The previous post I wrote about small intestinal bacterial overgrowth (SIBO) was simply a lead in to the post I really wanted to write. But the post I really wanted to write wouldn’t have made sense without the first post, which was, I suppose, the prologue.
A while back I was wading through the latest Medscape* had to offer when I came upon an article that almost put me over the edge. The offending piece was a video presentation by a Dr. Johnson, an academic gastroenterologist from a medical school in Virginia. The doctor was basically giving his top ten take aways from a recently published paper on the guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD). Although the doc delivered his presentation in a collegial doctor to doctor tone, it was the subject matter that drove me nuts, especially his selection of the number one take away item from his list.
A little background…
If a patient were to present to me with a medical problem, the first thing I would think of is how (or if) the problem could be treated nutritionally. If a nutritional treatment is appropriate, then pursuing that therapeutic option is the epitome of the first pillar of the practice of good medicine: Primum non nocere. First, do no harm.
It should be obvious, but just in case it isn’t, that nutritional therapy wouldn’t be the first thing flitting to my mind, if presented with victims of a car wreck, someone experiencing an acute heart attack, our kid showing up with a bleeding gash in his head, or a person in severe respiratory distress. But it is surprising how many chronic problems can be treated – or at the very least made better – by nutritional means. So in those disorders that can be improved by a change in nutrition, that is my default position.
Not so for the vast majority of physicians out there practicing mainstream medicine. For that lot, the default position is pharmaceuticals. Presented with a problem, they think drugs. Our professor in the Medscape video is a case in point.
In the last post, I discussed my experiences treating GERD using a low-carbohydrate diet, and I also described Dr. Norm Robillard’s research into SIBO as a driving force for GERD and irritable bowel syndrome (IBS) along with his methods of treatment using both high- and low-carb diets. Both his method and my method have proven successful in the vast majority of cases of GERD. Simple nutritional strategies.
Now let’s take a look at how the mainstream folks treat GERD.
Most of them immediately prescribe a proton pump inhibitor (PPI), a type of drug that produces a profound reduction in the stomach’s production of gastric acid (stomach acid). These PPI’s (Nexium, Prilosec, Prevacid, etc.) are potent inhibitors of stomach acid secretion, in fact, they’re the most potent drugs for this purpose so far developed.
Remember, GERD takes place when stomach acid is gets through the sphincter at the bottom of the esophagus and burns the delicate tissues of the esophageal lining, which, unlike the lining of the stomach, don’t have a thick coat of protective mucus. When the acid hits these tissues, it causes a variety of symptoms as described in the previous post.
For years, the mainstream way of treating GERD (also called acid reflux and heartburn) has been by reducing the acid content in the stomach’s digestive juices, so that when these juices get into the esophagus, they don’t burn the tissues—or cause symptoms—because the acid has been neutralized.
The first line of treatment, from as far back as the 1800s and still often used today, was antacids. If you have heartburn, you drink some bicarbonate of soda or pop a few Tumms or Rolaids or other antacids, which neutralize the acid in the stomach. About 35 years ago or so, pharmaceutical research scientists developed a new class of drugs called H2-receptor agonists (Tagamet, Pepcid, Zantac), which was the first major breakthrough in the treatment of ulcers, gastritis and even GERD. These new drugs reduced stomach acid by an order of magnitude as compared to simple antacids. And they offered the advantage of patent protection to the pharmaceutical industry, so they were widely advertised and prescribed. These medicines were the most effective treatment for years until the PPIs came on the scene, and now these newer drugs are some of the most prescribed on the planet.
Seems like the perfect treatment. You have symptoms caused by acid getting into your esophagus, so let’s take a PPI, reduce stomach acid production, and Voila! your symptoms vanish. All fine and dandy except for one little thing. Your stomach is full of acid for a reason. And if nature put stomach acid there for a reason, you can bet getting rid of it can cause problems. Let’s take a look at what stomach acid does.
It starts the digestive process of breaking down food into smaller particles
- It activates the enzymes needed for protein digestion
- It sends a message to the pancreas to begin producing and releasing digestive juices into the small bowel
- It initiates the process of peristalsis, the rhythmic contractions of the small bowel that moves food through the digestive process
- It is essential for the absorption of vitamin B12
- It is the first line of defense against bacteria and parasites found in food, water and the air we breathe.
This last function is one most people don’t understand. At least as it applies to the infectious agents in the air we breathe. How can stomach acid prevent respiratory infections? Let me explain.
When we take a breath, the air travels down the bronchial passages of the respiratory tract. These tubes, like the branches of a tree, get progressively smaller as they head deeper into the lungs, and they are lined with a coat of sticky mucus, which traps bacteria and other noxious substances. Tiny hairs, called cilia, on the inner surface of these tubes keep the crud-laden mucus moving up the bronchi where it is ultimately dumped into the back of the throat. When we swallow, we redirect this mucus down the esophagus and into the stomach where the stomach acid then kills the bacteria that actually came in through our respiratory tract.
Although the respiratory and digestive tracts are separate, both originate in the mouth. During sleep, refluxed stomach contents can make their way up through the esophagus and ‘spill’ into the nearby respiratory tract. Since, thanks to neutralization of the stomach acid by PPIs, bacteria are more likely to proliferate in the stomach contents and can thus cause an infection when they reach the respiratory tract.
That last bit may make you suppose that people who are on PPIs and other acid-suppressing drugs might have increased rates of respiratory infections. As it turns out, they do. Long term PPI therapy is associated with an increase in the incidence of pneumonia.
Understand all this, and you should realize why neutralizing stomach acid could lead to problems. Which indeed it does. And it should make clear why it is much better to treat GERD by eliminating the cause and preventing stomach acid from getting where it doesn’t belong instead of simply neutralizing it so it doesn’t burn when it gets there.
Most people who have GERD, have it for the long term. It’s not something that comes and goes. So these folks go on GERD therapy for the long term, and the most prescribed medications for long-term GERD treatment are PPIs, which, you now know, keep stomach acid neutralized for the long term, and, as you might imagine, creates a host of problems.
The scientific literature has shown long-term PPI therapy to be related to the following conditions:
- Vitamin B12 deficiency
- Impaired calcium absorptionImpaired magnesium absorption
- Increased rate fractures, especially hip, wrist and spine
- Rebound effect of extra-heavy gastric acid secretion
- Heart attacks
Of all these disorders associated with PPI therapy, the one most well known by the general public is the increase in rates of fractures. Which is why I got so annoyed with the doc in the video below. He gives his top ten guidelines for dealing with GERD. And his #1 guideline is to blow off any worries about increased rates of fracture. He says the number one question patients ask him about PPI therapy is about fractures. He even says he is dismissive of them as he basically blows off their concerns. Remember, though, not to be too hard on this guy because he is talking to other docs, not giving a talk to patients or even the general public.
This is a doctor to doctor platform. Still…
His top ten list was derived from a paper discussing 54 guidelines for the diagnosis and management of GERD. In the entire list of 54, there were only two that involved lifestyle changes. One was a recommendation to lose weight. The other was the
Routine global elimination of food that can trigger reflux (including chocolate, caffeine, alcohol, acidic and/or spicy foods) is not recommended for the treatment of GERD.
Which to me beggars belief since, as I pointed out in the last post, GERD is easily treated with a low-carb diet.
In another paper in the same journal, the authors actually asked patients what made their IBS symptoms worse. Since IBS, like GERD, can be caused by SIBO, the problematic foods are likely the same. When queried, the #1 cause of symptoms in the vast majority of patients (70%) were “food items with incompletely absorbed carbohydrates.”
So patients tell us carbs make their symptoms worse. Physicians who treated patients with low-carb diets experience almost 100 percent success. Patients who go on low-carb diets almost always find relief from their symptoms. Dr. Robillard has developed a reasonable hypothesis to explain the above results. So, on the one hand, we have a therapy that works without side effects.
On the other hand, it is well known that long-term PPI therapy can cause problems in varying degrees of severity. And PPIs are not free; they are expensive. And, behind psychotropic medications and statins are the third most commonly prescribed drugs in the United States. Vastly more people are on PPIs than are on low-carb diets. More is the pity.
And it bugs me to the max that docs, such as the one on the video below, tell other physicians to tell their patients to blow off fears of fractures and go full speed ahead on an expensive treatment regimen fraught with the potential for multiple serious side effects.
Here is the very short excerpt of the video that so riled me up.
If you want to see the entire thing, here are Dr. Johnson’s Top Ten Gerd Guidelines in Medscape.*
*Medscape is a free online subscription service to physicians to keep them abreast of all the latest medical breakthroughs and recommendations. Though Medscape was created for and is mainly read by physicians, anyone can subscribe. Just go to Medscape and register as a non-physician guest. Then you, too, can keep up.