Is eating chocolate making my acid reflux worse?

I have gastric reflux and have heard chocolate can make it worse, as it relaxes the lower sphincter in the oesophagus. Has this been proven? If so, I’d be willing to forgo my treats.

Philip Dominey, Bristol

You pose a fascinating question, but I must say, I have not previously been aware of a direct link between chocolate and acid reflux.

Gastric, or oesophageal, reflux describes the travelling of stomach contents back up into the oesophagus — a reversal of the normal flow.

This is due to a poorly functioning lower oesophageal sphincter, a ring of muscle at the top of the stomach that normally shuts to stop the contents of the stomach leaking out and up the foodpipe.

The contents are mixed with the hydrochloric acid produced by the stomach lining to aid digestion, so they are highly acidic — but the lining of the oesophagus is not adapted to this.

As the acidic liquid moves up the oesophagus, the result is inflammation, which can be severe and may cause both cramp-like spasm and pain — classic symptoms of reflux.

Repeated reflux over many years can damage the oesophagus lining, a condition known as Barrett’s oesophagus.

There are multiple factors that may upset the normal function of the sphincter — for example, a hiatus hernia (when part of the stomach squeezes up into the chest through an opening in the diaphragm), smoking and obesity, which can all reduce the tone of the muscles of the sphincter.

Certain foods, including peppermint, can irritate the muscle. But chocolate? Here, the evidence isn’t clear. Chocolate contains a mix of chemical components that not only give it its bitter taste, but have been known to affect the levels of various brain chemicals.

Two chocolate chemicals, which are known central nervous system stimulants, are caffeine and theobromine. The cocoa bean contains about 0.2 per cent caffeine (by comparison, tea leaves are 3 per cent and coffee beans 1.2 per cent before they are brewed).

Minor risk: Some anecdotal evidence suggests caffeine and theobromine may worsen reflux symptoms by increasing acid production, but it’s not robust

The theobromine content in cocoa beans is greater, at 1 per cent and, as well as affecting the central nervous system, it is a heart stimulant. This increases the heartbeat and dilates blood vessels.

Other molecules in chocolate that are active in the brain include salsolinol (which also occurs naturally in brain tissue), anandamide, a cannabis-like brain chemical that may have roles in feeding and sleep behaviours, and phenylethylamine, which may have mood-enhancing effects.

Clearly, chocolate is a mood-altering food, but I find no evidence of any of these chemicals having a direct action on gut motility or, specifically, the lower oesophageal sphincter.

Some anecdotal evidence suggests caffeine and theobromine may worsen reflux symptoms by increasing acid production. But the scientific evidence has been inconclusive and the amount found in chocolate is low and makes this unlikely to be a significant trigger.

My view is that if you wish to, you should continue to enjoy chocolate, provided, of course, you do not experience a direct link between your symptoms and the act of eating chocolate or drinking cocoa, which would speak for itself.

After a fall, I was diagnosed with severe osteoporosis in my back and hip. My doctor recommends yearly infusions of a drug and vitamin D tablets.

But I’m afraid that the side-effects will make me feel worse, particularly as I suffer with back spasms and am more or less housebound. Is it worth having treatment, given my condition is so advanced? I am 66.

Anne Luscombe, Plymouth.

Osteoporosis makes fractures more likely to occur — even after minimal or no obvious trauma — as reduced bone mass means strength is lost.

In your case, it seems, the first sign of the condition came after you suffered a fracture after a bad fall — the experience must have been a shock for you.

Given your description I believe you suffered a fracture of the lower vertebrae in your spine, those being the bones that carry the greatest load and as a result are particularly prone to fractures.

Added danger: Osteoporosis makes fractures more likely to occur — even after minimal or no obvious trauma — as reduced bone mass means strength is lost

However, the prospects for reducing your chances of further fractures — and therefore pain and disability — are good.

The preferred method of screening for osteoporosis is DEXA scanning, a type of X-ray. The results of the scan are presented as what is called the T-score, with osteoporosis being defined as a T-score below minus 2.5.

You mention in your longer letter that your T-score is minus 5.5 — this is significantly low and, therefore, treatment is essential to prevent further fractures.

I would suggest you carry on with the regimen you have been prescribed unless instructed otherwise by a specialist. And rest assured, the side-effects should be minimal.

The intravenous treatment that has been proposed for you is zoledronic acid, a type of drug known as a bisphosphonate that’s given once yearly as an injection into a vein over 15 minutes (known as an infusion). Bisphosphonates are used to prevent and treat osteoporosis and work by inhibiting the process by which bone is broken down. They are very effective and well tolerated.

The potential side-effects may be flu-like symptoms for 24 to 72 hours after the first dose but these can be eased with paracetamol. The subsequent doses shouldn’t cause this side-effect. In combination with calcium tablets and vitamin D (which helps the body absorb calcium), this will help reduce your risk of fractures.

Exercise can also help reduce fracture risk, by improving bone density (it helps stimulate the action of osteoblasts, which build bone cells) and by cutting falls due to improved balance and muscle strength.

Whether treatment now will help your back spasms is uncertain due to the information that you have given me. This may be due to other mechanisms, such as a compressed nerve in the spine, rather than a direct symptom of osteoporosis.

Your specialist will have a view about this pain and, if necessary, will investigate further.

There are other treatments you can discuss with your rheumatologist. One is denosumab, an antibody that acts on factors involved in the formation of the cells that break down bone. Another is parathyroid hormone, which involves a daily injection for two years, stimulating bone formation. There is also calcitonin, a hormone that acts on calcium concentration in the body.

But in my experience, the benefits of the once-yearly bisphosphonate can be considerable, and side-effects are minimal. So it is beyond doubt your best option — and not to be feared.

BTW, is this the key to a healthy old age? 

HAVE you heard the ‘snipers’ alley’ theory? This is the idea that between the ages of 47 and 52, sinister illnesses are particularly likely to occur — but if you get past this five-year corridor unscathed, then you can relax, settle in for the long-haul and look forward to a telegram from Buckingham Palace.

Recently, Radio 2 presenter Jeremy Vine, now 52, revealed his doctor had previously recommended he start exercising, to stop him succumbing to the risks of this ‘dark and scary’ period where, ‘if a person is still behaving like they’re 25, all the wear and tear, all the stress and strain, suddenly catches up with them’.

But are these five years really a time of life when a health disaster is likely to strike?

Or is the theory driven by the experiences of other well-known individuals who, unlike Mr Vine, go down like skittles in middle-age and are therefore drawn to our attention?

The data is far from easy to come by, but I am convinced so-called snipers’ alley is no more than a vivid, if disconcerting, idea and a reminder of our mortality. It may be that those dying in snipers’ alley have been hit by a combination of risk factors: increasing weight, drinking more alcohol, years of a less-than-ideal diet and lack of exercise.

These add up and lead to ill-health in some — and, for those of us who survive, they serve as a wake-up call; a warning that, without care, life can be short.

I see many people who, at this stage of life, turn over a new leaf and focus on controlling their risk factors. Better late than never.