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 30 minutes – 1 hour after a meal. 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). Animal trials of melatonin for GERD symptoms have found it to be not only effective in preventing acid-induced esophageal damage, but also damage caused by digestive enzymes and bile (Konturek 2007). Two human trials have investigated supplemental melatonin on GERD symptoms. In the first, 176 patients on a 6 mg melatonin /multi-nutrient combination were compared to 175 patients on 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 to two-thirds in the PPI group. Relief was reached faster in the melatonin (7 days) vs. PPI (9 days) group, with a much lower incidence of side effects (Pereira 2006). A second study compared 3 groups of 9 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 were decreased after four weeks and completely resolved after eight weeks in all treatment groups. However, only the two melatonin groups had significant improvements in LES function (Kandil 2010).
D-Limonene. D-Limonene is a component of the essential oil of citrus fruits. In a small, unpublished study of 19 patients with GERD or chronic heartburn, 1,000mg d-limonene daily or every other day for 14 days led to the remission of symptoms in 89% of the patients. In a small follow up investigation, 22 participants with GERD or chronic heartburn were randomized to receive 1,000mg d-limonene either once daily, every other day, or placebo. By day four, 29% of participants on treatment experienced significant relief, which rose to 83% by day 14 compared to 30% on placebo. The mechanism of d-limonene activity in GERD is not clear; in vitro research suggests mucousal protection and increased peristalsis (Willette, on file).
Deglycyrrhizinated Licorice (DGL). Licorice extracts have been shown to support the health of the stomach lining and combat H. pylori – bacterium that can cause ulcers (Wittschier 2009). This may convey benefits to those suffering from GERD, since recent evidence indicates that H. pylori eradication appears to improve GERD symptoms (Saad 2012). Unlike whole licorice, deglycyrrhizinated licorice (DGL) extracts provide beneficial licorice compounds without glycyrrhizin (a component of whole licorice that has been shown to cause side effects). While published, peer-reviewed literature supporting the use of DGL in GERD is lacking, some innovative doctors employ DGL with positive results (Martin 2011).