Proton Pump Inhibitors (PPIs) are medications that reduce the production of acid by the stomach. They work by irreversibly blocking an enzyme that controls acid production, H+/K+ ATPase. This enzyme is referred to as the proton pump and is located in the parietal cells of the stomach wall.
We have discussed the use of PPIs in infants, and many of you wanted to know more about how this applies to acid reflux in adults. While I do appreciate that in some cases PPIs may be required for immediate symptom relief, too often they are recommended without any education or additional support as to why the symptom is occurring in the first place, and what the long term strategy is. You will note the work ‘irreversibly’ above – this is a huge issue that should not be ignored. As a natural health practitioner, I am strongly against the prescription of PPIs. Here’s why:
- Acid is vital. It is essential that our stomach is extremely acidic to digest our macronutrients and to act as our defence mechanism to the outside world, preventing infections including Helicobacter pylori.
- Longer term use of PPIs including Losec, Nexium and Somac has been shown to compromise the assimilation of nutrients causing deficiencies of essential amino acids and micronutrients such as B12, iron, folate, calcium and zinc. There is also emerging research linking long term use of PPIs to stomach cancer. Read the side effects here.
- Reflux is a location issue. It is not a problem of too much acid, but acid in the incorrect location. This is an issue as reflux is not only uncomfortable to live with, but acid in the oesophagus causes erosion and over time, inflammation/oesophagitis and even cancer. Examples of the causes are dysfunction of the valve that separates the stomach from the oesophagus, microbiome disruption, hiatus hernia, and/or low tone of the diaphragm and surrounding areas. Let’s take a closer look.
- As discussed, PPIs irreversibly block the proton pump. Those that have taken PPIs for years or decades, often have life long issues. One client of mine who was taking high doses of Somac for decades has anaemia that is currently still unresolved, even after being off PPIs for years and addressing all relevant causes.
The Potential Causes of Reflux
- Valve Dysfunction
Valve dysfunction is a symptom of increased intra-abdominal pressure (IAP), which is essentially pressure that forces stomach contents into the oesophagus. Low stomach acid has been shown to contribute to IAP which of course means that PPIs will make this worse. The medication may appear to work in the short term because PPIs remove all acid, including that in the incorrect location which is causing the pain. However, PPIs do not treat the root cause.
- Microbiome Disruption
In the study, ‘Microbiome and Gastroesophageal Disease: Pathogenesis and Implications for Therapy’, the authors state:
There is growing evidence that gastroesophageal disease is influenced by the oesophageal microbiome, and that commensal bacteria of the oropharynx, stomach, and colon are thought to have a role in modulating pathogenesis. These emerging hypotheses are based on observed changes in the composition of the oesophageal flora, notably, repeated observations:
1. There is an abundance of gram-positive bacteria in the healthy oesophagus.
2. The oesophageal bacterial population becomes increasingly gram negative with disease progression.
Associated with this shift to a more gram negative prevalence is an increase in the potential for the presence of antigenic lipopolysaccharide (LPS). The immunoreactivity of LPS endotoxin thought to promote susceptibility to inflammation and disease. In clinic, I always work on addressing microbiome health as the long term strategy to treating reflux, and well as optimal immune health and longevity. You can screen for LPS via MetaBiome microbiome testing.
- Hiatus Hernia
Reflux can be a structural issue, such as a hiatus hernia, where the stomach protrudes in the chest through an opening in the diaphragm. While some are born with a hiatus hernia, many cases are caused by weaknesses in the opening between the oesophagus and diaphragm. Causes included pore posture, low diaphragmatic and the associated impaired breathing. As this is a structural issue, it is not possible that pharmaceutical intervention is treating the cause.
- Low Diaphragmatic Tone
While low diaphragmatic tone does not always cause reflux, addressing this has been shown to reduce reflux. Diaphragmatic breathing can strengthen the diaphragm to augment the lower oesophageal sphincter (LES) and relieve symptoms of mild reflux. Again, PPIs may help some of the initial symptoms, but they do not treat the root cause.
Treating Reflux Naturally
Due to the vital natural of acid and the significant detrimental impact of both long-term reflux and PPI use, we need to do our very best to treat reflux naturally.
First and foremost, we must establish health food behaviours to ensure we promote optimal stomach acid production. This ensures that we not only digest and absorb our food properly but minimises the risk of developing valve dysfunction. Here’s what you can do:
- Avoid drinking large volumes of water with a meal, focusing rather on small sips during meal times.
- Take 3-5 belly/diaphragmatic breaths prior to each meal to promote the parasympathetic or “rest and digest” state.
- Consume 1 tablespoon of apple cider vinegar (ACV) in water, 1-3 times per day. The best time to consume this is prior to your main protein/meat meals.
- Aim to chew each mouthful a minimum of 20 times. A huge component of digestion occurs in the mouth.
- Where possible, ensure you eat mindfully with minimum distractions such as social media or your inbox.
Secondly, a reduction in processed carbohydrates will starve problematic bacteria, which in time will support the recalibration of your stomach pH. The inclusion of essential fatty acids (from foods including olives, olive oil, oily fish, avocado, nuts and seeds) will down regulate inflammation and support appetite control to stop the vicious cycle of excess refined carbohydrate consumption and the associated stomach acid reduction and increased IAP risk.
Thirdly, there are incredible natural alternatives to PPIs (and over the counter antacids) including those which include chamomile, fennel, globe artichoke, liquorice and gentian. In clinic, we have great success with Metagenics GastroAid. This is a practitioner-only product, so as always, it is best that you work with an experienced practitioner for personalised herbal support. Aloe vera juice can be incredible for soothing the irritation causes by acid in the incorrect location.
Lastly, we must also identify any structural causes and ideally, treat these with Chiropractic or Osteopathic care. If many of the above strategies do not work, please ensure that your doctor refers you to a gastroenterologist for an endoscope to screen for a hiatus hernia. In many cases this can be addressed with the above therapies, however severe cases may need a Nissen fundoplication, a surgical procedure that uses laparoscopic repair or keyhole surgery.
Do you or a loved one suffer from reflux or use PPIs? Book in for a complimentary 15-minute consult here to learn how myself or the team TNN can assist you.
References
Corning B, Copland AP, Frye JW. 2018. The Esophageal Microbiome in Health and Disease. Current Gastroenterology Reports, 1, 20(8), 39.
D’Souza SM, Cundra LB, Yoo BS, Parekh PJ, Johnson DA. 2020. Microbiome and Gastroesophageal Disease: Pathogenesis and Implications for Therapy. Annals of Clinical Gastroenterology and Hepatology, 4, 020-033.
Meneghetti AT, Tedesco P, Damani T, Patti MG. 2005. Esophageal mucosal damage may promote dysmotility and worsen esophageal acid exposure. Journal of Gastrointestinal Surgery, 9, 9, 1313-1317.
Savarino V, Marabotto E, Zentilin P, et al. 2020. Pathophysiology, diagnosis, and pharmacological treatment of gastro-esophageal reflux disease. Expert Review of Clinical Pharmacology, 13, 4, 437-449.
Xie Y, Bowe B, Li T, Xian H, Yan Y, Al-Aly Z. 2017. Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans. BMJ Open. 7, 6, e015735.