Month: August 2016

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Health

THE CHOLESTEROL CONTROVERSY…

Did you know there is a controversy over whether low-density cholesterol (LDL-cholesterol) actually causes heart disease or is simply a secondary effect of the true cause? I didn’t until I stumbled across an article by researchers at several Japanese universities last winter…

This research article, written by independent university researchers in Japan, examined cholesterol levels and longevity, and reported that increased blood cholesterol was correlated to a longer life span – the opposite to what we would expect if high cholesterol causes cardiovascular disease (heart attacks and strokes). This study, entitled “Towards a Paradigm Shift in Cholesterol Treatment”, is available at www.karger.com/Article/PDF/381654 if you are interested in reading it yourself.

Having studied hormones for many years, I know that our hormones are made from cholesterol. Cholesterol is also used to make bile (a fluid produced by the liver and used to digest and absorb fat), and vitamin D, and it is a component of the walls of our cells. We get cholesterol from our food, and our liver also produces it; when we eat more cholesterol our liver produces less, and when we eat less the liver makes more, attempting to keep the blood level more or less constant. Our bodies do this with many essential nutrients, like calcium, magnesium, iron, sugar, etc. storing away, pulling from storage sites or producing as necessary to maintain the blood levels our bodies need to function. This is known as “homeostasis”. Cholesterol is one of these essential molecules in our body.

As a pharmacist, I have seen many reports of studies over the years that, I believed, proved the cholesterol/heart disease theory without question. Through my professional education, I learned that high cholesterol, especially LDL-cholesterol, in the blood was a major cause of plaques that blocked arteries carrying essential blood to the heart, and that lowering cholesterol would reduce the risk of a heart attack. I counseled patients to reduce their intake of animal fat and increase their consumption of “good” polyunsaturated fats such as the omega-3 oils.

Now that I’m retired and have more time to read, and with my interest piqued by the article I stumbled across in February, I started looking more closely at the research… I was shocked at what I found!

I found articles from researchers in several areas of the world that questioned cholesterol as a cause of heart disease. In particular, a text by Uffe Ravnskov, entitled “The Cholesterol Myths”, seemed to cover the controversy well, describing flaws in a number of studies that were interpreted to support the diet/cholesterol/heart disease theory. Dr. Ravnskov is a family physician, now retired, who noted that this new idea didn’t seem to agree with information he had previously read. He examined the original full version of studies used to support this idea, and found what he believed were flaws. He continued reading related research and found a number of other studies that appeared to conflict with the idea that dietary fat and cholesterol cause heart disease. He began writing articles and eventually wrote a book on his findings. The original 1998 version of the book is available free online at www.ravnskov.nu/cm/ and an updated version can be found at Amazon.com or at your local bookstore. It certainly is an interesting read.

Ravsnkov begins with discussing the original study done by Dr. Ancel Keyes in 1953 that started us into the world of low fat diets and cholesterol medications. This study used data from six countries that clearly demonstrated higher fat in the diet resulted in higher rates of heart disease. But, data were available from 22 countries at the time, and when all countries were included, the association was much less clear. Some countries with similar dietary fat to that in US actually had only 1/3 to 1/4 the rate of heart related deaths but these were not included in his assessment. It seems that he cherry-picked his countries to make a graph that best supported his idea.

Ravnskov also describes several studies of populations with high cholesterol and high fat diets that have very low heart disease rates, and populations within the same country, where the affluent are reported to have much higher rates of heart disease than the poor, but where blood cholesterol and genetics would be similar.

According to the “Scientific Method”, the basis of all scientific study, any consistent conflicting study results indicate that the original hypothesis or theory must be re-evaluated. While the “statin” cholesterol medications have been shown to reduce heart disease deaths, they have many actions in the body other than simply lowering LDL cholesterol. It appears that there is enough conflicting evidence that the benefit versus risk of these drugs should be reassessed.

Lack of physical activity, mental stress, smoking and obesity are all considered risk factors for heart disease and stroke. These factors also increase the level of cholesterol in the blood. If the blood cholesterol level is merely secondary to the actual causes of heart disease, then artificially lowering it without changing the underlying sedentary lifestyle, stress, smoking and overweight would have little effect on reducing heart disease risk. If this is the case, we need to reevaluate our focus on LDL-cholesterol, and place more importance on changing lifestyle factors that are associated with increased risk.

I am certainly not advising anyone to stop taking his or her medication, but the question is: Should we be focusing more on the factors that raise cholesterol and less on trying to lower our cholesterol numbers artificially? Statins are known to exert several beneficial mechanisms along with their cholesterol lowering effect, such as reducing inflammation and “thinning” the blood. As one reference suggests: “It may be wiser to search for the lowest effective dose instead of the dose with maximal effect on LDL-cholesterol.”

If you are taking medications for cholesterol, discuss this information with your doctor, encourage him or her to examine the evidence and discuss it with local specialists, and thoroughly review possible adverse effects of your medication to ensure you receive more benefit than risk from what you are taking. And, given the importance of increasing activity, reducing stress and quitting smoking in reducing cardiovascular risk, focus on continuing to improve your lifestyle in these areas.

By constantly questioning the status quo when new evidence comes to light, we can continually improve the quality of our healthcare.

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Article reprint Health

Keeping Acne Under Control

Here’s a little “Acne 101” for the students in your life heading back to school, and for those like me who have acne-prone skin… what causes those blemishes and how to prevent and treat them!

Sebum (a waxy oily substance produced by glands in our skin), mixed with dead skin cells, blocks the openings to the pores, creating whiteheads or, if oxidized, blackheads. When oil and bacteria (specifically propionibacterium acnes [P. acnes]) become trapped in pores, the bacteria breaks the oil down into fatty acids that create irritation and inflammation along with the P.acnes infection. It is known that androgen (male hormone) stimulation causes changes in the pilosebaceous units (the oil-producing glands in hair follicles) that result in increased production of the problematic sebum.

The actual cause of acne is actually not well understood, but we do know that it is often associated with a hormone imbalance that involves increased androgen production, leading to excessive sebum production.

During adolescence, both males and females have increased levels of androgens and, in perimenopause and conditions such as polycystic ovarian syndrome, this type of hormone imbalance can occur also. Acne vulgaris, or common acne, affects areas that have the largest density of sebaceous follicles, and hence occurs most commonly on the face, upper chest and back.

Some sources have suggested that in certain skin types, the stratum corneum (the outside layer of skin), grows into the pore opening, creating a condition where pores are more easily blocked than in normal skin; other sources suggest that certain individuals may naturally produce a thicker sebum that blocks the pores more readily. Although these theories have not been well demonstrated, they could explain why some people have a greater tendency to develop acne than others.

Treatments are aimed at reducing oil, decreasing bacteria counts on the skin and keeping pores open. Many of our more effective acne treatments, such as correcting underlying hormonal imbalance, reducing sebum production with vitamin A derivatives, or reducing bacteria counts through antibiotic treatments, require prescription. However, there are many non-prescription options for mild to moderate acne problems. I am one of those unfortunates who have acne-prone skin so, although I generally try to base my articles on research-based information, forgive me if I take the liberty of adding a comment or two based on personal experience.

The 3-Step Approach
One trend we have seen in the acne marketplace is treatment “packages” that include a cleanser, toner and treatment cream or gel. A positive aspect of this idea is that it encourages acne sufferers to take a multiple strategy approach to treatment. Some of the more widely advertised products of this type (such as ProActiv and Acne Complex) are not available for sale in pharmacies and must be ordered by mail or Internet. However, it makes sense to simply select multiple products from the acne section with an understanding of the rationale for each, and create a customized “kit” for yourself.

Step 1: First, you want a mild cleanser, preferably soap-free, to remove excessive skin oils and some of the bacteria. The natural acidic nature of the skin is unfavourable to the growth of P. acnes and, as soaps are generally alkaline in nature, they can tend to reduce some of our natural resistance to these bacteria. Extra additives to the cleanser, such as keratolytics that mildly peel the skin, or benzoyl peroxide (discussed below), are thought to have little additional effect because of the short contact time with the skin.

While most sources recommend avoiding cleansers containing “scrubbing” particles that may increase inflammation, I have found personally that these can work well on non-inflamed acne-prone skin to prevent pores from becoming blocked by promoting exfoliation (or removal of the outer layer of dead keratin cells). Be aware, though, that many of these particles are made of plastics that can contaminate the environment – if you use one of these, choose one with natural, biodegradable particles.

Another option is to use an exfoliating sponge. Buff-Puff is one brand name, but they are available from many generic manufacturers. As exfoliation is also a common strategy for reducing the appearance of fine wrinkles, this may be an option that will interest older women with mild non-inflammatory acne. The use of an exfoliating sponge with a non-soap cleanser has been a personal favourite for 30 years; however, remember the caution against use in inflammatory acne.

Step 2: The second step, using a toner, often functions simply to remove more of the oil. Many toners have a high alcohol content, in the range of 30%, which may also kill some bacteria. Toners designed for use in acne often have 0.5 to 2% salicylic acid added, however, and this keratolytic agent, when left on the skin, can be useful to help keep pores open, preventing the trapping of oil and bacteria that is problematic in acne. Toners are designed to be applied using a cotton pad and are not rinsed from the skin afterward. Note that salicylic acid, an oil-soluble beta hydroxy acid, is often preferred in acne preparations for its ability to penetrate the oily sebum that is plugging the pores. It is sometimes referred to as a “comedolytic” action.

Some sources of information I have read in the past have suggested that alcohol alone may make an effective acne treatment, but many will complain that 70% alcohol causes burning and irritation while the lower content of alcohol in toners is generally tolerated quite easily. However, if you are a teen on a limited budget this might be a “step” to skip to reduce cost.

Conversely, an adult woman might appreciate this additional treatment from which she may benefit. As an example, one available multi-kit contains a toner with a low percentage of the alpha hydroxy acid (AHA) glycolic acid as an exfoliant to keep the pores open, while another has arnica added for its anti-inflammatory activity. A toner designed to reduce inflammation might be a welcome addition to the skincare regimen of a client with adult acne.

Step 3: The third step included in the multi-kits is a treatment gel or cream. There are numerous treatment products that we can recommend. My personal favourites, based both on theory and experience, are the benzoyl peroxide products. The maximum concentration that can be sold without prescription in Canada is 5% but in US the 10% is also out on the shelf. Most can easily tolerate 5%, but those with very sensitive skin may want to try a lower strength initially.

Be aware that benzoyl peroxide can increase sensitivity to the sun, so using it at bedtime and washing off in the morning makes sense, especially in the summer. As well, higher strengths, up to 10%, are available in Canada with a prescription. For me, a prescription for Panoxyl 10% alcohol gel was a turning point in acne control.

Benzoyl peroxide 10% would be a logical product to ask your pharmacists about, however, as they now have the ability to prescribe for acne in most jurisdictions. They would likely first ask questions about the severity of your problem, what you have already tried, and would verify that you had previously tolerated a 5% version of benzoyl peroxide.

As well as the tried and true OTC favourites, some alternative anti-acne ingredients have appeared in the literature and in various acne products. Here’s a little about how these ingredients are understood to work:

Arnica and calendula are herbal/homeopathic ingredients that have anti-inflammatory action. Calendula is also reported to have antibacterial activity.

Benzoyl peroxide is a favourite because of its dual action: it kills P. acnes bacteria plus has a keratolytic action. Don’t forget to ask about the 10% prescription if the 5% on the shelf doesn’t make a difference. Note: Be sure to use white towels and washcloths, as benzoyl peroxide will bleach coloured ones—I once ruined some of my Mom’s pretty green ones [sorry, Mom!].

Niacinamide (or nicotinamide) appears, when used as a 4 to 8% gel or cream, to have an anti-inflammatory effect and was shown to have comparable efficacy to topical clindamydin (a prescription antibiotic cream/lotion). It has also been credited with increasing synthesis of collagen and keratin, reducing skin hyperpigmentation (as can occur with acne scars), increasing skin moisture and reducing fine wrinkles. This is likely an ingredient that women with adult acne would be interested in. LaRoche-Posay’s Effaclar Duo Cream contains 8% niacinamide, or a pharmacist could compound this for you.

Resourcinol is included in acne products for its antiseptic action, presumably against P. acnes, and is often combined with the keratolytic, salicylic acid.

Sulfur, commonly found in acne products, is effective as a micro-exfoliant and a mild antiseptic and is probably the oldest known acne remedy, having been cited in ancient Greek, Roman and Chinese texts for this use. It is also helpful in promoting collagen synthesis, and is an active ingredient in lotions, creams, gels, washes and shampoos. It has also been used for seborrheic dermatitis, rosacea, eczema, psoriasis, and, in much higher concentrations, for scabies and lice.

Tea tree oil (5%) has been cited as being comparable in effect to benzoyl peroxide but without excessive drying, so might be a good option for adult acne. It kills P. acnes and has been shown to have anti-inflammatory action. It would also present a good option for those allergic or sensitive to benzoyl peroxide, or for those who are keen on a more natural option.

Zinc supplements, taken by mouth, have been shown to be helpful in inflammatory acne, although less so than oral tetracyclines (prescription antibiotic). Zinc tablets would also present an option for those who wish to avoid long-term antibiotics.

Camouflage techniques
Acne can be a distressing condition, particularly when it occurs at adolescence, a difficult time for many. It is natural for many teenagers, especially girls, to want to “cover up” their acne, and some advice from a pharmacist or trained cosmetician may help them to successfully do this without making their acne worse.

First, be sure to realize that bacteria, including the P. acnes that are involved in the acne process, can grow in your makeup products. Wash your hands before using, avoid dipping into the product with your fingers, and replace the products regularly. Use oil-free cosmetics to avoid adding additional oil to skin that is most likely already producing too much. Sheer or translucent makeup is recommended for commodonal acne, and fuller, opaque types for lesions or scars. You can also mix translucent powder with your makeup or dust it on afterward for better coverage. Multiple thin layers can be applied for additional coverage with drying time between.

Skin camouflage, such as Hyperflage, Dermablend, and CoverMark Face Magic, may be “just what the pharmacist ordered” for a teenager with acne heading to a special event. Proper application is important for best results and, generally, these products include instructions for use that should be read carefully to achieve a natural look. General recommendations are to cleanse the skin first, apply the camouflage makeup sparingly, blend the edges carefully, let dry, then apply foundation with a dry wedge sponge, if desired.

Previously published in Drugstore Canada

Categories
Article reprint Health

Stress – The Elephant in the Room

Remember those predictions about working a four-day workweek in the new millenium? Well, it hasn’t worked out that way, has it! Computers and BlackBerrys, while making us more efficient, have also made us more accessible to work on evenings and weekends. Cutbacks often result in one person doing work that was previously assigned to several people. In my world, a lack of pharmacists often means long hours and less vacation time.

The result is increased stress—a contributing factor in many disease states that is rarely addressed in the course of a routine medical visit. Stress is listed as one of the modifiable causes of heart disease, and several of the effects of the stress hormone, cortisol, match up alarmingly with the symptoms of metabolic syndrome: increased blood pressure, weight gain around the waist, increased cholesterol and insulin resistance. Could it be that excess production of cortisol due to stress is that elusive cause of metabolic syndrome?

Researchers have observed that the appearance of cancer in many patients is preceded by a stressful event about two years earlier. Anyone who suffers from cold sores will tell you that they are most likely to show up when they are under stress. Emergency wards and student health centres note an increased demand for services during stressful times. Excessive production of cortisol is known to have a negative effect on the immune system, and the metabolic pathways by which this occurs have actually been identified. And stress hormones, being structurally similar to our reproductive hormones, can worsen the symptoms of menopause.

It’s enough to make you wonder why we don’t routinely test for and treat elevated cortisol blood levels…Perhaps it’s because physicians themselves have not been spared from the increased pace of life, and few are able to take time during an appointment to discuss the issues surrounding stress in a patient’s life.

Non-drug options for stress

Anti-depressants and tranquilizers are standard medications offered to highly stressed patients, but, as well as having high side effect profiles, they do not directly address the production of cortisol. However, in the herbal world, there are a number of medicines known as cortisol modifiers and adaptogens that lower cortisol production and lessen the impact of stress. As well, simple changes in lifestyle, attitudes and nutrition can result in a healthier response to the everyday stresses of life.

Those who really need help should be see a stress specialist. However, for those who are less severely stressed, I can pass along some self-help suggestions and recommend nonprescription supplements.

A good place to start is with a lifestyle assessment. Make a list of factors that are “good for me” versus “bad for me,” then devise a plan to relieve the worst factors, using a strategy to “change, adapt to, or leave” the most stressful situations. As stress hormones set up the body for “fight or flight,” exercise can be recommended to help reverse some of the effects of these hormones. Dietary recommendations to lower cortisol include eating balanced meals regularly throughout the day, ingesting a small amount of salt (sodium is required for adrenal function), avoiding simple sugars, increasing protein and essential fatty acids, and avoiding coffee, including decaffeinated (both contain theobromine, which tends to raise cortisol).

Substituting green tea for coffee, and vegetable juice for fruit juice is often advised. Vitamin C up to 3000 mg per day (either in divided doses or as a slow-release tablet) is recommended, as are B vitamins, particularly B5 or pantothenic acid, to support healthy adrenal function. Magnesium is a co-factor for many reactions that involve energy metabolism and nervous system function. Therefore the need for magnesium may be increased during periods of stress.

Magnesium is also necessary for muscle relaxation, and a deficiency increases the risk of muscle spasms that will often develop as a response to stress.

Herbal medications available for treating stress are divided into two major categories: the cortisol-modulating supplements (such as theanine, epimedium, and phytosterols) and the adaptogens or general anti-stress supplements (such as ginseng, schisandra, and astragalus). I will review some of the properties of some of these supplements to help distinguish which might be best for a particular client.

Cortisol modulating herbs

Theanine
Theanine is an amino acid. It acts as a non-sedating relaxant, helping to increase the brain’s production of alpha waves, one of the four basic brainwave patterns. Alpha wave production is associated with relaxed alertness, increased focus and concentration, promotion of creativity and improved overall mental performance. Theanine occurs naturally in tea leaves, and is converted by the plant gradually over time into catechins, the substance in tea known for its antioxidant benefits. Green tea, which is less aged than black tea, therefore contains more theanine than the other more aged varieties. As well, users should be aware that the decaffeination process removes theanine from tea along with the caffeine. Theanine has been shown in clinical studies to be effective in dosages from 50 to 200 mg per day. Three to four cups of green tea contain 100 to 200 mg of theanine. It is also available in supplement form.

Epimedium
Epimedium, also known as horny goat weed, has been shown to restore low levels of both testosterone and thyroid to normal levels, in addition to reducing cortisol levels when elevated. Hence, it has a reputation for improving libido in stressed individuals. Water-extracted epimedium, the traditional method of preparing this herb, is considered a safer form than the alcohol extract as rodent studies suggest that high doses of icariin, an alcohol-soluble constituent, may be associated with kidney and liver toxicity. A suggested dose for cortisol control is 250 to 1000 mg per day.

Phytosterols
Phytosterols include hundreds of plant-derived sterol compounds that are structurally similar to cholesterol but do not clog our arteries. By controlling production of inflammatory cytokines, phytosterols help modulate immune function, inflammation and pain levels. They have been shown to prevent immune system suppression and cortisol elevation usually seen in athletes after endurance events. Preliminary evidence from animal studies suggests that dietary phytosterols retard the growth and spread of breast cancer cells. Beta-sitosterol, one of the major phytosterols, has been shown in humans to normalize activity of T-helper lymphocytes and natural killer cells following stressful events that normally suppress immune system function. A typical dosage is 100 to 300 mg per day of mixed phytosterols, including 60 to 120 mg per day of beta-sitosterol. A handful of roasted peanuts or 2 tablespoons of peanut butter contain 10 to 30 mg of beta-sitosterol. Rice bran, corn, wheat germ and flaxseed are examples of rich food sources of phytosterols. See www.dietaryfiberfood.com for more information on the phytosterol content of foods.

Phosphatidylserine
Phosphatidylserine has been shown to modulate many aspects of cortisol overproduction, especially after intense exercise. There is scientific evidence that it can help improve mental function and depression, even in Alzheimer’s disease. Because cortisol causes catabolism of muscle tissue, athletes will frequently use this supplement to promote recovery from exercise and help slow muscle loss. Practitioners sometimes suggest phosphatidylserine supplements be taken late in the day to reduce nocturnal awakening due to surges in cortisol production during the night. Doses of 100 to 500 mg per day for one month are recommended for mental support, followed by a maintenance dose of 50 to 100 mg per day.

Tyrosine
Tyrosine is an amino acid that was studied by the U.S. military for its potential to help soldiers cope with the stress of battle. Their studies showed that 2000 mg of tyrosine helped memory and cognitive ability during stress. Studies, with volunteers exposed to stressful situations such as shift work, sleep deprivation and fatigue, found that 100 to 200 mg per day helped to prevent declines in mental performance and increased their ability to concentrate. Other amino acid groups, referred to as the branched chain amino acids (BCAAs) have been shown to counteract the rise in cortisol and drop in testosterone and immune function that is often seen in endurance athletes. Although tyrosine and BCAAs are available in supplement form, they can easily be obtained from protein foods. Hence, the recommendation above to increase protein content of the diet.

Adaptogenic herbs

Ginseng
Ginseng is the best known of the adaptogens. Many animal and human studies have shown that ginseng can increase energy and endurance, improve mental function and improve resistance to various stressors including infection, extreme exercise and sleep deprivation. Human studies have shown improved immune function and reduced incidence of colds and flu with Panax ginseng 100 mg per day. Siberian ginseng (Eleuthrococcus), while not a true ginseng, contains compounds that give similar effects. While generally considered safe, ginseng has been reported to increase blood pressure in some individuals, and caution should be used in those prone to hypoglycemia, due to its reported effect of reducing blood sugar levels.

Schisandra
Schisandra is a traditional Chinese medicine used to promote energy, protect the liver, alleviate exhaustion and correct immune system disturbances caused by stress. It is generally considered safe when used in recommended doses of 100-500 mg per day, although mild indigestion and skin rash has been reported. Because it may induce uterine muscle contractions, it should not be used by pregnant women.

Astragalus
Astragalus is an adaptogen herb commonly recommended for stimulation of the immune system and for energy-promoting properties. It has been used for centuries both in Traditional Chinese and Native American medicines, and animal experiments suggest that it enhances function of T-cells, lymphocytes and neutrophils. It is often combined with other adaptogenic herbs to keep the immune system functioning during periods of high stress. As a single ingredient it would be used in doses of 250 to 500 mg per day, or in combination as 100 to 200 mg per day.

Treating the cause

Many of these herbal medicines are available in combination “stress formula” products, and this is often the easiest way to supplement with them. People with high levels of stress on an ongoing basis would be well advised firstly to maintain a healthy diet and supplement with vitamin C, vitamin B complex and magnesium. If they are having difficulty coping with chronic stress or if stress is causing detrimental physical effects, they should next consider taking cortisol-modulating supplements as well. Adaptogenic herbs, available as combination products from several herbal manufacturers (for example: AdrenPlus from Enzymatic Therapy, Corti Lite from Vita Plus), would generally be used periodically during episodes of increased stress to counteract the detrimental effects of elevated cortisol.

Animal studies have shown that stress-induced rises in cortisol levels lead to increased visceral (in the abdominal cavity) fat deposits that are associated with disease states such as diabetes and heart disease. It would appear that we are focusing on treating all the diseases caused by excessive stress, while ignoring the “elephant” in the room. Perhaps the tools described above, along with improvements in diet and lifestyle, can help us to become healthier and improve our chances of avoiding chronic disease.

Originally published in Drugstore Canada

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Health

Acid Reflux Anyone?

Heartburn, sour taste, chest pain, hoarseness, sore throat, sensation of a lump in your throat, difficulty swallowing… sound familiar? You may have GERD (GastroEsophageal Reflux Disease), also called Acid Reflux…

WHAT IS GERD?

It’s common to have some stomach contents back up into the esophagus (the tube between the mouth and stomach) especially when we burp, and this is known as common heartburn. However, excessive backwash of stomach acid, sometimes also containing enzymes, causing symptoms twice weekly or more is what we refer to as GERD. It occurs regularly in an estimated 10 to 30% of us and, over time, can create damage in the esophagus, such as inflammation, bleeding, ulcers, narrowing or scar tissue, known as Barrett’s Esophagus, a pre-cancerous condition. It can even be the cause of chronic cough or asthma (when the acid is inhaled into the lungs), chronic sinusitis, dental erosions and laryngitis.

Risk factors include:

  • Conditions that increase the upward pressure on the “gastroesophageal sphincter” (the valve between the stomach and esophagus, also referred to as the “lower esophageal sphincter”) such as:

    • Being overweight (especially around the waist)

    • Being pregnant

    • Wearing tight clothes

    • Eating large meals

  • Anything that relaxes the sphincter, such as:

    • Smoking

    • Hiatal hernia – a tear in the diaphragm, the muscle surrounding the top of the stomach that supports the sphincter

  • Reduced “motility” – a decrease in the normal digestive movements that push food forward in the digestive system. Food sits in the stomach longer, increasing risk of reflux, and any stomach contents that do backwash into the esophagus will not be pushed back into the stomach as quickly.

  • A dry mouth – less saliva to help wash refluxed acid back into the stomach, plus saliva actually neutralizes some of the acidity.

Certain foods, such as coffee and tea, tomatoes and other acidic foods, alcohol, carbonated beverages, and chocolate, can aggravate reflux – note what you ate before episodes and avoid these foods as one strategy to help prevent the problem.

Keep in mind that the level of pain and the amount of damage are not necessarily correlated. Often we have reflux with no symptoms at all. Be aware that black, tarry stool is an indication of bleeding somewhere in the digestive system, and see your doctor as soon as possible if this occurs. Also, heartburn or chest pain that is not relieved by an adequate dose of antacid could be a sign of a heart attack – again don’t waste time getting medical help if this is the case.

Here is a link to a simple questionnaire to determine whether you may have GERD:

http://www.aafp.org/afp/2010/0515/p1278.html

Although questions 3 and 4 of the questionnaire seem counter-intuitive to me, with increased frequency of pain and nausea in the upper central abdomen awarding fewer points, this questionnaire has been found to be 65-70% accurate in predicting GERD, similar to a diagnosis by a gastroenterologist. Presumably, mild pain or nausea, such as is felt when hungry, must indicate an ability to sense the presence of acid and enzymes in the stomach and, therefore, also in the esophagus if present.

MEDICATIONS FOR REFLUX

Antacids can give rapid symptom relief, but do not help to heal any damage in the esophagus. Histamine H2-receptor antagonists, such as ranitidine (Zantac) and famotidine (Pepcid), like antacids, also give temporary relief, with slower onset but longer action than antacids. Long-term use is not recommended with these, as the body develops tolerance to their effect within 1 to 2 weeks, and they are not as effective as prescription medications for healing damage in the esophagus.

Proton pump inhibitors (PPIs), such as omeprazole (Losec or Prilosec), pantoprazole (Tecta or Pantoloc), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Pariet or AcipHex) and others, block the production of acid in the stomach, greatly reducing the acidity of any stomach contents that regurgitate into the esophagus. They are the drug of choice for healing damage from acid reflux. However, not everyone responds well to these medications. Studies suggest that those who are average or over weight, have nighttime pain, get relief from antacids or H2-receptor antagonists or do not have nausea as a symptom are more likely to respond to a 2-week therapy of PPIs.

Concerns with these drugs include failure to respond, increased chance of infection with H. Pylori (the bacteria associated with increased risk of ulcers), increased risk of C. difficile infection, increased risk of pneumonia and decreased absorption of vitamin B12 and calcium from food (with corresponding increased risk of bone fractures if taken long term). Rebound acidity with a return of symptoms can also occur when discontinued after as little as 8 weeks of use and can last for 9 to 12 weeks, creating a dependency on these drugs. It is suggested that tapering off the medication slowly may help reduce rebound.

And, acid itself is one of the factors that encourage the sphincter to close more tightly. So, chronically lowering stomach acid essentially opens the door to more reflux. This may be why one tablet of a PPI is often not enough – stomach acid needs to be completely blocked to eliminate symptoms.

POSSIBLE ALTERNATIVES

So, what other options are available? Surgery to create a replacement valve at the top of the stomach (similar to what is done to replace heart valves) is one option. Another new idea being tried, according to Mayo Clinic, is the surgical addition of a magnetic ring around the lower esophageal sphincter, strong enough to support it but weak enough to let food pass through.

Surgery is suggested for those with osteoporosis, serious respiratory or esophageal complications of GERD, or poor compliance to medication – those with more severe disease or for whom PPIs may be less effective or possibly harmful.

Small studies suggest low carbohydrate diets along with avoidance of trigger foods may help. One study found acupuncture (used to increase motility, the normal digestive movements that push food forward) along with a single daily dose of PPI was superior to doubling the daily PPI dose, in those who did not respond to the once daily dose of PPI.

Animal and “in vitro” (outside of the body) studies suggest that natural compounds such as curcumin and quercetin that lower inflammation may be helpful in reducing esophagitis, but no studies have yet been done in humans.

A human study comparing 175 patients on omeprazole (Losec) with 176 patients on a combination of melatonin and a specific nutrient supplement showed better response to the melatonin/nutrients than to omeprazole 20mg daily, with 100% response after 40 days vs 66% of those taking omeprazole. The non-responders to omeprazole were switched afterward to the nutrient combination, and 100% of those responded as well.

The nutrients used were: melatonin 6mg, tryptophan 200mg, vitamin B12 50mcg, methionine 100mg, betaine 100mg, folic acid 10mg and vitamin B6 25mg. All of these are known to either increase the pressure of the lower esophageal sphincter or to increase motility (food-pushing movements) of the digestive system and could offer an alternative to PPI therapy. Two of these ingredients, tryptophan and folic acid (at that strength) require prescription in Canada. Another smaller but interesting study (60 patients) found that melatonin 3mg increased the lower esophageal sphincter pressure and relieved symptoms, alone and along with the PPI, omeprazole 20mg. These studies suggest treatments that might be especially helpful for those trying to discontinue PPI therapy.

Lastly, “raft-forming agents”, natural substances that create foam that can float to the top of the stomach, are effective in reducing symptoms of GERD and may be helpful in those weaning off long-term PPI therapy. Gaviscon is a brand name of this type of medication, and generic versions are also available. It is recommended to chew 2 to 4 tablets and follow with ¼ glass of water to enhance effectiveness.

IN SUMMARY…

Things you can do to help reduce reflux include:

  • Avoid trigger foods

  • If you smoke, quit

  • Don’t overeat

  • Avoid tight clothing

  • Lose weight

  • If you have nighttime symptoms, elevate the head of the bed 6 to 9 inches and avoid eating for 3 hours before bedtime

See your doctor if you have reflux symptoms that are severe or frequent. If you have another condition that can be caused by acid, ask if reflux may be the cause. Remember that black tarry stools or chest pain not relieved by antacid are warning signs that you should see a doctor about right away. If you have been on PPI therapy for a long time, talk to your doctor about tapering off and using alternatives, if necessary, to avoid the consequences of long-term use.

Hopefully this has given you a good sense of the issues and concerns around what may just seem like an annoying symptom, enabling you to have a better discussion with your doctor.

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References:

Melatonin study: Regression of gastroesophageal reflux disease symptoms using dietary supplementation with melatonin, vitamins and aminoacids: comparison with omeprazole.

Mayo Clinic: Mechanisms of GERD

Which is the best choice for gastroesophageal disorders: Melatonin or proton pump inhibitors?