ACID REFLUX is an epidemic affecting as many as 40 percent of Americans. In addition to heartburn and indigestion, reflux symptoms may include postnasal drip, hoarseness, difficulty swallowing, chronic throat clearing, coughing and asthma. Taken together, sales of prescribed and over-the-counter anti-reflux medications exceed $13 billion per year.
The number of people with acid reflux has grown significantly in recent decades. Reflux can lead to esophageal cancer,
which has increased by about 500 percent since the 1970s. And
anti-reflux medication alone does not appear to control reflux disease. A
Danish study published this year concluded that there were no cancer-protective
effects from using the common anti-reflux medications, called proton
pump inhibitors, and that regular long-term use was actually associated
with an increased risk of developing esophageal cancer.
What
is responsible for these disturbing developments? The answer is our
poor diet, with its huge increases in the consumption of sugar, soft
drinks, fat and processed foods. But there is another important variable
that has been underappreciated and overlooked: our dinnertime.
I
specialize in the diagnosis and management of acid reflux, especially
airway reflux, which affects the throat, sinuses and lungs. Airway
reflux is often “silent,” occurring without telltale digestive symptoms,
like heartburn and indigestion. Most of the tens of thousands of reflux
patients that I have seen over the last 35 years are well today because
I treat reflux by modifying my patients’ diets and lifestyles.
Over
the past two decades, I’ve noticed that the time of the evening meal
has been trending later and later among my patients. The after-work meal
— already later because of longer work hours — is often further delayed
by activities such as shopping and exercise.
Typical
was the restaurateur who came to see me with symptoms of postnasal
drip, sinus disease, hoarseness, heartburn and a chronic cough. He
reported that he always left his restaurant at 11 p.m., and after
arriving home would eat dinner and then go to bed. There was no medical
treatment for this patient, no pills or even surgery to fix his
condition. The drugs we are using to treat reflux don’t always work, and
even when they do, they can have dangerous side effects. My patient’s
reflux was a lifestyle problem. I told him he had to eat dinner before 7
p.m., and not eat at all after work. Within six weeks, his reflux was
gone.
In
my experience, the single most important intervention is to eliminate
late eating, which in the United States is often combined with portions
of large, over-processed, fatty food. Europeans have fewer cases of
reflux than we do, even though many of them eat late. That’s most likely
from portion control. In France, for example, a serving of ice cream is
typically a single modest scoop, while in America, it’s often three
gargantuan scoops.
For
my patients, eating late is often accompanied by overeating, because
many skip breakfast and eat only a sandwich at lunch. Thus the evening
meal becomes the largest meal of the day. After that heavy meal, it’s
off to the sofa to watch television. After eating, it’s important to
stay upright because gravity helps keep the contents in the stomach.
Reflux is the result of acid spilling out of the stomach, and lying down
with a full stomach makes reflux much more likely.
And
if you add an after-dinner dessert or bedtime snack? Again, reflux is a
natural consequence. In a healthy young person, the stomach normally
takes a few hours to empty after a moderate-size meal. In older people
or those who have reflux, gastric emptying is often delayed. Further,
those dessert calories tend to be high in carbohydrates
and fat, and high-fat foods often create reflux by slowing digestion
and relaxing the stomach valve that normally prevents reflux. Other
popular but notoriously bad-for-nighttime-reflux foods and beverages are
mints, chocolate, soft drinks and alcohol.
Many of my patients find that eating earlier alleviates their allergies, sinusitis, asthma, sleep apnea and diabetes
symptoms. Although these conditions may not seem linked, postnasal drip
and a cough are typical reflux symptoms that can easily be mistaken for
something else.
Some
of my patients who arrive complaining of reflux already eat
healthfully. For them, dining too late is often the sole cause of their
problem. And yet, hearing that they need to change the timing of their
meals is sometimes a challenge they cannot meet.
A
New Yorker with reflux came to see me because both her father and uncle
died of esophageal cancer and she was afraid of getting it, too. This
patient was a prominent businesswoman and her nightly routine included a
9 p.m. dinner at an elegant restaurant with at least two bottles of
good red wine for the table. Her reflux was serious, and I explained
that changes were needed.
She
listened, then left and did not come back to see me for a year. When I
saw her again, she explained what had happened. “For the first two
months I just hated you,” she told me, “and then for the next two months
— I was having some trouble swallowing — I figured I was going to die
of esophageal cancer.” Then she nudged me and added, “You know, we’re
the reason that it’s not so easy to get 6 p.m. reservations at the good
restaurants anymore.”
To
stop the remarkable increase in reflux disease, we have to stop eating
by 8 p.m., or whatever time falls at least three hours before bed. For
many people, eating dinner early represents a significant lifestyle
shift. It will require eating well-planned breakfasts, lunches and
snacks, with healthy food and beverage choices.
Jamie A. Koufman is a physician in New York who specializes in voice disorders and acid reflux.
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