It is estimated that more than 17 million Americans are using one form of proton pump inhibitor (PPI) or another, primarily for the control of heartburn or GERD (gastroesophageal reflux disorder).
This class of medications was developed and approved for short-term use, generally 2-4 weeks, but they have for the most part become long-term, indefinite answers to acid reflux issues. Most individuals have accepted their use as a normal part of their daily life, making few if any dietary changes and receiving very little in the way of lifestyle recommendations from their MD.
For every action there is a reaction, especially within the fields of medicine and pharmacology. This past month yet another study emerges revealing just how damaging long-term PPI use is to health. Prior studies have shown the same with respect to risk of dementia and renal/kidney disease (1-3), while other studies have shown that in addition to having complications within these areas, PPI users could also expect to be at higher risk for heart disease, gastric and colorectal cancer, as well as gut infections and dysbiosis or bacterial overgrowth (4-8).
Proton pump inhibitors, such as omeprazole (Prilosec), esomeprazole (Nexium), or lansoprazole (Prevacid), work by shutting off the stomach’s production of hydrochloric acid. This is the goal, unfortunately, for most individuals experiencing heartburn. There is an assumption that, because individuals are feeling the effects of the acid in their esophagus, excessive hydrochloric acid production is the problem. This is just not the case. In fact, most people with GERD (gastroesophageal reflux disease) do not produce enough hydrochloric acid. As we get older, the stomach tends to produce less acid. Blocking its production can significantly limit our body’s ability to effectively digest and absorb nutrients.
PPI medications also create an intestinal environment that is much more conducive to the growth or overgrowth of pathogens. Clostridium difficile infections (C-DIFF) for instance, are much more prevalent in PPI users. This increased risk of infection combined with compromised digestion and/or reduced nutrient absorption can collectively explain many of the most common symptoms experienced by PPI users. These include diarrhea and constipation, as well as numerous psychological changes such as anxiety, dizziness or confusion, and mental fatigue.
There are however much more serious side effects that can dramatically alter an individual’s life and the aforementioned investigations demonstrate the relationship to numerous chronic diseases.
Heartburn and most stomach acid issues are caused by acid migrating out of the stomach and into other regions. Generally it becomes an issue when food is spending too much time in a person’s stomach. Stomach clearance of food requires ADEQUATE stomach acid, NOT LESS, along with eating foods that are more compatible with a person’s digestive capacity. Eliminating casein (the difficult to digest curd-component to milk) and gliadin (the most difficult type of gluten, found in wheat) are excellent first choices for alleviating GERD. For many sufferers, these two foods are responsible for the majority of their issues.
There are other helpful suggestions that can aid with stomach clearance and digestion. These would include going for a walk after a meal as opposed to sitting or lying down, eating smaller meals, or using digestive enzymes for particularly protein or fat-rich meals. Some individuals may need to skip coffee or wine at least temporarily while they get their digestion in order.
In many cases, those with chronic heartburn have an upper GI issue known as SIBO or small intestinal bacterial overgrowth. This may need to be confirmed with a breath test and those with SIBO may need antibiotic treatment and/or a low carbohydrate-density diet to alleviate both conditions.
However, avoiding those substances that can delay normal stomach emptying are the best first approach. Many of these foods are considered most important to avoid as what is often referred to as an elimination diet. Elimination diets limit food choices to those with the lowest potential as allergens as well as favoring those foods that are easiest to digest. This diet is free of dairy, all sources of gluten (including corn and oats), eggs, red meat, nuts, soy products and other legumes, and of course sugar and most sweeteners. In favor with a typical elimination diet are: fish, chicken, most vegetables (especially green leafy), brown rice, and olive oil.
In addition to some dairy products and gluten, tomato sauces, chocolate, red meat, and eggs are all foods that require extensive upper GI/stomach digestion before the pyloric sphincter will release stomach contents further into the small intestine. In the case that an individual is not interested or able to follow an elimination diet fully, eliminating these top priority foods as well as those others that are rich in saturated fat, favoring extra virgin olive oil, may also prove as effective interventions.
With long-term PPI use, individuals interested in weaning themselves may want to consider a more gradual process so that the resurgence of hydrochloric acid is not a shock to the stomach/gastric environment. Reducing the dosage or cutting it in half for the first week or so, are reasonable approaches worth discussing with your MD.
~ John Bagnulo MPH, PhD.
1. Wijarnpreecha K, Thongprayoon C, Panjawatanan P, Ungprasert P. Proton pump inhibitors and risk of dementia. Annals of Translational Medicine. 2016;4(12):240.
2. Arora P, Gupta A, Golzy M, et al. Proton pump inhibitors are associated with increased risk of development of chronic kidney disease. BMC Nephrology. 2016;17:112.
3. Moledina DG and Perazella MA. PPIs and kidney disease: from AIN to CKD. J Nephrol. 2016 Oct;29(5):611-6.
4. Shiraev TP and Bullen A. Proton Pump Inhibitors and Cardiovascular Events: A Systematic Review. Heart Lung Circ. 2017 Nov 20. pii: S1443-9506(17)31467-1. doi: 10.1016/j.hlc.2017.10.020. [Epub ahead of print].
5. Hwang IC et al. Emerging hazard effects of proton pump inhibitor on the risk of colorectal cancer in low-riskpopulations: A Korean nationwide prospective cohort study. PLoS One. 2017 Dec 7;12(12):e0189114. doi: 10.1371/journal.pone.0189114. eCollection 2017.
6. Brusselaers N, Wahlin K, Engstrand L, Lagergren J. Maintenance therapy with proton pump inhibitors and risk of gastric cancer: a nationwide population-based cohort study in Sweden. BMJ Open. 2017;7(10):e017739. doi:10.1136/bmjopen-2017-017739.
7. Naito Y et al. Intestinal Dysbiosis Secondary to Proton-Pump Inhibitor Use. Digestion 2018;97:195-204.
8. Trifan A, Stanciu C, Girleanu I, et al. Proton pump inhibitors therapy and risk of Clostridium difficile infection: Systematic review and meta-analysis. World Journal of Gastroenterology. 2017;23(35):6500-6515. doi:10.3748/wjg.v23.i35.6500.