Who hasn’t overindulged in a meal and paid the price later? Whether the food faux pas was a celebratory hot fudge sundae, a third chili dog at the ballpark or that burrito hastily eaten behind the wheel, the outcome is nauseatingly familiar — a sour taste at the back of the throat, a burning sensation in the middle of the chest.
Heartburn is a familiar foe. Roughly 50 percent of Americans feel the heat at least once a month; 20 percent suffer from symptoms two or three times a week and have chronic heartburn or GERD (short for gastroesophageal reflux disease). And those numbers are rising on the tide of obesity, which is a major contributing factor to the malady.
In fact, heartburn is such a universal sensation, says Elizabeth Lipski, PhD, clinical nutritionist and author of Digestive Wellness: Strengthen the Immune System and Prevent Disease Through Healthy Digestion (McGraw-Hill, 2011), that many have come to accept the associated discomfort as normal. “People think ‘this is just how my body works,’” she says.
The pharmaceutical industry is happy to lend a hand, of course. Prescription drugs that target heartburn are one of the top-10-grossing classes of drugs on the market in the United States.
In 2011, according to the IMS Institute for Healthcare Informatics, Americans spent more than $10 billion on heartburn medications, namely H2 blockers and proton pump inhibitors (PPIs).
Chronic heartburn can lead to sleep loss, fatigue, nutritional deficits and disruptions of healthy intestinal flora. And while heartburn medications do a good job of temporarily relieving symptoms, long-term reliance on them (especially big-gun H2 blockers like Pepcid AC) can undermine your health over time.
Gastroenterologist Jorge Rodriguez, MD, has firsthand experience with heartburn, and with how to heal it. Overweight for most of his adult life, Rodriguez, author of The Acid Reflux Solution: A Cookbook and Lifestyle Guide for Healing Heartburn Naturally (Ten Speed Press, 2012), had excruciating heartburn after nearly every meal. “I thought the pain was simply the price I had to pay to eat,” he says. “Happily, I was wrong.”
Think of heartburn as faulty plumbing. The mouth and stomach are connected by a pipe, called the esophagus, and after you swallow, food slides down the pipe before it plunks into the stomach.
On splashdown, an O-ring of muscle at the base of the esophagus (called the lower esophageal sphincter or LES) cinches tight to keep the mixture of food and gastric juices from moving back up the pipe. If the sphincter doesn’t seal correctly, the stomach’s contents slosh up into the esophagus and irritate the lining.
Stomach acid is strong stuff. “It’s meant to burn through flesh,” says Rodriguez. “After all, that’s what a hamburger is — flesh.” A drop or two of the stuff won’t burn a hole in your gullet, but when you have GERD it’s like continuous waves of acid lapping against the delicate lining of the esophagus. Eventually, that acid will erode the shoreline, making matters worse.
The most common sign of heartburn is a painful sensation in the stomach, throat or chest. Other signals include belching, persistent sore throat and a sour taste in the back of the mouth caused by food regurgitating.
Up to 50 percent of people with GERD have some damage to the lining of their esophagus. As many as 15 percent of people will develop Barrett’s esophagus, a lesion at the base of the esophagus that ups the odds of esophageal cancer.
While certain foods can contribute to the degree of acid in the stomach, that’s not necessarily where the problem begins. “When it comes to GERD, the content of acid isn’t the driving force as much as another factor: the function of the lower esophageal sphincter muscle,” says David Wolf, MD, assistant professor in the division of gastroenterology, hepatology and nutrition at the University of Texas Health Science Center at Houston Medical School. “The majority of people with heartburn don’t have an overacidity problem — they have a sphincter problem.”
Lots of things can mess with your esophageal sphincter. Pregnancy, weight gain and tight-fitting clothing can all exert pressure on the belly, pushing the contents of the stomach up against the LES. You could also suffer from a hiatal hernia, one of the most common causes of heartburn, which occurs when the upper wall of the stomach bulges through the diaphragm and puts pressure on the LES. By age 50, one in four Americans has a hiatal hernia. (As if you needed another reason to eat fiber, it’s worth noting that some people get hiatal hernias by straining during bowel movements. Other causes include lifting heavy objects, coughing or vomiting.)
Underlying inflammation in the gastrointestinal tract (which can result from many things, such as food allergies and autoimmune diseases, for example) can also cause serious problems. “If the sphincter gets inflamed, it can swell and get stuck partially open,” says Lipski. “The standard American diet is inflammatory. We need to take a hard look at how much processed food we eat, both at home and away.”
Many people mistakenly think that the simple act of eating processed or greasy, fried foods will cause heartburn, but it’s a bit more complicated than that. Eating poorly can make you obese and inflamed, which, in turn, ups your odds of suffering from heartburn.
For instance, if you are obese, that third chili dog is more apt to give you heartburn because the weight of your belly is pushing the contents of your stomach up against the LES valve. If you’re a stick-thin marathoner, the occasional dog may not faze you at all.
Ultimately it’s the stomach’s acid that burns the base of the esophagus, but it’s important to note that in many cases, heartburn results not because the stomach is too acidic (hyperchloridia), but because it is not acidic enough (hypochloridia).
If you suffer from the latter problem, medications that neutralize or block acid will only make things worse.
How do you know if your heartburn is a case of overabundance or underperformance? Lipski recommends an easy home test. Dilute a tablespoon of apple cider vinegar in a cup of water. Drink the mixture with a meal. If your symptoms don’t improve, you likely have too much acid in your stomach. (For natural remedies for this result, see “Heartburn Dos & Don’ts,” below.)
If you feel an improvement in heartburn symptoms, chances are your stomach isn’t making enough acid. In that case, you can boost digestive action in a few ways.
First, improve acid secretion by engaging all your senses in your meals. Taking time to enjoy the sight and smell of your food before you dig in triggers digestive juices, preparing your system for incoming food.
Second, once you start eating, chew your food thoroughly to give your digestion a head start. Avoid drinking large quantities of water with your meals, since this can dilute your stomach acid and interfere with digestion.
Popping digestive enzymes before or with a meal can also be a huge help. Specifically, pepsin (a time-released protein digestant) is available at health-food stores. (The typical treatment for low stomach acid is to supplement with hydrochloric acid [HCL], the main ingredient in stomach acid, but some experts warn that if you actually have normal-to-high acid production and take HCL, you can give yourself an ulcer.)
Playing With Fire
Chewing the occasional antacid (think Tums) or popping an H2 blocker like Pepcid AC once in a while won’t hurt you. But long-term use of heartburn medications, especially the strong stuff, such as proton pump inhibitors (PPIs) like Prilosec, Nexium and Prevacid, worries many physicians because these medications don’t address the root of the problem, and in those who already have low levels of stomach acid, they may make it worse.
Most heartburn medications ease symptoms by making the stomach less acidic, says Wolf, but the goal should be not only to alter the acid content of the stomach, but also to reduce the number of times the esophagus is exposed to acid in the first place. That means looking beyond the quick fix. You might need to consider a weight-loss solution or eating-habit changes; ask your doctor to test you for a hiatal hernia (diagnosis typically involves a barium x-ray or an endoscopic exam); or, if you are on a medication that causes the sphincter muscle to relax, switch to a different drug.
The second problem (and the more serious one) is that these drugs were never intended for the type of long-term use they are getting — especially PPIs. But not all doctors realize that.
“When acid-blocking drugs first came on the market, even the pharmaceutical representatives warned us of how powerful these drugs are. They told us not to prescribe them any longer than six weeks,” says Mark Hyman, MD, a functional and integrative physician and founder of the UltraWellness Center in Lenox, Mass. “Now these drugs are given like candy to anyone who ate too many hot dogs at a ball game.”
The concern for all these drugs is that chronic use changes the physiology of the stomach. “The supposedly ‘good’ effect of heartburn medications — shutting down stomach acid — is actually a bad effect,” says Hyman. That’s because the stomach needs acid to digest food and absorb nutrients. Hard evidence links heartburn medications to nutrient deficiencies of vitamin B12, magnesium, zinc and calcium, all of which have long-term health implications.
Moreover, when stomach acid is artificially suppressed, the body can’t oxidize calcium in a way that makes it useful, says Rodriguez. “If you aren’t absorbing enough calcium, your bones are going to get weaker and break.”
In 2010 researchers working with data from the Women’s Health Initiative found a 25 percent increased risk of bone fracture among women taking PPIs.
A third cause for worry is that heartburn drugs may open the floodgates for dangerous microorganisms to invade the intestine. Digestive acids are designed, in part, to kill off bacteria, viruses, fungi, and toxins in food. “If we’ve taken in something nasty, like salmonella, we need acid to break that down or else we’ll get sick,” says Lipski.
Take The Pressure Off
One of the best and easiest anti-heartburn strategies, say our experts, is simply to relax during and after meals. That’s because stress and indigestion go hand-in-hand. When the body is under stress, it puts off housekeeping chores, like making mucus to coat and protect the stomach’s lining.
Stress also leads to speed-eating, less chewing and, ultimately, disrupted digestion. “When you’re stressed, the LES relaxes and the sphincter at the bottom of the stomach tightens up,” Hyman explains. “The result is food traveling back up your esophagus.” Taking a few deep breaths during a meal may be enough to reverse that trend.
For more tips on how to ease heartburn, see the sidebar “Heartburn Dos & Don’ts,” below. “Most heartburn can be easily resolved,” says Lipski. “No one should accept heartburn as ‘just how it is.’
Catherine Guthrie is a health writer who lives in Boston.