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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). 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).

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).

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).

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).