Here is a topic dear to my heart, and I’ll share my own personal story below.
Heartburn occurs when stomach acid irritates the lining of the esophagus. Symptoms can range from mild burning to severe pain and chest tightness.
A little understanding of anatomy helps to appreciate why some therapies work or don’t work.
When you swallow food, it passes down the esophagus tube to your stomach. Between the esophagus and the stomach is a valve, called the lower esophageal sphincter. The stomach produces stomach acid, which helps to digest food and enhances nutrient absorption. If the valve closes properly, it keeps the acid in the stomach where it belongs.
The stomach lining is designed to tolerate stomach acid. The esophagus lining does not tolerate stomach acid, and is easily irritated by stomach acid if exposed.
Under normal circumstances, stomach acid signals the lower esophageal sphincter to close. Unfortunately, sometimes this valve doesn’t function properly and opens when it should not. Certain foods impact this valve function greatly.
Factors that cause the lower esophageal sphincter to open inappropriately, allowing acid to pass into the esophagus include:
- Drinking brown liquids, such as coffee, decaf coffee, black tea, chocolate, and colas.
- Carbonated beverages tend to weaken the lower esophageal sphincter allowing stomach acid into the esophagus, making a cola a double negative factor.
- Alcohol, wine, beer, and hard liquor, although beer might be the worse because it also bubbles upward into the esophagus.
- Highly fatty foods (think pizza, French fries, and fried food)
- Eating a heavy meal right before going to bed, as the stomach is full, pushing pressure upwards on the lower esophageal sphincter when you lie down.
The perfect storm for a night of dreadful heartburn would be excess coffee with cream in the morning, sodas at lunch, and a beer, hamburger, and fries less than 2 hrs before going to bed.
Some medications irritate your gastrointestinal lining, and make you more sensitive to mild acid reflux, in particular non-steroidal, anti-inflammatory drugs (NSAIDs). They include Naprosyn, Ibuprofen, Celebrex, Aleve, and Advil. Over time, these types of medications can cause major gastrointestinal bleeding. Generally speaking, although they are commonly used and available over the counter, I ask my patients to avoid them.
Nearly 25 years ago, I injured my knee skiing (damaged my ACL and MCL ligaments). My physician at the time suggested I take Naprosyn for a couple of months, which gave me horrible esophageal pain. My doctors suggested Omeprazole (Prilosec), a very potent acid blocking medication. This helped my heartburn, but every time I stopped it, the heartburn returned with a vengeance, even though I no longer used Naprosyn. The challenge now was to get off the omeprazole because of its damaging side effects.
What is wrong with heartburn medications?
Most of the potent heartburn (acid-blocking medications called proton pump inhibitors) are very effective for treating the symptoms of heartburn and blocking stomach acid production, but the problem is that when you stop them, you get a rebound of acid production, making it challenging to get off them.
The problem with these medications is that while they do block stomach acid, you need stomach acid to absorb nutrients, such as vitamin B12, magnesium, and calcium. The nutrient deficiencies are bad enough that most of these medications now have an FDA black box warning that using them can cause multiple problems, including hip and spine fracture. Taking these medications are also associated with a greater risk for Alzheimer’s disease and heart disease.
Not only are you far more prone to nutrient deficiencies, but without stomach acid, many bad bacteria pass into the intestinal tract, and you can develop dysbiosis, which is an abnormal accumulation of bad bacteria in the intestines, causing bloating and indigestion.
Ideally, nobody would need these type of heartburn medications, especially not long term, yet they are easy to obtain now that they are over the counter, and commonly used.
And for people with more severe acid reflux, proton pump inhibitors may be the only treatment that works effectively, so not everyone can avoid them. Plus for some people with pre-cancerous changes in their esophagus, long-term use may be absolutely required.
Yet the sooner you get your heartburn controlled, usually the less serve it becomes and the easier it is to control.
Treatments for Heartburn without medication
- Avoid eating or drinking anything within 2 hours of bedtime.
- Minimize brown liquid intake (coffee, colas, chocolate) with or without caffeine. As much as I hate to admit it, because I like a cup of coffee in the morning, switching my morning cup of coffee to a cup of green tea greatly reduced my heartburn. (I must share that giving up coffee in the morning wasn’t easy, but it really helped—who knew that one cup of coffee in the morning gave me heartburn all day long.)
- Avoid excess alcohol, especially before bedtime.
- Avoid fatty meals, especially before bedtime.
- Avoid mint, peppermint, and spearmint. Mint relaxes the lower esophageal sphincter allowing stomach acid to escape into the esophagus.
- Maintain a normal body weight, extra body weight worsens heartburn, as the extra fat on your abdomen pushes on your stomach, pushing acid into your esophagus.
- Elevate the head of your bed on blocks 3 to 6 inches. If you sleep flat, acid can easily stream into your esophagus at night. Elevating the head of your bed just a few inches keeps acid in your stomach and out of your esophagus. And raising the head of your bed 3-4 inches doesn’t change your sleep much. A website where you can order a wedge for your bed is: http://www.foamandupholstery.com/medical-bed-wedges/
- For some people, acidic foods induce heartburn as well, so foods you might want to try avoiding include tomatoes, citrus fruits, pineapple, and sauerkraut.
There are a couple natural treatments for heartburn that do not block stomach acid production and aim to heal tissue. These include:
- Betaine HCL. When you take Betaine (a source of plant-based acid) right before your biggest meal of the day, it helps to close the lower esophageal sphincter and helps you digest your food. Many naturopath physicians aim to restore normal stomach function, rather than block acid production.
Several natural compounds help heal the esophagus. These include:
- Glutamine (1-2 grams daily)
- Licorice (400 mg daily)
- Slippery Elm (200 mg daily)
- Marshmallow (100 mg daily)
- There is a product produced by Designs for Health: GI-Revive that includes each of these agents with a one tablespoon serving dissolved in liquid.
Please be aware that long-term heartburn is associated with serious medical problems, including esophageal cancer, and scarring of the esophagus. If you have had issues with heartburn for ten years or more, talk to your physician about whether you should have an upper endoscopy to exclude pre-cancerous changes related to long-term heartburn. If you have symptoms despite taking acid blocking medication, then you need to be evaluated sooner.
If you are able to wean off the most potent acid blockers and shift to a less potent drug (such as Ranitidine or Famotidine) and control your symptoms that would be better.
There are medical conditions when it is appropriate to continue acid blocking therapy indefinitely, such as precancerous changes noted in your lower esophagus, but keep in mind that this will block nutrient and vitamin absorption, making it more important that if you take heartburn medications long-term, you need to ensure you get a high-quality multi-vitamin and take a probiotic source daily.
Heartburn is super common, and the longer you have it, the harder it is to treat.
This approach worked for me and it has helped many of my patients as well. Getting off acid-blocking medications isn’t easy, but you can do it!
I wish you the best of health!
Steven Masley, MD, FAHA, FACN, FAAFP, CNS
Thank you for your research and advice on this topic.
Thank you for taking the time to write this. I will be very careful when taking the foods you describe above, as I do eat them. So far, I do not have heartburn and will guard against having it.
Once again, thank you.
Thank you for this very clear and complete explanation of the causes and treatment of “heartburn” ! Although it is not something I personally suffer with, as an integrative Physical Therapist I certainly have patients who do. The manner in which you have laid out this information will aid my explanations of the management of this issue, and bolster the credibility of my suggestions ( a PT treating heartburn?!). Thanks for the work you do- your knowledge and educational efforts have been part of my personal healing journey the last several years, as well as informed the care I GIVE of my patients. I am deeply grateful.
Tamerlane Downing. PT
Great article! Thank you Dr. Masley.
Something else I was advised to do was sleep on the left side.
Thank you for this great information. My 82 year old mother takes prescription meds daily for heartburn, so I plan to share this info with her.
Thanks so much