This article is one I’ve shared with my own practice audience – an example of the powerful Education, Inspiration, and Empowerment you can bring your patients and clients. This makes All the difference! Our patients can understand
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In the center of your chest, there is a small, muscular tunnel that separates the end of your esophagus from your stomach. Think of it like a fist that can be closed tightly or loosely. It’s called your lower esophageal sphincter (LES). When you’re eating, the fist should be open and loose, so food can travel to your stomach. But at all other times (unless you need to vomit), the sphincter should be tightly closed. This prevents all food and digestive fluids from traveling upward. Acid reflux is just having a loose sphincter when it should be tight. It does not mean that there is too much stomach acid.
Your stomach produces a few different digestive juices. A primary dominant one is hydrochloric acid (HCl). One of nature’s strongest acids, HCl is designed to make light work of breaking down proteins, like the tough meat in that burger you just ate. It’s also part of your passive immune function, killing pathogens that might otherwise move in and set up shop in your intestines. If you put HCl directly on your hand, it would quickly burn you – badly. Another key “digestive juice” component is pepsin, a digestive enzyme that breaks down protein. HCl activates pepsin and starts protein digestion.
If digestive juices are in the wrong place, it hurts. In part, because of the acidity and because the pepsin begins to digest your tissue instead of your lunch! Animal research also shows that pepsin in the esophagus triggers an inflammatory cascade which might be the largest driver of reflux pain. The cells of your stomach lining are coated with mucus to protect them from digestive juices. The lining of your esophagus is not nearly as well coated. So when the LES is loose and these juices bubble upward, it hurts. Acid reflux is not evidence of excessive stomach acid; it’s evidence of stomach acid in the wrong place.
There are many reasons why you (or your patients) might have acid reflux. I’m going to share some of my top tips for making acid reflux go away. Not because your clients have to pop a TUMS or use a PPI drug, but because you can help them to get rid of the true root cause(s). And their long-term health depends on it!
Slow Down, Sit Down, and Chew, Chew, Chew. This is what we call Eating Hygiene. The average American chews each bite of food only a few times before swallowing it down – hard. Often with several gulps of water as a chaser. Many of us eat so quickly that meals feel like a race – an annoying must-do to put hunger at bay. I like to teach my clients that meal time can be a meditation – a very real form of self-care and health-care. Try to chew your food until it’s mostly liquid. This significantly reduces the work of your stomach. I know this seems simple. But you would be stunned to know the number of clients I’ve seen cure their reflux this way. Just by chewing their food 20-30 times per bite and not drinking too much liquid with meals (below). The longer you chew food, the sweeter it tastes.
Avoid the Big Gulp. Certainly it’s fine to have some water along with your meals, but many people use meal time as an opportunity (maybe even the only time daily) to tank up and hydrate. Too much liquid during meals can dilute your stomach acid and make it less potent, leading to belching and bloating. Food can hang around in your stomach longer than it should and ferment. Gas builds up, putting presses on the LES that eventually blows open – causing symptoms of reflux. I recommend my clients – especially those with GERD and indigestion – focus on steady hydration in between meals and have just a small beverage handy during meals to help clear the palate.
Too Much Stuff in a Small Sack. Sometimes our LES gets blown open by the sheer volume of food we try to cram into our bellies. This is especially true when we eat at restaurants. Yes, the stomach will stretch. But only so far. Unsurprisingly, research shows better digestion for people who eat smaller meals. Note this is not the same as “grazing”. Your body needs a break from digestion, so eating here-and-there all the time is often counterproductive (the GI tract’s cleansing waves (MMC – the migrating motor complex) don’t happen while we’re digesting food). If we eat more slowly, we also allow the body’s natural hormonal satiety triggers (e.g. cholecystokinin) to work properly, so we don’t overeat. Many of my clients experience dramatic GERD relief when they cultivate the habit of stopping eating when they feel ~80% full. You have to leave (literally) room for digestion to take place.
Wear loose clothing around your midsection. If you wear a tight belt or waistband, you put tremendous pressure on your digestive organs (pregnant women can attest to the frequency of GERD due to physical impingement of organs and cavities). This can push food and digestive fluids physically upward and beyond your LES. Jeaned Muffin-Tops and Belted Beer Bellies, please take particular note of this one!
Address a need for magnesium. This is a widespread issue and a common nutrient deficiency. The USDA estimates that the majority of Americans don’t get optimal intake of magnesium. It’s less present in our agricultural soils now, so it’s less present in our foods! Low magnesium can cause your muscles to be too tight or to spasm erratically. This includes the LES. I often recommend the glycinate form of magnesium because it’s easy to find and well tolerated and absorbed. If you also struggle with any regular constipation, consider magnesium citrate instead.
Stop eating foods that cause your LES to spasm. Ok, here’s the big one. Unfortunately Americans love some of the foods which are most irritating to the LES. If your clients struggle with daily GERD, encourage them to consider giving their body a break from these foods. Yes, it will take some coaxing because they love these foods! But continuing to eat them and just pop a pill to ignore the pain is likely to turn eventually into a serious downstream dysfunction or illness. These are the most powerful triggers: cooked tomato sauce, citrus juices, coffee, black tea, soda, alcohol, peppery or spicy foods, fried food, chocolate, and things with mint in them (e.g. gum, mints, toothpaste, tea). Eliminating – or at least dramatically reducing – these foods while working on other root causes can bring important rapid relief.
Don’t eat or drink anything for 2-3 hours before bedtime. Reflux can often be worst at night. This is when all of our muscles relax at least a little bit, including our LES, and then we go horizontal. If your client puts food in their stomach and then goes to bed before it’s fully digested, reflux is much more likely. If this is your patient’s struggle, you might encourage them to eat throughout the day such that they go to bed with an empty stomach – but not hungry. Avoiding food for a full 2-3 hours before bed is also an excellent way for many to improve the quality of their sleep.
Fight-or-Flight as a way of Life. Our culture encourages you to Go-go-go and Do-do-do which promotes chronic mental/emotional stress. When we are in a “fight or flight” (sympathetic) nervous system mode, it is quite normal body functioning for digestive secretions and peristalsis to be reduced in order to support other body function that promotes survival (e.g. running for your life). And they are notably reduced (30-60%)! We are intended to live primarily with our parasympathetic nervous system mode active (aka “rest and digest”). Helping your client to understand the direct connection between her stress and her chronic GERD is a powerful tool of empowerment. This is especially true at meal time and why a few calming breaths and a conscious effort to sit and relax the body prior to, during, and after eating can help alleviate acid reflux.
Be aware of common medication triggers. These include a rich variety or oral drugs such as nitrates, anticholinergics, benzodiazepines (common for anxiety or insomnia), calcium channel blockers (common for hypertension), and theophylline.
Food sensitivities. In many cases, people know that certain foods trigger their reflux (beyond the LES irritants above). In over 60% of my clients, dairy foods (e.g. milk, cheese, cream, ice cream) are a major trigger, and dairy elimination from the diet brings tremendous relief. Other food sensitivities might be at play too (e.g. gluten, soy). While food sensitivity testing is available, no single test assesses all possible pathways via which the immune system can react negatively to a food. In most cases for GERD in particular, a simple elimination experiment works very well (e.g. 2-3 weeks cold-turkey elimination before reintroduction – one food category at a time per three days).
If all the above fails, rule out other physiological drivers of chronic reflux. In particular, encourage them to work with their primary care physician (or you!) to find out if they have any of the following. I have successfully supported many clients in working through all of these.
Long-term use of acid-suppressing medications can be dangerous, in particular Proton Pump Inhibitors (PPIs). These drugs were actually originally developed to help those with gastritis or ulcers to heal and were prescribed for a few weeks at most. PPIs can impair absorption of critical protein and minerals that, over years of use, can be the true root cause of ailments such as osteoporosis, arthritis, depression, heart disease, and diabetes. In particular, don’t just suddenly stop cold-turkey taking these meds; that can actually do more harm than good. And GERD root causes for a unique individual should be addressed before weaning off of acid-suppressing drugs. A progressive titration downward (typically over 6 weeks) allows the body to adjust, and during the weaning, targeted supplements can help to fortify and soothe the protective mucosal lining in the stomach. This is a detailed intervention arena covered in our Deep Dive Clinical Course Disease Begins in the Gut 101 (which is a favorite of – and reserved for – our Core 101 Semester students).