If you’ve ever had acid reflux, then you know how uncomfortable and gross it can be to burp up stomach acid or even chunks of semi-digested food. Gastro-esophageal reflux disease (GERD) is a common upper gastrointestinal disorder. In fact, GERD is the most common GI complaint.
14-20% of adults in the US have GERD to some degree. (1) Although the condition may seem relatively harmless, it isn’t. GERD negatively affects quality of life, and can lead to strictures, gastrointestinal bleeding, or Barrett’s esophagus. Other symptoms include discomfort in the upper abdomen, epigastric fullness after eating, feeling like there is a lump in the throat, chest pain, recurrent cough, hoarse voice, and increased risk of developing cancer. (1, 2) GERD is associated with adenocarcinoma of the esophagus, but the risk of developing cancer in anyone with GERD is low.(3)
The costs associated with GERD are quite high. Healthcare costs and lost productivity from GERD in the US is approximately $24 billion a year. (4) The primary treatments include dietary changes and either over the counter or prescribed acid suppressing drugs like H2 blockers or proton pump inhibitors (PPIs). Approximately $10 billion is spent on PPIs each year. (5) I generally don’t have anything against medication, as long as the benefits are worth the risks, and dietary and lifestyle changes have been made in order to reduce the need for drugs. Acid suppressing drugs does have some risks, and they are associated with decreased absorption of calcium, increased risk of hip fracture, food borne illness, and clostridium difficile infection. (4) I always believe in trying natural “remedies” first, if possible, so that the side effects from medication are minimized.
To determine whether you have GERD or not, there are different procedures and examinations such as 24-h pH monitoring and endoscopies to evaluate the gastrointestinal tract, but none of these are actually used to diagnose GERD. Instead, treatments are based on symptoms alone. In order for GERD to clinically significant, symptoms must occur at least twice a week. (5) If the symptoms go away with either dietary changes and/or medication, then it’s likely GERD.
What Causes GERD?
The main mechanisms that allow acid reflux to occur revolve around delayed gastric emptying, and more importantly, the dysfunction of the lower esophageal sphincter (LES). (1) The lower esophageal sphincter is a group of muscles at the bottom of the esophagus where it meets the beginning of the stomach. This sphincter closes to prevent stomach contents from entering the esophagus. The stomach is unique in that it has a protective barrier of mucus so that acid doesn’t destroy it. The esophagus does not have this protective coating of mucus like the stomach. When the lower esophageal sphincter malfunctions by relaxing and opening when it shouldn’t, it allows stomach acid to come into contact with the esophagus and “burns” it (heartburn). This burning sensation is actually the stomach acid damaging the esophagus.
Short chain fatty acids are generally thought to be very beneficial to our health. Something to consider is that bacterial fermentation of carbohydrates into short chain fatty acids delays gastric emptying and promotes gastric distention, both of which are associated with GERD. (6) Overweight and obesity are also associated with GERD, and weight loss may help reduce symptoms of GERD. (7)
If you smoke tobacco and you have GERD, you should know that tobacco causes the lower esophageal sphincter to relax. (8) If you smoke and want to live a health life, you should stop whether you have GERD or not.
The shape of the stomach may play a role in GERD as well. Lying on your left side with your head slightly elevated has shown to help reduce symptoms, while laying on your right side may promote reflux. (8)
Exercise has more of an indirect effect on GERD. Moderate exercise may help reduce symptoms and help you lose weight to help reduce symptoms, but vigorous exercise might actually worsen it. (9) If you have GERD, stick to moderate exercise and be aware of how you feel with various exercise intensities.
Diet for GERD
We know diet can affect the gastrointestinal tract; it’s obvious. It’s important to try to get a deeper understanding of how and why certain foods cause certain symptoms in different people. A controlled, double blind study found that food intolerance may play a role in the etiopathogenesis of GERD. Leukocytotoxic test-based exclusion diets for food intolerance might be a therapeutic approach. (1)
Another study found that patients had increased severity of symptoms when they consumed foods high in fat, that were fried, sour, spicy, or ate fruits and sweets.(2) Fruits are likely conditionally based on the acidity of them. It’s more likely that a lemon would cause reflux than a banana. Foods that are more likely to cause reflux are known as refluxogenic foods. These types of foods increase symptoms by decreasing tension of the LES, delay gastric emptying, or increase gastric juice secretion. Patients with GERD have been found to eat more refluxogenic foods than people without GERD. (2)
- Foods high in fat
- Alliums (garlic, onion)
- Hot spices
- Citrus fruits and juices
- Peppermint tea
- Carbonated beverages
Peppermint is good for gas, but not necessarily for GERD. Peppermint likely decreases LES tension, and peppermint oil has been shown to relax smooth muscles of the gastrointestinal tract, which would allow acid reflux to occur more easily. (2)
Alcohol reduces lower esophageal sphincter pressure, increase stomach acid, decrease esophageal motility, and slow gastric emptying. (3) In other words, if you have GERD symptoms, drinking alcohol is a terrible idea.
The quantity of food eaten at one sitting has also been shown to affect GERD. People are more likely to have reflux or heartburn if they eat one giant meal, particularly in the evening, compared to eating a few smaller meals spread throughout the day. Eating larger meals over time can weaken the mechanisms that regulate the functions of the lower esophageal sphincter. (2) It’s recommended to eat a minimum of 3 meals a day, and 4-5 meals may be more appropriate. I like fat, but since fatty meals can slow gastric emptying and reduce LES pressure, it’s a good idea to be aware how you feel after eating fatty foods. Also, try not to eat within a few hours before bed, particularly a fatty rich meal. (4)
Lastly, chewing gum for 1 hr after consuming a meal has been shown to reduce acid reflux. I recommend something chewing something other than mint though, since mint can increase GERD symptoms. (10)
The Association Between Melatonin and GERD
Melatonin is a hormone that is most notably known for initiating sleep, but it is also a strong scavenger of free radicals. Melatonin is produced in a circadian fashion, and its peak production occurs during the night. Melatonin has been found in cells of the gastrointestinal tract, indicating it has some roles in the health of our digestive system.
Patients with GERD have been found to have significantly lower levels of melatonin than healthy control groups. Lower levels of melatonin have also been found in those with duodenal ulcers. (11)
Since GERD can cause sleep disturbance, (12) and those with GERD have lower levels of melatonin, it’s possible that GERD, sleep disturbance, and lower levels of melatonin are potentiating one another.
One study found that after treatment with melatonin or omeprazole for four weeks did not completely improve GERD symptoms. However, patients treated with melatonin for 8 weeks had complete improvement, and patients treated with melatonin and omeprazole for 4 weeks had complete improvement. (11) So, melatonin takes a little while to work, and if used in conjunction with a proton pump inhibitor like omeprazole, it can shorten the time it takes to completely improve symptoms of GERD. Melatonin used with omeprazole seems to work better than omeprazole alone, and less omeprazole is needed to be taken, which should help reduce side effects.
L-tryptophan is a precursor of melatonin. One study found that all patients (100%) receiving supplemental L-tryptophan and B vitamins for 40 days had complete regression of symptoms without any significant side effects, while only 66% of the other group receiving omeprazole had complete regression of symptoms. (11) Therefore, either L-tryptophan or melatonin may be a suitable therapy for GERD.
Disclaimer: Always check with your doctor before trying any of the supplements or diet strategies discussed.