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Health Protocols

Gastroesophageal Reflux Disease (GERD)

Targeted Nutritional Interventions

Raft-Forming Agents. Raft-forming reflux suppressants have been used to treat GERD for more than 30 years (Hampson 2010). Raft-formers are combinations of a gel-forming fiber (e.g., alginate or pectin) with an antacid buffer (commonly sodium or potassium bicarbonate). When the combination reaches the stomach, chemical reactions cause the release of carbon dioxide bubbles. These bubbles become trapped in the gelled fiber, converting it into a foam that floats on the surface of the stomach contents (hence “raft-forming” agent). Several studies have demonstrated that rafts reduce GERD symptoms by mechanisms independent of acid reduction. They can either move into the esophagus ahead of the stomach contents during reflux (protecting it from exposure) or may act as a barrier to reflux episodes (Mandel 2000). A recent multicenter study of patients with mild to moderate GERD symptoms demonstrated that an alginate-based raft-forming agent was as effective as the PPI omeprazole at reaching an initial heartburn-free period and reducing reflux pain (Pouchain 2012).

The properties of raft-forming agents can be modified by adding calcium salts, which can cross-link fibers and form stiffer gels (Mandel 2000). Raft-formers are most effective when taken after the heaviest meal of the day. If taken with a meal, they can mix with stomach contents and fail to form a “raft” (Mandel 2000).

Melatonin. Melatonin is a hormone most often associated with the sleep cycle, but is found at levels hundreds of times higher in the gut than in the brain (Werbach 2008). Melatonin helps mitigate damage caused by free radicals and inflammatory reactions. Melatonin also helps maintain the mucosal integrity of the oral cavity and esophagus (Brzozowska 2014). Animal studies of melatonin for GERD symptoms have found it to be effective in preventing acid-induced esophageal damage (Konturek 2007). Two human trials have investigated the effect of supplemental melatonin on GERD symptoms. In the first, 176 patients took a multi-nutrient formula that contained 6 mg melatonin. A group of 175 control subjects took a PPI (20 mg omeprazole). The effects were measured by the length of time it took for the patients to become asymptomatic (defined as no heartburn or regurgitation) for 24 hours. All patients in the melatonin group reported improvement in GERD symptoms compared with two-thirds in the PPI group. Relief was reached faster in the melatonin (7 days) versus PPI (9 days) group, with a much lower incidence of side effects (Pereira 2006). The second study compared three groups of nine GERD patients, each on a different regimen (3 mg melatonin, 20 mg omeprazole, or both) to a group of healthy control subjects. Heartburn and gastric pain decreased after four weeks and completely resolved after eight weeks in all treatment groups. However, only the two melatonin groups had significant improvements in lower esophageal sphincter function (Kandil 2010).

Deglycyrrhizinated Licorice (DGL) Extract. Licorice root is a time-honored treatment for digestive ulcers, and modern research continues to confirm its ability to heal the tissues of the digestive tract. Some of the mechanisms behind this remarkable ability are now well understood. Compounds from the licorice plant increase the concentration of prostaglandins at the site of erosive lesions, causing increased mucous secretion and cell proliferation to aid healing. Licorice can also inhibit production of pro-inflammatory cytokines such as interleukins, tumor necrosis factor, and nuclear factor kappa-B; and is a powerful oxidative stress modulator. These properties contribute to its ability to protect the delicate lining of the gastrointestinal tract (Baker 1994; Furusawa 2009; Asl 2008; Aly 2005).

A compound found in unrefined licorice root, glycyrrhizin, may cause side effects in high doses including bloating, high blood pressure, low blood potassium levels, hormonal changes, and diarrhea. When these compounds are removed from licorice root, the product is called deglycyrrhizinated licorice, or DGL. DGL retains the gastrointestinal healing properties of the licorice while avoiding most side effects (Larkworthy 1975; Isbrucker 2006).

Research has shown that DGL extract is an effective treatment for indigestion. In a randomized controlled trial, 50 subjects with functional dyspepsia were randomized to receive a placebo or 75 mg of a patented DGL extract twice daily for 30 days. At 15 and 30 days, subjects taking the GutGard reported significant decreases in total symptom scores compared with those taking placebo. The GutGard recipients also showed significant improvement on a standardized dyspepsia assessment index compared with placebo recipients. GutGard was found to be safe and was well tolerated by all subjects (Raveendra 2012).

Mineral carbonates (calcium, magnesium, and potassium). Calcium and magnesium carbonate, and potassium bicarbonate, neutralize stomach acidity and have been used in antacid preparations for many years (Maton 1999; Gold Standard 2002). Magnesium and calcium carbonate interact with hydrochloric acid in the stomach to form chloride salts, water, carbon dioxide, hydrogen, and other benign products (GCSE Bitesize 2014; The American Society of Health-System Pharmacists 2016).

By neutralizing stomach acid, antacid mineral carbonates decrease irritation of the delicate lining of the gastrointestinal tract. Antacids also inhibit the activity of the gastric enzyme pepsin, and this action may also protect against damage to ulcerated or eroded gastrointestinal lining (Gold Standard 2009). Importantly for those suffering from GERD, antacids such as calcium and magnesium carbonate neutralize acid in the esophagus; and chewable calcium carbonate has a relatively long duration of action. Chewable calcium carbonate has demonstrated an ability to improve contraction of the esophagus, resulting in increased clearance of acid (McRorie 2014; Robinson 2002; Rodriguez-Stanley 2004). Calcium carbonate has a rapid onset of action and is capable of relieving GERD symptoms in minutes (Robinson 2002).

Protecting against Barrett’s Esophagus and Esophageal Cancer

GERD increases the risk of metaplastic (i.e., transformation of tissue) events that lead to Barrett’s esophagus, which in turn significantly increases the risk of esophageal cancer. Therefore, the most effective way to reduce the risk of these two serious conditions is to control the symptoms of GERD. However, the following additional considerations may be beneficial as well.

Several observational studies have examined the effects of dietary patterns on the incidence of Barrett’s esophagus or esophageal cancer (independently of GERD). Some foods and supplements appear to reduce cancer and metaplasia risk.

Total fruit and vegetable intake has been associated with reductions in the risk of esophageal adenocarcinoma in some studies (Chen 2002; Navarro Silvera 2008; Navarro Silvera 2011). It has been noted that risk reductions associated with citrus fruits as well as yellow, brassica, or raw vegetables were consistently positive (Gonzalez 2006; Steevens 2011; Chen 2002). Strawberries, due to their powerful antioxidants, have also piqued the interest of researchers looking for compounds able to protect esophageal tissue. In order to test the hypothesis that strawberries might protect against esophageal cancer, scientists administered freeze-dried strawberry powder to 75 patients with precancerous esophageal lesions for six months. At a dose of 60 grams daily, freeze dried strawberry powder improved the appearance of the esophageal tissue under microscopic examination. Moreover, several inflammatory markers were reduced, including a 63% reduction in cyclooxygenase-2 (COX-2) activity and a 62% reduction in Nf-kB activity. The investigators remarked that “Our present results indicate the potential of freeze-dried strawberry powder for preventing human esophageal cancer” (Chen 2012).

Fiber from cereal or whole grain was generally associated with reduced risk of esophageal cancer (Chen 2002; Mayne 2001; Terry 2001; Navarro Silvera 2008). On the other hand, increased consumption of animal protein, saturated fat, and dietary cholesterol consistently led to increased risk of esophageal cancer (Mayne 2001; Navarro Silvera 2008).

Vitamins C, E, beta carotene (Mayne 2001; Bollschweiler 2002; Kubo 2007; Carman 2009), and dietary folate (Mayne 2001; Ibiebele 2011; Bollschweiler 2002) appear to confer a reduction in esophageal cancer risk in the majority of studies. Likewise, general supplement (i.e. multivitamin) usage was associated with risk reduction in one population study (Dong 2008).

Several fruits and vegetables contain a powerful polyphenol (antioxidant) called ellagic acid. It exerts cellular protection in a variety of settings and is well-documented in animal studies as an inhibitor of esophageal cancer as well as aiding in ulcer healing (Whitley 2005; Beserra 2011).

Zinc, a trace mineral essential to many biological processes, may protect against esophageal cancer (Grosvenor 1995). One observational study evaluated serum zinc levels in 60 people with esophageal or gastric cancer and 120 healthy controls. People with esophageal cancer had significantly lower serum zinc levels. This study suggests lower levels of zinc in the body correlate with development of esophageal cancer (Hashemi 2017). In a recent laboratory study on human cell lines, the addition of zinc to the cell culture significantly inhibited proliferation of squamous cell esophageal cancer cells. Nonmalignant esophageal cell lines did not display this significant inhibitory response to zinc. Also, zinc’s ability to inhibit the proliferation of esophageal cancer cells was reversible with a zinc chelator. The investigators identified modulation of calcium signaling as a possible mechanism by which zinc mediated this anti-cancer effect (Choi 2017). Importantly, proton pump inhibitors, which are often overused by people with GERD, can impair zinc absorption and reduce stores of zinc in the body (Farrell 2011), highlighting the importance of adequate zinc intake in this group.

Various other dietary constituents have been investigated in cell culture or animal models of esophageal cancer with positive results. These include sulforaphane (from broccoli) (Qazi 2010), vitamin E with N-acetyl cysteine (Hao 2009), proanthocyanidins (from apples) (Pierini 2008) and cranberries (Kresty 2008). Betaine (trimethylglycine) intake was associated with a reduction in Barrett’s esophagus in one study (Ibiebele 2011).

Disclaimer and Safety Information

This information (and any accompanying material) is not intended to replace the attention or advice of a physician or other qualified health care professional. Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle change intended to prevent or treat a specific disease or condition should first consult with and seek clearance from a physician or other qualified health care professional. Pregnant women in particular should seek the advice of a physician before using any protocol listed on this website. The protocols described on this website are for adults only, unless otherwise specified. Product labels may contain important safety information and the most recent product information provided by the product manufacturers should be carefully reviewed prior to use to verify the dose, administration, and contraindications. National, state, and local laws may vary regarding the use and application of many of the treatments discussed. The reader assumes the risk of any injuries. The authors and publishers, their affiliates and assigns are not liable for any injury and/or damage to persons arising from this protocol and expressly disclaim responsibility for any adverse effects resulting from the use of the information contained herein.

The protocols raise many issues that are subject to change as new data emerge. None of our suggested protocol regimens can guarantee health benefits. The publisher has not performed independent verification of the data contained herein, and expressly disclaim responsibility for any error in literature.