Patients have been known to hug Lauren Gerson, MD, so overjoyed are they at hearing her words. What does she say to them?
Go ahead and eat chocolate. Indulge your passion for spicy cuisine. Drink red wine. Enjoy coffee when you want it, have that orange juice with breakfast and, what the heck, eat a grapefruit, too. Gerson says that for most heartburn patients, there's insufficient evidence to support the notion that eating these foods will make heartburn worse or that cutting them out will make it go away.
Many of Gerson's patients walk into her clinic upset, having been advised elsewhere to severely limit their diets to help reduce their heartburn symptoms. But recent research by Gerson, assistant professor of medicine, indicates there's no evidence to support a need for dietary deprivation, except for the unlucky few whose heartburn is clearly triggered by a particular food.
Gerson's advice runs counter to the long-standing recommendations of virtually every professional organization of gastroenterologists, including the American College of Gastroenterology, as well as the National Institutes of Health.
For the past 15-20 years, the standard treatment for heartburn has been to cut out the aforementioned culinary joys—along with fried and fatty foods, all alcoholic and carbonated beverages, tobacco and mint—and to stop eating three hours before lying down. In addition, you're advised to keep your weight under control. Those lifestyle changes coupled with antacids and various over-the-counter and prescription medications have been the accepted first line of treatment.
But Gerson, a practicing gastroenterologist for seven years and director of Stanford's Esophageal and Small Bowel Disorder Center, said the stream of "very unhappy" patients referred to her clinic by outside doctors caused her to doubt the efficacy of the usual treatment advice. "The patients were on very bland diets and cutting out coffee and wine and everything that they enjoy—and basically their heartburn wasn't getting any better," she said. "So I decided that maybe it's time to look and see if these lifestyle measures really work."
In the May 8 issue of Archives of Internal Medicine, Gerson and two other physicians at the School of Medicine—Tonya Kaltenbach, MD, and Seth Crockett, MD—published the results of a systematic survey they conducted of more than 2,000 studies published worldwide on heartburn, also known as acid reflux or GERD (gastroesophageal reflux disease), between 1975 and 2004. They found 100 studies looking at lifestyle factors thought to be associated with heartburn. Only 16 of those studies examined how implementing lifestyle changes affect heartburn symptoms, and these studies were the focus of their article.
Their conclusion: There is currently no evidence to show that any of the dietary restrictions usually recommended make a difference. They found only two lifestyle changes for which there was evidence of a clear benefit from making a change. First, if you're overweight, then losing some pounds will reduce or even eliminate the amount of heartburn you suffer. Second, raising the head of your bed will cut down on the amount of stomach acid that can enter your esophagus while you sleep.
But Gerson noted a conundrum in her counsel. Although there is no evidence that ceasing consumption of the suspect foods will reduce heartburn, some of the studies did show that certain of the foods (such as chocolate and carbonated beverages) can reduce the pressure exerted by the esophageal sphincter, the control valve that keeps the food you've swallowed and your digestive acids down in your stomach, where they belong.
Heartburn is most commonly caused when the esophageal sphincter relaxes more often than it is supposed to, allowing stomach acid to flow up into the esophagus. That causes a burning sensation behind the breastbone or acidic fluid surging up into the mouth. So it might seem logical to think that if a particular food has been shown to cause a loosening of the sphincter, then eliminating that food from your diet would allow the sphincter to tighten up, thus reducing your heartburn. But, no, said Gerson, that doesn't necessarily seem to be the case, because simply eliminating a certain food doesn't fix the main problem of the esophageal sphincter relaxing too readily.
Gerson's experiences with her patients back that up.
"It's very rare to see a patient who says, 'Oh, I just changed my diet and everything got better,'" she said, "though this might be the case for patients with milder heartburn symptoms who never walk into the doctor's office for advice."
The cause of the conundrum lies in the nature of the studies that have been done. They generally looked at whether a particular food decreased the pressure exerted by the sphincter or increased the acidity in the stomach, but not at whether taking that food out of a patient's diet made any difference.
For example, Gerson said, "There were 14 studies that examined the effect of coffee on sphincter pressure and acidity in the esophagus, and none of them demonstrated a change after coffee consumption. To date, no one has done a study where they took patients and told them to cut coffee out for several days to see if their sphincter pressures or acid profiles markedly improved."
Gerson and her co-authors said that to really sort out how effective, or ineffective, dietary and lifestyle changes are in combating GERD, future research has to be designed to specifically look at the effects of implementing those measures.
Most physicians treating a heartburn sufferer will generally put them on a medication, in addition to any lifestyle changes they recommend. These days that's usually a proton pump inhibitor, which reduces the amount of acid secreted in the stomach.
Gerson said that for the most part, medication alone is adequate to treat the symptoms of heartburn. "The main reason they probably have heartburn is that their sphincter muscle is relaxing too much and taking the medicine will decrease the amount of acid that's going into their esophagus," she said.
"Since I don't have a lot of evidence that changing their diet dramatically is going to take the heartburn away, it makes more sense just to take the medicine," she added.
That said, Gerson allowed that for some patients, a minor change in diet can make sense. "If a patient comes in and states, 'Red wine really gives me terrible heartburn,' then it may be reasonable to say, 'Well, you could avoid it, or you could take a medication before you drink some red wine,'" she said.
According to the ACG, more than 60 million Americans experience heartburn at least once a month and estimates are that more than 15 million suffer from it daily. For the great majority of those sufferers, Gerson's recent findings could free them from the bonds of dietary self-denial. She is considering doing studies of her own to learn more about what effects dietary changes actually have—or don't have—on heartburn.
"It probably wouldn't be that hard to recruit volunteers for a study of chocolate," Gerson noted. "People like to eat chocolate."
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