Proton Pump Inhibitors vs Diet in the Management of Reflux

Most clinicians know that patients who present with complaints and symptoms indicative of gastroesophageal reflux diseases (GERD) can be amongst the most challenging to diagnose since they mimic so many other conditions and, are often the most difficult to effectively treat. Symptoms indicating reflux diseases are also increasingly more commonly being diagnosed  in the clinician’s office and often directly attributed to the weakness of the gastroesophageal juncture (EGJ) which begins at the terminal end of the esophagus and beginning of the cardiac orifice of the stomach. Obesity and increased abdominal (belly) fat can cause pressure on the stomach and lead to hiatal hernia; the herniation can cause acid backflow. The EGJ serves as a physical barrier to all reflux fluids (acid, bile, pepsin etc). It’s interesting to note that are also more than one type of reflux disease:

  • Gastroesophageal reflux (GERD)
    • Where the gastric contents in the stomach reflux back into the esophagus in causing typical symptoms of heartburn and/or acid regurgitation
  • Non-erosive reflux disease (NERD)
    •  Characterized by reflux-related symptoms; these patients are often less responsive to PPI therapy
  • Extra esophageal disease (EER) which includes respiratory or  laryngopharyngeal reflux
    • Often the result of the rapid transit of gastric contents to the esophagus, and up into the larynx, bronchi, lungs, etc

Treating GERD, according to association recommendations, should involve a stepwise approach with lifestyle modification (including weight loss) and exercise as the first step. Subsequent use of pharmacologic agents such as antacids, proton pump inhibitors (PPIs) or surgical treatment may be considered only if lifestyle modification over the course of several weeks is not successful. The goals of GERD treatment are to control symptoms, to heal esophagitis, and to prevent recurrent esophagitis or other complications. Unfortunately, too often the clinician starts the patient with pharmacological interventions and this can lead to unintended and unwanted complications later on including increased risk for C. difficile infections (CDI) which was outlined in a prior article on this site.

A recent, small, retrospective study undertaken by researchers from New York Medical College assessed the efficacy of totally dietary approach to manage reflux—specifically laryngopharyngeal reflux—in  two cohorts of patients at a New York hospital from 2010 to 2015. One cohort of 85 patients were managed with proton pump inhibitors (PPIs) plus standard reflux precautions; the other cohort of 99 patients were treated with alkaline water (pH >8.0) and a plant-based, Mediterranean-style diet plus standard reflux precautions.

Results showed after 6 weeks, 63% of the diet group and 54% of the PPI group had achieved a clinically meaningful improvement in a reflux symptom score. Additionally, the diet group had a significantly greater mean reduction in the score than did the PPI group (40% vs. 27% reduction).

Why is this Clinically Relevant?

  • Reflux diseases are an increasingly common clinical finding in adults today and linked to numerous conditions including increased weight and lack of activity
  • First line of therapy in managing reflux disease is lifestyle modification and exercise
    • Most clinicians and patients opt for PPIs
      • Often they are unaware of long term consequences of PPI use
    • The results of this small study support the use of plant based, Mediterranean diet as a first line management consideration in the management of reflux conditions
      • Particularly laryngopharyngeal reflux
    • This 6 week study demonstrated compared to PPIs, dietary modification is more effective at improving reflux symptoms
    • Clinicians should consider step wise approach to managing reflux diseases by first encouraging lifestyle modification and exercise before pharmacologic interventions


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