Stomach ‘acidity’ and acid reflux are common problems, and the mainstay treatments for these ailments are medications that suppress acid secretion. Back in the olden days of when I was a junior doctor, these came in the form of so-called ‘H2 receptor antagonists’ such as cimetidine (Tagamet) and ranitidine (Zantac). Subsequently, a whole new type of drugs with acid-suppressing action were discovered in the form of ‘proton pump inhibitors’, the most prescribed of which is omeprazole (Losec). Expenditure on these drugs is considerable, and in 2006 amounted to £425 M ($872 M) in the UK and £7 billion ($14.36 billion) globally.
This week’s British Medical Journal carried an interesting editorial which suggests that proton pump inhibitors are massively over-prescribed . According to this editorial, between 25 and 70 per cent of individuals on these medications have no appropriate indication to be taking them. I have to say, I do see quite a lot of patients for whom this appears to be true in practice. The classic picture is of a male individual who has suffered from upper abdominal discomfort/indigestion for some time. Investigations (e.g. endoscopy ” looking at the upper digestive tract through a flexible scope) have usually found little or no explanation for the symptoms. Then a doctor makes a decision to ‘try’ a proton pump inhibitor to see what effect this has. Usually the individual describes feeling ‘a bit better’ or is unsure whether the medication is benefiting them at all
My experience in practice is that many of these individuals are suffering from what might be described as ‘poor digestion’. This can be a product of many issue including rapid eating (inadequate chewing) and overwhelming the digestive system with too much food at one time. Another common feature in these individuals is actually low levels of stomach acid (contrary to the popular belief that these individuals are over-secreting stomach acid).
A few years ago I used to be able to test for stomach acid secretion in a specialised lab using something known as the Heidelberg capsule (a tiny pH sensitive device) and radiotelemetry (the device would send a pH reading from the stomach to a device outside the body). Before this test was, I believe, outlawed by the European Union, I estimate that I ran about 200 or so of these tests on patients with symptoms of indigestion and/or acid reflux. Only ONE came back as showing signs of excess acid. The significant majority actually showed LOW stomach acid levels (the minority had ‘normal’ acid levels).
So, why would someone with low stomach acid feel like they have ‘acidity’? One theory to explain this is that low stomach acid causes digestion to stall, which makes it more likely for a big meal to ‘sit’ in the stomach. Leakage of stomach contents into the oesophagus (gullet) is more likely too. Now, the oesophagus is not designed to have acid in it. So even something not very acid may feel ‘acidic’ once it’s in the oesophagus. Also, stomach acid is thought to be important for the production of ‘mucin’ ” basically a substance that protects the stomach lining from its own acid. Low stomach acid in the long term might mean less mucin, which leaves the stomach lining open to attack from whatever acid is in the stomach.
But it’s not all bad news. My experience in practice is that most individuals with these symptoms can resolve them well using the strategies I outline in a piece I have pasted in below. I’ve also found that individuals on proton pump inhibitors can usually stop these, simply by taking steps to enhance their digestion. The BMJ editorial cites one study in which 27 per cent of individuals were able to discontinue their medication. My experience is that this percentage is a lot higher. However, my advice is to work with a practitioner on this and in particular, to institute the recommendation here for a month or two before attempting to get off the medication. It is also important that the medication is weaned off gradually, over about a month. Also, it’s worth bearing in mind that if acid-suppressing medication has been taken for some time, there is a risk of inadequate mucin, and therefore quite a case can be made usually for using some DGL (liquorice preparation described below) to help here.
1. Forgacs I, et al. Overprescribing proton pump inhibitors. BMJ 2008336:2-3
Combating Indigestion Without Drugs – 30 October 2001
Indigestion is thought to affect about a third of the UK population. Acid-suppressing medications, of both the over-the-counter and prescription variety, are some of the most commonly used drugs of all. However, experience shows that indigestion can often be effectively combated without drugs. Just this month, the medical journal Gut published a study which suggests that fat can increase the pain and discomfort of heartburn. However, apart from avoiding fat in the diet, there is a whole host of natural approaches which may be help to control digestive discomfort. Here, we look some of the most effective strategies for quelling this most common of conditions.
When we swallow, food is carried down a tube called the oesophagus into the stomach. At the end of the oesophagus (gullet) is a valve which is designed to keep the acidic contents of the stomach from escaping back into the oesophagus. In some people, however, the valve is somewhat lax, and this can lead to problems with indigestion and heartburn. The medical term for this condition is ‘acid reflux’. Because of the feelings of excess acidity commonly associated with it, heartburn is often assumed to be partly related to excess production of acid. This is why the conventional medical drugs prescribed for indigestion and heartburn are essentially geared to reducing stomach acidity. However, for many individuals, problems with indigestion stem from not too much acid, but too little.
A low level of acid in the stomach stalls the digestion of food, causing it to ferment. Indigestion, bloating and burping are the result. Also, acid in the stomach stimulates closure of the valve between the stomach and the oesophagus. When stomach acid levels are low, there can be a tendency for the valve to remain open, increasing the risk of acid reflux. While it is best to have low stomach acid diagnosed by a health care practitioner, a simple home test can help identify this condition. A level teaspoon of bicarbonate of soda should be dissolved in water and drunk on an empty stomach. If sufficient quantities of acid are present in the stomach, bicarbonate of soda is converted into gas, producing significant bloating and belching within 5 or 10 minutes of drinking the mix. Little or no belching is suspicious for low stomach acid.
Very often, indigestion and reflux can be remedied without recourse to medication. Some simple dietary modifications often help to improve digestive function and reduce digestive discomfort, whatever the cause. Of particular importance here, is the need to chew food thoroughly. Proper chewing is essential for digestion. Chewing mixes food with saliva which contains an enzyme called amylase. Amylase starts the digestion of starchy foods such as bread, potatoes, rice and pasta. Chewing also breaks food up, which increases the surface area exposed to acid and digestive enzymes. Each mouthful of food should be chewed to a cream before swallowing.
In addition to thorough chewing, it helps to avoid large meals (the larger the meal, the larger the load on the digestive system) and late meals (digestion is at its lowest in the evening). Generally, it helps to avoid drinking with meals, because this can dilute the digestive secretions which break food down, disturbing digestion. Finally, it can often help to separate protein-based foods such as meat, fish and cheese from carbohydrates such as bread, potatoes, rice and pasta at mealtime. This makes it much generally easier for the body to digest food efficiently.
Apart from poor digestion, another common cause of indigestion is a condition known as ‘peptic ulcer’. The lining of the gut is shielded from potentially damaging digestive secretions by a coating of protective mucus. Sometimes, this protective mechanism breaks down leading to the development of a raw area or ‘ulcer’ in wall of the intestine. The majority of ulcers develop in the part of the gut just after the stomach called the duodenum. Many ulcers are caused by an organism known as Helicobacter pylori (H. pylori). The usual treatment for H. pylori is a combination of antacid and antibiotic medication. However, re-infection is quite common, and some sufferers may experience recurrent problems despite treatment.
Dietary changes and certain nutritional supplements may promote ulcer healing and help prevent a recurrence of the problem. In general, sugar, alcohol, coffee and tea should be avoided, as all of these foodstuffs seem to increase the risk of developing an ulcer or slow down its healing. Certain nutritional supplements may also help heal ulcers. Vitamin A at a dose of 10,000 IU per day for women and a dose of 25,000 IU a day for men and zinc at a dose of 30 mg per day can both be beneficial because they enhance tissue healing. Another effective natural remedy for ulcers is deglycyrrhizinated liquorice (DGL). This compound has been shown to be about as effective as conventional drugs in healing ulcers. The normal recommended dose is 250 – 500 mg, 15 minutes before each meal and 1 – 2 hours before bedtime.
With regard to the H. pylori infection specifically, this is often helped with a supplement called mastic gum. This product is prepared from the resin of a tree which grows on an island in the Aegean Sea. 1 g of mastic gum should be taken each day for two weeks.