of GERD (gastro-esophageal-reflux-disorder, a chronic case of reflux) is somewhere in the region of 10-20% of all adults in the U.K. (Boulton et al, Dettmar 2014). 

Although a non life-threatening condition, reflux can significantly decrease an individual’s quality of life. This article will look into the many different causes of reflux and how we can use nutrition and lifestyle to support it.

Burn, baby burn.

Heartburn, indigestion and dyspepsia are terms all used interchangeably to describe reflux and the lower oesophageal sphincter (LOS) is at the centre of this condition. 

Although there is currently no exact known cause for the development of reflux, there are several known risk factors that can increase your chances of experiencing it.

A normal functioning LOS is usually kept closed and only opens upon swallowing to allow food contents to travel into the stomach. During a transient lower oesophageal sphincter relaxation (TLOSR) the LOS opens up outside of eating - giving the contents of the stomach an opportunity to reflux back up the oesophagus (Giorgi et al, 2006). 

This relaxation of the LOS is the main mechanism behind reflux and we will continue to explore why this happens.

The contents of the stomach are incredibly acidic (with a PH of about 2), which is why it is considered as acid reflux. Sufferers will typically experience a burning sensation at the base of the throat which varies from mild discomfort to more severe cases where the lining of the oesophagus becomes heavily damaged leading to a condition called Barrett’s oesophagus.

A second risk factor for reflux is the presence of hiatal hernia, a condition where the top of the stomach protrudes through the diaphragm and into the LOS. Hiatal hernia can occur independently without reflux but it can also impact the functioning of the LOS, making it weaker and therefore more susceptible to relaxing and spurring more reflux episodes (Patti et al, 1996). 

The presence of hiatal hernia can be both congenital or acquired through lifestyle and it typically increases with age. Obesity, chronic constipation, pregnancy and chronic obstructive pulmonary disorder (COPD) are all known risk factors for developing hiatal hernia. (Smith & Shahjehan, 2022). 

It is therefore no surprise that excessive BMI has been shown to increase the risk of GERD (Zheng et al, 2007).

Acidic diet?

Have a quick google search on diet & reflux and you’ll become quickly aware of the general do’s and don’ts. Pages upon pages of google search results will show you lists of foods that are inexplicably banned for GERD patients - suggesting that specific foods can increase the frequency and exacerbate reflux and therefore should be avoided.

But what does the science actually say?

Both carbonated drinks and coffee are common drinks that are purported to exacerbate GERD and reflux due to the high acidity and carbonation. While there are studies to suggest that there may be a very short and transient dysregulation of the LOS, the overall consensus is that there is no clear cut evidence proving causation between these beverages and the worsening of GERD symptoms (Kim et al, 2014). 

While there may not be clear evidence to prove causation, this also does not mean we shouldn’t be practicing control when it comes to drinking coffees and sodas. Through my clinical practice, there is often an individual response to this sort of thing and it very well could be dependant on the volume ingested. To sum up, you definitely do not need to completely cut it out unless you are fully aware that it is to the detriment of your symptoms however, taking your time to understand how much you can tolerate is advised.

When it comes to alcohol consumption and GERD, the data is less mixed. There is a robust amount of evidence that shows alcohol consumption is strongly associated with reflux symptoms leading to damage of the oesophagus (Pan et al, 2019). 

This is likely to be a result of the way that alcohol can impact the pressure of the LOS and affect oesophagus motility. When the pressure inside the stomach exceeds the pressure created by the LOS, a transient relaxation can occur, leading to reflux.

Smoking is also increased during alcohol consumption and a study done on rabbits showed that the ethanol in alcohol predisposes the oesophagus to the effects of cigarette smoke, making it even more dangerous (Bor & Capanoglu, 2009).

As far as chocolate consumption and GERD goes, the data on this is limited with more studies pointing towards abstaining from chocolate as a way to manage symptoms than not. This is likely due to the double-whammy of the cacao and caffeine found in chocolate, both shown to reduce the pressure of the LOS. Similar to the carbonated drinks and coffee, chocolate intake should be personalised and reviewed (Murphy, 1988). 

Spicy foods has been shown to exacerbate reflux by irritating the mucosal lining, which is likely to be suffering from inflammation as well as fatty meals that are fried and greasy. It is not clear as to what type of fat ingested causes reflux issues - as well as whether it is a trigger for reflux or a mediator (Milke et al, 2006).

Having a balanced diet which includes heart protecting monounsaturated fats as well as anti-inflammatory boosting polyunsaturated fats should still be the aim whilst limiting saturated fats which has been linked to heart disease. GERD sufferers should start paying closer attention to their dietary intake in the days leading up to a reflux attack as quite commonly we see a combination of food and beverage triggers consumed simultaneously. E.g. spicy fried chicken with alcohol. Using a food diary can assist with this.

Finally, the carbohydrate content in your meals may have an impact on GERD. 

Specific carbohydrates called FODMAPs (fermentable oligo-di-monosaccharides and polyols) are only partially digested in the mouth and small intestines and require the bacteria of the colon to complete digestion and absorption. This process can lead to fermentation of the carbohydrates which creates increased intestinal gas production which results in increased abdominal pressure. Again, impacting the LOS (Plaidum et al, 2022). 

Vicious circle

Proton pump inhibitors (PPIs) like omeprazole are commonly prescribed for the management of reflux. They work by lowering the secretion of hydrochloric acid (otherwise known as stomach acid) to alleviate reflux symptoms. 

Whilst for acute reflux flare ups the prescriptions are indeed warranted, longer term usage may pose issues. 

SIBO (small intestinal bacteria overgrowth), a condition of bacterial overgrowth in the small intestines is perpetuated by the fermentation of specific carbohydrates called FODMAPs and long term PPI usage has been linked with reoccurrence of SIBO (Sieczkowska et al, 2018). As we know that the presence of SIBO may lead to an increase in gas production and therefore abdominal pressure, this could potentially be forming a mini vicious circle going around.

Constipation is also part of the picture as dysmotility (or a dysregulation in the time it takes for stools to make it’s way through the digestive tract) is a known risk factor for developing bacterial overgrowth - which may lead to SIBO (Achufusi et al, 2020). A side effect of PPI usage is constipation, which makes it an even more complicated picture to navigate.

The exact link between IBS and GERD is not clearly understood but there is certainly an overlap between the two, making it increasingly important to ensure that the digestive system is functioning optimally.

Here is a diagram that may explain the ongoing loop that is functional gastrointestinal disorders.

Medication

Certain medications can also cause the LOS to relax, these include, 

• NSAIDs like ibuprofen

• Nicotine

• Birth control

• Aspirin

• Diazepam

• Progesterone

It may be worth raising with your GP if this sounds like something you may be dealing with.

High or low stomach acid?

It is only logical to assume that because acid reflux is conventionally treated with anti-acid medication like omeprazole, that this must mean that it’s a problem of having too much stomach acid.

Our ability to produce stomach acid decreases with age, and so if the above hypothesis were true, we would see more cases of reflux in the younger population, however the opposite is true as we see more cases in the older population. 

Having low stomach acid may be the driving cause behind developing bacterial overgrowths in the small intestines as we have a diminished ability to kill off bacteria and pathogens in the food that we eat.

H. Pylori

Helicobacter pylori (H pylori) is a bacteria found in most people. It usually lays dormant and causes no issues but during low acidic stomach environments, has the ability to overgrow and create active infections. Active H.Pylori infections is associated with chronic gastritis (symptoms of gnawing or burning pains in the upper abdomen region, nausea and feelings of fullness after eating) and should be identified via stool testing to either rule in or out.

6 steps to manage reflux

A lot of this stuff can be incredibly confusing and overwhelming as there are simply too many moving parts and ‘chicken or the egg’ questions. 

I’ve simplified things for you below to map out your plan of action when it comes to gaining back control over your reflux symptoms.

1. Make an appointment with your GP if you haven’t already done so to discuss symptoms and potentially take this further with a gastroenterologist.

2. Review your diet, the common food triggers above and lifestyle factors such as smoking and alcohol intake to see if removal could potentially improve symptoms. I recommend reintroducing foods back in one at a time to understand if it has had any impact.

3. Avoid eating too close to bedtime, large meals in one go or too close to exercising. Lying down too soon after eating won’t help the digestive system pass food down the G.I. tract. Large meals require a large amount of digestive enzymes and acid to break down, both of which may be low in a person suffering from reflux. Exercising too soon after eating will also impede digestion as the body will divert blood away from the G.I. tract over to the musculoskeletal system.

4. A few natural remedies to aid reflux symptoms include;

• Cabbage juice. Contains the amino acid glutamine which is a natural gut healer as well as a plant compound called glucosinolates, which can aid with the anti-inflammatory process.

• Slippery elm. A herb that coats and soothes the mucous membrane, which is likely inflamed and irritated in GERD. You can drink this as a herbal tea or take as a capsule too.

• Digestive enzymes. Inability to breakdown food properly is one of the fundamentals of correcting a sub-optimal digestive system. 

5. If high-stress levels are suspected, practice ‘mindful eating’ to improve meal hygiene. How we eat our foods has a great impact on the way we digest, absorb it and ultimately the functioning of our digestive system. Chewing food thoroughly, taking deep diaphragmatic breaths before and during eating as well as away from screens would be a good start.

6. Consider working with a practitioner to run a comprehensive stool test to rule out infections like H. Pylori, bacterial overgrowths, levels of pancreatic enzymes and more. A more focussed and targeted treatment protocol can then be formulated based on the findings

I hope you have enjoyed this article and found it helpful. If you need further support please feel free to get in touch. 

References

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Patti, M.G. et al. (1996) “HIATAL hernia size affects lower esophageal sphincter function, esophageal acid exposure, and the degree of Mucosal Injury,” The American Journal of Surgery, 171(1), pp. 182–186. Available at: https://doi.org/10.1016/s0002-9610(99)80096-8.

Plaidum, S.; Patcharatrakul, T.; Promjampa, W.; Gonlachanvit, S. The Effect of Fermentable, Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (FODMAP) Meals on Transient Lower Esophageal Relaxations (TLESR) in Gastroesophageal Reflux Disease (GERD) Patients with Overlapping Irritable Bowel Syndrome (IBS). Nutrients 2022, 14, 1755. https://doi.org/10.3390/nu14091755

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