PODCAST: Is Heartburn Inevitable or Preventable?

ZACH: Welcome to On Health with Houston Methodist. I'm Zach Moore. I'm a photographer and editor here, and I've worked in multimedia and television for over 15 years — and I'm also a longtime podcaster.

 

TODD: I'm Todd Ackerman. I’m a writer/editor who previously covered Science and Medicine for the Houston Chronicle.

 

ZACH: And Todd, you know, we just came back from a work lunch here and I had a couple of grilled cheese sandwiches, and I think I might be starting to feel some heartburn here.

 

TODD: Already?

 

ZACH: Have you experienced a lot of heartburn in your time?

 

TODD: You know I haven’t. I think I can vaguely recall one or two times where I’ve kind of felt that sour eruption but not a lot.

 

ZACH: Sour eruption, I like that. I think that’s a perfect description of what heartburn is. I have unfortunately -- I feel like anyway, I’ve experienced heartburn quite a few times in my life. Usually, when I’m -- It’s a combination of not eating the healthiest things and then also an overindulgence in those unhealthy things I would say as well, and -- What is going on with your body when you have heartburn? Like, what is going on inside your throat, your chest? ‘Cause that’s the main area of where it’s concentrated, right?

 

TODD: Right. So, what occurs in heartburn is as the food passes into the stomach it goes through a tube, the esophagus, at the base of which there’s a muscular ring called the sphincter and when you’re experiencing heartburn, it’s because that ring hasn’t sealed properly,

 

ZACH: Okay.

 

TODD: And so, the food can kind of just slosh back up.

 

ZACH: Which explains perhaps why overindulgence is [Laughter] is a factor in developing the heartburn. Okay, that makes sense.

 

TODD: Right.

 

ZACH: So, everything you described there doesn’t involve the heart, Todd, so why do we call it a heartburn?

 

TODD: Well, you feel it there but your heart’s not really affected by it.

 

ZACH: Your heart -- Yeah, yeah. Your heart’s slightly over to the left. It’s right -- not in the middle there.

 

TODD: It’s the chest area.

 

ZACH: Yeah. They should call it “chestburn” then.

 

TODD: [Laughter] Yes, that might be better, but the name heartburn has stuck. But people can often confuse the two. It’s not unheard of for people to go to their doctors thinking they have heart issues and only to learn it’s just really heartburn.

 

ZACH: Heartburn, chestburn, I’m just gonna call it ‘sour eruption’ from now on, Todd.

 

TODD: Let’s hope that that catches on.

 

[Laughter]

 

ZACH: And so, if you’re listening to this and you say, “I’ve never had heartburn. It’s not something I need to worry about.” That’s not necessarily the case. Just because you haven’t had it before, doesn’t mean you can’t develop a tendency for it in the future, right?

 

TODD: Right. It’s not like it has to hit by a certain age, or if you have a history of it in your family you’re necessarily gonna get it. It can happen any time.

 

ZACH: Okay, okay. So, who do we talk to this week about heartburn, Todd?

 

TODD: We talked to Dr. Neeharika Kalakota, a gastroenterologist at Houston Methodist. She gave us the full low down on everything you need to know about heartburn.

 

ZACH: Alright, let’s get into it.

 

[Sound effect signaling beginning of interview]

 

TODD: Well, we are here today with Dr. Kalakota. Welcome. Thanks for being here.

 

DR. KALAKOTA: Thank you so much for having me.

 

TODD: Talking a little bit about what percentage of people experience heartburn with some regularity.

 

DR. KALAKOTA: Sure. So, heartburn itself as a colloquial term -- So, we in the medical community refer to it as gastroesophageal reflux disease as well. It’s pretty common. In the most recent population-based studies, I’ve seen anywhere from about 15-28% of Americans state that they’re having symptoms such as burning in the chest after eating as well as regurgitation. The only kind of limitations of those studies is that quite a few people can have what’s termed “silent reflux” as well, so they don’t have symptoms associated with it, but they are having gastric contents come up into their esophagus.

 

TODD: So, I always thought heartburn by itself wasn’t necessarily GERD, that it was only when it occurred with some regularity and that was just one form of GERD, that’s not true?

 

DR. KALAKOTA: So, typically they’re pretty interchangeable. It’s a little bit easier to discuss with patients by using the term heartburn just ‘cause they’re more familiar with it, but GERD is usually the way that we refer to it say, in your medical notes or our research studies and things like that. GERD or heartburn refers to gastric contents, particularly acid or bile acid, coming up into the esophagus causing symptoms. So, most typical symptoms: burning typically after eating, behind your breastbone, as well as regurgitation of your previous meal.

 

TODD: And it has nothing to do with the heart?

 

DR. KALAKOTA: No. Just in the fact that it’s in the chest as is the heart.

 

TODD: So, what are the symptoms?

 

DR. KALAKOTA: Typically, burning in your chest particularly after eating, sometimes after eating something spicy, or something with a lot of acid in it. Sometimes burning in your stomach as well or in your sort of like, right in the middle of your stomach. And then, regurgitation. Belching is also a very common symptom related to acid reflux. Those are the most common ones that people complain of.

 

TODD: Demographics, does it hit ages, sex, race, any more than the others?

 

DR. KALAKOTA: So, as far as the symptoms go, it’s pretty much across the board for men and women of all ages. If we’re talking about things like Barrett's esophagus, which is a finding you can see with people who have chronic acid reflux, that we typically find above the age of 55. Typically in white males, and higher incidence in folks who have truncal obesity, as well as who are smokers.

 

TODD: How about pregnancy?

 

DR. KALAKOTA: Pregnancy certainly can be a risk factor for acid reflux. Especially both earlier in the pregnancy before you start to show, or before the baby gets really big in the uterus. Just because morning sickness can lead to more of those bile acid reflux, you throwing up a lot. And then, as the baby grows inside the uterus you get more and more pressure on your stomach, which can force gastric contents into your esophagus.

 

TODD: Is there thought to be much of a genetic component to this?

 

DR. KALAKOTA: At least in my review, I haven’t seen much of a genetic component to GERD, but it does tend to occur in families because families tend to have similar diets. So, I do see that a lot, especially couples that come to see me together or even families, sons, daughters, that kind of thing. As far as other risk factors, I think pretty similar to the risk factors for Barrett’s esophagus. So male sex, eating or having truncal obesity, or increase waist circumference. Smoking is a big one. Drinking alcohol can also be related to increased acid reflux. Those are the big ones typically.

 

TODD: Is there anything that you emphasize to patients about prevention?

 

DR. KALAKOTA: So, the biggest, most modifiable risk factor I stress to my patients is maintaining a healthy weight, because it’s quite a linear experience in terms of -- Just in the past few years a lot of people have gained quite a bit of pandemic weight, so-to-speak and a lot of them have noticed an increase and worsening in acid reflux, or even new symptoms of acid reflux because of this weight gain.

 

TODD: One practical question for you. Say you’re going to a party or some other event in which there’s gonna be a lot of food there ripe for heartburn. What tips would you give of people how to handle that?

 

DR. KALAKOTA: So, Todd, I think it depends on how severe your acid reflux is. For patients who are having it very frequently, almost daily, I would probably say take a Pepcid or famotidine before you head out to the party. For people who just have occasional heartburn depending on what they eat, I think Tums is probably a better bet. You can take that right before you go to bed when you come home.

 

TODD: Let me a throw out a list to you of some down-home things that I read can be helpful. Eating a ripe banana.

 

DR. KALAKOTA: I don’t know that it would help everyone specifically, but certainly if it makes you feel better that’s fine. It may just be that putting something in your stomach is neutralizing the acid that’s already there, and that helps.

 

TODD: Chewing sugar free gum.

 

DR. KALAKOTA: That one I’m not familiar with as far as helping with acid reflux. The only thing I’ll caution about sugar free gum is that some of them can contain sorbitol, which can lead to diarrhea if you chew it constantly.

 

TODD: Milk.

 

DR. KALAKOTA: Milk is a good one. I get a lot of people that drink a glass of milk, or a glass of buttermilk. The idea behind that is similar to Pepto-Bismol or Mylanta in that it coats the stomach, and so it helps neutralize the acid that’s there in the stomach.

 

TODD: Apple cider vinegar.

 

DR. KALAKOTA: So, that one’s kind of a loaded one. I get questions about apple cider vinegar a lot in its various forms. Drinking diluted apple cider vinegar, you know, eating the gummies, and you know, cooking with it. What I’ll say is, vinegar, acetic acid so it’s again, high acid food. There are some people who have anecdotal improvement with their heartburn. I have not seen any literature to confirm that, so I try to let people know to try to avoid vinegar containing foods when they’re trying to eat a low acid diet. That being said, if you like it and it’s not bothering you, it’s not dangerous to eat or anything like that. I’m not sure it contains all of the health benefits that the media continues to portray.

 

TODD: Avoiding late night eating.

 

DR. KALAKOTA: Yes. Absolutely. In terms of maintaining a healthy weight and trying to avoid heartburn. Absolutely.

 

TODD: Wearing loose fitting clothing.

 

DR. KALAKOTA: Yes. Related to the increased truncal obesity, you know, wearing really tight pants just puts more pressure on the adipose tissue and the other organs that are in your abdomen, thus putting more pressure on your stomach bringing the gastric content into your esophagus.

 

TODD: And finally, adjusting your sleep position.

 

DR. KALAKOTA: Certainly, yeah. So, I don’t know if you’re a big Amazon shopper, Todd, but you can buy a wedge pillow on Amazon that will raise your upper body by like, to about 45 degrees and so just gravity helps keep gastric contents inside of your stomach.

 

TODD: And so, what do you think of the theory out there that the problem may also involve food going down, not just sloshing back up? High acid food.

 

DR. KALAKOTA: You mean doing like a low acid diet? I got you. So, actually, yes. I recommend a low acid diet to all of my patients who have heartburn symptoms. The reason being, you don’t want to add to the amount of acid that’s already sitting inside the stomach. So, what typically -- What you typically don’t want is to add in a high acid food which will then increase the amount of acid produced by the stomach, and then thereby increasing the amount of reflux you get into your esophagus. So, certainly, the contents of your diet definitely makes a difference as far as heartburn symptoms go.

 

[Music plays to signal a brief interjection in the interview]

 

ZACH: We mentioned acidic foods contributing to heartburn but didn’t get specific. If you suffer from heartburn, here’s what to watch out for. High fat foods. They are some of the worst foods for heartburn. Greasy foods like French fries and pizza are especially bad. Spicy foods. They slow down digestion and cause foods to sit in the stomach longer. They can also irritate the esophagus. Carbonated beverages. The bubbles expand in your stomach sometimes creating pressure and pain. Caffeinated beverages. Coffee and other caffeinated beverages relax the esophagus sphincter causing stomach acid to rise up. Alcohol. Booze can be a double whammy. It relaxes the sphincter valve and stimulates the acid production in the stomach. Citrus fruits. Fruits such as oranges and grapefruit also relax the esophageal sphincter, so do tomatoes. Chocolate. Everyone’s favorite treat has a trifecta of heartburn causes: caffeine, fat, and cocoa. Peppermint and spearmint. Don’t be fooled by their reputation for soothing the stomach, both can trigger heartburn. But a word of caution, everyone reacts differently to different foods. Lots of people's heartburn isn’t triggered by many of these foods and some people who cut them out continue to suffer heartburn. They’re just common triggers. Figure out which are bad for you, and which don’t cause you problems.

 

[Music]

 

TODD: Coming up after the break, we’ll get to what frequent heartburn sufferers need to know.

 

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[Music ends to signal return to the interview]

 

TODD: And we’re back with Dr. Kalakota.

 

[Sound effect signaling return of interview]

 

TODD: How much of a concern is it that a lot of patients will dismiss it as sort of a minor annoyance that they can treat with Tums and not realize the real danger that it could pose?

 

DR. KALAKOTA: So, to be quite honest with you, it’s pretty much a normal factor of having a stomach that produces acid. So, I wouldn’t automatically be very concerned if somebody came in telling me that they’re having heartburn. Things that would make me more concerned about it are if the heartburn symptoms were accompanied by things like feeling as though food is getting stuck in their chest after they swallow it. Things like losing weight without trying. Having frequent vomiting. Not being able to keep down food. Those are what I would term “alarm symptoms.” Just having heartburn once in a while and using Tums is not a problem at all.

 

TODD: If you’ve been doing this for 10 years and you’re regularly using Tums that seems to relieve the issues, that’s probably okay?

 

DR. KALAKOTA: Yes.

 

TODD: So, talk a little bit more about how GERD is diagnosed.

 

DR. KALAKOTA: Certainly. So, there’s a number of ways -- Our typical GERD or heartburn type symptoms. So, if somebody’s coming in and saying, “Hey, I’m having burning in my chest after I eat. I’m having a little regurgitation. I have really gross burps.” Those are all things I hear a lot in clinic. Typically, the first step is to start someone on an antacid to see if they improve. All of them can be obtained over the counter, but the proton pump inhibitor group is usually my first go-to. If the patient comes back to me and says, “Hey, I’m not improving on this medication.” My next step would probably be to do an endoscopy which would be an upper endoscopy. We would put them to sleep, put a camera down, look inside their esophagus, and their stomach, and the first part of the small intestine. We can look for signs of reflux, of stomach contents by looking for inflammation in the bottom of the esophagus, or evidence of gastritis and things like that.

 

TODD: It can, if not treated, lead to damage to the esophagus, right?

 

DR. KALAKOTA: It certainly can. Yeah. The most common effect of that that we see is called Barrett’s esophagus which is a change in the skin right at the junction where the esophagus and the stomach meet. So, that change -- There’s quite a bit of study going into it, but we have seen that in certain people it can form precancerous changes in the cells in that mucosa, and then, sometimes even lead to esophageal adenocarcinoma, or cancer of the esophagus.

 

TODD: Which is on the rise?

 

DR. KALAKOTA: It is being found more because there’s actually some changes to our screening guidelines for Barrett’s, but the one thing that has stayed the same is the indication for screening. So folks who have -- Typically, the risk factors seen are white males who have a history of smoking and truncal obesity who have had reflux for a number of years. There are, you know, several other indications for endoscopies that usually vary from patient to patient. It typically depends on the physician’s degree of suspicion that something else is going on than something just besides regular old heartburn.

 

TODD: Just esophageal cancer not gastroesophageal cancer? Those are related I take it.

 

DR. KALAKOTA: They can be. You know, typically, what will happen when you refer to gastroesophageal cancer is that it will start in one place or the other and then grow over that junction. Speaking about acid reflux though, it is only related to an increased risk of esophageal cancer, not necessarily gastric cancer. There’s different risk factors for gastric cancer.

 

TODD: And do you think there’s any need to sort of push, increase awareness of this and surveillance?

 

DR. KALAKOTA: I think right now, we are not always screening the people that need to be screened. Now, for Barrett’s esophagus, particularly doing endoscopies for them or upper EGDs. That being said, there are a lot EGDs being done for acid reflux that maybe don’t need to be done. So, it’s hard to say. I don’t know that we need to do any more, but I think we need to be more selective in our patients that we’re screening with endoscopy.

 

TODD: I know we already hit on this but let’s talk a little bit about the treatments: over the counter, prescription, and surgery.

 

DR. KALAKOTA: There are a plethora of options if you’ve ever went down the digestive aisle at H-E-B. Typically, they are separated into a few different groups. So, the most common first step that most people take is the Tums route, so calcium carbonate. Again, that’s, you know, eating a base to neutralize an acid, so it essentially neutralizes the acid that’s already sitting in the stomach. Things like Pepto-Bismol, and Gaviscon, and Mylanta kind of coat the stomach lining and they also neutralize the acid that’s in the stomach so that it doesn’t reflux into the esophagus. Thirdly, there’s histamine 2 blockers which are things like Pepcid, or Famotidine, which is the tradename for that. Those work on the histamine receptors in the stomach to help decrease acid production. Lastly, and frankly the most effective medications for GERD are proton pump inhibitors. Which would be things like Omeprazole or Esomeprazole. You would see them in the pharmacy like Prilosec, or Nexium, or Protonix. And those medications bind to the proton pumps in the stomach to help prevent acid production as well.

 

TODD: And surgery?

 

DR. KALAKOTA: And surgical options -- There’s actually many of them. Here at Houston Methodist, the most common ones are typically transoral incisionless fundoplication, which is performed by the surgeons, and essentially, they take the top part of the stomach and then they wrap it around the bottom of the esophagus to keep the sphincter tight, so that gastric contents does not come up into the esophagus and cause heartburn. There’s a different version of that just called a Nissen fundoplication which the idea is the same, but it is done with incisions as an open surgery. The -- And it can also be done robotically. The other options are more related to both reflux and to weight gain which is the Roux-en-Y gastric bypass, and so that’s a very common weight loss surgery, but it does help with acid reflux symptoms as it takes out the sort of bottom part of the stomach out of continuity with the rest of your GI tract. And the bottom part of the stomach is where all the acid is produced, so it tends to help with the acid reflux as well.

 

TODD: So, between all these kinds of treatments, is most people’s heartburn usually pretty well treated, or do you have some that it’s just a chronic, bad condition that --

 

DR. KALAKOTA: So, there are unfortunately some that it is a chronic condition. They don’t respond very well to the proton pump inhibitor medications, or they’re not good surgical candidates. Or unfortunately they’ve had surgery before and it wasn't effective, or they had bad outcomes with the surgery. Another population that unfortunately the symptoms are somewhat difficult to control are the patients with NERD not GERD. So, non-erosive esophageal reflux disease. It is a group of patients that unfortunately do not respond as well to proton pump inhibitors. So usually, it’s a typically diet modification and using the proton pump inhibitors as needed for those kind of patients.

 

TODD: And Zantac, it’s back on the market. It’s now without the ingredient that was linked to cancer. New ingredient and it’s perfectly safe now?

 

DR. KALAKOTA: So, actually now, the ingredient in Zantac is the same as the ingredient in Pepcid. It's Famotidine. There is of course different ones. I believe like Pepcid AC which has like, the, some aspects of Tums in it as well. But yes, the ranitidine is no longer on the market.

 

TODD: Do we have any idea that -- Did that cause much cancer?

 

DR. KALAKOTA: From what I could tell from a brief literature search, there was a lot of investigation into it causing gastric cancer, which they could not establish a link, but there was some concern that it could lead to bladder cancer which is the reason that it was removed.

 

TODD: Okay. Anything you wanna say in conclusion? Any advice or summation to leave the listener with.

 

DR. KALAKOTA: Bottom line, and for most people this is applicable, losing weight will help with your heartburn symptoms. I know that’s much easier said than done, but it’s one of the most modifiable things in most people’s lifestyle. So rather than taking medicines, if you can try to drop a little weight, I think you can feel better pretty quick.

 

TODD: Alright. Very good. I learned a lot here. I appreciate you’re taking the time to help us all understand this better.

 

DR. KALAKOTA: Absolutely. Thank you so much. It was a pleasure talking to you guys.

 

[Sound effect signals the end of the interview]

 

ZACH: Now, Todd, you said you had not experienced a lot of heartburn in your life. I have, so listening to this conversation was pretty insightful for me and I’m gonna try and apply a lot of the things you guys talked about.

 

TODD: For instance?

 

ZACH: Using antacids. I just haven’t really been one to do that. At some point -- It’s one of those things I never have like, in my medicine cabinet so I have never like, “Oh, I got up at 2:00 a.m. with heartburn, I better go get some fill-in-the-blank antacid.” I didn’t have that as an option so I just kinda powered on through and I’ve gotten used to it so -- It doesn’t happen frequent enough where I’ve felt like I need to go to the drugstore and keep some around, but sounds like they’re a good tool to have.

 

TODD: Right. I think that’s the appropriate first step and as Dr. Kalakota mentioned, if you can manage it with antacids, you don’t really have anything to worry about. That’s fine. It’s a good way to keep it under control.

 

ZACH: Yeah, like you said, that’s a good step one. For me personally, step zero, is probably just my consumption. You know, less, smarter, that sort of thing ‘cause when I think back, I’m like, “Oh, I had a really big bowl of chili.” You know, the night before I had heartburn, something like that. That’s something to be aware of or just know like, “You know what? You can eat this” -- And you could still eat all these things, right? But just be aware what might be coming later and then how to help alleviate the side effects.

 

TODD: Yes, I think those are the appropriate first steps. If you’re still not getting relief after that, it’s time to see your doctor. The important thing to remember is there are lots of treatment options for heartburn so if you’re having issues, your doctor should be able to get you on the appropriate thing to manage it better.

 

ZACH: Yeah and put a stop to those sour explosions. Right, Todd?

 

TODD: Sour eruptions, Zach.

 

ZACH: Alright, well, that's going to do it for us this week. And be sure to share, like, and subscribe On Health with Houston Methodist wherever you get your podcasts. If you enjoyed this conversation, for more topics like this, visit our blog at houstonmethodist.org/blog. Stay tuned and stay healthy.

 

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