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 at the Stanford University School 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 to 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 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 a May 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."