How to stop heartburn RUINING your summer

As one in three people with reflux says it gets worse on holiday, experts reveal what really causes it and. . .

BARBECUES, ice creams, prosecco — the summertime indulgences that can come with a price: heartburn. An estimated seven million Britons suffer from acid reflux — where acid or other substances leak from the stomach into the gullet, or oesophagus, causing an unpleasant burning sensation behind the breastbone. And in one recent survey a third of people said their condition got worse during holidays abroad.

To anyone not affected, heartburn might sound like nothing more than a nuisance, but studies have shown it can have a devastating effect on quality of life — comparable to suffering from depression, angina or heart disease. As many as one in five adults in the UK experiences regular attacks of reflux, says Nicholas Boyle, a consultant upper gastrointestinal surgeon at Maidstone and Tunbridge Wells NHS Trust as well as Bupa Cromwell Hospital in London.

‘People may be waking at night with reflux and so feel chronically fatigued, or the reflux may be damaging the larynx and affecting their ability to speak, which can impact on your livelihood.’

More worryingly, chronic reflux is also a leading cause of oesophageal cancer in the western world, a cancer with a poor outlook as it’s so often diagnosed late.

Drugs called proton pump inhibitors (PPIs), which combat reflux by reducing acid production in the stomach, have become one of the most commonly prescribed drugs in the UK, with the NHS spending more than £100 million on them every year in England alone.

But research now suggests these drugs may have adverse side-effects, from osteoporosis to dementia, and more patients are seeking alternative ways of getting their reflux under control.

Meanwhile, experts believe some people diagnosed with reflux could actually have a type of food allergy (see panel on opposite page). REfLUx

occurs when the lower oesophageal sphincter, a muscular valve at the bottom of the oesophagus that opens to let food into the stomach and then closes behind it, becomes weakened.

Stomach acid starts to leak backwards into the oesophagus, creating chest pain and regurgitation (a feeling of liquid entering the throat) often after consuming alcohol or fatty foods (think chips, ice cream and rich, creamy sauces) or after eating too much in one sitting, which is why barbecues can be a problem.

‘Everybody has a few relaxations of that valve and a small amount of reflux every day, and that’s normal,’ says Mr Boyle. ‘ The oesophagus clears it back into the stomach unnoticed.’

In people with reflux however, the valve mechanism fails. When reflux occurs at least once a week, it is defined as GORD — gastrooesophageal reflux disease.

This is on the rise. A major study by King’s College London and two universities in Norway and Sweden in 2011 found that rates of GORD had increased from 11.6 to 17.1 per cent in the past ten years.

Experts believe this is largely due to poor diet (rich, high-fat foods exacerbate reflux) and the rise in obesity (excess weight exerts more pressure on the abdomen, encouraging regurgitation).

So what can you do about it? The most unequivocally proven advice for reflux is to lose weight. This reduces pressure on the stomach, improving the function of the sphincter at the bottom of the oesophagus, which helps keep acid down in the stomach.

However, while studies have shown reflux is significantly more common among the obese and overweight, the condition can run in families and trouble those of a healthy weight, too. Experts stress that it’s vital to look at your eating habits. ‘Increasingly, people don’t want to take pills, and there are many for whom they don’t work,’ says Mr Boyle, who belongs to the specialist network RefluxUK. ‘Lifestyle changes should be the first move for everybody.’

One thing every reflux sufferer can and should do is try to establish the foods and drinks that trigger their attacks.

In the first of a two-part series, we asked some of the country’s leading experts for their advice on how to stop heartburn ruining your summer — and keep it at bay for good. Next week, we reveal the latest thinking on treatments, from drugs to surgery.

THE NEW FOOD RULES THE PERILS OF PASTRY

You’ve probably been told that the biggest triggers for heartburn are alcohol, coffee and rich, spicy foods such as curry — but what about that innocuous Cornish pasty or breakfast croissant?

‘Pastry is a potent trigger,’ says Professor Peter Whorwell, a gastroenterologist at Wythenshawe Hospital. ‘I’ve had reflux all my life and it’s certainly true for me — shortcrust, rather than puff.’

Dr Anthony Hobson, a gastrophysiologist at the functional Gut Clinic, also says a pasty is guaranteed to give him indigestion. The main reason is that pastry is made with butter and is rich in fat. fat takes more time to be broken down by the stomach.

‘The stomach has to secrete more acid and it stays for longer in the stomach,’ he says. ‘So avoiding these things or having small portions is advised, and certainly not eating them just before bedtime.’ CURRY COULD BE BACK ON THE MENU IT’S the first thing people are often told to avoid, but spicy foods might not be bad news for you after all. ‘ If you look at the literature, there isn’t a great deal about spicy foods [and reflux],’ says Professor Whorwell.

‘If it upsets you, then obviously avoid it, but often it’s the fat that’s causing the problem rather than the chilli.’

If you suspect that high-fat meals trigger your heartburn, you could opt for a tomato- based curry rather than a creamy one, says dietitian Helen Bond.

‘ However, some people find tomatoes are a trigger, and peppers, too, which are often used in curry. Another option would be to have a dry tandoori or tikkastyle curry, which allows you to avoid both tomatoes and fat.’ PICK YOUR FIVE A DAY CAREFULLY CERTAIN fruit and vegetables can bring on symptoms of reflux, with many of those affected reporting tomatoes and tomato sauce, as well as citrus fruits such as grapefruit and orange juice, as big triggers. That’s because these foods are relatively acidic, so when they travel down an oesophagus that’s already irritated and sensitive from regular attacks of heartburn, it sets off the same burning feeling people have when acid travels up from the stomach.

‘In the old days, before we were able to perform endoscopies [where a camera on a long thin tube is inserted through the mouth

to examine the oesophagus], orange juice was almost seen as a test for oesophagitis (inflammation of the gullet),’ says Professor Whorwell. ‘We’d get patients to drink it and see how they reacted.

‘It’s well known that citrus tends to make heartburn worse because it mimics the symptoms of reflux — it’s acid coming from above rather than below.

‘I always advise people to be cautious of orange juice, and apple juice seems to be a bad one, too, though it’s not clear why.’

FIZZ CAN GIVE MORE THAN A HANGOVER

BrItons’ thirst for bubbles shows no sign of slowing, with imports of sparkling wines such as prosecco, cava and champagne set to reach 15 million cases per year by 2020.

But alcohol is a well- known trigger for reflux attacks — and fizzy alcoholic drinks may be even more problematic because they encourage us to burp, says Professor Whorwell.

‘the belch will inevitably allow some acid up,’ he says.

It’s still not completely clear why alcohol in general so often triggers reflux, and the evidence that has been published is mixed, but experts believe that it may weaken the lower oesophageal sphincter or increase the production of acid in the stomach.

WATCH OUT FOR TINNED SOUP

As WELL as identifying your own unique triggers, experts agree that sticking to a diet that’s low in fat and high in protein and fibre is probably a good place to start, as foods such as lean meat, wholegrains, fruit and vegetables and nuts and seeds aid digestion.

Dietitian Helen Bond adds that omega-3 fats, found in oily fish such as mackerel and salmon as well as oils including flaxseed, reduce inflammation and so may help soothe an irritated gullet.

In his recent book, the Acid Watcher Diet, the U.s. ear, nose and throat specialist Dr Jonathan Aviv says many processed foods — including fizzy drinks, cakes, biscuits, ice cream and even canned soup — are highly acidic due to the additives and preservatives they are made with, and should be avoided by those wanting to reduce their reflux symptoms.

COULD BREAD BE THE PROBLEM?

MEAnWHILE, other researchers are examining whether a diet that’s been shown to have significant results for irritable bowel syndrome (IBs) might also benefit those with reflux.

this involves avoiding certain types of carbohydrates known as FoDMAPs, including food containing wheat such as bread and pasta, dairy, some pulses, and fruit and vegetables, such as onion and garlic, apples, pears and honey.

these are poorly absorbed in some people’s small intestine, and so they ferment, triggering symptoms such as bloating. More research is needed, but Professor Whorwell says: ‘People with IBs have a lot of reflux.

‘so there might be an indirect effect, in that if you reduce your bloating with a low FoDMAP diet, that reduces the pressure on your oesophageal sphincter, therefore reducing reflux.’

For further information go to kcl. ac.uk/fodmaps.

TAKE YOUR TIME . . .

ExPErts stress that how you eat is as important as what you eat when it comes to beating reflux.

If we eat too quickly, for example, it means the stomach has to churn out more acid to cope with the sudden high volume of food.

one study, published in 2004 in the American Journal of Gastroenterology by the Medical University of south Carolina, found eating a meal in five rather than 30 minutes increased reflux by 50 per cent.

Eating small, frequent meals rather than a few very big ones is also likely to help reduce reflux, says Professor Whorwell.

. . . AND EAT EARLY

tHE stomach takes around three hours to empty after eating a meal. so if you’re having dinner late at night, then collapsing into bed, it’s a recipe for reflux — because if you’re lying flat, it’s much easier for acid and other gastric contents to splash up into your gullet and cause you pain.

‘Eating right before bedtime is not a good idea at all because when you go to sleep the stomach goes to sleep as well,’ says Dr Hobson.

‘so you certainly shouldn’t eat for two or three hours before bed.’

Exercising too soon after eating may also make it easier for acid to surge upwards because the motion may put pressure on the valve.

PROP UP YOUR BED

IF yoUr reflux is worse at night, try propping up the bed. ‘I’m still a believer in simple, old-fashioned remedies like tilting the bed,’ says Professor Whorwell.

‘I see patients who are propping themselves up with pillows, and you can buy these wedge pillows now, too, but I like the idea of the whole bed being at an angle, of at least four inches.

‘you can go to your local timber shop and get a four-inch block, or use books. that way gravity is being given the best chance.’