Medical Compass: Assessing Reflux Disease Treatment Options

Increased fiber and exercise improve symptoms

By David Dunaief, MD

Dr. David Dunaief

After a heavy meal, many people occasionally experience heartburn and regurgitation, where stomach contents back up into the esophagus. This reflux occurs when the lower esophageal sphincter, the valve between the stomach and the esophagus, relaxes inappropriately. Nobody knows exactly why this happens with some people and not with others. Many incidences of reflux are physiological (normal functioning), particularly after a meal, and do not require medical treatment (1).

Gastroesophageal reflux disease (GERD), on the other hand, is long-lasting and more severe, affecting up to 28% of the US population (2). It’s one of the reasons pharmaceutical companies pay so much attention to it, stocking our drug store shelves with over-the-counter and prescription solutions.

Risk factors for GERD range from lifestyle — obesity, smoking, and diet — to medications, such as calcium channel blockers and antihistamines. Other medical conditions, like hiatal hernia and pregnancy, also contribute (3). Dietary triggers may also play a role. They can include spicy, salty or fried foods, peppermint and chocolate.

One study showed that smoking and salt intake significantly increased the risk of GERD (4). The risk increased by 70% in people who smoked. Surprisingly, people who regularly used table salt saw the same increased risk as seen in smokers.

Let’s look at the treatments available and ways to reduce your risk.

Assess medication options

The most common and effective drugs for treating GERD are H2-receptor blockers (eg, Zantac and Tagamet), which partially block acid production, and proton pump inhibitors (eg, Nexium and Prevacid), which almost completely block acid production (5). Both classes of drugs have two levels: over-the-counter and prescription. Let’s focus on proton pump inhibitors (PPIs), for which just over 90 million prescriptions are written each year in the United States (6).

The most frequently prescribed PPIs are Prilosec (omeprazole) and Protonix (pantoprazole). Studies show that they are effective with short-term use in the treatment of peptic ulcers induced by Helicobacter pylori, symptoms of GERD and prophylaxis of gastric ulcers associated with the use of NSAIDs (aspirin, ibuprofen, etc. .) as well as upper gastrointestinal bleeding.

Most of the data in the package inserts is based on short-term studies that last weeks, not years. The landmark study supporting the long-term use approval only lasted one year. However, maintenance treatment usually continues for many years.

Side effects that have occurred after years of use include an increased risk of bone fractures and calcium malabsorption; Clostridium difficile, a bacterial infection in the intestines; potential vitamin B12 deficiencies; and weight gain (7).

Understanding PPI risks

The FDA has warned that patients who use PPIs may be at increased risk of a bacterial infection called C. difficile. This is a serious infection that occurs in the intestines and requires treatment with antibiotics. Unfortunately, he only responds to a few antibiotics and that number is decreasing. In the FDA meta-analysis, 23 of 28 studies showed an increased risk of infection. Patients should contact their doctor if they develop diarrhea while taking PPIs and the diarrhea does not improve (8).

Suppressing stomach acid over long periods of time can also lead to malabsorption issues. In a study where PPIs were associated with B12 malabsorption, it typically took at least three years to cause this effect. Although B12 was not properly absorbed from food, PPIs did not affect B12 levels from supplementation (9). If you are taking a PPI chronically, have your levels of vitamin B12 and methylmalonic acid (a metabolite of vitamin B12) checked and discuss supplementation with your doctor. Before stopping PPIs, consult your doctor. Rebound hyperacidity (high acid production) can result from stopping them suddenly.

Increase fiber and exercise

A number of modifications can improve GERD, such as raising the head of the bed about six inches, not eating before bedtime, and treating obesity, to name a few (10 ). In the study that quantified the risks of smoking and salt, fiber and exercise both had the opposite effect, reducing the risk of GERD (5). A Journal Watch analysis suggests that the fiber’s effect may be due to its ability to reduce the production of nitric oxide, a relaxant for the lower esophageal sphincter (11).

Manage your weight

In a study that looked at the role of obesity in exacerbating GERD, researchers showed that obesity significantly increases pressure on the lower esophageal sphincter (12). Intragastric (in the stomach) pressures were higher in overweight and obese patients on inspiration and expiration, compared to those with a normal body mass index.

Avoid eating late at night

One of the most powerful modifications we can make to prevent GERD is among the simplest. One study showed a 700% increased risk of GERD for those who ate within three hours of bedtime, compared to those who ate four or more hours before bedtime (13). Therefore, it is better not to eat right before bedtime and avoid “midnight snacks”. While medications have their place in the arsenal of options for treating GERD, lifestyle changes are the first, safest, and most effective approach in many cases.


(1) Gastroenterol Clin North Am. 1996;25(1):75. (2) Intestine. 2014 June; 63(6):871-80. (3) (4) Intestine 2004 December; 53:1730-1735. (5) Gastroenterology. 2008;135(4):1392. (6) Kane SP. Proton Pump Inhibitor, ClinCalc DrugStats Database, version 2022.08. Updated August 24, 2022. Accessed October 11, 2022. (7) World J Gastroenterol. 2009;15(38):4794–4798. (8) (9) Linus Pauling Institute; (10) Arch Intern Med. 2006;166:965-971. (11) JWatch Gastro. 2005 Feb 16. (12) Gastroenterology 2006 Mar; 130:639-649. (13) Am J Gastroenterol. 2005 Dec;100(12):2633-2636.

Dr. David Dunaief is a speaker, author, and local lifestyle medicine physician who focuses on the integration of medicine, nutrition, fitness, and stress management. For more information, visit