An analogy I was introduced to in medical school is this parable, attributed to medical sociologist Irving Zola (1): pretend that you and I are standing on the bank of a river, enjoying the view, the sounds of the water, maybe even the gentle motion of the water underneath our toes. All of a sudden, we look out into the middle of the river and see someone floating downstream, struggling to keep their head afloat. You and I look at each other, and what do we do? We can jump out there and bring that person to shore, we can throw them a lifesaver or a life vest and pull them in. We may even feel heroic or satisfied in doing so. But unfortunately, these people keep coming and coming, and we may run out of life vests or feel like our efforts are futile.
Thinking about this analogy, let’s consider its application in the current medical community/climate…
Imagine that the person in the water is a symptom you are experiencing. We’ll take heartburn as our example. We can throw TUMS tablets your way, which might help resolve the problem for a little while. We can even go so far as to start proton pump inhibitors like Prilosec (aka omeprazole, as well as other PPIs like pantoprazole & esomeprazole)) or H2 blockers like Zantac (aka ranitidine). These things can help for a short period of time, but the question I’d like to pose… are they really resolving the problem? Do we even know what the real problem is?
My argument is no. When we throw in these life vests/lifesavers, we might be helping the problem at hand, we might be providing some immediate relief, but ultimately we aren’t resolving any of the long term causes of having heartburn in the first place. In fact, we might even be causing a whole new slew of problems by adding in these pharmaceuticals, neutralizing the stomach acid or preventing it from being formed in the first place.
Proton pump inhibitors (PPIs) are among one of the most common pharmaceutical drug classes dispensed in the United States (2). I have had a handful of patients come into my care on proton pump inhibitors. When I’ve asked these people I’ve been working with the reason why they’ve been on their proton pump inhibitors, it’s because they suffer from heartburn. When I’ve asked them how long they’ve been on it, I’ve had some patients tell me up to 15 years. [image: 🤯]
The intention of PPIs, or the on-label use for this medication, is for short term relief of gastroesophageal reflux, or GER, aka heartburn. Their mechanism of action is to block the hydrogen pumps in the stomach to prevent the stomach from being too acidic. Most people who have used these pharmaceuticals with any regularity will tell you, coming off of them is TOUGH. Imagine a volcano erupting… it may be bubbling under the surface, below our consciousness, until we finally stop the PPIs, when it explodes and the molten acidic “lava” goes everywhere. That is what happens when someone abruptly discontinues a PPI, but imagine it’s lava, and the space it’s filling is the sensitive tissue of your stomach.
PPIs are generally safe to take in short durations and for specific reasons (the only reasonable purposes I see are for H.pylori infections, as this bacteria thrives in acidic environments, and for Barrett’s esophagus or esophageal cancers/erosions). But they have their slew of downstream side effects. Blocked stomach acid production can lead to an imbalanced GI microbiome and increased risk of infection from food borne vectors. Blocked stomach acid can also lead to poor nutrient and mineral absorption, & the risk of dangerous health conditions like osteopenia & osteoporosis increase.
For heartburn, the real question we need to be asking ourselves is WHY. Why are we having heartburn in the first place? Is it related to the spicy burrito I just ate? Is it because I’m laying down too quickly after eating dinner and gravity is not being kind to me currently? Is it because my lower esophageal sphincter, the connection between my stomach and my esophagus, is a little lax? Am I stressed? These are all reasonable questions as to why we might be having heartburn in the first place.
Going back to the medical river analogy, the important lesson there is that we can stay stuck on the river bank, throwing our solutions to the problem at hand. This can get us out of the sticky situation at the moment, but it’s exhausting, and it can feel like 1 step forward and 3 steps backward. The purpose of naturopathic medicine, however, is to take the trek up the mountain to figure out WHY these people are in the river in the first place; what’s going on at the headwaters. Find the root of the problem. That’s my job.
With that being said, one really significant paradigm shift I’d also like to introduce as a more likely reason WHY many people deal with heartburn, and thus turn to pharmaceuticals like omeprazole is LOW stomach acid (known as “HYPOchlorhydria”).
Not only is hypochlorhydria something I have observed clinically but there have been research studies to support the hypothesis that hypochlorhydria may often be the root cause of heartburn. Researchers at USC studied the gastric and esophageal pH of 1,582 patients with symptoms of heartburn and found that on average these folks had lower stomach acidic than normal. (5)
Now this is not the scenario that we often think about when we think about heartburn. When we have heartburn, things feel TOO acidic (HYPERchlorhydria), this is why PPIs exist in the first place. The simple solution would be to block stomach acid. But this often isn’t the real problem.
We live in a really stressful time. Certainly the COVID 19 pandemic showed us how quickly life can get flipped on its head. Many of us are still recovering in various ways from the last few years. But in general, it seems like the “times” have become increasingly more stressful, and activating to our nervous system. Let’s also think about our food systems… It’s nearly impossible in an urban setting to not pass fast food restaurants on the corner. We find ourselves eating “girl dinners” (3), using our air fryers religiously, or spending way too much money on delivery costs with uber eats or door dash. While all of these things can come in handy if we’re in a bind, here’s what they end up doing if it’s a habit we find ourselves in…
These “life hacks” don’t prepare us to actually break down and digest our meals properly. Our bodies haven’t had the necessary time to prep the system for food coming in. We haven’t had enough time to smell the food, to hear the sizzle while sautéeing, to watch our pans to make sure we aren’t burning anything, to set the table or prepare our digestive tracts at all through the sensory nervous system. We are eating food quickly, swallowing our food before it’s fully chewed, and then asking the digestive tract to pick up the slack because we’re hungry. We’re waiting until our blood sugar and cortisol levels are unstable (think: “You’re not you when you’re hungry” Snickers advertisements – (4) because we’ve gone so long without eating that you’ll eat whatever is placed in front of you.. But even then, your stomach isn’t activated and ready to go.
Unfortunately so many of us live our lives in this mode. And it’s leading to what I would consider an epidemic of low stomach acid, hypochlorhydria, leading to poor digestion and overcompensation of our stomach, which leads to the sensation of heartburn.
So the lesson here?
Prepare your meals.
Have some sensory experiences before eating.
Chew your food, ideally until it becomes a liquid.
Eat with loved ones if you can.
Never eat while driving (pull the car over if needed).
Add in digestive culinary herbs/spices, or consider bitters. Don’t intentionally block your stomach acid unless indicated.
When my patients start eating mindfully, slowing down, not doom-scrolling on their phones during meal times or eating in front of their TVs or computers, they actually start paying attention to their meals, digestion IMPROVES. They can slowly start coming off the proton pump inhibitors. They aren’t noticing as much heartburn, even without the PPIs. They might not be experiencing as much bloating, indigestion, or constipation. The digestive tract is on and functioning as it should. And the stomach is doing its job – creating acid to not only prevent infectious agents from entering the system, but also to actually help break down our food for its nutrients.
Work with a provider who is going to ask the right questions, challenge you to change up some aspects of your lifestyle, and will work collaboratively WITH you to get your body back to balance.