Healing Reflux with Dr. Steven Sandberg-Lewis: Rational Wellness Podcast 319
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Dr. Steven Sandberg-Lewis discusses Healing Reflux with Dr. Ben Weitz.
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Podcast Highlights
2:50 Heartburn. Heartburn is a subjective sensation of burning, usually over the sternum, and it can be intense and sharp. People can even feel like they are having a heart attack. Not all patients who have heartburn have reflux, though the majority do have reflux. Regurgitation is when fluid or food comes up into the throat or mouth and this can be related to reflux.
4:57 Reflux. Reflux can have to do with any fluid going through a tube in the wrong direction. When the contents of the large intestine move from the large intestine to the small intestine instead from the small intestine down to the large intestine, this is called cecoileal reflux or ileocecal reflux. If things move from the small intestine up into the stomach, that’s called bile reflux. If things move from the stomach into the esophagus, that’s called gastroesophageal reflux disease, GERD. There is also GER, which is a normal reflux that occurs say three times after every average meal when some food or fluid from the stomach will move up into the lower esophagus and it doesn’t cause symptoms. This is not a disease and considered normal. Reflux doesn’t have to cause reflux disease, but it can if it’s prolonged or if the esophagus is not able to protect itself with various protective factors. Normally our saliva, which is slightly alkaline and which is being swallowed every minute and helps to neutralize any acid that comes up. There are secondary contractions that contract the lower esophagus to move things down. There’s also mucus production that coats the mucosal membrane of the esophagus. If these mechanisms fail, then you can get Gastroesophageal Reflux Disease. Therefore it is important to naturally bolster the protective factors in the esophagus.
7:32 What causes reflux? For one thing, while it is often called acid reflux most patients do not start out having too much acid production. In fact, many of them have too little stomach acid production. But after being on proton pump inhibitors like Prilosec, AcipHex, Prevacid, Protonix, and Nexium for a while, if they stop them even for short period of time to get the Heidelberg test that Dr. SS-L often performs, they will often get a rebound hypersecretion of acid, which makes it difficult to accurately test their acid levels in their stomach. While the proton pump inhibitor is preventing the parietal cells in the stomach from making acid, the body keeps secreting more and more gastrin to stimulate those parietal cells to make acid.
10:25 The major causes of GERD include a sliding hiatal hernia. This is when the upper 2-3 cm of the stomach slides up through the diaphragm that engages the lower esophageal sphincter that normally protects from reflux. When the stomach moves up, you lose a lot of that anti-reflux muscle function. Another reason is people who overeat or who eat rapidly will more likely have reflux. When you eat too quickly, you don’t get the signal to your brain that you’re full. Overeating or anything that causes distension of the stomach, such as gas, will lead the lower esophageal sphincter to relax and stay open for up to 20 seconds. This is why SIBO can be a trigger for reflux. Food sensitivities can also lead to reflux. Atrophic gastritis, those who don’t make enough stomach acid, can lead to heartburn symptoms.
18:25 H. Pylori is generally protective against reflux. H. pylori is a bacteria in the stomach that is a major cause of ulcers and many feel that it is a cause of reflux. While H. pylori can cause a type of lymphoma in the stomach called MALToma and it can cause gastritis and it can increase the risk of stomach cancer. H. pylori can live in the entire stomach or just in the antrum, or bottom part. Since H. pylori was discovered in the early 1990s the dictum is to test and to treat, though Dr. SS-L generally does not agree with this. H. pylori is treated with two antibiotics and a proton pump inhibitor. But H. pylori is actually part of the microbiome of the stomach and it has a lot of benefits, including protecting against allergies, eczema, asthma, hay fever, and it also is a major protector against reflux and the complications of reflux, which include Barrett’s esophagus and cancer of the esophagus. 80% of the time H. pylori is all over the stomach and these patients usually make too little acid, but if H. pylori is in the antrum, which is 20% of the time, that tends to trigger gastrin secretion and increased acid production, which can cause ulcers in the stomach or the duodenum.
24:52 How to examine, analyse, and work up a patient with heartburn or reflux symptoms. If the patient has been to see a gastroenterologist and had an upper endoscopy, you should get the results and the biopsy report and look at it and get used to reading them. There are cases of erosive esophagitis where there are erosions of the membrane in the esophagus and then there’s NERD, non-erosive reflux disease. If the patient has also had a Bravo pH monitoring test you can determine the degree of erosive esophagitis–grades A, B, C, D. Patients with grade D should definitely be on a proton-pump inhibitor medication. These are patients who are having severe damage and at strong risk for Barrett’s esophagitis, which is precancerous. If they are NERD or Erosive grade B or A and are willing to change their diet and make lifestyle changes, we have them start with all the basics listed in Dr. SS-L’s book, including eating slowly and mindfully and not eating within three hours of going to bed. If they are a side sleeper, there’s less reflux if they sleep on their left side because of the shape of the stomach and the esophagus. You should be well hydrated, but ideally you should drink most of your water away from meals. If food is well masticated by chewing 20 or 30 times, you should not need water to wash it down. In particular, you should not drink ice water while eating, since cold will slow down gastric emptying. It is more likely to cause reflux if you only chew four or five times and then take a sip of water to wash the food down.
34:31 Let’s continue discussing our patient with reflux. Let’s say we found out they’re sensitive to tomato or we found out they’re sensitive to gluten and removing that could be enough to normalize their vagus nerve connection. Then let’s say that we do labs and find out they have high blood sugar or high hemoglobin A1C. If your blood sugar is too high, your digestive tract can malfunction and this can lead to reflux. We should also do flexibility testing to see if they are hypermobile. Such patients with ligamentous laxity tend to have a high incidence of sliding hiatal hernia and laxity of the ileocecal valve. We also need to see if they have a lack of stomach acid, hypochlorhydria. When can do the challange with betaine hydrocloride capsules or we test with a Heidelburg test. Bitter herbs can also be used to stimulate stomach acid and apple cider vinegar can also work. On the other hand, if the patient has erosive esophagitis, this would not work well.
Dr. Steven Sandberg-Lewis has been a practicing naturopathic physician for nearly 40 years and he teaches gastroenterology at the National College of Natural Medicine. Dr. Sandberg-Lewis: is a well-received presenter at educational seminars around the world and he has authored or co-authored multiple articles and is frequently interviewed on digestive health topics. Dr. Sandberg-Lewis: wrote the second edition of his textbook, Functional Gastroenterology in 2017 and in 2023 he published Let’s Be Real about Reflux: Getting to the Heart of Heartburn, intended for the general public as well as practitioners. You can find out more information about him at FunctionalGastroenterology.com and at his office website, HiveMindMedicine.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure. Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.
Hello, Rational Wellness listeners. Today I’m very excited to be speaking with Dr. Steven Sandberg-Lewis about reflux, which is a very common, mostly functional gastrointestinal disorder. Heartburn is the main symptom in reflux and is often described as a discomfort or burning pain felt in the chest or throat. It occurs at least once a week in about 30% of most Americans, and in up to two third of those with IBS. Heartburn can be caused by reflux of the gastrointestinal contents up into the throat or esophagus, or it can occur without reflux. Other symptoms of reflux include: regurgitation, chronic cough, sore throat, vomiting, hoarseness, chronic throat clearing, et cetera. Reflux is often used interchangeably with gastroesophageal reflux disorder or GERD, but there are other forms of reflux, including bile reflux and silent reflux, which is also known as laryngopharyngeal reflux. The NIH website has now introduced a new term, G-E-R as distinguished from G-E-R-D to confuse us even further. This condition is very complex and confusing, and I’m hoping that Dr. Steven Sandberg-Lewis will help bring some clarity on this topic for us.
Dr. Sandberg-Lewis has been a practicing naturopathic physician for 40 years. He teaches gastroenterology at the National College of Natural Medicine and lectures around the world, and he wrote an awesome medical textbook, Functional Gastroenterology, which is now in its second edition, and everybody in the functional medicine world should have. And his new book is, Let’s Be Real About Reflux, Getting To The Heart of Heartburn. Dr. Steven Sandberg-Lewis, thank you so much for joining us today.
Dr. Sandberg-Lewis: You’re very welcome, Ben. It’s good to be here.
Dr. Weitz: Great. Steven, let’s start by explaining some of the terms. What’s heartburn? What’s reflux? What’s GERD?
Dr. Sandberg-Lewis: All right. So heartburn is a subjective sensation of burning, usually over the sternum, somewhere over the sternum. It can be really intense and sharp. People can feel like they’re having angina or a heart attack, and it has to be differentiated from that sometimes. It can also just cause chest pain. So some people, if they’re truly having some kind of distension of the esophagus, can either feel it as burning or as chest pains, just kind of depends on their nervous system. So that’s basically heartburn.
Dr. Weitz: And some of these patients are often wrongly diagnosed as having heart problems.
Dr. Sandberg-Lewis: Or as having reflux when they really don’t.
Dr. Weitz: Right.
Dr. Sandberg-Lewis: Probably the majority do have reflux, but there are many different types, so we’ll talk about that. But regurgitation is when fluid or food actually comes up into the throat or even the mouth, and that can be related to reflux. Of course, if material from the stomach is, that’s the next thing, reflux. If food or fluid from the stomach is moving up into the esophagus, if it continues to go up into the upper third of the esophagus or the throat, that’s regurgitation. People sometimes mistake that as vomiting, but vomiting is actually a whole separate thing. It’s a big process, but you can have regurgitation, which is kind of like when babies burp up their milk. That’s just called regurgitation and it’s a more minor kind of a thing, but can be quite disturbing.
Dr. Weitz: Okay. What are some of the causes of reflux and GERD?
Dr. Sandberg-Lewis: All right, so you asked me to try to keep this simple.
Dr. Weitz: Yeah.
Dr. Sandberg-Lewis: So tell me if I’m going off the deep end. So again, reflux can have to do with any fluid going through a tube. We talk about reflux, like you said, from the large intestine to the small intestine. That’s called cecoileal reflux or ileocecal reflux. Things moving backward toward the mouth instead of down toward the anus, which is the normal flow in the digestive tract. If things move from the small intestine, the duodenum, into the stomach, that’s called bile reflux. If things move from the stomach into the esophagus, that’s called gastroesophageal reflux, GERD.
And the thing is, like you said, there is a term G-E-R, there is normal reflux that occurs. Some books say three times after every average meal, some food or fluid or gas from the stomach will move up into the lower esophagus and it doesn’t cause symptoms. So they don’t put the D on the end GERD, they just call it gastroesophageal reflux. Physiologic, it’s normal, but the saliva being swallowed every minute, a liter or more a day, excuse me, a liter or more a day of slightly alkaline saliva, pH seven and seven and a half, that helps to neutralize any acid that comes up. There’s also something called secondary contractions that contract the lower esophagus to move things down. There’s a lot of protective factors. There’s mucus production that coats the membrane. So reflux doesn’t have to cause reflux disease, GERD, but it can if it’s prolonged enough or there’s enough volume of it, and especially if the esophagus and its lining is not able to protect itself. So that’s a lot of what I… You noticed I talk about that a lot in the book. Bolstering the protective factors in the esophagus. So what causes reflux? Boy, I have that picture that I make. It has about 10 different things pointing all to heartburn and reflux-
Dr. Weitz: And by the way, it’s commonly referred to as acid reflux, but you’ve pointed out in your book and in your talks that only 20% of patients that you test actually have hyperchlorhydria or increased acid production.
Dr. Sandberg-Lewis: Yeah, I got to say, not to make it more complicated, but I have to say when I do the Heidelberg test, I am noticing more people that make too much acid. But there are almost always people that have been taking proton-pump inhibitors and we have them stay off their proton-pump inhibitor whenever you’re doing any kind of acid testing, at least a week before you do the test. And I’m finding that so many of those people have rebound hypersecretion where they make too much acid now because their gastrin levels are so high from taking proton-pump inhibitors for a long time. It’s a real problem that I’m finding.
Dr. Weitz: Meaning the medication is trying to decrease the body’s production of acid. The body knows it needs acid, so it’s secreting the precursors to create more acid even though the drug is telling it not to.
Dr. Sandberg-Lewis: Yeah. The proton-pump inhibitor prevents the parietal cells in the stomach from making acid. It blocks the proton pump in them that does that. And so the body, in its wisdom, it knows how important acid is in the stomach, will trigger the production of more and more of a hormone called gastrin. And gastrin, its job, its major job is to trigger the parietal cells to make more acid so that the gastrin level in the blood goes higher and higher and higher, but it can’t do anything because the parietal cells are inhibited by this medicine. You take the medicine away for a week and then do a test and all that gastrin is now stimulating a lot of acid production and it looks like they make too much acid. So what do you do? Oh, you better go back on that medicine because you make too much acid. Well, yeah, you do. It’s a real catch-22. So I prefer to mostly test people that have never taken proton-pump inhibitors because I think I’m getting a more realistic picture.
Dr. Weitz: There aren’t too many people like that with reflux now because that medication is handed out like candy and it’s over the counter now.
Dr. Sandberg-Lewis: It is. I tell my students that it’s basically prescribed for any problem above the umbilicus. It’s not really a joke.
Dr. Weitz: No, I know.
Dr. Sandberg-Lewis: So the major causes of GERD, let’s just make a little list here. A big one would be sliding hiatal hernia. And that of course is when the stomach, the upper two centimeters or three centimeters of the stomach on the average move up through the diaphragm into the chest that just engages the lower esophageal sphincter that normally protects from reflux. It moves it up a couple of centimeters, and now it’s not engaged with the diaphragm. The diaphragm is a muscle, if people don’t know that. It’s a big flat dome-like muscle, and it’s very important for a lot of things. Of course, it’s the separation between everything that’s in the chest or thorax from the abdomen.
And the digestive tract travels through the chest, the esophagus, and then has to meet up with the stomach, which is below in the abdomen underneath the diaphragm. And so that diaphragm muscle is supposed to hug that connection where the esophagus meets the stomach, it’s called the lower esophageal sphincter, and that’s a really important relationship. So when you move the stomach up, you don’t have that anymore. You lose a lot of the muscle function of the anti-reflux valve.
Another common reason is people who overeat and people who eat rapidly. And I guess part of it is when you eat rapidly, you can overeat because you don’t get the signal to your brain that you’re already full. But overeating or anything that causes more distension, rapid distension of the stomach, especially if there’s gas production in the stomach, people who have enzyme deficiencies and bacterial overgrowth in the small bowel or the stomach. When there’s more gas in the stomach, that valve, that lower esophageal sphincter will open to let the gas come out as a burp. That’s called a transient lower esophageal sphincter relaxation. It’s got that lower esophageal sphincter right in the middle of it. And when that happens, that valve can stay open for up to 20 seconds.
Now, normally that valve is closed all the time, it’s right at the top of the diaphragm. It’s closed. The food moves through the esophagus, takes less than 10 seconds to come down. When it gets to the lower esophageal sphincter, it opens up, food moves through, it closes, a second, maybe two. But when it stays open for 20 seconds or up to that amount of time, and it does that periodically to let the gas out and people are burping, burping, you can have a lot of intense reflux during that. So that’s another important point.
Dr. Weitz: This is also why SIBO can be a cause because you get all this gas.
Dr. Sandberg-Lewis: Yeah, there’s a whole chapter on that in my book about the differential and pressure from all those parts per million of gas below the diaphragm pushing things up.
I’d say another important reason why people get reflux is food sensitivity. So individual food sensitivities. For one person it might be white potatoes. For somebody else it might be corn. For somebody else it might be dairy products. And if they find out what they’re sensitive to and remove it, they don’t have reflux anymore. So those are some common reasons. There is, of course, the whole question about is it acid reflux? According to some pathology books, over age 60, the incidence of atrophic gastritis in the US is over half the population. That means those people don’t make enough stomach acid in atrophic gastritis, chronic atrophic gastritis. And even so, you can have just the same kind of heartburn symptoms with not enough acid as you can with too much acid or normal acid. Most people have normal acid that have reflux. It’s not that they have too much acid, it’s it’s getting up into their esophagus, and if their esophagus doesn’t have the protective mechanisms to protect itself from that, they can have all kinds of severe heartburn and even esophagitis.
Dr. Weitz: And how many of them don’t have enough acid, so the food is not getting properly broken down?
Dr. Sandberg-Lewis: Well, again, it depends. When we do a Heidelberg test, there are two kinds of hypochlorhydria, two kinds of not enough acid. There’s what we call frank hypochlorhydria, which means on a Heidelberg test, the patient swallows a capsule. The capsule has a low frequency radio telemetry device in it, and it feeds the pH of the surrounding solution in the stomach to a computer and we see the readout. If the patient swallows a capsule… Like the other day, I had a patient, he swallowed the capsule, the pH was 5.5 or six, stayed right there. Well, we could have said, all right, you don’t make enough acid because the pH should be definitely less than three. And usually it’s less than one. Very acidic. Seven is neutral for those that aren’t familiar with the pH scale. So what we do is sometimes when you see that, you have to give the patient one piece of popcorn to eat and have them swallow it with a little water because-
Dr. Weitz: One piece of popcorn.
Dr. Sandberg-Lewis: … popcorn is… They’re fasting, so there’s no food in their stomach. One piece of popcorn when you swallow it with a little water will move the capsule down out of the esophagus into the stomach. It’ll plop into the stomach if it’s stuck in the esophagus. And that’s what we saw there. It works every time. It’s really great. So all of a sudden it goes from 5.5 or six, dunk, goes down to 0.5. It’s now in his stomach and he makes plenty of acid. So then we periodically give him a small amount of bicarb solution to neutralize the acid and bring the pH… As soon as it changes, we see the pH go back up to six and we see how long it takes him to make enough acid to bring the pH back down to where it was at the first of the test. And if it takes longer and longer, and sometimes eventually it takes 20 minutes, 30 minutes, it’s just staying neutral at alkaline, that’s when we know that they have what we call hidden hypochlorhydria. So you can have frank hypochlorhydria right away, or you can see it when you test the stomach to see how well it can make acid and it fails to do it after a couple of challenges. So I’d say that’s the 40 to 50% of the population that has low acid production.
Dr. Weitz: Okay. One of the things I wanted to bring up is this concept of H. pylori, which I know you’ve discussed in the past on other podcasts. H. pylori is this bacteria in the stomach, and it’s common to think that this might be playing a role in acid reflux because the theory is that this is a major cause in increased acid in the stomach, and that’s how it leads to potentially ulcers. And therefore there’s this concept that we should test for H. pylori, and if we see it, we should try to eradicate it and that this might be beneficial for reflux.
Dr. Sandberg-Lewis: Yeah. There’s a little bit of truth in that about increased acid production, but that doesn’t necessarily mean reflux. So the most important thing to understand is H. pylori was discovered as a cause of peptic ulcers, stomach and duodenal, especially duodenal. It can also cause a few other diseases, and it’s kind of a long list, but the major ones can also cause a type of lymphoma that occurs in the stomach called MALToma, and it can cause gastritis of course, and it can increase the risk of stomach cancer. So the thing that most people and most doctors don’t realize, and this is all over the research for H. pylori, is that H. pylori, it lives in the stomach. It can either take up residence in the entire stomach or just in the antrum, which is the very bottom.
Usually it’s in the entire stomach. And we think until probably the 1920s or so, a hundred percent of the world’s population had H. pylori in their stomach. Since antibiotics were invented in the ’20s and ’30s, and more and more generations have lived through being treated with antibiotics throughout their lives, H. pylori has dwindled somewhat. And now since it was discovered in the early 1990s and now the dictum is test and treat, meaning if you test somebody and it’s positive, you find H. pylori, you kill it with usually two antibiotics plus a proton-pump inhibitor. And the problem is H. pylori is actually… If you read the research on H. pylori’s protective effects, H. pylori is the major bacteria in the gastro biome, in the group of bacteria that live in the stomach. There’s esophageal biome, there’s gastro biome, there’s a small intestine microbiome and a large intestine microbiome, and there’s oral biome. There’s different bacteria and viruses and fungi in different parts, and they belong there. And H. pylori is the central bacteria in the gastro biome in the stomach. It’s really important for newborns and kids in their first couple years of life to fully mature the immune system in their gut. And it turns out that besides protecting against allergies, eczema, asthma, hay fever, H. pylori in the stomach is a major protective factor against reflux and the complications of reflux, which include Barrett’s esophagus and cancer of the esophagus. So H. pylori is really important in reflux because it protects against reflux, not because it causes it. And the research is all clear about that.
On the other hand, remember I said you can either have H. pylori living in the whole stomach or just in the antrum, the very end of the stomach. When it’s antral predominant, which is maybe 20% of the time, that can trigger more gastrin production and stimulate more acid to be produced. In that way, it can be a cause of stomach ulcers or duodenal ulcers from too much acid. The other 80% or so of people, they actually make too little acid. And actually, according to the research, everyone when they first get H. pylori, which you should get when you’re a kid, but most people don’t anymore, they make too little acid for the first three months. They’ll make hypochlorhydria, too little acid. And then depending on whether it’s in the antrum or the whole stomach, they’ll either make too little, most people, or too much about 20%. So the people that have the antral type are more prone to ulcers. And the people that have what’s called pangastritis, their entire stomach having H. pylori, they’re more prone a slight increased risk of getting gastric cancer, stomach cancer later in life. And they’re more likely to possibly develop reflux from not enough stomach acid. Again, you can get reflux from too much or too little, but H. pylori in general is protective against reflux and its complications.
Dr. Weitz: So now I’d like you to do a little exercise where we go through a patient who comes into your office with heartburn reflux symptoms and how you would work them up. And then also keeping in mind that you’re a gastroenterologist. Most of the listeners are not, and if we’re practitioners, we’re often on the functional side of things and maybe the patient has seen a gastroenterologist who’s done maybe an endoscopy and maybe typically doesn’t see any erosive damage.
Dr. Sandberg-Lewis: All right. First of all, if the patient’s already had an upper endoscopy, please get the results and look at them. And get the biopsy report and look at that and get used to reading those and being comfortable with the words in them and what they mean. Because again, there’s erosive esophagitis or reflux esophagitis where there’s actual erosions of the membrane, usually of the lower third of the esophagus. And then there’s NERD, non-erosive reflux disease. Patients that have heartburn, even proven heartburn if they’ve had pH impedance testing or what’s called Bravo testing, which actually measures to see does the person have significant amount of reflux occurring, not just do they have the symptom of burning because that can be caused by other things. But look at the endoscopy and figure out do they have NERD? Meaning the lower esophagus looked fine, it was normal. Or did they have erosive esophagitis, which can be grade A, B, C, or D.
People with grade D esophagitis, they’re a really good candidate for taking a proton-pump inhibitor and in standard medicine, they’re expected to take it forever. It’s a miracle drug for grade D esophagitis because people go from feeling like they’re having a heart attack all day long and night to, “Oh, that’s gone.” It’s so great. Those are people that are really having severe damage from reflux and they’re at more risk to go on to have Barrett’s esophagus, which is precancerous.
On the other hand, if you know your patient has NERD, their esophagus is completely normal, well, first of all, they might not even have reflux and that’s why they don’t have any damage. So there are further tests in medicine, like I said, the Bravo test and the pH impedance test where there’s actually a measurement of something called a DeMeester score that tells you how much reflux they’re having, how long it lasts, whether it’s acid, whether it’s alkaline. And if you know that they have reflux from some kind of testing like that, or they have erosive esophagitis like we just talked about, then you know that there’s reflux.
Dr. Weitz: How often are those tests you just mentioned, not the endoscopy, but the other two, how often are those done?
Dr. Sandberg-Lewis: Well, they’re always done if a patient is considering surgery for reflux, like a Nissen fundoplication because no surgeon wants to do the surgery on a patient who actually didn’t have reflux because it won’t work. So they’re always done for that. But they’re also done for people that… 40% of the people that have heartburn symptoms that are put on proton-pump inhibitors don’t respond to that standard treatment for many reasons. And so that’s kind of the next step if then they double the dose, it still doesn’t work, and they send the patient to a gastroenterologist and they get more of a workup. So I can’t tell you how many patients out of a hundred actually get that test. I don’t know, but it’s not too many.
Dr. Weitz: Yeah. From what I’ve seen, the endoscopy is common. The other tests that you mentioned in your book are not that common.
Dr. Sandberg-Lewis: Yeah, like I say, they’re more common when nothing has worked and they’re considering reflux surgery because it has to be done before you do reflux surgery to prove that it is or isn’t reflux. So the theoretical patient, they’ve come in, let’s say… Okay, let’s say we know that they have erosive esophagitis grade B, it’s not the D, the worst one. And they’re willing to make lifestyle changes. So first of all, we could do all the basic things that are in the chapter about lifestyle. I have them read that chapter and make sure they’re finishing eating within three hours before going to bed. If they’re a side sleeper, preferably they sleep on their left side, there’s less reflux with sleeping on the left side.
Dr. Weitz: Can you explain why that is?
Dr. Sandberg-Lewis: Yeah. Well, the picture in the book shows it the best I think.
Dr. Weitz: I know. I know.
Dr. Sandberg-Lewis: Basically when you’re lying on your left side, it’s very easy for the contents of your stomach, which are on the top to drain into the esophagus, whereas the stomach’s kind of moon shaped. So when you’re lying on your… Sorry, when you’re on your left side, the stomach is hanging down like a moon this way, and so it’s like a bowl that holds the material and it’s not going to reflux as much into the esophagus. But when you’re on your right side, the stomach can just empty into the esophagus like that. You can also of course raise the headboard six inches or so. You can use a wedge pillow that decreases the issue of gravity being lost when you’re lying flat instead of being upright during the day. They can also chew their food, take their time and eat smaller meals slower. And that’s been shown to really reduce reflux too. Even in people who don’t normally have reflux, if they eat a meal in 30 minutes versus the same exact meal in five minutes, significantly more heartburn even though they don’t normally get heartburn with the five-minute meal.
Dr. Weitz: By the way, that’s one of the problems with fast food. We know that fast food is unhealthy generally, but it’s also meant to be eaten fast. It’s often so you can hold it in your hand while you’re in the car. And so that unfortunately encourages that behavior more.
Dr. Sandberg-Lewis: If you’re going to eat fast food, eat it slowly. Do it well. I mean there are a lot of factors. There’s the fact that cold food tends to slow down gastric emptying, whereas hot food tends to increase the speed. If the stomach holds onto food too long, it tends to encourage reflux. I mean, think of it like a bag filled with liquid and mixed up with food. If it’s slowed down and it can’t drain into this small intestine as fast and it stays in the stomach, it’s more likely to reflux up. It’s like a full bag.
Dr. Weitz: Is drinking water good or bad? You hear some people say drinking water will dilute your enzymes. Other people feel like water helps push the food down while you’re eating.
Dr. Sandberg-Lewis: Okay, you don’t need water to push food down. You do need to be well hydrated, but ideally you do that away from meals. Now, if somebody wants to take a sip of water in between swallows of well masticated food, that’s not a big problem, especially if it’s not ice water to slow everything down. But I really think the big problem is when people instead of chewing 30 times to have the food be liquid so you can swallow it easily, but instead chewing four or five times and then taking a sip of water to wash it down. That’s a problem.
Dr. Weitz: My patients, it’s worked to get them to chew it four or five times.
Dr. Sandberg-Lewis: That’s a problem because that actually turns on the sympathetic nervous system, fight or flight, and mostly shuts down digestion. Your brain thinks you’re being chased by a wild animal because why else would you be eating so fast? Why would you be so rushed?
Dr. Weitz: But that seems to be the best way to win the hot dog eating contest.
Dr. Sandberg-Lewis: On July 4th, they did a little thing about that on the radio, and boy, is that a nauseating thing to hear about.
Dr. Weitz: Okay.
Dr. Sandberg-Lewis: Anyway, so here’s our patient. Let’s say we found out that they’re sensitive to tomato or we found out they’re sensitive to gluten and removing that from their diet could be enough to totally normalize their nerve connection, their vagus nerve connection in their gut. What if we do a little more testing and we find out they have high blood sugar, their hemoglobin A1c is high? Well, there’s this thing called gastroparesis, and there’s another thing called diabetic enteropathy. Basically, when your blood sugar’s too high, your entire digestive tract over time, your entire digestive tract can start malfunctioning and reflux is a major symptom of that. Also, what if we do some flexibility testing, a Beighton score, and we find out the patient is hypermobile, their joints are hypermobile? Well, unfortunately, those people have a very high incidence of sliding hiatal hernia, which causes reflux, of laxity of the ileocecal valve, which causes cecoileal reflux. They have a high incidence of heartburn, abdominal pain, lots of other symptoms. So that’s a good thing to know about because you have to really take special measures. That’s a whole four-hour discussion. Hypermobility syndrome.
What if they don’t make enough stomach acid like 50% of people after age 60? And some younger people too, especially younger kids with asthma and many people with autoimmune disease. So there are lots of ways to deal with that. If you know that they have frank hypochlorhydria, you can use betaine hydrochloride and you can actually test during the Heidelberg test. You can give the person a capsule of betaine hydrochloride or you can give them bitter herbs and see what does that do to the pH? Was that enough? No. You give a second one and then it brings it down where it should be. So betaine hydrochloride capsules when it’s indicated. People can use different kinds of bitter herbs. Gentian is one of the most bitter herbs, but fenugreek, bitter orange oil, there are many different ones.
Dr. Weitz: People will drink vinegar.
Dr. Sandberg-Lewis: You can use one or two teaspoons of apple cider vinegar in a quarter cup of water, 10, 15 minutes before meals when you’re preparing your food. These are all things that can really help reflux and can really help the pH of the stomach if the person doesn’t make enough stomach acid. Now, if someone has that little test with drinking one to two teaspoons of apple cider vinegar and water, that’s a good little test. If your patient has erosive esophagitis, they’re going to tell you, “Wow, I’m never doing that again. That was like putting fire in there.” So you get a little clue. It’s just the opposite situation.
And then there are people that if they’ve had their upper endoscopy, like you said, one thing you want to ask if you know your patient’s going in for upper endoscopy or you’re referring them for one, please ask the gastroenterologist to give you a reading of what’s called the gastric flap valve, gastric flap valve. It’s also called the hill criteria, H-I-L-L, and it’s just a way to grade how well the lower esophageal sphincter stays closed. And sometimes you read an upper endoscopy report and it says the lower esophageal sphincter was gaping or the lower esophageal sphincter was open, and you know there you can’t fix their reflux unless you do something about that lower esophageal sphincter. A number of things you can do. You can work with the vagus nerve. I’m sure those doctors out there know about different exercises people can do for their vagus and of course take care of their blood sugar if it’s off because that really damages-
Dr. Weitz: Yeah, we’ve been experimenting with an electrical vagal nerve stimulator. I’ve also used infrared light on the vagal nerve.
Dr. Sandberg-Lewis: Yeah. And lots of simple exercises people can do too, but those are great.
Another important piece here when the lower esophageal sphincter is open, is loose, is hypotonic, is to strengthen the diaphragm. Remember I said the lower esophageal sphincter is surrounded by the diaphragm muscle and it really is like… The diaphragm’s like the outer half of the lower esophageal sphincter. And if the diaphragm’s hardly ever being used because your patient doesn’t do diaphragmatic breathing, they’re always breathing shallowly in their chest, which also triggers the sympathetic nervous system and decreases vagal tone. If you can train them to do slow, full diaphragmatic breathing exercises every day, over time, the diaphragm gets really strong.
There’s a great little exercise that I love to show patients where you stand a foot away from the wall and you put a single sheet of toilet paper on the wall, and then you take a nice slow abdominal breath and you breathe out with pursed lips. And you keep the toilet paper on the wall. And you do that every day and see how long you can do it because it takes a good diaphragmatic tone to keep that pressure of the air coming out for a long time. It’s a fun little exercise. Kids like it too, but toning the diaphragm, really, really important. Singing from the diaphragm. People know how to use their diaphragm to sing loudly, that’s a really good exercise for the diaphragm. Lots of things you can do.
On the other hand, you can also work through the parasympathetic nervous system to tone the lower esophageal sphincter by using huperzine A, which is an extract of Huperzia serrata, an herb that has anticholinesterase activity, so it decreases the breakdown of acetylcholine in the body and raises acetylcholine. In addition, you can use [inaudible 00:41:40]-
Dr. Weitz: By the way, typically part of a brain formula.
Dr. Sandberg-Lewis: Yeah, because people that get dementia don’t have enough acetylcholine in their brain either. And then you can also use things like phosphatidylcholine or acetyl-L-carnitine to support the choline production as raw material to give the choline to make acetylcholine. So that combination of… I usually use 420 milligrams of phosphatidylcholine twice a day with meals and huperzine A anywhere from 50 to 200 micrograms twice a day with meals. I haven’t done that with hundreds of patients, but when I know that they’ve had this hill criteria showing a real laxity of the LES, I’ve seen that work beautifully in six or seven patients that I’ve tried it with, especially younger patients.
Dr. Weitz: I know you’ve mentioned the use of demulcent herbs.
Dr. Sandberg-Lewis: Yeah, well, there’s the other world you can go into and that is, can the lower esophagus protect itself from any normal reflux even, gastroesophageal reflux, GER, that’s going to happen after every meal? Can the lower esophagus protect itself? So what’s important there? Melatonin, one of the most important things for protection.
Dr. Weitz: In this context, is melatonin taken just as a capsule? Is it more important as part of a formula? Is it a similar dosage for sleep? Melatonin is… A lot of discussion about melatonin recently especially.
Dr. Sandberg-Lewis: Yeah. It’s hard to say at this point except that we know that if you give rats melatonin supplements, it does concentrate in the esophageal mucosa. So it does get there where you want it, and it raises their blood level as well. Probably the best way to have normal melatonin is to sleep well, and it is proven that research shows that sleeping less than six hours is a risk factor for Barrett’s esophagus, which is one of the precursors to esophageal cancer in patients who have reflux. So getting seven or more hours of sleep, eight hours is ideal they say for most people, that’s real important. But of course, without going into adrenal function in a big way, high cortisol and/or low DHEA from the adrenals is a major way to suppress melatonin production because as cortisol…
Cortisol is high in the morning, comes down, plateaus in the afternoon and gets to its nadir at midnight. As it’s going down, cortisol going down, that allows melatonin to come up and stay up during the night. So they have this dance where cortisol is doing this in the day, melatonin’s doing this at night. And they trade off. As the melatonin’s dropping in the morning, the cortisol is coming up to its peak. So, so many of your patients have an imbalance between cortisol and DHEA. They have high cortisol levels or they have very low DHEA levels. That’s going to suppress their melatonin. That’s going to be a risk factor for heartburn. So that’s just one of the things, but you can also do protective things like demulcents.
Dr. Weitz: By the way, if you use… Yeah, okay. I was just going to ask about the demulcents and if you use those… What I’ve done with some patients is have them use a slippery elm powder and have them try to slosh it around and keep it in their throat for a bit to kind of soothe that area.
Dr. Sandberg-Lewis: Yeah, you can make a gruel with it where you mix it with just enough water, so it’s sort of like applesauce or something like that, or like oatmeal, and then they swallow it. They don’t take any other food or liquid afterwards and just let it sit there on the lining of the esophagus. And that can be a dramatic, almost instant relief from heartburn if they already have the heartburn. DGL is wonderful also. So licorice root that has the Glycyrrhiza removed from it so it doesn’t raise blood pressure or cause edema. Aloe vera juice for some people. There’s one study that shows it works as well as PPIs for acute heartburn relief. So it depends. You have a lot of options.
You know about the interesting treatment. There’s a product that comes in the health food store. It’s 10 capsules in a blister pack, 10 capsules of d-Limonene, and the patient takes one capsule every other day for 20 days. And for some people, that has proven to totally take care of their heartburn. It’s sidal protective for the mucosa, and it’s also a prokinetic, so it helps the stomach and the whole digestive tract move things through better and is healing and protective against cancer-
Dr. Weitz: Do we want to use natural prokinetics as part of our protocol?
Dr. Sandberg-Lewis: Well, definitely if your patient is diabetic or pre-diabetic, if your patient has SIBO, if you know your patient has slow transit constipation, a prokinetic can be really helpful. And some prokinetics are more focused on the upper digestive tract, some more on the lower digestive tract. So the ones that focus more on the stomach and small intestine in my experience are ginger and artichoke combination, and also something called Iberogast, also called STW-5 in some of the research. There are many research studies on it, a German liquid formula, herbal formula. I find that Iberogast is also especially good for that upper GI motility, which is really important with reflux. But then again, if your patient has IMO or SIBO, you got to treat that. Otherwise, you got all that pressure below pushing up. So these are some of the real common things that you can do.
Dr. Weitz: What’s the best diet for GERD?
Dr. Sandberg-Lewis: So in the book, I have five or six diets that I discuss in that diet chapter, but basically when you look at lifestyle factors in diet, the thing that’s the best proven is that lower carbohydrate diets seem to be the most effective. Now, certainly if you have a patient with frank gastroparesis, fat is going to be really important because fat is what keeps food in the stomach the longest. So if someone has delayed gastric emptying, eating a lot of fat is going to be really problematic. But for everybody else, you can look at the research studies that I’ve talked about in that diet chapter and in the lifestyle chapter, reducing total carbohydrate is the thing that works the most dramatically. Even if people don’t necessarily lose weight, the weight loss is helpful, and of course, being overweight, especially around the waist, the apple fat is a risk factor for reflux and Barrett’s esophagus.
Dr. Weitz: But it makes it easy to keep that paper against the wall.
Dr. Sandberg-Lewis: If your diaphragms in good shape. But on the other hand, especially for men having pear fat or gluteal-femoral fat around the buttocks and the legs, upper legs, that’s actually protective against reflux and protective against heart disease, cardiovascular disease, and diabetes.
Dr. Weitz: Benefits of being a fat ass.
Dr. Sandberg-Lewis: Yeah. Yeah, I mean, it’s totally different. It’s totally different than the visceral apple fat, which is a risk factor for heart disease, diabetes, and reflux, and its complications. So for some patients, they say, “I got COVID. I didn’t eat for two weeks and I lost 20 pounds and my reflux is gone.” Or they did it intentionally. They lost weight intentionally. So that can be a big factor for some people. I’ve had at least two or three times, I remember now, men came in and they said, “I got rid of my reflux doc. Notice anything different?” “Well, you’re wearing suspenders.” “Yeah, I used to wear a belt. When I wore a belt, I had reflux all the time. Now I wear suspenders and no belt, and I don’t have reflux.”
Dr. Weitz: Okay.
Dr. Sandberg-Lewis: My wife calls that designer gene reflux, because if you’re wearing a tight waist, if you have a tight band around your waist, it can suppress you from using your diaphragm when you breathe and you do more shallow chest breathing, which turns on your sympathetic nervous system, decreases vagal function, makes you more prone to reflux and other causes of indigestion. If you have a nice loose waistband because you’re wearing suspenders… Some people have said that. So it’s important, again, make your clothing more likely to allow you to use your diaphragm. And it’s pretty cool, some of the fabrics they make now for jeans, they have a little stretch to them instead of just being rigid, like the old-fashioned jeans. That’s helpful.
Dr. Weitz: So you are working with a patient and you’ve done an endoscopy and you know they don’t have Barrett’s or some erosive damage. What do you do about them being on PPIs? How do you get them off of them?
Dr. Sandberg-Lewis: All right, well, the first question is does it help? Because if you ask your patients if [inaudible 00:53:09]-
Dr. Weitz: Well, it’s hard to know. If they’ve been taking them for a long time and then they stop taking them and it comes back, then they’re like, “Well, I have been with it, but when I stop, it gets worse.” That’s what I hear a lot.
Dr. Sandberg-Lewis: Yes, yes. And that again is the rebound hypersecretion, and I’ll tell you how to get around that. But some patients will say, “No, it doesn’t really help.” They probably don’t have grade D esophagitis. It doesn’t really help. So it never really helped in the first place. So those people may not have much problem getting off of them. But if they have rebound hypersecretion like that where they get much worse when they stop it, first, treat the cause of the reflux-
Dr. Weitz: Of course.
Dr. Sandberg-Lewis: … which could be a number of things, of course. And that’s why I wrote the book to really explain what to look for. And once you’ve done that, you don’t have it going on anymore. Maybe now your diaphragm is in good shape, your lower esophageal sphincter is in good shape, your hiatal hernia has been reduced and it’s back in the abdomen, the stomach’s back in the abdomen, you’ve normalized acid production if it was too low. Now what you can do is you can do a reverse titration, you can wean them off. And so, one way to do that is see if they respond to famotidine, which is the most common H2-receptor antagonist. All these things are over the counter, of course. So they can get some famotidine, Pepcid AC is the brand name, and they can see if taking famotidine instead of the PPI works just as well.
So for instance, let’s say they’re on a PPI twice a day when you first see them and they want to get off of it. Treat the causes, get things as good as you can, and then go to just taking the PPI once a day. If they’re fine with that, they’re not having problems with heartburn, try going every other day where they take it. And on the day they don’t take the PPI, take the famotidine, which is much easier to get off and is much less likely to cause rebound hypersecretion. So it’ll be easy to wean off of that later. So they switch off where they’re taking famotidine one day, PPI another day, or maybe a combination of the two if they were on a higher dose twice a day of PPI. So you just kind of wean it down. Eventually then if they’re doing okay with that, they take the PPI every third day, Monday, Thursday, Sunday, something like that, and they’re taking the famotidine on the other days. They can also be taking DGL and other things that are happening, right?
Dr. Weitz: Right. There’s natural products.
Dr. Sandberg-Lewis: Yeah.
Dr. Weitz: I love that exercise you had in a book where they drink a bunch of water and then go up on their toes and come down on your heels. That’s a really cool idea.
Dr. Sandberg-Lewis: Well, heel drops exercise for sliding hiatal hernia helps to weigh the stomach down and move the stomach back down. I use that after exercise, after I do a correction on hiatal hernia, manual correction. Just helps it stay in place, but people can use that all by itself. Sometimes they’re lucky it’ll work. So yeah, so weaning off that way. Once they get to taking the PPI every third day, they can probably just stop it and now they’re just on the famotidine. And then they can just slowly remove that where they’re taking it every other day and if they feel just as good on the day they don’t take it, take it every second day, every third day, and then stop it. Even if the process of weaning off takes three to six months, really do it really slowly. Don’t change anything for two or three weeks at a time. That’s a good way to slowly bring down the gastrin levels because remember, their blood gastrin levels are very high, and so you have to gradually allow that to come down.
But yeah, you’ve had patients on proton-pump inhibitors, omeprazole, the first one that was invented, probably for 20 years. They’ve been on it for 20 years. So if it takes six months to get off of it, that’s fine. It’s better than continuing it for the next 20 years if they don’t need it.
Dr. Weitz: Right. All right, Steven, this has been great. We’ve covered a lot of information. Obviously we could continue to discuss this topic for hours and hopefully in the future we’ll have more discussions about it, but perhaps you can tell our listeners and viewers how to get ahold of you.
Dr. Sandberg-Lewis: So the website for my private practice Hive Mind Medicine, got to say that slowly, like a beehive, is either hivemindmedicine.org or for short, HMM, Hive Mind Medicine, PDX, which is Portland, it’s where my practice is, dot com, hmmpdx.com. And there’s a lot of great blog posts because my wife and I both write a blog post every month. There’s a lot of great blog posts on reflux and other GI topics in there if you want to enjoy those. And the book is available through any major booksellers website. Ben, held it up before, but let’s be real about reflux. I like telling people, hey, use barnesandnoble.com or powells.com because Powell’s Books is the best bookstore in the world. It’s here in Portland. You don’t always have to use Amazon. It is available on Amazon-
Dr. Weitz: I always put a link to the book with Barnes & Noble on my website because I agree, I would like to see the last few remaining bookstores stick around. By the way, this book is awesome. It’s really readable. It’s really [inaudible 00:59:54]-
Dr. Sandberg-Lewis: It has limericks and cartoons.
Dr. Weitz: Every single chapter.
Dr. Sandberg-Lewis: Yeah, and we wanted to make it fun. [inaudible 01:00:06]-
Dr. Weitz: NERD is a comical name for erosion-free reflexive theme. What leads into GERD instead of just NERD? This chapter is here to explain.
Dr. Sandberg-Lewis: That’s a good one.
Dr. Weitz: Thank you, Steven.
Dr. Sandberg-Lewis: All right, Ben, it’s been great talking with you.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. That way, more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen, and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at (310) 395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.
