Heartburn is something most people associate with eating too much, like that classic post-Christmas dinner feeling.
And yes, large meals are a major cause — but sometimes the problem can be down to less obvious triggers, such as wearing tight clothing (too tight a belt, high-waisted jeans or even a bra), constipation or bloating.
How are any of these related to your heart, you may ask. In fact, heartburn has nothing to do with the heart, but is all about your oesophagus (or food pipe).
Heartburn is a common symptom of acid reflux. This occurs when stomach acid and other stomach contents travel in the wrong direction and are regurgitated up into your oesophagus via a trapdoor (the oesophageal sphincter, a circular ring of muscle that acts as a gateway between your oesophagus and acid-filled stomach).
Heartburn is something most people associate with eating too much, like that classic post-Christmas dinner feeling
Unlike your stomach, your oesophagus isn’t built for harsh acid, and this causes a nasty burning sensation just behind your breastbone — that’s heartburn.
When you overfill your stomach in one sitting, it creates an unequal pressure between the stomach and the oesophagus, and essentially lifts the trapdoor.
Tight clothing can also cause this kind of imbalance of pressure, as can constipation.
But if you experience heartburn and/or reflux at least twice a week and it’s not related to overeating, tight clothes or constipation, then you may have gastro-oesophageal reflux disease (GORD).
This common condition affects more than ten per cent of adults. Causes vary — some people are genetically more susceptible to reflux, for instance, they may have a weaker oesophageal sphincter; others may have a physical cause such as a hiatus hernia (where part of your stomach pushes up through the diaphragm).
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But not all chronic heartburn occurs because of acid reflux — indeed, it’s thought that in as many as four in ten people, the symptoms are caused by a sensitive intestine as a result of miscommunication between the gut and the brain.
The first-line medical treatment for acid reflux is proton pump inhibitors (PPIs), which suppress the production of stomach acid.
Yet various studies have estimated that these drugs (even at higher doses) don’t provide adequate relief for between ten and 40 per cent of patients with suspected GORD.
And when you test such ‘non-responding’ patients, the acid level (i.e. pH) tests typically come back normal, despite them having very real symptoms.
This type of heartburn, where there is no clinical explanation or abnormal test result, is what’s known as a ‘functional’ oesophageal disorder — structurally, everything is normal but it’s like a display home, where everything seems to be in the right place, but the fridge isn’t switched on (irritable bowel syndrome is another form of functional disorder).
If you’ve been prescribed PPIs and they don’t help, don’t assume you need a stronger prescription — you could have functional heartburn, which means you’re taking the medication needlessly and, like all medicines, PPIs have potential side-effects over time.
For instance, long-term use has been linked with a higher risk of vitamin B12 deficiency (stomach acid is needed to release B12 from food). In turn this can cause problems such as fatigue and in severe cases, particularly in older people, even neurological damage.
PPIs also affect your gut microbiota, that colony of microbes that’s so important to our wellbeing. Indeed, PPIs have been shown to raise the risk of gut infections (our stomach acid normally kills off pathogens and creates a healthy environment for the right balance of microbes to grow and protect from invasion).
But there are several key diet and lifestyle strategies that can help you get on top of your heartburn and reflux.
The evidence behind most of these strategies is, admittedly, limited in terms of good-quality trials — by which I mean studies where treatments are tested in a controlled setting, e.g. a clinic.
However, observational studies (where people are observed in their normal environment) and the consensus from experts support trying these strategies before moving on to medication.
Here are my suggestions for the things you can implement now to make a difference:
- Avoid large meals. Split food into smaller portions, eating five or six meals across the day.
- Allow at least three hours between your last meal of the day and bedtime. This ensures that most of your food has moved through your stomach and therefore reduces the pressure on your oesophageal sphincter.
- Identify your triggers. Keep a seven-day food and symptoms diary and look for any patterns between foods, lifestyle factors (e.g. stressful days) and your symptoms.
Commonly reported diet triggers include high-fat meals (e.g. deep-fried foods and pastries — switch to the grilled and wholegrain options); fizzy drinks and citrus fruit or juice (swap to herbal teas such as ginger); spicy foods (swap for cayenne or other flavoursome herbs, such as smoky paprika or turmeric); tomatoes; chocolate, caffeine (opt for decaffeinated drinks); and alcohol.
Several of these commonly reported triggers have been shown to impact the pressure on the oesophageal sphincter.
- Avoid tight clothing — and that includes belts! Think of that sphincter pressure balance.
- If you get reflux while in bed or sleeping, try lying on your left-hand side. Because the oesophagus is connected to the right side of the stomach, lying on the left prevents the acid from being pushed back up it.
- Raise one end of your bed by 10cm to 20cm so your head and chest are at a level just above your waist — this again helps reduce the pressure that can pop open the oesophageal sphincter. And the following longer-term strategies can also help:
- Keep your weight in check — a higher body weight is linked with a higher risk of reflux. It’s that oesophageal sphincter, again — the extra weight increases the pressure on it. For instance, one U.S. study in 2014 with people who were overweight (with an average BMI of 35) found that losing weight improved their symptoms, and in 65 per cent their symptoms completely disappeared.
- For the same reason, constipation and bloating may also worsen reflux — see my column last week on how to tackle the former (I’ll be writing about bloating soon).
- Stop smoking. Yes, I know, easier said than done, but a 2016 study from Osaka City University in Japan showed that people who quit smoking for a year had a nearly 50 per cent improvement in their GORD symptoms.
Of course, if you need medication, you need it — it’s all about weighing up the pros and con.
For those tempted to just put up with the symptoms, it’s important to be aware that chronic reflux is not only burdensome in terms of discomfort but can also increase your risk of diseases such as oesophageal cancer. So whichever pathway you decide to take, getting on top of it is important.
Note: If you have any of the red flags below, discuss with your GP straight away:
- Any lumps or tenderness in your throat or tummy;
- A family history of either oesophageal or stomach cancer.
Try this: Avocado ice lollies
Fibre-packed ice lollies to keep you (and those gut bacteria of yours) thriving during this heat wave.
- 2 ripe avocados
- 240ml coconut milk
- 2 tbsp honey
- 2 kiwis, cut into chunks
- 60g frozen raspberries
- 1 tbsp chia seeds
- Juice from half a lime
- 2 tbsp water, to loosen the mixture if needed
Put everything in a blender, apart from the raspberries, and blend until smooth. If the mixture looks too thick, add the extra water. Stir the raspberries into the blended mix, pour into the moulds, add lolly sticks and freeze until solid (which will probably take around four hours).
I’ve been struggling with my gut health — it starts with chills, headaches, bowel cramps and then hunger and tiredness. This lasts for a few days at a time and is happening more regularly than ever. It’s really dragging me down.
John Watkins, Swansea.
Although many of these symptoms are ‘nonspecific’ — i.e. many different things could be triggering them — the collection you’ve described is particularly common in ‘dumping syndrome’.
This is when food moves too quickly from your stomach into your small intestine. As a result your intestine produces more hormones than normal and your intestine can swell with extra fluid, triggering a cascade of symptoms, like yours.
This occurs most commonly after stomach surgery but I’ve also seen it in people with recently developed diabetes or pancreas problems. I’d recommend discussing your symptoms with your GP. In terms of dietary management, try:
Eating smaller meals, more frequently — instead of three large meals, divide the same amount of food across five meals.
Limiting foods high in added sugar such as breakfast cereals (try porridge oats) and fizzy drinks (try soda water sweetened with squashed fresh fruit).
Eating more slowly. Aim to chew each mouthful at least 20 times.
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Replies should be taken in a general context; always consult your GP with any health worries.