Updated 13th March 2023

Heartburn: Why it happens and what you can do

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    The acid in your stomach is so powerful it can dissolve metal. Luckily, your stomach is fine-tuned to deal with it, but the rest of your body isn’t quite as hardy.

    So, if acid escapes from your stomach and reaches your esophagus, it can cause a painful sensation in your chest — heartburn.

    In today’s short episode of ZOE Science & Nutrition, Jonathan and Will ask: Why do we get heartburn, and what’s the best way to deal with it?

    If you want to discover the best foods for your body, head to joinzoe.com/podcast and get 10% off your personalized nutrition program.

    Studies referenced in today's episode:

    • "Prevalence and clinical spectrum of gastroesophageal reflux: A population-based study in Olmsted County, Minnesota" from Gastroenterology

    • "Proton-pump inhibitors and risk of fractures: An update meta-analysis" from Osteoporos International

    • "Proton pump inhibitors alter the composition of the gut microbiota" from Gut 

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    Find our other podcast transcripts here.

    This podcast was produced by Fascinate Productions.


    [00:00:00] Jonathan Wolf: Hello, and welcome to ZOE Shorts, the bite-sized podcast where we discuss one topic around science and nutrition. I'm Jonathan Wolf, and today I'm joined by my friend Dr. Will Bulsiewicz. Today's subject is acid reflux, or heartburn, as it is often known. 

    [00:00:23] Will Bulsiewicz: The condition goes by many names, acid reflux, you can call it GERD. It can also have many symptoms with the classic being a burning sensation in your esophagus, which we often refer to as heartburn. This is so widespread that it affects nearly two in every 10 people globally.  

    [00:00:39] Jonathan Wolf: And Will, before we go any further, I've heard of the esophagus, but what exactly is it? 

    [00:00:45] Will Bulsiewicz: The esophagus is a dear organ, from my perspective. It's a tube that connects the throat down to the stomach, and it serves a simple purpose, which is transfer. It transfers the things that you swallow from your throat down to your stomach, and it's supposed to be a one-way street. Things are not supposed to go back into the esophagus, Jonathan. 

    [00:01:04] Jonathan Wolf: Got it. And so the acid reflex is when this is traveling in the opposite direction from the way that nature intended.  

    [00:01:11] Will Bulsiewicz: That is correct. It's intended to be a one-way street, and so this is like a car driving the wrong way down the road.  

    [00:01:16] Jonathan Wolf: And so given that, why is it so common and are there ways to prevent it? 

    [00:01:21] Will Bulsiewicz: Absolutely. There is some strong evidence that there are ways we can prevent acid reflux, and there are some myths that we need to deal with when it comes to treatment.  

    [00:01:28] Jonathan Wolf: Fantastic. So let's get into it. 

    Now I'm sure that some of the audience has had experience with heartburn or indigestion in the past. Especially when you think about events where maybe you drink a little bit too much alcohol or you overindulge in terms of what you're eating, you can experience these symptoms that we often call heartburn. 

    Obviously not something I would ever do Will, but for other people, I know the festive period is just around the corner, and there could be people going to maybe office Christmas parties or celebrations with their family who might be particularly interested in this topic.  

    So let's start with the basics. I did some research and although it's called heartburn, it's not actually your heart that's burning, but it's this sort of burning sensation in the chest caused by acid from your stomach. How does this happen?  

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    [00:02:24] Will Bulsiewicz: Heartburn can occur when acid from your stomach travels in the wrong direction back up into the esophagus. 

    You have to understand, Jonathan, the lining of your esophagus is very different from the lining of your stomach. It simply isn't designed to handle acid. What happens is the acid causes injury in this area, and it can be either microscopic or in some cases even manifest as a full-blown ulcer. So heartburn is what you feel when the acid is irritating the nerves. 

    [00:02:49] Jonathan Wolf: And so for you, heartburn and acid reflux aren't the same things as a doctor who's specializing in this area.  

    [00:02:57] Will Bulsiewicz: Yeah, so I get a little bit picky because I'm a gastroenterologist and these terms are meaningful in different ways for people in my field, but heartburn is the classic symptom of acid reflux, but it's by no means the only thing people need to be cautious of. 

    Other symptoms could include regurgitation, where you don't necessarily have nausea, but things come back up. This could also be associated with what we call acid brash, which means that you get a sour taste in the back of your throat. That's coming from the regurgitation. And you can even have trouble with swallowing and the feeling that your food is not going down easily. 

    [00:03:29] Jonathan Wolf: And so what causes the acid to travel in the wrong direction here?  

    [00:03:33] Will Bulsiewicz: It's a common misconception that heartburn is caused by an excess of stomach acid. That's not the root of the problem.  

    [00:03:39] Jonathan Wolf: I'm shocked to hear that. I think I have seen so many ads on the television of sort of unhappy middle-aged men, you know, rubbing their stomachs with pictures of too much acid on the inside. So if that's not what's going on, what is happening?  

    [00:03:56] Will Bulsiewicz: So really, it involves two main parts. If I were to just sort of break this down. The first involves compromise or weakness of the valve that separates your esophagus from your stomach. So at the bottom of your esophagus, there is a valve that we call the lower esophagal sphincter. 

    And its purpose is really to keep things in the stomach and stop them from going backward. But if this barrier is disrupted, such as if a person has a hiatal hernia, then we become vulnerable to the reflux taking place. Additionally, the esophagus and stomach are supposed to have coordinated movements that keep things moving along in the direction that they're supposed to go and we call this motility. 

    And so if you mess up these coordinated movements, it disturbs the forward flow. Between an impaired barrier and messed up motility, you ultimately get inappropriate backward flow from the stomach up into the esophagus, and then here we go. These symptoms start to take place. 

    [00:04:55] Jonathan Wolf: So I have this vision of my littlest one sort of splashing in the bath and the water going everywhere. What you're saying is it's designed to be this nice flowing start of the lake going into the river, but it's going everywhere. I'm not managing to keep this closed and it's getting into in my case, the bathroom floor in, in your case, into the esophagus. Then I guess that's where for the audience who's familiar with many of these symptoms, they're like, okay, so what do I do? And I think they go to the doctor and take these medications that are used to treat heartburn. Can you tell me a little bit more about them?  

    [00:05:31] Will Bulsiewicz: Sure. So the most commonly used medicines are called proton pump inhibitors. They have drug names like Omeprazole or Pantoprazole. So these medicines work by blocking the stomach acid from being secreted, which makes people feel better because what refluxes into the esophagus is now less acidic. 

    Just to be clear, it's not an excess of acid that is the actual problem, but if you reduce the acid, people do feel much better. And so these medicines end up being highly effective.  

    [00:06:01] Jonathan Wolf: And so I think a lot of our audience will be thinking, I've got a little heartburn or indigestion. What's the big deal? 

    I just have to pop a tablet. Either I'm having it all the time. One of the drugs you're describing, or maybe if it's occasionally just an antacid. A 10th, of the world's population, is believed to have used some form of medication to treat these gastric issues we saw with some research. So why are we discussing this if we already have these great medical solutions? 

    [00:06:28] Will Bulsiewicz: So their effectiveness is why they have become some of the most widely prescribed medicines globally, and they're incredibly popular over the counter as well. In the US alone, over 10 million doses of these medicines are used every day. I mean, that's a staggering number.  

    [00:06:42] Jonathan Wolf: 10 million. That is an enormous number. 

    [00:06:45] Will Bulsiewicz: Yeah. So for occasional symptoms to take these medicines, it's not that big of a deal. The issue is that people with symptoms several times per week can become very dependent on these medications to suppress their symptoms. And there are a lot of people who end up on these medicines for years or in many cases, even decades. 

    [00:07:03] Jonathan Wolf: And so why is that a problem Will, , there are lots of medications that people use for decades for their blood pressure or whatever. Why are you concerned? I'm guessing this is linked to your explanation, that the medication reduces people's stomach acid in the long term.  

    [00:07:19] Will Bulsiewicz: Jonathan, we evolve to have stomach acid for a reason, and so reduction of stomach acid can alter the balance of bacteria. 

    It can increase our risk for infections. There have been a number of infections that have been associated with taking these medicines chronically. One specifically that people may have heard of is called Clostridioides difficile, more commonly referred to as C. diff.  

    [00:07:40] Jonathan Wolf: And I'm guessing that in addition to this, if we are reducing our stomach acids, then it's, somehow going to alter the way that our bodies are going to process the food that we eat? 

    [00:07:49] Will Bulsiewicz: Yeah. Stomach acid is a part of our digestive process, and so it can change how we digest our food. And this could affect access to our nutrients. So those who regularly consume heartburn medications could potentially become deficient in vitamin b12, calcium, and iron, just the name of a few.  

    [00:08:04] Jonathan Wolf: So if we don't want people to be depending on this medication for the rest of their lives, what other alternatives are there to treat the underlying acid reflux? 

    [00:08:13] Will Bulsiewicz: Well, the answer isn't as quick and as easy as popping a pill, and this is part of the reason why these choices don't get the attention that they deserve in your doctor's office. But you know what's exciting, Jonathan, is that we can change what we eat and how we eat and that could potentially improve acid reflux. 

    And generally, those choices come with additional benefits beyond just improving your heartburn.  

    [00:08:36] Jonathan Wolf: And so what are the things that our listeners need to be conscious of? And is this the part where you take away all of their favorite foods? 

    [00:08:44] Will Bulsiewicz: Oh, sorry to the listeners at home, just the messenger. The reality is that lifestyle choices and foods that we often find to be fun can actually provoke acid reflux. 

    So just to name a few spicy or acidic foods like citrus and cooked tomatoes can irritate the esophagus and aggravate the symptoms. You'll want to be conscious of fat intake from fried foods, meat, and full-fat dairy. And the reason why is that the fat slows down the stomach emptying, which can worsen reflux. And some sweet treats like chocolate or peppermint, relax the lower oesophageal sphincter. So these foods also could potentially make things worse.  

    [00:09:20] Jonathan Wolf: I've always been told that you need to put some distance between when you last eat and when you go to bed. Like I remember my mum always saying this and we did a podcast episode recently on intermittent fasting apparently a lot of people see their heartburn complaints reduce, and they're assuming this is because they're no longer eating just before they go to bed.

    I know that when I've just eaten before I go to sleep, I can quite often still feel my stomach churning and although I generally don't have any issues with heartburn on those occasions, it happens. It's normally this in particular, how does that tie into acid reflux?  

    [00:09:53] Will Bulsiewicz: Ideally, we want to go to bed with an empty stomach, so when you lay down flat, gravity stops helping you because you're laying flat, and so anything that's in your stomach could start to reverse up into your esophagus, into your chest while you're lying there. 

    So ideally, we should have dinner. Three or even better four hours before bedtime because that's how long it takes for most of the food to exit our stomach. 

    [00:10:17] Jonathan Wolf: Four hours. Okay. I don't think I can sign up for that Will. That's quite a late night. It's not to say that it's impossible. I mean, we all know we can. Go upside down and the food doesn't suddenly come out. Right?  

    So we've got a valve that normally keeps this closed, but you are saying that if you're lying flat, it's putting more pressure on this. And so if you're prone to these issues, this is going to be worse. Or you're saying this is sort of a problem for anybody who's listening to this. 

    [00:10:40] Will Bulsiewicz: Well, the beautiful thing is that ultimately, if you are having a problem with acid reflux, you're going to manifest symptoms. One of the things that I've said to many of my patients through the years is to let the symptoms guide you. If your symptoms are getting worse, then you know that there's a problem. 

    [00:11:22] Jonathan Wolf: So I think a lot of our listeners will now be thinking twice before grabbing an antacid. It's a very complicated issue. There are a lot of treatment options. What do you think are the key takeaways that our audience should learn from this topic?  

    [00:11:35] Will Bulsiewicz: One of the things I just wanna be clear on, the point isn't that we should never use medicine to treat acid reflux. 

    The point is that we have diet and lifestyle options that can improve our reflux and we should take advantage of them as much as possible, Not only minimizing our dependence on long-term medicine use but also addressing the root of the problem and improving our health more globally. There are benefits that we get that go beyond just improving reflux. 

    This isn't an instant fix, but it's the best long-term strategy for these chronic conditions. So given time, you may find that your reflux symptoms improve and that the dose of medicine you require can be reduced. Or in some cases, it's even stopped. And if that's the case, I'm dancing and celebrating with joy. 

    Some of the things that we can do include taking time to enjoy our food and eating in a relaxed manner. Avoid bending or lying down after eating. Give yourself time. We just mentioned, you know, three to four hours before going to bed. And again, we want to move towards a more high-fiber diet, and this absolutely can be a delicious diet that you are just thrilled to sit down it makes you salivate.  

    Just because we're giving up things like reducing our red and processed meats or fried foods, and high-fat dairy. Or keeping our alcohol and caffeine to a minimum. You deserve to enjoy your food, and one of the ways that we can express that is through a Mediterranean diet pattern. That's sort of a general construct that we could follow.  

    [00:12:57] Jonathan Wolf: Brilliant. Well, thank you so much. If you'd like to try ZOE's personalized nutrition program to improve your health based on the science of your own body, you can get 10% off by going to joinzoe.com/podcast. I'm Jonathan Wolf 

    [00:13:11] Will Bulsiewicz: and I'm Will Bulsiewicz. 

    [00:13:17] Jonathan Wolf: Join us next week for another ZOE podcast.

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