Indulgences over the holiday season lead many to experience symptoms of indigestion, part of the discomfort that fuels our renewed January focus on exercise and “eating right”. With this in mind, we need to have a discussion about how we as a nation handle GI distress or GERD (gastroesophageal reflux disease) symptoms. Typically, here in the US, there are 2 methods we typically use: 1. The quick way by popping a Tums or Rolaids or 2. The prolonged way by taking PPI’s (proton pump inhibitors) or H-2 blockers on a regular basis (eg. Pepcid AC or Zantac). Both are reliable ways to efficiently feel a little less GI distress.
The immediate relief strategies neutralize the acid that is already in the stomach whereas the longer-acting PPI’s and H-2 blockers actually block or suppress acid production in the stomach. And even though these “longer term” drugs are designed for short term use, the more I inquire about their use with my patients, the more a troublesome pattern emerges. Many of my patients struggling with complex symptom constellations (eg. a non-relaxing pelvic floor, perineal skin issues, gut issues, anxiety, depressive symptoms etc.) describe that they have taken these “digestive aides” continually for years. YEARS! To take care of their indigestion or digestive discomfort that began YEARS ago.
So, this approach is fine, yes? We know acid reflux can lead to esophageal irritation, not to mention pain and nagging discomfort. It can lead to disordered sleep and its associated sequelae. In extreme cases, esophageal irritation could even progress to esophageal cancer. Therein lies the justification for using drugs that suppress or block acid production in the stomach over the long term. Even though long term safe use of these drugs has never been established.
Hmmm. I hope this is cause for pause. It’s true we don’t want GERD or indigestion, yet it remains pervasive. The prevalence of at least weekly GERD symptoms in the US is approximately 20%,3 with overall prevalence estimated up to 30% in the US. 2 This prevalence of GERD is deemed “exceedingly common”, ranking as the most frequent gastrointestinal diagnosis associated with outpatient clinic visits in the US 1. For as frequently as I see these drugs listed on patient intake forms - or forgotten to be listed since it is such a part of one’s routine - I feel strongly that we are dealing with an epidemic I call “indigestion nation”.
Instead of blaming our stomach acid, it’s time for us to start scratching our heads and asking why. Why are so many struggling with digestion? And is there a better way to get a handle on this under-appreciated situation?
Next question: how often is nutrition or food digestibility considered in scenarios involving GERD symptoms, GI upset or indigestion? When I ask my patients about this, the standard answer prevails: they try their best to avoid known triggers including fried and spicy foods. Beyond that, there is little forward thinking in terms of where our collective indigestion originates.
Further, how many health care providers or patients contemplate what long-term acid suppression might look like? I happen to be one of those……so in my pondering, I peeled back layers of my own mental cloudiness on the topic and kept asking questions about basic principles of digestion such as: 'Isn’t our stomach is SUPPOSED to be acidic?' (Answer: it is) and 'What happens if it isn’t?' (Answer: lots of undesirable things). From there, I began connecting the dots and found points of clarity.
How often is the other side of this coin discussed? Is it common knowledge that in order to digest proteins, there has to be acid in the stomach? Is it common knowledge that the acid in the stomach kills or deactivates harmful viruses and bacteria that could otherwise gain access to the rest of our system via the intestinal barrier? The unfortunate answer is no, this isn’t common knowledge nor frequently discussed principles of digestion. Especially not in our conquest to battle indigestion.
We are conditioned to seek the quick fixes to our digestive woes - woes which have increased in prevalence in North America by approximately 50% relative to the baseline prevalence in the early to middle 1990s.1 Our go-to quick (Tums and Rolaids) and long term strategies (Zantac, Pepcid AC) are not without consequences. And I’m not even referring to the recently elucidated serious issue of the H-2 blocker ranitidine (generic Zantac) containing N-nitrosodimethylamine (NDMA)…. a probable human carcinogen. 4
Facts like these will sometimes get us to take notice, however, the more pervasive problem is this: components of our diets have become so difficult to digest, so physiologically incompatible with us, that we forget to examine this issue through such a simple lens. If our diet consists of foods that are difficult to break down or contain substances that can be disruptive to our digestive processes, it’s no surprise our body may reject them or be unable to digest them fully. If our diet consists of foods that are designed for nourishment, naturally pre-digested and ready to assimilate or use by the body for building blocks and fuel, our body will know how to break them down and utilize them fully…..miraculously reducing the digestive burden and improving symptoms of GI distress including GERD and indigestion.
It sounds simple enough.
But in this day and age, the savvy health care provider will do well to learn and appreciate the breadth and depth of this concept and what it means to you as both a consumer of food and one who cares for others who consume food - all of your patients. This understanding -especially for a pelvic rehab provider- is critical to harness. From simple but nuanced concepts one can help prompt remarkable changes. I’ve seen it firsthand innumerable times.
I invite each of you to learn more about this fascinating topic and how it interrelates with so many facets of your patient experiences. Take advantage of the multiple offerings of Nutrition Perspectives for the Pelvic Rehab Therapist across the nation in 2020. Join me at live course events in San Diego, CA on March 20-22; Columbia, MO on July 24-26; Winfield, IL on September 25-27; or Seattle, WA on November 6-8 to take your understanding of the far-reaching effects of digestion to the next level!
1. Richter, J. E., & Rubenstein, J. H. (2018). Presentation and Epidemiology of Gastroesophageal Reflux Disease. Gastroenterology, 154(2), 267-276. doi:10.1053/j.gastro.2017.07.045
2. Eusebi LH, Ratnakumaran R, Yuan Y, et al. Global prevalence of, and risk factors for, gastro- oesophageal reflux symptoms: a meta-analysis. Gut. 2017
3. El-Serag HB, Sweet S, Winchester CC, et al. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2014; 63(6):871–80. [PubMed: 23853213]
4. Mahase, E. (2019). FDA recalls ranitidine medicines over potential cancer causing impurity. BMJ, 367, l5832. doi:10.1136/bmj.l5832