Why You Should Eat Twice As Much Alkaline Food (1:37)
Heartburn is one of the most common medical conditions experienced by upwards of 40% of Americans on a monthly basis. Sixty million or more Americans have heartburn once a week. It occurs when a faulty valve (lower esophageal sphincter) responsible for keeping acid-containing food in the stomach fails to do its job and acid-laden contents are allowed to reflux into the esophagus (food tube). If heartburn persists, it can lead to gastroesophageal reflux disease (GERD).
Acid reflux, or heartburn, can happen when there is large amount of pressure in the stomach (such as after a big meal) or if the valve at the lower esophageal sphincter becomes inappropriately weak after consuming certain substances (caffeine, chocolate, alcohol, etc.) Frequently, both mechanisms of action are the cause. When reflux occurs, the lining of the esophagus is not designed to handle this displacement of acid and it can become irritated and that irritation causes heartburn.
One frequently unappreciated fact is that there are two faces of heartburn as to how it presents. The typical (classic) symptoms and atypical symptoms for heartburn are:
- Burning breast-plate (sternal) chest pain; increased by bending or lying down, worse at night, and relieved by antacids
- Food sticking after swallowing behind breast plate
- Acid in back of throat/sour taste on awakening
- Upper abdominal pain
- Temporary relief obtained with off-the-shelf antacids
- Postnasal drip
- Persistent cough
- Lump in throat
- Raspy or hoarse voice
- Noncardiac chest pain
Whether you have typical or atypical symptoms, reflux is a health issue that you cannot ignore. It is imperative that you realize that all heartburn is not created equal. You must work with your doctor to quickly assess your symptoms and determine if you have reflux or something more serious called gastroesophageal reflux disease (GERD). Frequency of symptoms can be an important risk factor for diagnosis for GERD. About 3% to 7% (9-21 million) of Americans have reflux every day and, unfortunately, the incidence is rising. About 22% of the primary-care visits in this country involve GERD symptoms. Over the last seven years, this is an increase of 46%.
The prolonged presence of acid in the esophagus leads to complications that can produce a range of problems from annoyance to a potentially fatal condition.
The following are the complications that can occur with GERD:
- Erosive esophagitis
- Esophageal ulcers
- Esophageal strictures
- Aspiration pneumonia and asthma
- Poor quality of life
- Barrett's esophagus (and this can lead to esophageal cancer in a small percentage of cases)
In light of the potential negative impact of the above complications on your life, you must take this condition seriously. You do not want to think that you are a heartburn sufferer that is actually a GERD hostage and then turn into an esophageal cancer victim.
Diet and Lifestyle Change: The First Line of Defense
The good news is, most people who have heartburn can manage symptoms on their own. Lifestyle and dietary changes can be the first line of defense. These include...
- Changing what you eat
- Changing when and how you eat
- Elevate the head of your bed to help avoid nighttime symptoms
- Weight loss
We are in a war against heartburn, and the American diet is full of land mines that cause us to suffer. It is high in heavy, fat-laden meats, carbs and processed foods. Most notably, there is not a good balance between the bad (acid-promoting) foods that cause heartburn and the good (alkaline-promoting) foods that help to prevent heartburn. What can you do? Strive to balance your culinary equation by pursuing a more alkaline diet.
Good (Alkaline-Promoting) Foods
- Grilled and baked meat
- All veggies
- Breads, rice, oatmeal
- Alkaline water, soy and coconut milk
- Chamomile tea
- Manuka honey
Bad (Acid-Promoting) Foods
- Carbonated and citrus beverages
- Canned foods (heavy acid for preservation)
- Raw tomatoes
- Breath mints
No More Acid in the Morning
The following are good tips for launching a diet with more alkaline balance. The first principle is to suppress the traditional dominance of acid at breakfast. Oatmeal with an alkaline selection of nuts and bananas, mixed with Manuka honey for sweetness, followed by a serving of melon can be a delicious and filling option for breakfast. Smoothies are a great choice because you can put many alkaline options into one serving. For lunch, salads are a great alkaline diet champion. Just like smoothies, they offer an excellent opportunity to infuse your diet with alkaline-promoting foods while limiting total calorie intake. Give that salad a tasty pop and take advantage of an opportunity to provide alkaline balance by adding pears and apples.
Remember to watch the salad dressings (hidden calories). Snacks are another place where a more healthy and alkaline balance can be added into your diet. Parmesan and dill can add tasty dimensions to a snack like popcorn. For dinner, grilled and baked meats are always excellent choices and even pasta (a weakness for many of us) is allowed. However, a slight modification must be observed. Avoid acidic choices such as marinara or alfredo sauce and use light olive oil with lemon and creative combinations of herbs and spices.
Chew on This
I cannot overemphasize that doing the simple things can go a long way in winning the war on heartburn. Always take small bites of food and chew it ten times before swallowing. Try not to drink after every bite. It causes you to swallow air and that can increase the pressure inside of the stomach and promote reflux and heartburn. Try not to eat a large meal less than three hours before going to bed, and raise the head of your bed on cinder blocks to recruit gravity to keep the acid in the stomach.
Other measures that can be taken include wearing loose-fitting clothing and undergarments, mild exercise after eating and getting into a smoking-cessation program. In spite of all your good intentions, from time to time the desired alkaline focus may be difficult to maintain. If you fall short, do not panic; just remember for every acid-promoting food, you need to ingest two alkaline-promoting foods.
Let’s face it, having a glass of wine can be a temptation that is difficult to resist. If you do succumb, remember to drink alkaline coconut water and eat one of the good fruit choices to help to counter the acid-reflux-promoting effects of the alcohol. And finally the great thing about following this kind of diet is that you are more likely to achieve a moderate weight loss of 10-20 pounds.
Do not be fooled by the modest nature of this weight loss, it can be effective in helping to decrease the pressure inside the abdomen being applied to the stomach and lessen the chances for reflux.
What Happens When the First Line Fails? Remember SOS
As stated before, the majority of patients with this problem require only lifestyle and dietary modifications. But, as you might expect, one approach may not be the right solution for everyone for a complex problem such as heartburn. There is a chance that in spite of consistently executing all of the above, you still will have significant life-altering symptoms. At this point, you must remember that all heartburn is not created equal. You may not have simple heartburn. You may have something more serious called gastroesophageal reflux disease (GERD). And as we stated earlier, GERD is not something that you want to have. It can cause devastating complications. If you have these concerns remember SOS. The S reminds you to get a better handle on signs and symptoms associated with GERD. The O reminds you to get evaluated and get the tests done that give you objective-based numbers that can tell you the extent of your problem. Finally, the S tells you to get an objective evaluation that includes getting scoped (endoscopy).
Know Your Heartburn Numbers by Heart
Being educated on the signs and symptoms of GERD is very important. But if you are continuing to have symptoms in spite of the frontline measures, you must go further to investigate your condition. You have to know your numbers: your HeartBurn Numbers (HBNs). To determine these values, the first step is to take the Heartburn (GERD) Risk Test.
This test gives a numerical value to your symptoms, both typical and atypical. The test begins by asking you if you take heartburn medications of any type. If the answer is no, you have to calculate only one score. If the answer is yes, you have to calculate two scores, one on medication and one off medications. Do not feel intimidated by being asked to give an answer. Just give your best guess. You have to keep in mind when it comes to your health, the first step in getting it right is to find out what’s wrong.
The Heartburn (GERD) Risk Test will give you a validated suggestion as to whether or not you have simple heartburn or a significant chance that you have GERD. The typical symptom score has 8 as an upper limit of normal on or off medication. The atypical upper limit of normal is 15. If you are above these numbers, you have upwards of a 90% chance of having gastroesophageal reflux disease (GERD).
What Happens When Your Heartburn Numbers Lie?
If your HBNs are elevated, your physician must evaluate you. Up to 20% of the patients treated for GERD do not actually have GERD. You have to establish the diagnosis by the numbers. This has to be done because you don’t know what you don’t know, and what you don’t know can hurt you. There are testing technologies that can take the guesswork out of determining not only if you have GERD but also how bad it is. These tests provide critical information that serve as important guides for your treatment, such as: Are medicines the right treatment option? If so, in what dosage and what time of day? Is surgery a better option for me?
A Closer, Longer Look – Bravo!
The Bravo capsule pH monitoring procedure is a patient-friendly test for identifying the presence and severity of acid reflux. During the performance of an endoscopy, a capsule is attached to the lining of the esophagus. This allows detailed information about the nature and extent of your heartburn to be collected over multiple days. Your doctor can then evaluate reflux symptoms by determining the frequency and duration of acid flowing back up into the esophagus. Bravo pH monitoring allows patients to maintain their regular activities. Maintenance of regular activities and a normal diet during the test has the potential to provide a more accurate picture of acid exposure, compared to data collected using catheter-based systems where normal activities may be limited.
Estimate the Strength of Your Esophagus
Additionally, you should ask your physician if esophageal manometry should be added to your objective evaluation in the beginning of your journey with GERD rather than later. This tests the muscular activity of your esophagus. It can tell you if the contractions of your esophagus are well coordinated and functioning properly to clear it of food and acid. It can detect if the contractions are spasmodic and nonpropulsive in nature, which can cause atypical chest pain and GERD-like symptoms. Manometry also measures the strength of the lower esophageal sphincter (LES). With GERD, the problem is often that the valve (LES) responsible for keeping the acid in the stomach is consistently, or at times, too weak to do its job. Esophageal manometry can tell you the strength of that valve, and if it is below 6mm Hg, there is probably no amount of medicine that is going to treat you appropriately. In this case, surgery may be a good option and manometry can tell you which of several operative options is the best for you. It is common for your physician to start you on medication as a trial without performing these tests. That is fine if it is only for a short period of time to evaluate your response. However, whether that empiric trial addresses the problem or not, I believe that your physician should consider these evaluations very early to establish your GERD identity. This can only be done if he knows your numbers and those numbers can be determined by these tests. I strongly believe in "don’t treat when you don’t know." It is always best to start a treatment based on an accurate diagnosis.
Don’t Forget to Get the Scope
Remember when you undergo this objective evaluation you must make sure that the foundation of a heartburn (GERD) workup includes getting “scoped” (endoscopy). This procedure typically takes place in a hospital or outpatient facility and involves placing a flexible tube with a light and camera through your mouth to look at the esophagus and stomach. During the procedure you will be sedated with medication given through an IV. Tissue samples can also be taken of any suspicious area that may be seen.
Another approach has been made possible by miniaturized technology. Transnasal esophagogastroscopy allows visualization of the upper gastrointestinal tract without anesthesia. This technology from Vision Science enables acquisition of evidence as to what your problem is right away. Upwards of 20% of patients that are on medications for GERD do not have the problem and have been misdiagnosed. In addition, there are some patients that have complications from long-term use of antacid medication. Both these factors make early accurate diagnosis a highly valued goal for good outcomes. For years, ear, nose and throat surgeons have used this type of technology to evaluate the nasopharynx and vocal cords, but now we can use this platform to go all the way into the stomach. I call this the scout scope initiative. The mantra: “When in doubt, scout it out. Don’t treat when you don’t know!”
Telemedicine Means “Game On,” Scout!
Another concept under early investigation is using video games and simulations to teach primary-care physicians, nurse practitioners and physician assistants to use this technique supported by experts with remote oversight using “telemedicine.” When combined with mobile platforms, screening and diagnosis of this disease can be done earlier and more cost effectively. The goal is to decentralize the evaluation of this disease and connect patients to specialists early rather than later. The primary-care physicians that are involved with this early investigation are called “GERD Warriors.” Mario Perez, MD, and Allison Hanley, MD, in Orlando, Florida, are using two distinct paths in this new approach. Dr. Hanley is now screening all his patients who present with heartburn with the Heartburn (GERD) Risk Test. Those whose numbers are in the range for a high probability of having GERD are designated to have a scout scope.
Get With the Scout Scope Home Program
The scout scope team then comes to his office and performs the procedure. The patient never has to leave their medical home. This is called the scout scope home program. “With the knowledge of the patients’ HeartBurn Numbers (HBNs), I am finally not flying in the dark when taking care of my heartburn patients,” states Dr. Hanley. “The other outstanding feature of the scout scope program is that the patient is more comfortable because they remain connected to my office." Dr. Perez is the first physician to sign on to train to become a primary-care procedure specialist. He hopes to offer this service to his patients in his office. “I serve a medical-provider-shortage area. I must offer as many services to my patients as I can," Perez says. “They are very resistant to going outside of the practice unless absolutely necessary. This program allows them to have the cutting edge of care without leaving home.” It should be stressed that the scout scope does not take the place of a full endoscopy performed by a gastroenterologist or a surgeon. It is a screening tool that helps the right care to get to the right people right away.
Medicine Is Sometimes the Best Medicine
The good news is that GERD can be controlled most often with the addition of medications. The medications most frequently used are proton pump inhibitors (PPIs). Nexium, Prevacid, Prilosec, Protonix and Aciphex are the dominant players. But to be honest, in spite of the manufacturers’ claims, they have different names but the same game. They work by inhibiting the release of acid in the stomach. By reducing the concentration of acid, there is very little acid to cause irritation, when the weak valve (LES) allows the fluid in the stomach to come into the esophagus. The result is that there is no heartburn. Most of the time, when taken in the face of an accurate diagnosis at the right dose and dosing interval, most patients can manage their GERD successfully. A new issue has emerged with the offering of these medications over the counter without a prescription: Many patients cannot resist treating themselves. There are two problems with this. First, if the patient does not have GERD, this could delay treatment for another problem. Second, the patient could have complications from GERD that they do not know about. Both of these behaviors can lead to poor patient outcomes because they have not been evaluated. Remember: Don’t self medicate, get yourself a checkup date.
Sometimes You Need More Than Medicine
One of the most distressing misconceptions by patients and physicians alike is that after medications there is no safe and effective treatment for GERD. This is absolutely not true. Each day patients complain that their current treatment regimen is not working. Countless patients who have developed complications from GERD are told there is nothing else to do but to give double and triple the dose of medications. Depending on the particular profile of your case, there may be a time and a place for surgery; however, there might be other interventions for the successful treatment of GERD and its complications.
One of the reasons I am so adamant about an early systematic objective workup of patients with GERD is that you can know whether or not patients should be treated conservatively with lifestyle changes and medications or if they fall in the surgical-intervention category. That is why it is so important to know your numbers. The numbers generated from a combination of the Bravo test and manometry can tell you if you are a surgical candidate and what operation will be best. The most common operations that have been done through the years include the Nissen and Toupet fundoplication. The Nissen uses the upper part of the left side of the stomach to support the valve (lower esophageal sphincter) by wrapping a liberated portion of the stomach 360 degrees around it.
This approach can be used when the pumping power of the esophagus (as determined by manometry) is strong. If the pumping power is weak, the Nissen will offer too much resistance for food and liquid to pass into the stomach, and food will stick (this is called dysphagia). Therefore a partial wrap called a Toupet fundoplication is used. Both these operations can be done with traditional open or minimally invasive approaches. Today, the minimally invasive route is the one most preferred. It uses small incisions with the assistance of a miniaturized camera, scope and small, thin instruments to complete the procedure. The advantage is less pain, less time in the hospital and faster return to normal activities. But the operation calls on surgeons to have a great deal of expertise and experience to offer long-term success.
A revolutionary treatment option for GERD is the LINX Reflux Management System. LINX is a small, flexible ring of magnets placed around the lower esophageal sphincter during a minimally invasive procedure.
The strength of the magnets helps keep the weak lower esophageal sphincter closed to prevent reflux. Unlike the fundoplication procedures, LINX does not require alterations to the stomach that may limit future treatment options. Therefore, one day this may become the first option for surgical intervention for GERD.
I am one of the select surgeons in this country certified to implant LINX, and my early experience has been outstanding. One patient traveled all the way from Guam to have me perform this procedure at my Celebration, Florida, based practice, Advanced Laparoscopic Surgeons. She is a first-grade teacher and a master diver, and GERD was threatening her diving career. LINX was the only option she would consider.
One of the most concerning complications that can occur from long-term severe reflux and GERD is Barrett’s esophagus. In an effort to protect the esophagus from the reflux of acid, the body attempts to change its lining to become more like the stomach. Acid is necessary to digest our food, and the stomach is designed to resist the effects of acid. But the esophagus has no inherent protection. The appearance of this transformation is significant because it a precancerous condition called Barrett’s esophagus. It is important that this condition is identified as early as possible. Once Barrett’s esophagus is identified, radiofrequency ablation (RFA) can be conducted to reduce the likelihood that Barrett’s esophagus will progress to cancer. This intervention is called Barrx™ radiofrequency ablation. Radio waves are delivered via a catheter in the esophagus to remove diseased tissue while minimizing injury to healthy tissue of the esophagus. The patient then can have a surgical procedure to address the weakness of the valve with a Nissen or Toupet. This is the same approach used for any patient that has a complication from GERD. First address the complication, then fix the problem.