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The Functional Medicine Approach to GERD

Gastroesophageal Reflux Disease, better known as GERD, affects around 25% [1] of the people in the United States. Just to put it in perspective that is around 82 million people! If you’re one of these millions of people, you’ll already know that symptoms occur when stomach contents wash back up the esophagus (the tube that connects the mouth to the stomach). These symptoms include a burning sensation behind the breastbone (sternum) that shows up mainly after eating, but also may happen when lying down. Regurgitation of stomach contents can occur as well, with fluid making it up all the way to the back of the throat or into to the mouth. Other symptoms of GERD include difficulty swallowing, chest pain, a sensation of a lump in the throat or chest, pain with swallowing, and even chronic cough, hoarseness, or wheezing. It is important to accurately describe your symptoms to your licensed practitioner so that he/she can properly treat you. Some details to which you should pay particular attention include the following:

  • Is it heartburn or is it dyspepsia? Heartburn is a burning sensation behind the sternum (breastbone). Dyspepsia, on the other hand, is epigastric pain or burning (the epigastric area is below the xiphoid/sternum in the center of the upper abdomen just below the xiphoid/sternum).

  • When do the symptoms occur—only while lying down or while upright as well?

  • What makes the symptoms worse and what makes them better?

  • Have you had previous evaluation for this problem such as endoscopy or an x-ray?

Using endoscopy (EGD), conventional medicine does a good job at ruling out serious diseases like cancer or Barrett’s esophagus that may be associated with GERD, but what do you do if you have GERD and it is not associated with a life-threatening disease? Standard medical practice is to prescribe proton pump inhibitor (PPI) medications such as Prilosec (Omeprazole), Protonix (Pantoprazole), Prevacid (Lansoprazole), or other such options. There are several problems with these medications:

  1. First of all they don’t treat the root cause of reflux. Why is it that for many years you didn’t have reflux problems but now you do? The problem is not the acid—we’re supposed to have acid in our stomachs. The problem is that the acid is washing up into an area that’s not supposed to be exposed repeatedly to lots of acid. The question is, “Why is this reflux of acid occurring?” Why isn’t it staying, for the most part, where is supposed to be? What has changed allowing this dysfunction to occur?

  2. Even though PPI’s are widely prescribed, about 40% of those taking PPI medications either have little relief of their symptoms, or no relief at all [2] If you’re on a PPI and you’re still having symptoms, your doctor may recommend a different PPI or increase the dose of your current medication, but that still doesn’t address the reason that the reflux is occurring. Why not treat the root cause of GERD?

  3. Long-term use of PPI’s can pose some significant risks, not the least of which is worse outcome following heart attacks, more risk of bone fractures, kidney disease, and SIBO [3] More recent studies have shown an increased risk of developing COVID-19 if a person is taking a PPI once a day, and even worse risk if taking a PPI twice a day [4]

Now, don’t misunderstand, even though they don’t treat the root cause of GERD, PPI medications may be very helpful in treating the symptoms of GERD; and in that case they are useful. However, they have never been indicated for long-term use (more than 2-3 months), and if you’re on them for a long time, it can be very difficult to get off these medications.

So what do you do if you have GERD, you want to try to avoid just treating the symptoms, and would like to address the reason that reflux is occurring? Well, then it’s time to look for and address the root cause! Given all the possible contributing factors, a holistic approach is necessary where the whole person is addressed, and not just the GI tract. Exercise, diet, sleep, stress levels, habits, etc. must be addressed in every case. In addition, it’s important to note that there is a growing body of research that supports the position that every person’s GERD treatment must be personalized to their unique set of imbalances and dysfunctions that are contributing to their GERD [5]. Therefore, you need (1) a comprehensive look at all the factors that play in to the development of GERD, (2) have all of these factors addressed at the root cause level, and (3) have a personalized treatment protocol designed to meet your unique set of imbalances.

Ever heard of exercise for reflux?

Let’s start with exercise. Exercise in general is important, but when it comes to GERD, exercising the diaphragm is crucial. In some people, the diaphragm has a hernia and that may be a major factor; but what I see more of is a loss of diaphragm strength and tone. If the diaphragm is weak and floppy, then it has loosened its “grip” on the esophagus as it passes through the diaphragm. If the tissue surrounding the esophagus is weak, then stomach contents may more easily reflux up into the esophagus. I prescribe diaphragm exercises for all my patients with reflux.

What about diet?

The next area that needs to be addressed is diet, and the most important thing to remember about diet is this: THERE IS NO SUCH THING AS A ONE-SIZE-FITS-ALL DIET! It will be necessary to personalize each and every person’s diet to conform to his/her unique set of sensitivities, allergies, digestive abilities, and microbiome balances. The good news is that if you find your best diet, this may be all that is needed to control your GERD! I’ve seen this happen time after time with my patients. But even if diet isn’t the only intervention that is needed, it’s a foundational part of your holistic treatment. That being said, you will need a place to start to find the diet that is best for your unique gut, and I’ve found that the best place to start for my patients is our Legacy Health GERD-specific elimination diet. However, an antigen elimination diet or a Paleo diet are reasonable places to start as well.

Another consideration is what foods you already know aggravate your GERD symptoms. It’s important to eliminate these even if these foods are not included on the elimination diet list. If you’re not sure what might be contributing to your symptoms, here is a list of foods that are problems for a lot of people:

  • Acidic foods (such as citrus and tomatoes)[6]

  • Greasy or high fat foods [7]

  • Canned foods [7]

  • Alcohol

  • Fried food, fast food, pizza, chips/processed snacks, chili powder/chili pepper, cheese, tomato sauces, citrus, chocolate, and peppermint

  • Carbonated beverages

On the other hand, there are a number of foods that actually can help decrease GERD symptoms. These include foods that are alkaline, such as bananas, melons, cauliflower, fennel, nuts, avocado, and fish. Foods with high water content may also be beneficial: celery, cucumber, lettuce, watermelon, broth and broth-based soups.

Low Histamine diet

A low histamine diet may help if a standard elimination diet isn’t effective in relieving your symptoms. A low histamine diet limits foods that contain histamine and foods that cause your body to release histamine. Some of these foods include fermented drinks like kombucha, fermented foods like yogurt and sauerkraut, canned fish, processed meat such as ham, salami, and sausage, spinach, tomatoes and vinegar. For a more exhaustive list, see our Low Histamine Diet document.

Make lifestyle modifications

  • Eat smaller meals

  • Make sure to avoid lying down/sleeping within 3 hours of eating

  • Elevate head and shoulders while sleeping. This can be done with blocks under the legs of the bed or by using a wedge (extra pillows are not effective)

  • Sleep on your left side

  • Stop smoking

  • Avoid alcohol

  • Lose weight

Add good quality probiotics

There is an increasing amount of research that suggests that, in many people, the root cause of GERD is a microbial imbalance in the gut. Adding probiotics to the regimen has been shown to be an effective adjunct in treating GERD. [8] Most studies support blends that contain Lactobacillus gasseri, but other particular species may be beneficial as well.

Could it be SIBO?

I have had a large number of patients whose GERD was completely abolished just by diagnosing and treating Small Intestinal Bacterial Overgrowth (SIBO). This makes sense in light of the research that shows two main things:

  1. Around 35% of patients diagnosed with IBS actually have SIBO as the reason for their symptoms [9]

  2. People who have IBS are much more likely to have GERD than those who don’t have IBS [10]

Admittedly, we don’t have a lot of data directly addressing how many people with SIBO also have GERD, but my clinical experience as well as these large meta-analyses suggest that the relationship is quite strong. So, in my opinion, if a person has GERD and some degree of bloating then SIBO also needs to be considered. The practitioners at Legacy Health Integrative GI and Functional Medicine diagnose and treat GERD and SIBO on a daily basis, and we have the comprehensive, holistic approach that is necessary for you to reach your health goals.

Is Healing Possible?

The great news is that healing from GERD is possible. With a holistic methodology that addresses all aspects of nutrition, microbial balance, stress, exercise, and motility, GERD can be successfully treated. We’ve seen it many times at Legacy Health Integrative GI and Functional Medicine. If you’re already being treated for GERD using conventional treatments such as Proton Pump Inhibitors (PPIs), it is also possible to discontinue these medications using a stepwise approach. So if you need assistance, reach out to us. We utilize the best of conventional medicine and combine it with the best of functional/natural medicine for optimal results. Let us know if we can help you.


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