Doesn’t it seem like when it comes to nutrition there are more opinions than facts to go around? Every day we hear new theories about diets, and supplements, and the best foods to eat. My role is to take the mystery out of good nutrition, and look at the science. Welcome to the Nutrition Facts Podcast. I’m your host Dr. Michael Greger. And I’m here to bring you an evidence-based approach to the best way to live a healthier longer life.
Today we get to know Gerd. And no that’s not the name of my great aunt. It’s short for “gastroesophageal reflux disease,” or reflux for short.
In our first story we look at which foods we should eat to prevent and treat acid reflux before it can place us at risk for Barrett’s esophagus and cancer.
Gastro-esophageal reflux disease (GERD) is one of the most common disorders of the digestive tract. The two most typical symptoms are heartburn and regurgitation of stomach contents up into the back of the throat. But it’s not just burning pain and a sour taste in your mouth. It causes millions of doctor visits every year, millions of hospitalizations. And the most feared complication is cancer.
You start out with a normal esophagus. And if the acid keeps creeping up, it gets all inflamed, and you can get esophagitis, which can turn into Barrett’s esophagus, which can turn into cancer–adenocarcinoma. To prevent all that, we just need to prevent the acid reflux in the first place.
In the last three decades, the incidence of this cancer in the US has increased sixfold–an increase greater than that of melanoma, breast, or prostate cancer. And that’s because acid reflux is on the rise. In the United States, we’re up to like one in four people suffering at least weekly heartburn and/or acid regurgitation, compared to down around 5% in Asia, suggesting dietary factors may play a role.
In general, high fat intake is associated with increased risk, whereas high-fiber foods appear to be protective. The reasons fat intake may be associated with GERD symptoms and erosive esophagitis is because studies on volunteers have shown that when we eat fatty foods, the sphincter at the top of the stomach that’s supposed to keep the food down and acid down is relaxed in the presence of fat, and so more acid can creep up into the esophagus.
For example, if you have volunteers eat a high-fat meal—a McDonald’s sausage and egg McMuffin–and compare that to a low-fat meal–McDonald’s hot cakes–there was significantly more acid squirted up in the esophagus after the high-fat meal.
Then in terms of later stages, over the last 20 years, 45 studies have been published on the association between Barrett’s esophagus, esophageal cancer, and diet. In general they found that meat and high-fat meals appeared to increase cancer risk.
Though different meats were associated with cancers in different places: red meat was more associated with cancer in the esophagus, but poultry was more associated with cancer at the top of the stomach. Whereas “meat alternatives” such as beans and nuts were associated with a significantly decreased risk of cancer, consistent with previous data suggesting a protective effect of plant protein sources, as well as fruits, vegetables and antioxidants, in produce form, not pill form.
Those eating the most antioxidant-rich foods had half the odds of esophageal cancer, whereas practically no reduction in risk among those who used vitamin supplements, such as Vitamin C or E pills.
The most protective produce may be red-orange vegetables, dark green leafies, berry juice, apples, and citrus. But it may not just be the plants. Eating healthy foods crowds out less healthy foods, so it may be a combination of both.
Based on a study of 3,000 people, the consumption of non-vegetarian foods was an independent predictor of GERD, which in this study in India presumably included eggs which are considered non-vegetarian.
Egg yolks appear to induce an increase in a hormone cholecystokinin, which may overly relax the sphincter that separates the esophagus from the stomach. The same hormone is increased by meat, which may help explain why vegetarianism appeared to be a protective factor for reflux esophagitis.
Researchers found that those eating meat had twice the odds of reflux-induced esophageal inflammation. Therefore, vegetarian diets may offer protection, though it’s uncertain whether it’s attributable to the absence of meat in the diet again, or the increased consumption of healthy foods. Vegetarian diets are characterized by greater consumption of fruits and vegetables containing innumerable phytochemicals, dietary fiber, and antioxidants than omnivores, in addition to just restricting their consumption of animal sources of food, which tend to be fattier, and then can relax that sphincter and aggravate reflux.
Bottomline, GERD is common; its burdens are enormous. It relapses frequently and can cause bleeding and strictures, not to mention a deadly cancer. The mainstay of treatment is the proton pump inhibitors, which rake in billions of dollars. We spend four billion dollars on Nexium alone, three billion on Prevacid, two billion on Protonix, one billion on Aciphex. But they can cause nutrient deficiencies, increase the risk for pneumonia, food poisoning, and bone fractures. Thus, it is important to find correctable risk factors and correct them. Known correctable risk factors are things like obesity, smoking, and alcohol consumption, but there hadn’t been studies on eating meat versus not eating meat. But now we have another correctable factor to help prevent this disease.
In our next story we look at low-acid coffee, and whether or not it helps those who suffer from acid reflux, heartburn, and indigestion.
“Dark roast coffee is more effective than light roast coffee in reducing body weight.” But, what about the effect of different roasts on heartburn and stomach upset?
We know that “Coffee consumption is sometimes associated with symptoms of stomach discomfort.” And so, researchers stuck pH probes down into people’s stomachs to measure the amount of stomach acid generated by different types of coffee. The way you chart stomach acid secretion in the stomach is called a “gastrogram.” You basically give people some baking soda, which starts out alkaline, and measure the pH in the stomach to see how long it takes the body to restore the stomach back into an acid bath: about 15, 20 minutes. But if you mix that same amount of baking soda with dark roast coffee, it takes longer, meaning the dark roast coffee is suppressing stomach acid secretion, since it takes longer to normalize the pH.
Give people more of a medium roast coffee, though, and we see a dramatically different effect— an acceleration of stomach acid secretion, returning the stomach to acidic conditions three times faster than drinking dark roast coffee. Hence the title: “A dark roast coffee is less effective at stimulating stomach acid secretion compared to a medium roast coffee.” But, you don’t know if that translates into symptoms,clinical effects until you put it to the test.
“The most commonly used coffee bean roasting process is referred to as convection or ‘flash’ roasting,” which just takes a few minutes. “An alternative method is conduction roasting,” which roasts at a lower temperature for a longer time, hours and this results in so-called low-acid coffee. And, supposedly, there are anecdotes from coffee-sensitive individuals suggesting that this low-acid coffee “does not precipitate or aggravate heartburn.” When you look up that citation, though, they just cite data from the Puroast Coffee company, makers of low-acid coffee. It should therefore come to no surprise that it was the same company that funded the study.
If you go to their website, they claim that “The health benefits associated with drinking Puroast Low Acid coffee will become almost immediately obvious to those who suffer from acid reflux, heartburn, or indigestion,” with over 90 percent of customers surveyed receiving symptom relief. And so, they decided to put their money where their mouth was. But before I get to the results, it’s important to realize that when they say low-acid, they’re not talking about stomach acid; they’re talking about roasting so long that they destroy more of the chlorogenic acid within the coffee bean. You know the antioxidant, polyphenol, phytonutrient chlorogenic acid? You know the “anti-diabetic, anti-cancer, anti-inflammatory, anti-obesity” antioxidant?
That’s like an orange juice company going out of their way to destroy the vitamin C, and then branding their OJ as “low-acid.” And, that would be technically true—vitamin C is ascorbic acid—but they’d be bragging about destroying some of the nutrition, and that’s exactly what low-acid coffee makers are doing. But hey, if it causes less stomach discomfort, maybe it’s worth it?
“Thirty coffee-sensitive individuals completed a randomized, double-blind, crossover study in which the symptoms of heartburn, regurgitation and stomach upset were assessed following the consumption of the Puroast brand low-acid coffee versus conventionally roasted regular Starbucks coffee.” And, to the funder’s chagrin, no benefit whatsoever was found with the low-acid coffee. “Consumption of both coffees resulted in heartburn, regurgitation, and stomach upset in most individuals.” So much for that ridiculous 90 percent-of-customers claim. “No significant differences in the frequency or severity of heartburn, regurgitation, or dyspepsia were demonstrated between the two coffees, either in the fasting state or after the test meal.” They couldn’t find any way to make the low-acid coffee look better.
So, they had this initial thought that a difference in coffee acidity may explain the company’s claims. However, when put to the test in a randomized, controlled study, they found “no difference” in symptoms, suggesting the whole coffee acidity thing doesn’t explain the sensitivity some people have. And, I think, further acts as a reminder that we should never believe claims made by anyone trying to sell us something.
Finally, today we look at treating reflux in children with diet.
Excessive spitting up and vomiting in infants may be treated with putting them on their left-side down after meals, but of course never when sleeping—it’s always face-up to wake-up to reduce the risk of crib death. Also, you can try smaller, more frequent feedings, thickening or changing formulas, and in breastfed infants which is ideally how all infants should be, “eliminating cow’s milk and eggs from the mother’s diet.”
I’ve talked about how more than 40 percent of infants with reflux can be successfully treated with cow’s milk removal. It can also affect them on the other end, too, can be a major contributor to diaper rash, and contribute to chronic constipation in 80 percent of affected kids, though only a single kid tested positive for an actual cow’s milk allergy. So, it was like some kind of sensitivity reaction that can really only be diagnosed by giving a cow’s milk-free diet a try. “Anal fissures in infants” may be practically “pathognomonic” for “cow’s milk allergy,” meaning so characteristic of the condition that it could be used as a diagnostic sign: no allergy testing required.
It’s like when cow milk hypersensitivity was demonstrated in 10 of 17 children with severe reflux. In the majority of patients, the hypersensitivity to cow milk was identified only by eliminating it and then re-challenging to confirm. They did endoscopies, measured the acid gurgling up before and after milk, and then verified by repeating milk exposure with double-blind, placebo-controlled challenges when necessary. Yet all but one of the children proven to have this adverse reaction to dairy tested negative on allergy tests. So, they tested negative for a cow’s milk allergy, but still got better by cutting the cow’s milk out, showing that this association between cow milk hypersensitivity and severe GERD, this severe reflux, was observed not only in infants but also in older children.
Another disease that can be cured with cow’s milk elimination is “eosinophilic esophagitis,” a chronic inflammatory disorder of the esophagus (the tube that connects the mouth to the stomach). To figure out what’s causing the inflammation, an elimination diet is prescribed, where you basically remove everything, and then every time you add back a food, they stick an endoscope down your throat and take biopsies to see if that one food made things worse. And how many freakin’ foods are there out there! So, you can imagine how “difficult and costly” and invasive this is for families, how “confusing and frustrating.”
So, these researchers at Northwestern figured let’s just see what happens if you just remove one food from their diet instead of making them go through all that. And just eliminating cow’s milk induced remission in 65 percent of the children they tried it on. I mean, normally you’d have to put these kids on steroids, where they try to coat their throat with steroids to knock down their immune response. But then that sets you up for infections like thrush. And of course, as soon as you stop the steroids, the esophageal inflammation comes raging back, because you’re not treating the underlying cause. But steroids are considered the standard of care. Too bad there’s never been like a head-to-head test of cow’s milk elimination versus steroids, until now.
A “comparative effectiveness trial of cow’s milk elimination” versus a swallowed steroid, and they both appeared to work just as well — which is to say the cow’s milk elimination worked better, because no side effects and you’re treating the actual cause, suggesting getting rid of dairy products should be considered the “first-line therapy.”
In adolescence, cow’s milk protein intolerance can contribute to chronic fatigue syndrome, evidently a common problem in young people with chronic fatigue, and. most importantly, “a treatable contributor to their symptoms.” But again, most were unaware that dairy was a problem, possibly because it can take hours between milk ingestion and when you start feeling worse, so people don’t make the connection. So, even those “who report no problems after milk ingestion” may still be suffering problems after milk ingestion.
And finally, what about adults? Well, there’s lactose intolerance. Most people on Earth are lactose intolerant after weaning, with the exception of some human populations that developed lactose tolerance about 10,000 years ago, thanks to a “mutation in the lactase gene,” which enables adult humans to digest lactose (milk sugar). Or, at least those select European populations. Whereas most Hispanics, most Africans and Asians remain intolerant, which may be a good thing, since acid regurgitation, reflux, heartburn is so common among adults in the Western world. Food intolerance may play a role in adults as well. Milk was found to be the leading culprit, but they were using what’s called a “Leucocytotoxic Test,” where you see how someone’s white blood cells react to individual foods in a petri dish.
This test is frowned upon by professional allergy associations as not being sufficiently sensitive and specific. Can’t hurt, though, to put it to the test. “A double-blind, randomized, controlled trial performed in 38 reflux patients” for which proton pump inhibitor drugs failed to completely control their symptoms. Okay; well, let’s give diet a try. They randomized people to a diet in which they excluded foods they tested sensitive to most often dairy versus a diet which instead excluded foods for which they didn’t test positive for to control for the placebo effect. A month later, the symptoms in the control group dropped, but the symptoms in the true diet exclusion group dropped significantly further. They kinda felt bad for the control group, so they switched them to the right diet too, and two months later everyone was feeling better.
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