Heartburn

What Is Heartburn?

The basics

Heartburn is a term used to describe the pain of gastroesophageal reflux disease.  This condition affects mostly adults when the esophageal sphincter becomes lax, or there is too much pressure on the abdominal contents, which causes gastric contents to be pushed up into the esophagus, causing esophageal irritation and pain.

Know this

It is important to know that conditions other than gastric reflux can cause chest pain. Cardiac-related chest pain can mimic symptoms of heartburn. Costochondritis is a condition of inflammation of the cartilage of the sternum that can cause sharp central chest pain.  These, as well as many other conditions, can cause reflux-like heartburn symptoms.   Be sure to get a proper medical evaluation to have other causes of chest pain ruled out before treating yourself.  

Certain conditions like pregnancy and obesity can make heartburn worse.  For overweight individuals, losing weight can significantly improve your symptoms by reducing pressure on abdominal contents. Additionally, there is some evidence that avoiding certain foods and adding other foods to the diet can lessen heartburn symptoms.

To manage heartburn symptoms, try this:

• Eat smaller meals, which helps to reduce abdominal pressure and prevent reflux.
• Wait at least 3 hours before lying down after eating
• Raise the head of the bed 30 degrees at night while you sleep
• Wear loose-fitting clothing
• If you are overweight, work on losing weight

Foods that have been shown to contribute to reflux symptoms:.

•     Spicy foods
•     Beer
•     Wine
•     Chocolate
•     Coffee
•     Carbonated beverages
•     Fried foods
•     Acidic foods, like tomato sauce and juices
•     Citrus foods, including citrus juices

    

In addition to avoiding particular foods, certain diets also reduce symptoms of acid reflux.  These include the Mediterranean diet, a very low carb diet, and a high fiber diet. 

Get a prescription

There are over-the-counter medications to try.  These should be used on a short-term basis and according to package instructions.  If your symptoms last longer than two weeks, see your doctor for proper evaluation and treatment options.  

Two common classes of medications used to treat acid reflux are proton pump inhibitors like Prilosec and Prevacid, and histamine blockers (H-2 antagonists) like Pepcid and Tagamet.

Medications are thought to be safe for short-term use but become problematic when used longer.  Proton pump inhibitors can adversely affect kidney function, block absorption of certain vitamins and minerals, and may contribute to osteoporosis by reducing bone metabolism with long-term use.

It is important to discuss your specific medical situation with your health care provider, who can help make the best decision about treatment options.

Common concerns:

As mentioned above, one concern with acid reflux is to rule out other conditions and ensure a proper diagnosis is made.  Gastroesophageal reflux can lead to irritation to the lining of the esophagus and stomach and can cause erosive lesions, which can be cancerous. These more serious conditions can be treated with further testing and appropriate medical care.

References

Cesario S, Scida S, Miraglia C, Barchi A, Nouvenne A, Leandro G, Meschi T, De' Angelis GL, Di Mario F. Diagnosis of GERD in typical and atypical manifestations. Acta Biomed. 2018 Dec 17;89(8-S):33-39. doi: 10.23750/abm.v89i8-S.7963. PMID: 30561415; PMCID: PMC6502210.

Fossmark R, Martinsen TC, Waldum HL. Adverse Effects of Proton Pump Inhibitors-Evidence and Plausibility. Int J Mol Sci. 2019;20(20):5203. Published 2019 Oct 21. doi:10.3390/ijms20205203.

Heartburn. Mayoclinic.org. https://www.mayoclinic.org/diseases-conditions/heartburn/symptoms-causes/syc-20373223 Updated April 17, 2020. Accessed July 29,2021.

Morozov S, Isakov V, Konovalova M. Fiber-enriched diet helps to control symptoms and improves esophageal motility in patients with non-erosive gastroesophageal reflux disease. World J Gastroenterol. 2018 Jun 7;24(21):2291-2299. doi: 10.3748/wjg.v24.i21.2291. PMID: 29881238; PMCID: PMC5989243.

Surdea-Blaga T, Negrutiu DE, Palage M, Dumitrascu DL. Food and Gastroesophageal Reflux Disease. Curr Med Chem. 2019;26(19):3497-3511. doi: 10.2174/0929867324666170515123807. PMID: 28521699.

Placebo and Nocebo effects and thoughts on COVID-19 immune reactions

I am often asked by patients for an opinion on the health benefits of various supplements and over-the-counter remedies.  This has always intrigued me, and the entirety of this blog could be devoted to just that.  So many factors weigh in on whether a treatment is beneficial.  One factor that intrigues me, is placebo and nocebo effect.  These are well-studied brain changes much more complex brain changes that make.

Placebo effect:  A beneficial effect of taking a substance that has nothing to do with the substance itself

Nocebo effect: When negative expectations of a patient have a more negative effect than expected

In practice, these factors are observed regularly.  Nocebo effect occurs in patients who, being anxious about taking a particular medication, read all the negative side effects and experience almost all - including the rarest of side effects. Or for example in pain control, a patient assumes that Drug X never works for me - and it never does.  Also quite frequently, a patient will begin treatment and almost instantly feel relief - physiologically the drug hasn't even had time to work yet, but the patient is significantly improved.  I've even experienced this myself, smirking at the power of my subconscious mind.

Placebo effects are now an important part of drug research, but for many years were not.  In order for a drug to be considered effective, the therapeutic effects in the non-placebo group must be reproduced at a higher rate than the placebo group.  Interestingly, most drugs used for depression and anxiety show the placebo group at equal recovery rates as the therapeutic drug group.

When I first learned that therapeutic drugs for depression had the same rate of efficacy as placebo, I was disheartened and actually went through a period of existential crisis.  What was I doing peddling all these drugs to patients when they were no better than taking a sugar pill?  Everything I do is a sham!  Slowly I came to the realization that getting better is getting better and IT DOESNT MATTER how it happens.  What matters is people find healing. I still peddle drugs - including ones that work at the same rate as placebo.  I still support treatments that I know have no therapeutic value other than the patient believes that they do, therefore they do.  The mind is the most powerful placebo/nocebo weapon, and the body for the most part is self-healing.

For further reading on this, I recommend Suggestible You by Eric Vance 2016

Another one on my list, but not yet read You Are the Placebo by Joe Dispenza 2014

With some knowledge of placebo and nocebo and does anything really work at all, let's now turn our attention to the body's own defense mechanisms.

Studies have been conducted on the immune response that shows that blood cells release immune-boosting proteins when a person witnesses another person sneezing.

You're welcome.  Now, how's that for an amazing operating system?  Without doing a conscious thing, your body is protecting you from disease.

When a patient brings an herbal supplement, or article about the new latest and greatest anti-aging product, my advisement is first, ensure the substance is not HARMFUL.  Is it going to affect liver or kidney function, interact with your other medications, affect your personal medical conditions (do you have cancer history, immune-suppressive condition, diabetes, high blood pressure)?  It truly is a unique decision for each person, and I strongly encourage you to consult your own personal health advisor to help with your decision-making.

After establishing that it likely won't cause direct harm, we then discuss the fact that otc supplements are not FDA regulated and studies repeatedly find that the actual ingredients and potency of stated supplement is often way off from advertised.  Buyer beware.

Last, and most difficult to determine is the actual efficacy of a substance.  Do we have peer-reviewed research to back the claim?  Prescription drugs do, they must pass FDA approval.  Foods, herbs, supplements, treatments sometimes do.  That is what I hope to share through this blog.

Now back to all those things the store shelves are slam out of?  Echinacea, Zinc, Zycam, Cold Eeze, Vitamin C, Vitamin E, Vitamin D. Elderberry.  Are any of these scientifically proven to reduce the incidence of viral illness?  Is it the substance itself? Anecdotal evidence? Placebo effect?

Let's look at a few:

ZINC

Theories about zinc include the idea that zinc coats the mucous membrane providing an extra layer of protection against viral invaders.

Cold Eeze zinc lozenges are evidence-based to shorten the duration of the common cold (a virus) by HALF.  Two separate double-blind peer-reviewed studies in 1992 and 1996.  Participants took 1 lozenge every 2 hrs while awake. Each lozenge containing 13mg zinc

Another study showed zinc at doses of 75mg per day was effective, but not less than.

Also of note, zinc taken intranasally can cause irreversible loss of smell.  Not recommended.

Cold Eeze is absorbed directly through the mucous membrane and that is a very different delivery route than swallowing pills.

These studies were all performed on the common cold virus.  Influenza patients were excluded.  COVID-19 is a coronavirus that is in the same family of viruses as the common cold. Based on this data, I would suggest that zinc can be safely used and there is a possibility it may shorten the duration of symptoms by half.

VITAMIN C

In 2013, a meta-analysis of 29 trials showed a small 8% reduction in duration of symptoms.  In soldiers, marathon runners, and artic skiers there was a 50% reduction.  Why the variation in findings in this very small group was so different is unknown. Perhaps the vigorous body stress creates an increased demand for vitamin C? Just my own musings.  However, if you are a vigorous exerciser more than 5 days per week, then Vitamin C appears to be of greater benefit than it would to an average active or more sedentary person.

ECHINACEA

Earlier studies prior to 2000 showed a reduction in severity and duration of cold symptoms, however many repeat studies in the next decade disproved this benefit showing no benefit of echinacea supplementation over no supplementation.

HAND HYGIENE

A resounding Yes.  We have 100s of years of studies backing the fact that hand washing reduces and prevents the spread of germs.

EXERCISE

People who exercise 5 or more times a week suffer the same rate of viral infections as sedentary people.  Personally disappointing to me, but certainly has other benefits to still recommend

SLEEP

People who sleep greater than 7 hrs have significantly less viral illness than people who sleep less than 5 hours a night who were three times as likely to get sick.

Day 1: The diet starts tomorrow

It's always that way.  The day you decide to go sugar free, you stop at Krispy Kreme after your run to cash in your gift certificate for 12 original glazed doughnuts still warm in the box.  My 16 year daughter in the passenger seat, also a runner says, "Let's eat one right now" in the car on the way home.  I tell her I am starting my anti inflammatory diet today and I can't eat sugar. It barely took 1-2 sentances to convince me that it would be ok to have a little sugar.  After all, everything in moderation right?  Ugh.

Breakfast:  1 krispy creme donut in the car, scrounge in the fridge at home for anti inflammtory additions to my 190 calories of pure sugar and came up with 3/4 cup fresh berries and 5 boiled shrimp. Bizzare, insane perhaps but salvaged from the first bite of the first day of the new change.

Lunch:  The internet has loads and loads of recipes, thoughts, and lists of what is and isn't anti inflammatory.  I'm a perfectionist and this is going to try my patience.  I found a recipe for a chick pea budda bowl and went cabinet surfing for something similar.  I came up with pinto beans spiced with chili pepper and tumeric, collard greens, diced fresh tomato and garnished with a tablespoon of crushed peanuts.  I still feel a little insane, but I am determined and I will eat it, like it or not! It actually was pretty tasty - I'd eat it again.  I have a lot of left over beans and greens and could meal prep a few lunchs for work next week. I have read in the past a good way to put together a meal: a green, a bean and a grain. That's actually why I bought that can of collard greens 6 months ago...

I'm going to have to ease my way into a perfect diet.  Step 1 - cut sugar (donuts), processed food (chips) and eat more anti inflammatory foods (tomatoes, veggies, dark colored fruits, salmon).  I also intend to cut dairy (there goes pizza).  As I research more, I will decide on just how strict I need to be with grains, gluten and legumes.  For now, it's no brainer baby steps. No more Krispy Kreme doughnuts.

Practice What You Preach

I started this blog with the intention of helping others.  

I strongly believe in natural wellness, and that generally, most medications we use are necessary only because modern humans don't diligently take good care of ourselves.  Somewhere, we forgot that proper fuel and habits impact the performance of the suits we live in.  I take my car to the car wash.  I fill it with proper fuel - regardless of gas prices. I have the oil changed, the brakes checked, the tires changed.  While I've never totaled up the cost, I would venture to guess I spend more money on caring for my vehicle than I do for my body.

Over the past couple of years, my body has started to change.  I thought it was menopause, and geared my health efforts on restoring hormone balance.  I sleep like it's my religion: 8 hrs regularly. I exercise regularly: 5-6 days a week including cardio and strength training.  I try to manage stress load, work on good relationships, take time to meditate and decompress.  Where I fail, is diet.  Sure, I am maintaining a healthy weight, but I am 45 years old and still eat pizza, ice cream, chips, and candy; like I'm a teenager. 

So back to the body changes: I am a lifelong runner. For the past 25 years, I have regularly run 5-6 days a week and for many years averaged 40 - 50 miles a week.  Our family went through a traumatic life event that turned my life upside down. My children's father died, and I suddenly became a single mother of three teenagers. Every mother lives for her kids, but suddenly I was all they had. The weight of that responsibility was intense. What if I lost my job? What if I couldn't do all the things they still needed? Who would pick up the pieces if I failed?  I worked full time, I was driving 100 miles a day to get them to respective schools and myself to work. This drastically impacted my running.  I strung together running 20-mile weeks as best I could, but I would come home every day and just crash. 

Time heals all wounds, and within a couple of years, we had a rhythm going.  My oldest started driving, the 100-mile daily driving trips were over.  I had more TIME to run!  The problem was, I couldn't make a comeback.  I was always breaking.  At first, I thought it was just stress and deconditioning.  I added in strength training, I trained very carefully. But still, I was not performing anywhere close to the level I used to.  You could blame age - but my same-aged peers were still moving along while I was left behind unable to keep up, still frequently getting injured.   Next, I thought it was menopause - hormones wreaking havoc on my cardiovascular system, muscles, joints, and bones.  So, I started taking hormone replacement therapy.  Now my hormones are in check, but STILL, I am piling up injury after injury and now new injuries are coming even before old ones heal. I am in chronic pain.  It's depressing and taking every ounce of passion and drive to keep fighting to do what I love. Almost 2 years into this chronic pain situation, I begin to wonder if something more is wrong with me than stress or hormones, or aging.  Maybe I have lupus, rheumatoid arthritis, or some autoimmune issue that is generating all this chronic inflammation? Maybe it's stress, but has my life really been that much more stressful than everyone around me?  I find that hard to believe.

This is where I find myself today 2/29/2020.  I have had some initial lab testing that raised an eyebrow at lupus.  I have a strong family history of autoimmune disease, including lupus and rheumatoid arthritis on both sides of my family.  The next step will be to see a rheumatologist. The next step after that will be to start taking immunosuppressive drugs.  The thought of that goes against everything I believe in. I believe that fresh air, peace, diet, exercise, and a good night's sleep cure most diseases. I have witnessed this firsthand over and over in my practice.  Patients have bariatric surgery, they lose 50 - 75 - 100lbs and their medications start dropping off:  no more hypertension, diabetes, arthritis, depression.

I am putting the brakes on this freight train, and before I dive any further into what is wrong, I'm going to focus on what I can do right.  For the next 3 months, I intend to overhaul my diet and eat like my life depends on it.  It kinda does.  Running is that important to me.  Living without chronic pain is too.

What is Well Care?

In 1994, I entered the field of health care.  My young heart's desire was to enter a vocation in which I could also earn a living. For the past 20+ years, I have devoted much time to the practice and promotion of health and wellness.  I do this in my personal life, as well as for my family and everyone I encounter.  After all this time, it is still my heart's desire, my passion to move lives in the direction of health and wellness and away from self-harming thoughts, emotions, and behaviors.  They say a good salesman believes in his product.  I believe in being healthy.

I am currently a board-certified family nurse practitioner with a master's degree in nursing.  I am an avid runner, nutrition enthusiast, mother, health coach and still work full time practicing primary care in an outpatient medical group.

What I have learned over the past 20+ years teaching and helping patients, is that most of us could live pill-free and stay out of the doctor's office if we took better care of ourselves.  I have also learned that while most of us deep down truly know the basics of what to do, we have difficulty making healthy changes, staying on track, persevering despite failures and setbacks.  We are also constantly bombarded with the latest fad diets, self-help books, and magic pills that promise to change everything.

Through this blog, my hope is that readers will find ideas, tools, and motivation for well care.  Wellness is the foundation of disease prevention.  It is the path to feeling good, living well.

oatmeal energy balls

Oatmeal Energy Balls

adapted from sweetpeachef.com 5 day anti-inflammatory meal prep

I love granola bars!  I eat cliff bars and apples for breakfast on my way to work most days.  Over Christmas, I tried my first batch of healthy snack balls and gave them to running friends as gifts.  Our first batch used protein powder and got thrown right in the trash.  The second batch was decent using a basic mix of dry oats, nut butter, cinnamon.  Upgrade that idea with anti-inflammatory add-ins:

1 cup dried old fashioned oatmeal
1 cup nuts (I used peanuts) almonds
6 dried plums (dates)

Hello ITBS

ITBS: Hello Hip Pain

Your hip aches when you lie on your side at night. 

There's a tender spot when you touch on the outside of your leg bone.  

Or maybe it's the outside of your knee?  You know, just above that little bony knob that sticks out on the side of the knee?   

Whatever it is, this lateral pain can be sharp - like someone stabbed you with an ice pick.  It can be mild and intermittent, dull and aching at night, or sharp and painful every time you take a step.  ITBS can be a minor irritation, or it can become so severe, the pain prevents you from running at all. 

Lateral leg pain is often a sign of a troubled iliotibial band associated with trochanteric bursitis, which is a syndrome that plagues many runners – both newbies and veterans.  It is affectionately known in running circles as iliotibial band syndrome, or ITBS for short.   

So what exactly is this, and why does it hurt so bad? 

The iliotibial band is a long strip of connective tissue on the lateral side of the leg which attaches at your hip and distally at your knee.  You remember the song, right?  Hip bone connected to the knee bone... Conveniently located under this tight band of soft tissue are little cushions called bursa sacs.  When a too-tight IT band (ITB) moves back and forth against these little bursa cushions while running, the bursa sacs become irritated, which leads to trochanteric bursitis of the hip.  

Women are more prone to ITBS at the hip, while men are more prone to develop ITBS near the knee.  I have experienced this on several occasions throughout my running career.  A few years ago, while training for the Boston Marathon, I had a bout that flared up when my long runs were extending past 15 miles.  I tried a few of the short term fixes discussed in this article, however with the training cycle nearing the end, I was unable to achieve the long term fix needed to run pain free and ended up missing out on racing the Boston that year.  Once I was able to lengthen the IT band, long runs were no longer painful.  The happy ending to this story was that after learning how to correct the ITBS, I was able to train for and complete the Boston marathon the following year with my second best ever marathon time. 

 

 

The fix 

To relieve pain from ITBS or bursitis, a two step process is helpful.  First, runners can get temporary relief and reduced inflammation from use of ice massage, anti-inflammatory medications, or joint injections into the bursa.  But more importantly, the long term fix requires some concentrated effort on your part.  This means stretches and exercises to lengthen the illiotibial band which takes the pressure OFF the bursa sac and prevents pain and inflammation all together.  Shown below are some basic stretches that can eliminate ITBS pain.  I also recommend a search on you-tube of "illiotibial stretches" or "ITBS pain" or "trochanteric bursitis" which should produce some physical therapy vidoes demonstrating stretches to loosen and lengthen the IT band. 

Here is a youtube video clip of 2 physical therapists performing the top 3 stretches to lengthen the IT band.  Two of these stretches require no equipment, however the third requires a 6" foam roller which you can purchase at a running store, or sporting equipment store. 

 

https://www.youtube.com/watch?v=MO2ZNz03YEI 

Top 3 Stretches for the IT Band (Iliotibial Band) Physical ... www.youtube.com Famous Physical Therapists Bob Schrupp and Brad Heineck describe 3 top ways to stretch your IT Band- your Iliotibial Band. Make sure to like us on FaceBook https ...

For icing, a recent study found that using a point focused ice massage for just 5 minutes is as effective as generalized icing an area for 15-20 minutes.  To perform a point ice massage, simply use an ice cube directly on the most tender point and gently massage for 5 minutes.  Ice massage is a natural anti inflammatory that is safe, effective and has no side effects that medications can cause.   

Original blog post published Dec 2016 for

High Intensity Training Institute. Reprinted with permission.