What You Eat Could Be Eating You

Almost everyone has some reflux, the upward backflow of the stomach’s contents. Managing it will always require thought, creativity, and attention to what you eat and when. There’s no one-size-fits-all strategy for beating it.

This chapter describes the science behind reflux in a way that will help you understand how and why The Reflux Diet works. To understand it further, the chapter “Reflux Science You Can Digest” later in this book contains a more in-depth look at the scientific state of the art of research in this field, including many of the relevant references from the medical literature.

Things Are Not What They Seem

Acid reflux has been poorly understood until recently, even by doctors in closely related fields. For example, your family doctor or even a specialist might have told you that it’s asthma, sinusitis or allergy, when in fact you had reflux. Or perhaps your doctor prescribed an over-the-counter antacid. The real villain, however, is the digestive enzyme pepsin, not acid, and an antacid therefore won’t do a thing for many reflux symptoms. At present, there is no “anti-pepsin” medication, so the disease that is literally eating away at you keeps on growing.

Why should you care? Because reflux is not only uncomfortable and inconvenient, it’s dangerous. If left untreated, reflux can wreak havoc on your throat, airways, lungs and digestive system. It can even cause cancer.

The American diet has changed dramatically since WWII, but there has been no captain steering the ship—no overarching body to monitor all aspects of the safety of the food supply. This may explain why reflux and many reflux-related diseases are increasing in America.

Here’s what happened. In the 1960s and 1970s, fast food and pre-packaged food became popular and many people stopped eating home-cooked meals. In general, the obesity epidemic has paralleled the increase in the saturated fat content of our diets, but there has been a second, more insidious trend: Prepared foods have been increasingly acidified to discourage bacterial growth and add shelf life. Today, many prepared foods and beverages are just as acidic as stomach acid itself.

Until this book, no one has investigated the adverse effects of too much acid in the foods and beverages we consume. Everyone worries about equalizing the stomach’s natural acid, yet we continue to pour ever more acidified foods and drinks into it. Again, it’s not stomach acid that’s the main problem. The term “acid reflux” is misleading, since it is the digestive enzyme pepsin, not acid, that causes most of the trouble. The confusion is because pepsin can only do its job when acid is around to activate it. Then it gets busy breaking down proteins into smaller, more easily digestible particles. Without acid to supercharge it, pepsin can’t do its thing.

Here’s the catch: At a certain point, pepsin doesn’t go away meekly after digesting your meal. It’s still hanging around like the bully at a playground. All it needs is some acid to wake it up again. Your stomach produces acid when you eat a meal, but pepsin doesn’t care where the acid comes from; any acid will do. Any foods you eat that are high in acid are perfectly sufficient for activating pepsin, and if there’s no protein around that needs digesting, the pepsin will gnaw on whatever is handy—such as the linings of your throat and esophagus. The old adage “You are what you eat” might in this case be rephrased: “Be careful what you eat, because what you eat could be eating you.”

Imagine that your stomach is full of seawater and lobsters. The seawater is acid, and the lobsters (big, aggressive ones with mighty claws) are the pepsin molecules. When you reflux, the seawater splashes around. Some of it splashes upward into your throat. The lobsters ride this wave of seawater and attach themselves to the shore wherever they land—the shore being the delicate tissue and membranes lining your throat, larynx (voice box), esophagus and lungs.

The lobsters are hanging on by their claws. It doesn’t really matter now whether the seawater they need for survival splashes up from below or pours down from above. To these lobsters, it’s all just a delicious, rejuvenating splash. Once a pepsin molecule is bound to, say, your throat, any dietary source of acid can reactivate it: Soda pop. Salsa. Strawberries.

We suspect that Dropping Acid: The Reflux Diet Cookbook & Cure will not be popular with Federal regulatory agencies and the Congress that funds them. Or with some of the companies that produce commercial foods and beverages, because many common products are as acidic as stomach acid and just as potentially harmful. The acidification of prepackaged foods and beverages extends their shelf life and discourages bacterial growth, which is good. But it is also likely that this acidification of our food is one of the reasons reflux is approaching epidemic levels.

This book might also irritate certain members of the medical community. After all, different medical specialties have different perspectives. However, the prevailing clinical model of reflux disease is about as wrong as the ancient belief that the world is flat.

For one thing, there is a huge misconception about how pepsin works. Many doctors mistakenly believe that pepsin is only active below pH 4. Nothing could be further from the truth. Pepsin, those lobsters, can continue to be somewhat active up to pH 6.

By the way: The pH scale, used to measure acidity, is somewhat counterintuitive. pH 7 is neutral; pH 1 is very acidic, and caustics like bleach have values from pH 8-14. For example, distilled water and most tap water is pH 7 (neutral), but vinegar at pH 2.9 and lemon juice at pH 2.7 are acidic. The normal range of stomach acid is pH 1-4. Also note that the pH scale is a logarithmic scale, so pH 4 is ten times more acidic than pH 5, and pH 4.9 is twice as acidic as 5.0. That’s why simply diluting acidic beverages doesn’t make them non acidic.

Pepsin does maximum damage at pH 2 (100 percent activity), but it can still do some damage up to pH 6 (10 percent activity). This pepsin activation curve has important implications for reflux, because protein can be digested—and tissue damaged—to some degree whenever any acid is present. (In case you were wondering, Coca-Cola is pH 2.8.)

The Pepsin Activity Curve

When pepsin binds to tissue, it remains stable for a long time. The question is not whether it is active, but how active. All those popular and expensive anti-reflux medicines don’t actually turn off the acid, they just turn it down, reduce it somewhat. On television, you’ll see those little acid pumps in the stomach give up at the sight of a powerful purple pill, but that’s not what really happens. Despite the strongest anti-reflux medications, the proton pump inhibitors (e.g., Prilosec, Protonix, Nexium), everyone’s stomach still churns out significant amounts of acid. About 10 percent of people who try proton pump inhibitors do not respond to them, and another 15-20 percent get side effects such as nausea, gas, bloating, diarrhea and abdominal pain.

We still don’t have a universally effective anti-reflux medication. The best medications we have are only pretty good, and they’re only pretty good for about two-thirds of the people who need them.

By now you’re probably wondering: “Why not forget the acid and just treat the pepsin?”

There is not yet an effective anti-pepsin medication. However, what has been missing from the treatment equation until now is an understanding of the profound impact of dietary acid. To correct this misunderstanding, here is a summary of exactly how reflux causes problems for you, the sufferer:

• Acid and pepsin work together to cause reflux-related symptoms and diseases.
• None of the available anti-reflux medications turns acid off completely.
• When pepsin attaches to human tissue, disease may result.
• Dietary acid can activate pepsin already in or on tissue.
• Sick from reflux, that tissue needs a period of recovery.

Why Doesn’t My Doctor Know About This?

Patients frequently ask us, “Why doesn’t my doctor know about this?” Part of the answer is that specialists are too specialized. Many reflux symptoms (hoarseness, the sensation of a lump in the throat, post-nasal drip, chronic throat clearing, cough, chest pain) cross medical specialty lines and are non-specific. The correct diagnosis is often confused with other diagnoses, including upper respiratory infections, allergies and sinusitis.

Patients with reflux-related chronic cough, for example, often see a number of physicians without receiving proper diagnosis and treatment. They might find a knowledgeable specialist only after browsing the Internet and stumbling across information about “silent reflux,” also known as laryngopharyngeal reflux (LPR). These frustrated patients may find relief only after being disappointed by visits to doctors in otolaryngology, allergy, immunology, gastroenterology, and pulmonary and internal medicine.

Remember, what makes silent reflux insidious and difficult to diagnose is that people who have it DO NOT have heartburn and indigestion. To most people (and their doctors), reflux and heartburn are synonymous, so they miss the big picture.

Silent reflux has much in common with other relatively recent medical discoveries that were at first misunderstood, but it is time to give silent reflux its due. It is the most important disease of the breathing passages, and it contributes to the development of many diseases of the ear, nose, throat, lungs and esophagus—including the development of cancer. At present, reflux-related esophageal cancer (most common in white males) is the fastest growing cancer in the United States. In addition, research on the cell biology of LPR has shown that laryngeal cancer and reflux exhibit similar cell damage profiles.

We, the authors, believe that reflux is the most important risk factor for esophageal and laryngeal cancer.