Overcoming Digestive Disorders

There’s almost nothing worse than a stomach ache. Joe’s mother used to complain that if her belly was hurting, she couldn’t think about anything else. Like many of us, she tended to sometimes abuse her digestive system—overeating, skipping the occasional meal, snacking late at night, and eating all the wrong foods.

Lots of us do things we know our stomachs might not like: guzzling coffee by the gallon, overdoing it on spicy foods, indulging in rich, chocolatey confections, reaching for just one more bottle of beer after eating one last piece of pepperoni pizza. And even though we know on a gut level, as it were, what foods, beverages, and behaviors can exacerbate a bad belly, we sometimes can’t help ourselves. Then we moan about it later. (They don‘t call it bellyaching for nothing.)

Pills and Abdominal Pain:

But it’s not just what we eat that can cause digestive woes. Lots of things can cause a stomach ache. Medications can lead to abdominal pain. Think aspirin or NSAIDs (nonsteroidal anti-inflammatory drugs) like celecoxib (Celebrex), diclofenac (Voltaren), ibuprofen (Advil, Motrin), meloxicam (Mobic) or naproxen (Aleve, Anaprox, Naprosyn). Such drugs can not only cause stomach pain, they can also irritate the lining of the stomach to the point of ulceration. Hundreds of other medications can also lead to digestive distress. They include the stop-smoking drug varenicline (Chantix), the diabetes drug metformin, the corticosteroid prednisone and the osteoporosis medication alendronate (Fosamax), to name just a few.

Other Causes of Bellyaches:

Gas and bloating can make you quite uncomfortable. So can gallstones! Actually, gallstones represent a level of pain way beyond discomfort. Irritable bowel syndrome (IBS) is another potential problem along with nasties like diverticulitis or appendicitis. Any pain that persists, is out of the ordinary or worse than usual, requires a medical workup.

Heartburn & Indigestion

We consider it strange that indigestion is so often referred to as “heartburn.” It actually has nothing to do with the heart. However, the symptom of burning and pain in the esophagus usually manifests high under the sternum (or breastbone). That means it’s chest pain. Sometimes the symptoms of heart attacks masquerade as upper gastrointestinal (GI) tract discomfort, especially for women, who don’t always have the same onset symptoms as men. If you think there’s any chance that what you may be experiencing is a heart attack instead of a terrible attack of heartburn, chew an aspirin, call 911, and get to the ER.

A Brief Historical Perspective

Humans have suffered from heartburn for all of history. Hunters and gatherers consumed just about anything that was edible and some things that probably weren’t. Hippocrates warned in 400 BC that eating cheese after a full meal could cause indigestion, especially if accompanied by wine. Your gastroenterologist is likely to give similar advice today. Centuries ago, doctors called heartburn dyspepsia, from the Greek words meaning difficult to digest. Some doctors still like to use that term for reasons that mystify us.

Whether you call it indigestion, reflux, sour stomach, acid stomach or dyspepsia, heartburn is unpleasant. It can quickly wipe out the memory of a fabulous dinner. Trying to sleep with a burning sensation in the middle of your chest is difficult at best and impossible at worst.

Complications of GERD

Of course, even though gastroesophageal reflux disease (GERD) is not life threatening, it should be treated seriously. Recurrent reflux can lead to health complications. The longer that corrosive stomach acid remains in contact with the fragile tissues of the esophagus, the more damage it can do.

Symptoms may include chronic cough, laryngitis and asthma. Over time, reflux can cause scarring, narrowing (stricture), abnormal cell growth (Barrett’s esophagus), and, potentially, esophageal cancer. If you are experiencing frequent or prolonged heartburn, you absolutely must see a gastroenterologist for a full examination and tests. Taking care of chronic heartburn isn’t for us amateurs!

What Causes Indigestion? Is It All Due to Excess Acid?

The cause of heartburn is not as obvious as you might think. While it’s true that stomach acid is partly to blame, ads for acid-reducers would have us believe that stomach acid is the sole culprit behind indigestion. Was stomach acid a huge evolutionary mistake stretching back hundreds of millions of years? Almost all animals have complex digestive systems that create powerful stomach acid, including dogs, cats, chickens, cows, rhinos, elephants, beavers, vultures, penguins and wombats.

Drug companies may have figured out highly effective ways to shut down acid production in our stomachs, but there are good reasons our bodies make it: acid is essential for digestion and for facilitating the absorption of specific nutrients. Stomach acid also creates an inhospitable environment in our upper digestive tracts. That makes it harder for germs we may swallow with our food to set up housekeeping and create infection. You will shortly learn that long-term acid suppression may have some negative consequences.

What’s In Your Belly?

Stomach contents are corrosive. There is hydrochloric acid. It’s nasty stuff. If you were to get it on your skin it would burn. Consider this: battery acid has a pH of around 1.0. Stomach acid ranges from about a pH of 1 to 3. For comparison, tap water in New York City is about 6.7 and the pH of an average cup of coffee is around 4.5.

You might not think the change from a pH of 1 to a pH of 2 is that big a deal. Remember, though, the pH scale is logarithmic. If you go from pH 4 to pH 5, that is a ten fold decrease. If you go from a pH 2 to a pH 4 that is 100 times less acidic. Consider that acid-suppressing drugs like esomeprazole (Nexium) can change the pH of the stomach from around 2 to at least 6. That is a 10,000 fold difference in stomach acidity. Not exactly what mother nature intended, eh?

The stomach has lots of other stuff besides acid. There’s gastrin for starters. This hormone stimulates the production of hydrochloric acid. Gastrin also gets the muscles in the stomach moving as part of the digestive process. More about gastrin shortly. There are other hormones in the stomach along with bile acids and enzymes such as pepsin. This gemish of chemicals helps us digest our food properly.

If you have ever thrown up you know how nasty stomach contents can be. Ever wonder why that corrosive hydrochloric acid doesn’t regularly eat holes in your stomach lining? It’s complicated, but a key factor is mucus. Specialized “goblet” cells in the lining of your stomach protect your delicate tissues from caustic acid and enzymes. Your esophagus is not as well protected as your stomach.

Lazy LES: The Real Culprit Behind Heartburn?

Heartburn is not so much caused by acid as by a lazy muscle that lies just above the stomach at the end of the esophagus. Usually, when food is chewed and swallowed, it’s pushed into the stomach past a one-way valve called the lower esophageal sphincter (LES). The LES is supposed to keep food and gastric juices from getting back up into the esophagus. If it functioned perfectly, the corrosive chemicals in your stomach would not work their way back up into your food tube.

Sometimes, though, this muscle loses its contractility, which leads to reflux. Scientists aren’t entirely sure why this happens. A surprising number of medications, including benzodiazepines (benzos for short) can make LES laziness worse. Benzos include alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium) and lorazepam (Ativan). Blood pressure pills such as verapamil (Calan, Verelan), nitrate-type heart medicines such as nitroglycerin, progesterone and anticholinergic drugs (see list here) can also relax the lower esophageal sphincter. Bronchodilators for asthma or COPD can also do it. We suspect that many health professionals do not always mention that a medicine they have prescribed can potentially increase the risk for heartburn because they alter LES function.

Zolpidem (Ambien) and Heartburn

Visitors to our website alerted us to a surprising side effect of the sleeping pill zolpidem (Ambien) over a decade ago. The unexpected complication is heartburn (acid reflux). We don’t know if it is because the drug relaxes the LES. That seems as plausible as any other mechanism.

Although the official prescribing information for zolpidem now includes “dyspepsia” as a frequent adverse event, we suspect that many patients do not realize that is the medical term for heartburn. And we doubt that many health professionals warn patients about this problem.

We think this is a serious adverse drug reaction that deserves attention.

This reader describes the situation:

“Why is it that doctors (even my gastroenterologist) are not aware of the severe heartburn side effects of zolpidem (Ambien)? It seems that in some people, this drug causes a malfunction of the esophageal sphincter.

“I took Ambien daily for several years before the heartburn symptoms started. I was put on strong proton pump inhibitors to control my symptoms for over a year. I also had lots of diagnostic tests — an upper GI endoscopy and esophageal manometry — all unnecessary. I finally discovered the connection of GERD [gastroesophageal reflux disease] to Ambien on my own.

“How can we make the side effects of Ambien more well known?”

A study published in BMJ Open (Feb. 27, 2012) confirmed this adverse reaction is real, but there is hardly any mention of this side effect in the medical literature. Nevertheless, we have heard from a surprising number of people that it is real.

Here are just a few more reports from readers:

“I was prescribed Ambien for insomnia, then began experiencing reflux and heartburn nightly. After a few weeks, it occurred to me that the heartburn began about the same time I started the Ambien.

“As I was only instructed to take the Ambien ‘as needed’, I stopped immediately and went online to research this. I found many, many instances of people who’d experienced the same thing. Of course, my doctor was surprised, as she had never heard of this before…..”

R.M. was dismissed by his doctor:

“After taking zolpidem for 20 days I started having stomach cramps, bloating, acid reflux, heartburn and a nervous feeling. Finally, after 4 days of not taking it, I’m feeling better. The doctor that prescribed zolpidem didn’t agree that these side effects were due to the medicine.”

No one should stop zolpidem cold turkey. Doing so can cause rebound insomnia. Should you need to discontinue this sleeping pill to overcome reflux, please discuss a gradual tapering process that might last several weeks or months.

Preventing Heartburn

Food Fight: Is There Science to Support the Heartburn Diet?

Most people are told that to avoid heartburn, they have to cut out many of the foods they love: chocolate, coffee, fatty foods, citrus fruits, tomatoes, onions, spicy foods, red meat, mint and alcohol to name just a few of the major targets. If you follow the doctors’ heartburn diet, that means no more mint chocolate chip ice cream (my personal favorite). It’s got chocolate, mint and is high in fat. Ouch!

When we looked for well-controlled trials to demonstrate that such foods are indeed culprits, we were surprised to find that there is little research you can hang your hat on. Read on for some actual science.

The Fat Fight:

We live in an era of “evidence-based medicine.” That is, doctors are supposed to have clear cut data to make recommendations about drugs or dietary changes. In the case of indigestion, we are underwhelmed by the data that supports the classic heartburn diet handed out by many health professionals to their heartburn patients. Take fat, for example. Virtually every list we have seen forbids fatty foods. How good is the evidence?

A review published in the European Journal of Gastroenterology & Hepatology (Dec. 2000) was titled “Fat and Gastro-Oesophageal Reflux Disease.” The author notes:

“It is common practice to prescribe avoidance of fatty foods to patients with gastro-oesophageal reflux disease; however, there is no good evidence supporting the benefit of such a prescription…It is concluded that, in the light of present evidence, there is no sound rationale for clinicians recommending that patients with GORD follow a low-fat diet.”

European journals spell esophagus with an o as in oesophagus. Hence GERD in the U.S. is GORD in Europe. A study published in the Scandinavian Journal of Gastroenterology, (Jan. 2002) concluded:

“Our data suggest that advice on dietary habits in patients with GOR [gastro-oesophageal reflux] disease should be concentrated on decreasing the caloric load of meals rather than their fat content.”

Many other things that heartburn sufferers have been told to avoid, like spicy foods, citrus fruits, chocolate, mint, coffee, tea and alcohol, also haven’t been proven to be problematic.

What About Spicy Food?

Everyone knows that spicy foods cause heartburn, right? Not so fast.

Here is a message we received from a reader of our syndicated newspaper column:

“My acid reflux was so severe that I was on four prescription acid suppressors a day. I could not sleep more than an hour at a time because the reflux would wake me. If I did sleep, I’d have a bad headache upon waking from reflux.

“Then I ate some Thai hot sauce. I thought the hot sauce pain would be better than the constant reflux, but to my surprise, the reflux went away!
“I now consume about 4 ounces of the spicy hot sauce a day to keep the acid reflux away, and I feel great. I don’t need acid fighters any longer and all my stomach pain is gone.

“My 80-year-old dad told me vinegar would cure the heartburn. I ignored him because that sounded counterintuitive, but he was so right. I wish I had listened before the acid reflux hurt my esophagus. The good news is that my doctor says it is healing now. He cannot believe how hot peppers cured it.”

Another reader shared this story:

“Here in the U.S., I get acid reflux about every other day. Even bland food can set it off. I treat it occasionally with acid-suppressing drugs.

“When I’m in Thailand, however, I eat the spiciest food I’ve ever put to my lips. For some odd reason, I get no heartburn whatsoever.”

Researchers in Mexico City, where they know about hot peppers, studied the effect of chilis on heartburn symptoms (Revista de Gastroenterologia de Mexico, Oct-Dec. 2010). They found that capsaicin, the compound that gives hot peppers their zing, caused heartburn in most subjects with reflux and about a third of healthy subjects.

Those with Barrett’s esophagus, however, were less sensitive to subsequent heartburn triggers after exposure to capsaicin. Barrett’s esophagus is a condition in which chronic reflux has damaged the cells lining the esophagus.

A study from Thailand also suggests that spicy foods might not be everyone’s heartburn enemy (Journal of Neurogastroenterology and Motility, April, 2010)

“Recent small studies suggest that the chronic use of capsaicin-containing chili can decrease heartburn and abdominal pain in GERD and dyspepsia, respectively. In addition, the ratio of the prevalence of heartburn/regurgitation symptoms in the population is lower in several parts of Asia; this lower rate may be related to the high prevalence of chili or spicy food.”

If you know from personal experience that spicy foods (or any of the other foods such as oranges or tomatoes) cause you discomfort, you should avoid them, of course. Keeping a food diary might help you identify which things to leave alone and which can be consumed safely.

What About Carbs?

One reader shared this story:

“Years ago, I was overweight and had high blood pressure. So my doctor put me on a diet, and later told me to cut out bread. It worked. I lost the desired amount and my blood pressure normalized.

“During this diet, I found that I could eat corn or wheat chips in place of bread and continue to lose weight. I love them, so I ate lots.

“Looking back, I began having indigestion about the same time, though I didn’t make the connection. This indigestion occurred nearly every evening for several years.

“Recently I developed borderline high blood sugar, and my doctor recommended that I cut down on carbohydrates. I cut out the chips completely, and my indigestion disappeared. I don’t mean it diminished, I mean it totally stopped. I have not had indigestion since.”

The reality is that, as with weight loss, the conventional wisdom about doing away with fats may be less effective than cutting out carbs. We’ve heard from many of our readers that high-carb diets can cause them GI distress. Some report that following a low-carb approach, such as that found in a South Beach-type diet, a partial ketogenic or “keto” diet or a Paleo diet can reduce symptoms significantly.

Such reports are supported by findings in the medical literature dating back to 1972. A more recent small study, conducted at Duke University in 2001, also seemed to back up the conclusions that carbs are more troublesome than fats when it comes to GERD (Alternative Therapies in Health and Medicine, Nov-Dec. 2001).

A study of overweight women concluded (Alimentary Pharmacology & Therapeutics, Nov. 2016):

“Contrary to long-held belief that higher fat intake promotes GERD symptoms; nationally representative data do not show a strong association between dietary fat and GERD. Thus, the present study provides important insights that contribute to the accumulating evidence of a role for dietary simple carbohydrates in GERD pathophysiology. We found that simple carbohydrates, particularly sucrose, contribute to GERD in obese women and the likelihood of having GERD was predicted by simple carbohydrate (total sugars) intake…The discontinuance of GERD symptoms and medication use in all women within ten weeks of the high-fat/low-carbohydrate diet suggests that further research is warranted to determine potential mechanisms underlying the relationship between carbohydrates and GERD.”

One final word on diet. Two gastroenterologists writing in the Journal of Thoracic Disease (Aug. 2019) acknowledge that:

“Although dietary manipulation is commonly employed in clinical practice, data is conflicting on definitive recommendations.”

They go on to note that recommendations to avoid certain foods, spices and beverages “are based on limited data and need to be personalized.” In other words, if you can tolerate chocolate or peppermint or even spicy food without problem, don’t worry, be happy. If you discover that citrus fruit is the culprit, you can decide to avoid oranges or grapefruit. That’s what a “personalized” plan is all about.

The People’s Pharmacy Perspective

Many doctors firmly believe that they are practicing evidence-based medicine when they recommend the classic low-fat, high-carb heartburn diet. And yet we have discovered that just the oppositve may be a better option for many people. Of course everyone is different. Some people cannot tolerate chocolate or onions or mint chocolate chip ice cream. Trial and error will be your best guide to what works or doesn’t work for you.

Another thing to keep in mind when considering how best to treat heartburn is that acid-suppressing drugs only curb acid production. As we mentioned above, acid is not the only thing that gets back into the esophagus during reflux—gastric juice contains the enzyme pepsin, which can also irritate delicate esophageal tissues, as can bile acids. Bacteria that can thrive in the stomach when acid is suppressed may also create carcinogenic chemicals like nitrosamines and acetaldehyde.

We don’t have drugs for getting rid of those nasty chemicals. So even if you don’t feel the symptoms of heartburn because you’re taking an acid-suppressing drug, other things in gastric juice can still do damage to your esophagus. The real goal is to keep the whole slew of irritating stomach contents out of your esophagus, which means that there may be some approaches and treatments other than acid suppressors that are worth a try. It may also mean eliminating medications that relax the lower esophageal sphincer and contribute to reflux.

Treating Indigestion

If dietary changes do not solve the heartburn problem, it is time for some personalized creativity. Before we get to pharmaceuticals, however, we would like to suggest some low-cost options. Many can be found in the kitchen.

Nondrug Approaches

There are lots of home and herbal remedies that may work just as well as medications for curbing digestive woes, and that carry far fewer risks of side effects or other complications.

Melatonin

Mention the hormone melatonin and almost everyone thinks sleep. And yes, a lot of people are taking melatonin before bedtime for just that purpose. We would like to suggest a completely different use for this OTC dietary supplement.

We were first alerted to the use of melatonin for reflux by our dear friend Tieraona Low Dog, MD. She has been the most frequent guest on our nationally syndicated public radio show for decades because she is so knowledgeable about herbs and other natural remedies. Dr. Low Dog mentioned that melatonin is found in much higher levels in our digestive tract than in our bloodstream. What’s it doing in our stomachs?

Remember the discussion above about the “Lazy LES: The Real Culprit Behind Heartburn?” The lower esophageal sphincter is a ring of muscle that is supposed to keep food and harsh gastric juices from refluxing up from the stomach back into the esophagus. Well, it turns out that melatonin improves the strength of the LES. A stronger sphincter can help keep acid and other nastiness out of your delicate food tube. According to Dr. Low Dog, melatonin also improves the mucosal barrier of the stomach and esophagus.

We suspect that most health care providers have never heard of melatonin’s other benefits in the digestive tract. They are likely unaware that there is science to support its use against gastroesophageal reflex disease (GERD).

A review in the journal Nutrients (Feb. 1, 2022) reveals that melatonin works through a number of pathways to reduce heartburn symptoms, especially at night. The dose in one randomized clinical trial trial was 3 mg at bedtime while the dose in another randomized controlled trial was 5 mg at bedtime. Both studies resulted in positive benefits for GERD.

Saliva

Saliva is our body’s natural heartburn combatant. We first heard about this method for dealing with heartburn back in 1984. That’s when we read in the New England Journal of Medicine (Feb. 4) that:

“…residual acid [in the esophagus] is neutralized by swallowed saliva.”

And not only does saliva neutralize acid, but swallowing also causes the esophagus muscles to contract, which moves acid and other nastiness back into the stomach where it belongs.

The researchers who did the saliva study recruited 22 volunteers. The scientists squirted hydrochloric acid labeled with a radioactive isotope into their throats. They measured pH and clearance of the acid from the esophagus. Their results:

“Our findings indicate that in normal subjects esophageal acid clearance occurs as a two step process consisting of esophageal emptying followed by acid neutralization. First, virtually all acid volume is emptied by one or two peristaltic sequences, and then the minimal residual acid is neutralized by swallowed saliva…An oral peppermint lozenge stimulated saliva flow and increased the ability of saliva to neutralize acid.”

One of the easiest ways to get your saliva flowing is to chew gum. We recommend sugarless, which has fewer calories and is less likely to damage teeth. (But keep in mind that sorbitol, found in many sugarless gums, can actually increase the chances of other forms of digestive upset. Overdoing on sugarless products of any kind can lead to diarrhea) One kind of chewing gum (Orbit) has even been proven effective against heartburn in a clinical trial.

We’re not sure why gastroenterologists have mostly ignored this research. Here is a little more documentation to show your doctor:

Researchers have found that gum chewing:

“…appears to be a useful adjunctive antireflux therapy” (Annals of Otology, Rhinology and Laryngology, Dec. 2001)

And dental researchers have noted that (Journal of Dental Research, Nov. 2005):

“Chewing sugar-free gum for half an hour after a meal can reduce acidic postprandial esophageal reflux.”

Walking and chewing gum at the same time may help even more! One study indicated that a walk after a heavy meal helped reduce heartburn symptoms. But chewing gum for an hour actually helped more—and the effect lasted longer. (If you’re not a gum chewer, sucking on flavorful candy, such as a peppermint lozenge, could also help increase saliva production.) One cough lozenge that is likely to stimulate saliva is Fisherman’s Friend. It dates back to the 19th century contains menthol, capsicum, eucalyptus oil and natural licorice. Don’t overdose, though. You will learn about the potential dangers of too much natural licorice shortly.

Tea

Another remedy that may help soothe heartburn is tea. Sipping it slowly also causes the esophageal muscles to contract, and flushes stomach acid out and back into the stomach. Herbal teas with calming properties might be especially helpful. For centuries, people have used teas made from anise or caraway seeds, catnip, lemon balm, licorice, sage, chamomile and ginger for indigestion. Our favorites are the latter two.

DGL

Be careful not to get carried away with licorice, though. An ingredient in natural black licorice (glycyrrhizin) can cause a lot of mischief. Overdosing on natural licorice (licorice root tea) can cause low potassium levels, abnormal heart rhythms, headaches, edema (swelling) and high blood pressure.

One form of licorice is substantially safer. DGL (deglycyrrhizinated licorice) has most of the glycyrrhizin removed. This makes it less likely to raise blood pressure or cause hormone disruption. DGL is often used to treat heartburn, ulcers, canker sores and other digestive distress.

Ginger

Ginger has been used to combat nausea and stomach upset for a very long time. It can be brewed in tea by steeping about one teaspoon of fresh, grated ginger in a mugful of boiling water. Let steep for several minutes, then strain out the ginger, and sweeten to taste. There are also some ready-made teas that you can buy in the store that contain ginger root, like Tazo Chai, which one of our readers recommended to us.

Another reader told us about Persimmon Punch, a strong cinnamon-ginger drink that you can get at some Korean restaurants. She had tried unsuccessfully to stop taking her acid-suppressing drug, but the heartburn kept coming back:

“Someone ordered Persimmon Punch, a concentrated cinnamon-ginger drink, for dessert. A few sips later, I felt fantastic. After a month of adding 3 tablespoons of the cinnamon-ginger drink to my tea morning and night, my heartburn was in control.”

We found the following recipe for persimmon punch on the Food Network Web site, courtesy of Hyungshin Song:

“Combine 2 quarts of water, ½ cup of thinly sliced fresh ginger and 3 cinnamon sticks. Simmer for ½ hour. Strain the liquid and stir in 1 and ½ cup sugar and 1 cup of sliced dried persimmons. Chill in the refrigerator overnight and serve cold.”

We suspect you could cut back on the sugar. It is probably there to make this a dessert beverage. We doubt that the sugar offers any therapeutic benefit and might be counterproductive.

And there’s always ginger ale (we like Carver’s Original or Blenheim), candied ginger, or even ginger cookies. If you’re taking a blood thinner like warfarin (Coumadin), Plavix, or aspirin, you may be slightly more susceptible to bleeding while taking ginger.

Vinegar

Another counterintuitive remedy is vinegar, the opposite of an antacid. But again, we’re not even so sure that acid is really the problem when it comes to reflux. We suggest diluting a couple of teaspoons of apple cider vinegar (ACV) in water. Straight vinegar is just too strong to take on its own. This reader describes his experience with ACV:

“I took prescription meds for GERD [gastroesophageal reflux disease] for ten years. Finally, I tried apple cider vinegar after my evening meal. Although it seemed counterintuitive, it worked! I’m pleased to have found this remedy for heartburn.

“I also sleep with the head of my bed raised. I use the things they sell to raise all bed legs for under-bed storage, but only put them under the headboard feet.

“I’m happy to be med free so I don’t need to worry about side effects. I didn’t go cold turkey with the meds but weaned off them gradually. We have stomach acid for a reason–to digest our food. If we don’t digest it properly, we can’t absorb the nutrients in it.”

We cannot begin to tell you how many readers of our syndicated newspaper column and visitors to the website have written to tell us that apple cider vinegar is helpful for their heartburn symptoms. Although it has not been studied in a clinical trial, doctors are beginning to take notice of its use (Current Gastroenterology Reports, July 10, 2019).

Some naturopaths have adopted the use of apple cider vinegar and deglycyrrhizinated licorice (DGL) to treat reflux (Integrative Medicine, Aug. 2018).

We have to add a few words of caution to the vinegar story. While some people sing the praises of ACV against heartburn, others tell us that it is total torture. They say vinegar makes their indigestion far worse. Obviously, ACV must be avoided by anyone who finds it counterproductive! We are reminded once again that people react differently to drugs and home remedies. That’s why personalized medicine is the name of the game!

Maybe just the plain old apple will work—we’ve heard of this as a remedy, too! An apple a day, as they say . . .

Mustard

Mustard seems like a strange recommendation for someone suffering from heartburn, right? You would think that this spicy condiment might make things worse. And some people really can’t tolerate it. But for those who can, we’ve heard that a teaspoon can really help during a bad bout, and a preventative dab on foods that normally cause heartburn can help, too. It may be the healing properties of turmeric (what makes mustard yellow), or it might just kick-start saliva production. Then again, there is some evidence that spicy foods help some people.

Celia shared this mustard anecdote:

“I was prescribed Nexium for reflux. Well yellow mustard worked a lot better, faster and longer. Nexium was working at the beginning but not any more; besides I was concerned about side effects and contraindications.”

Almonds

We don’t have a good explanation for almonds against heartburn. All we can tell you is that the almond anecdotes keep piling up. Here is just one example:

“I have suffered with heartburn for years. The most recent prescription medicine made my reflux way worse.

“Then I read that almonds helped someone else with a similar problem. I tried it and it works for me.

“Sometimes three almonds will do the job–raw, blanched, roasted or roasted with salt. They work if I eat them before a meal or after or when the heartburn starts. I carry snack size packs of almonds in my purse just in case.

“A friend of mine who has a chemistry degree feels it may be the amino acids in the almonds that help heal the stomach lining and also help cut down the acid production.”

Antacids

Our human ancestors often had to eat some pretty challenging stuff. Remember, refrigeration is relatively new in the global scheme of things. Consequently, early healers were always on the lookout for digestive aids. It is reported that the ancient Sumerians used plant ash or sodium carbonate to calm digestive woes. That was more than 3,000 years BC. It was made by burning seaweed and other marine plants.

Stomach Warning:

There is an intriguing “Stomach Warning” on the Arm & Hammer Baking Soda box that says:

“IT IS VERY IMPORTANT NOT TO TAKE THIS PRODUCT WHEN OVERLY FULL FROM FOOD OR DRINK. Consult a doctor if severe stomach pain occurs after taking this product.”

There is an amazing back story here. If you search the medical literature you will discover an article in the journal Gastroenterology (Nov. 1984) titled “Gas production after reaction of sodium bicarbonate and hydrochloric acid.” The authors note that if you follow the instruction on the box (1/2 teaspoon of sodium bicarbonate) only a small amount of gas would be released. But some people don’t follow instructions. The authors go on to note:

“Some people selected doses of bicarbonate that would result in several hundred milliliters of gas release within 3 min; it seems likely that such injudicious ingestion of sodium bicarbonate, if taken when the stomach was distended with air, food, and liquid, could be an important factor in spontaneous gastric rupture.”

There are about 15 cases in the medical literature in which people ruptured their stomachs by taking large doses of baking soda after eating too much. In one notorious case, a man ate a large meal, accompanied by margaritas, at a Mexican restaurant (Annals of Internal Medicine, Nov. 1984). He blew a hole in his stomach because of the rapid buildup of gas that had no place to escape.

In 1991 the New York Times (Nov. 27) reported:

“‘I nearly died after taking this stuff,’ said William Graves, who suffered a rupture through the wall of his stomach in 1979 after taking baking soda mixed in water for indigestion after a big meal. The 64-year-old resident of Bethesda, Md., who is editor of National Geographic Magazine, said that only emergency surgery saved his life and that six more operations were needed to repair the damage.”

Baking Soda

If sodium carbonate sounds vaguely familiar that’s because it is chemically related to sodium bicarbonate or baking soda. These are alkaline substances that can act as antacids in the stomach.

In fact, sodium bicarb or bicarbonate of soda is still one of the fastest-acting and cheapest antacids you can find. A 2-pound box provides 373 doses. If you look on the back of a box of Arm & Hammer Baking Soda you will see a “Drug Facts” table with the following:

“Uses relieves
* heartburn * acid indigestion
* sour stomach * and upset stomach due to these symptoms
Directions
* add 1/2 teaspoon to 1/2 glass (4 fl. oz.) of water every 2 hours or as directed by physician. Dissolve completely in water. Accurately measure 1/2 teaspoon.
* do not take more than the following amounts in 24 hours:
* seven 1/2 teaspoons
* three 1/2 teaspoons if you are over 60 years”

Following such directions is crucial. Baking soda contains a significant amount of sodium. A reader of our syndicated newspaper column shared this sad story:

“My husband had chronic indigestion due to an ulcer. He insisted it could be treated with baking soda, but he was not careful and drank much more baking soda in water than is recommended. He didn’t even wait for it to dissolve. Instead of helping, it made him throw up and he took more baking soda to counteract that.

“He ended up in the hospital with a potassium level of 1.9, the lowest the ER doctors had ever seen in a living person. If people want to use baking soda for heartburn I think they should stick with something like Alka Seltzer because the dose is controlled.”

We would add: or follow the directions on the box!

We are always astonished that people assume they can be creative with dosing whether its something like baking soda or an over-the-counter medication.

Calcium Carbonate

We’re talking chalk! For those old enough to remember using chalk on a blackboard, that is the material found in many popular antacids. Like sodium bicarbonate, calcium carbonate can help neutralize stomach acid and ease symptoms of indigestion. Perhaps the most famous brand is Tums®. According to the manufacturer:

“Created in 1928 by pharmacist James Howe to treat his wife’s indigestion, the TUMS® brand was introduced to the public in 1930 and quickly became an American favorite among antacid treatments.

“TUMS® provides fast-acting relief from the pain of heartburn. The secret is its primary active ingredient – calcium carbonate, which is naturally mined from limestone – that quickly gets to work tackling the symptoms of heartburn.”

We used to be big fans of calcium carbonate. It is inexpensive, fast-acting and inexpensive. As an extra bonus, this is a good source of calcium. There was a time when almost all middle-aged and older women were advised to take a calcium supplement to “keep their bones strong.” There was even some suggestion that taking calcium might reduce the risk of colorectal cancer.

Calcium Supplements Fizzle:

We are no longer so enthusiastic about calcium carbonate as a dietary supplement or an antacid, especially if it is taken frequently for long periods of time. Why, you may ask, have we turned sour on daily calcium? First, the evidence that taking added calcium in pill form will “build strong bones” is weak at best.

A meta-analysis published in JAMA (Dec. 26, 2017) reviewed 33 randomized clinical trials invovling more than 50,000 participants.

“In this meta-analysis of randomized clinical trials, the use of supplements that included calcium, vitamin D, or both compared with placebo or no treatment was not associated with a lower risk of fractures among community-dwelling older adults. These findings do not support the routine use of these supplements in community-dwelling older people.”

Calcium Complications:

Just because calcium supplements have not lived up to expectations as bone boosters would not be a reason to write off calcium carbonate antacids for heartburn. But here is the rub. Research has begun to suggest that regular calcium intake from pills (over several years) might pose problems. A study published in the journal Gut (March 1, 2018) reported that people taking 1,200 mg of calcium daily had double the risk of developing precancerous colon polyps years later. If they were also taking vitamin D the risk was even higher.

More worrisome than the development of colon polyps is an increase in cardiovascular risks in general and heart attacks in particular. The Women’s Health Initiative was one of the most comprehensive randomized controlled trials of its day. Data from that research was reported in the BMJ (April 19, 2011). Researchers noted a modest cardiovascular risk associated with calcium supplements with or without vitamin D. A prior analysis of 15 trials involving over 8,000 participants concluded:

“Calcium supplements (without coadministered vitamin D) are associated with an increased risk of myocardial infarction [heart attack].”

One explanation is that if calcium intake is too high it could lead to calcification of soft tissues. The plaque in arteries is made up largely of calcium. If people regulalry take a lot of calcium carbonate to control indigestion it is conceivable that this extra calcium could lead to blood vessel calcification and an increased risk of cardiovascular complications (Nutrients, July 5, 2013).

One final concern: Kidney stones. There is reason to believe that calcium supplements could raise the risk for kidney stone formation (Clinical Interventions in Aging, Nov. 28. 2018).

Does this mean you should avoid calcium carbonate as an antacid? No! It works quite well. Occasional use should pose no problems. It is daily intake that worries us.

Aluminum & Magnesium

For decades doctors have recommended antacid mixtures that combine aluminum hydroxide and magnesium hydroxide. This combo is found in Di-Gel Liquid, Maalox Advanced Regular and Maximum Strength and Mylanta Maximum Strength Classic Flavor. Of course there are dozens of other brands that also contain aluminum and magnesium hydroxide. There is no question that these ingredients are quite effective at neutralizing stomach acid.

What makes this formula popular, besides the effectiveness of the antacid activity is the counterbalancing side effect profile. Aluminum hydroxide has a tendency to be constipating. Magnesium hydroxide has a modest laxative effect. Put the two ingredients together and voilà, you get a standoff. That is to say you cancel out the negative GI effect of each ingredient alone.

The Aluminum Controversy

What gives us pause about this classic antacid formula is the aluminum component. Scientists have been debating the issue of aluminum neurotoxicity for decades.

A small case-control study of 130 matched pairs was conducted in Seattle, Washington (Journal of Clinical Epidemiology, January, 1990). People who used aluminum-containing antiperspirants frequently had a greater likelihood of developing Alzheimer’s disease (AD). People who used antacids regularly had 11 times the rate of Alzheimer’s disease compared to nonusers. Interestingly, there was no association with AD in the people using aluminum-based antacids. The study was small, however, and the authors admit that their results were provacative but inconclusive.

More recently, there have been studies that have suggested aluminum is neurotoxic. A reveiw in the Journal of Research in Medical Sciences (June 6, 2018) noted:

“Aluminum (Al) is widely found in the nature. Although the relation between Al and neurodegenerative diseases is still controversial, Al is related with many brain diseases including Alzheimer’s disease, Parkinson’s disease, and multiple sclerosis.

“It is well established that Al is a neurotoxic agent…Al exposure should be kept to minimum since the potential effects on human health of Al are not fully understood. Future studies should be done in vulnerable subgroups of population including children, patients receiving antacids or Al-containing pharmaceuticals on a daily basis…”

Clearly there are unanswered questions about the safety of aluminum, including its use in antacids and other aluminum-containing pharmaceuticals. We find this uncertainty alarming given the fact that millions of people have been using such products for many decades.

To be fair, many scientists believe that aluminum poses no risk to human health. In particular, they note that there are no studies that establish a clear-cut association between the use of aluminum-containing antacids and the development of Alzheimer’s disease.

That said, one researcher is quite concerned about aluminum (Journal of Alzheimer’s Disease Reports, June 8, 2017). He states that: “Aluminum is unquestionably neurotoxic.” He goes on to write that:

“Aging is the major risk factor for Alzheimer’s disease though the advent of Alzheimer’s disease within a normal human lifespan is suggested to be brought about through human exposure to aluminum. Essentially without aluminum in brain tissue there would be no Alzheimer’s disease.”

Whether aluminum-containing antacids contribute to human health problems remains to be determined. We wish that there were large, high-quality, randomized controlled trials that lasted several years so we could have excellent data to make a recommendation one way or the other. Until that day arrives, however, we are being cautious about aluminum-based antacids. There are alternatives for easing symptoms of indigestion.

Alka-Seltzer

There are few brands as iconic as Alka-Seltzer. The intriguing formula got its start almost 100 years ago at the Dr. Miles Medicine Company in Elkhart, Indiana. In 1931 it was launched to relieve minor aches and pains, ease heartburn, stomachache, indigestion and acid reflux. Many people thought of it as the hangover remedy.

This commercial made Alka-Selzer a household name: “Plop, Plop, Fizz, Fizz, Oh What a Relief It Is!” To view some of the vintage ads, here is a link to AW360. The company worked hard to convince Americans that Alka-seltzer could help “headache and indigestion after over-indulgence in food and drink.” It was a very successful pitch because a lot of people fit that profile.

What’s in Alka-Seltzer?

The classic formula contained three primary ingredients:

• Aspirin (325 mg)
• Sodium bicarbonate, aka baking soda (1,916 mg)
• Citric acid (1000) mg

The dose is 2 tablets dissolved in water every 4 hours. Adults under 60 are told that they can take up to 8 tablets a day.

When you put citric acid together with sodium bicarbonate you get the effervescent “fizz.”

When we wrote the first edition of The People’s Pharmacy (St. Martin’s Press, 1976), we weren’t kind to Alka-Seltzer:

“Unfortunately, this combination of a pain killer with an antacid is of very dubious medical value. For just a headache, you do not need to pay an outrageous price for Alka-Seltzer, since you are paying extra for the antacid properties. If you have indigestion or upset stomach, the last thing you want is aspirin included in the tablet. That is like trying to put out a fire with gasoline. Even though dropping their fizzy tablets into a glass of water converts the aspirin to a less irritating form called sodium acetylsalicylate, it offers no benefit for heartburn.”

We’ve mellowed a bit on Alka-Seltzer over the decades. But we still don’t think it makes sense to take aspirin to ease symptoms of heartburn. We do think that soluble aspirin does make sense for headaches or other aches and pains. Many other countries sell various brands of soluble aspirin (Aspro, Disprin). You drop a pill into water and it fizzes. Such products never caught on in the U.S. We think that soluble aspirin might be helpful because, to quote the current makers of Alka-Seltzer (Bayer):

“There are multiple advantages to using Alka-Seltzer effervescent products. In short: the medicine dissolves fast and goes to work instantly, neutralizing acid on contact.”

We see this as especially important if someone suspects he is having a heart attack. Emergency physicians often recommend chewing a baby aspirin. But our homemade formula would also get aspirin into your system fast:

“Put uncoated aspirin into a glass of club soda or seltzer water. It will take a minute or so to dissolve with a bit of stirring. You can add one half teaspoon of baking soda to eight ounces of sparkling water to buffer the aspirin. For flavor, squeeze in the juice from a lemon wedge.”

It will be a lot less expensive than a store-bought product. The citric acid will make the baking soda fizz, not unlike the fizz you see with Alka-Seltzer.

Pepto-Bismol

Here is another old-fashioned digestive aid. Pepto-Bismol has been sold in the U.S. for more than 100 years. A physician developed the product to treat the severe diarrhea brought on by cholera. At the beginning of the early 1900s the original formula contained pepsin, the primary digestive enzyme found in your stomach. It helps break down protein. Other ingredients included zinc, oil of wintergreen (methyl salicylate) and salol (phenyl salicylate). In those days salol was thought to be an “antiseptic” for the digestive tract, hence its use for the treatment of cholera. On yes, there was one last ingredient, the distinctive pink color!

Eventually the formula was changed to contain primarily bismuth subsalicylate. It is sold for heartburn, nausea, diarrhea, indigestion and upset stomach. You’ll also find house brands of bismuth subsalicylate. This ingredient has an interesting property. It turns brown stool into black poop. Some people find this “side effect” alarming. Others discover that their tongues turn color as well. The bismuth interacts with sulfur in saliva and stool to form bismuth sulfide, which leads to the sometimes alarming color change. As far as we can tell, though, this byproduct is not dangerous.

We don’t know quite how Pepto-Bismol works against heartburn. The product has gotten more attention from health care providers as a component of triple or quadruple therapy to banish Helicobacter pylori, the bacterium linked to stomach ulcers (Helicobacter, Oct. 2019). Pepto-Bismol has also been used to prevent or treat travelers’ diarrhea (Recent Patents on Inflammation & Allergy Drug Discovery, 2019).

A People’s Pharmacy Puzzle:

By now you have probably noted that both Pepto-Bismol and Alka-Seltzer contain either a salicylate or aspirin. Remember, aspirin is a salicylate (acetyl salicylic acid). Seems illogical, right? We suspect that if you asked a gastroenterologist whether you should take aspirin or another salicylate to treat your heartburn or diarrhea, you would be told no quite emphatically. And yet both these products have been hugely successful for roughly a century. How is it that two of the best-selling OTC heartburn products include a class of compounds that is thought to be irritating to the digestive tract? We do not have a good answer. That’s why it is a PPP (People’s Pharmacy Puzzle).

Some Pepto-Bismol cautions: Like any medication, P-B may have side effects if it used on a regular basis. Too much bismuth can lead to loss of appetite, canker sores and poor absorption of nutrients. The aspirin-like salicylate component can cause ringing in the ears (tinnitus). Because of the subsalicylate, you should not combine it with aspirin. That could lead to a salicylate overdose. In addition, don’t mix Pepto-Bismol with warfarin (Coumadin) or other blood thinners/anticoagulants (clopidogrel, dabigatran, enoxaparin). Check with your pharmacist and physician before combining Pepto-Bismol with corticosteroids such as prednisone, or medications like methotrexate, valproic acid or dichlorphenamide.

Acid-Suppressing Drugs

There are two general categories of acid-suppressing drugs: histamine-2 (H2) blockers and proton pump inhibitors (PPIs). You will be familiar with both of them when we spell out the brand names, as they are widely available over the counter.

H2 Blockers

Sir James Black was one of the giants in the field of drug development. He helped invent the heart and blood pressure pill propranolol (Inderal) in the early 1960s. It went on to become the most prescribed drug of the early 1980s. Dr. Black received the Nobel Prize for this discovery in 1988.

After achieving fame for his beta blocker research, this pharmacologist turned his attention towards histamine. Most scientists of the day thought of histamine as the culprit behind the sniffles and sneezes of allergies. Antihistamines such as chlorpheniramine (Chlor-Trimeton) and diphenhydramine (Benadryl) helped relieve nasal symptoms but did zilch for the stomach.

Antihistamines for the Stomach?

James Black realized that histamine was important througout the body. This neurotransmitter is abundant in the stomach and plays a key role in stimulating the production of stomach acid. The typical antihistamines of the day did nothing to stop acid production in the stomach, however. What if Dr. Black and his SmithKline colleagues could create a new kind of antihistamine that could work in the stomach rather than in the nose?

The project almost got the axe, though. The company was experiencing a cash crunch. The Chairman of SmithKline, Robert Dee told the New York Times (Sept. 16, 1979):

“He [Dr. James Black] sank a lot of dry holes. We were within an ace of calling it quits in 1969. We then decided to go one more year.”

Dr. Black confided to us on April 20, 1983 that:

“Control of acid secretion was no place for histamine…The intellectual climate was against the idea. I was absolutely certain I would find the antagonist…I just didn’t doubt that we would finish it.”

They spent 10 years and created over 1,000 compounds before they hit on cimetidine (Tagamet). This histamine antagonist (H2 blocker) became the hottest drug in the history of the pharmaceutical industry. In 1981 The Wall Street Journal called it:

“…the most successful prescription drug ever marketed.”

From Histamine Blockers to Blockbusters!

By 1983 over 30 million people had taken Tagamet. This drug became the very first pharnaceutical billion dollar baby. Sales hit $1 billion in 1986. It’s chemical rival, ranitidine (Zantac), became the second billion dollar drug in 1987. Clearly, the H2 blockers had turned into blockbusters. It wasn’t too long before famotidine (Pepcid) joined the club. They were initially prescribed to heal stomach ulcers, and they worked quite well for that. All of them cut down on stomach acid production, which can allow an ulcer time to heal.

Bit by bit, though, doctors and patients started to use them for less specific digestive woes. Currently, these medicines are marketed mostly for heartburn relief. Most people tolerate them well. Occasionally, however, they may cause constipation, dizziness, diarrhea or fatigue. Cimetidine, in particular, has been identified as a potential problem for older individuals, who may experience confusion, disorientation or headache.

The Rise and Fall of Ranitidine

Recently, researchers have discovered that ranitidine can contain a nitrosamine impurity called NDMA. This probable carcinogen can show up during shipment or storage of the drug. There is also concern that ranitidine may degrade in the human body and produce unacceptably high levels of NDMA.

It is shocking to learn more than 30 years after Zantac was approved that a potential cancer-causing chemical could have have been lurking in this H2 blocker for so long. On April 1, 2020, the FDA requested that all ranitidine-containing products be removed from the marketplace.

When faced with the need for quick relief, we might pick Pepcid Complete. It contains the antacids calcium carbonate and magnesium hydroxide in addition to the H2 blocker famotidine that provides more lasting acid suppression.

Proton Pump Inhibitors: Dialing for Dollars

Scientists didn’t stop their search for acid-suppressing agents when they developed H2 blockers. Further research produced powerful medications called proton pump inhibitors, or PPIs for short. The initial PPI, omeprazole (Prilosec), has been joined by dexlansoprazole (Dexilant), esomeprazole (Nexium), lanzoprazole (Prevacid), pantoprazole (Protonix) and rabeprazole (AcipHex).

Drug companies have also created combination drugs. For example, omeprazole combined with sodium bicarbonate (aka baking soda) is the heartburn drug Zegerid. Esomeprazole with naproxen is Vimovo. These combination therapies may be far more expensive than taking the individual components separately (JAMA, Aug. 21, 2018). By the way, that caveat also applies to the combination of the H2 blocker famotidine with ibuprofen to create a pricey pill called Duexis.

Just as the H2 blockers dominated the ulcer and heartburn market during the 1980s, the PPIs began to make waves during the next decade. Prilosec was introduced in 1989 as the first of this new class of acid-suppressing drugs. By the year 2000, this prescription medication was bringing in $4 billion a year for the maker and had become the # 1 drug on the doctors’ hit parade around the world. It wasn’t long before other PPIs hopped on the bandwagon. Both Nexium and Prevacid became multi-billion-dollar drugs as well.

There is no doubt that PPIs can speed healing from ulcers. Studies have shown that adding esomeprazole to an aspirin regimen can keep ulcer-prone people from suffering recurrences (New England Journal of Medicine, Jan. 20, 2005; Clinical Gastroenterology and Hepatology, July 2006). But the promiscuous prescribing of these powerful acid-suppressors for routine indigestion was starting to give some doctors heartburn. That’s because proton pump inhibitors turned out not to be as safe as everyone imagined.

PPIs and a LONG List of Side Effects:

When Prilosec lost its patent protection, the FDA decided that the drug was so safe it could be sold without a prescription as Prilosec OTC. It was eventually followed by Nexium 24HR and Prevacid OTC. Americans love to play doctor and the idea of taking “strong” medicine appealed to millions of consumers. That and the advertising made these PPIs hugely popular. The only trouble with the plan was the growing list of serious side effects. Too few people, including doctors, are aware that these medications can cause potentially grave problems. In addition, they can trigger reactions that are not considered serious but may be bothersome: headache, nausea, stomach pain, diarrhea, vomiting and flatulence.

Allergies:

Hives are certainly not the most serious reaction people may have to PPIs. However, we imagine most people wouldn’t naturally associate their heartburn medicine with a newly discovered allergy. When doctors in Austria reviewed records for the entire country, they found that individuals taking PPIs were two to three times more likely to be prescribed an allergy medicine (Nature Communications, July 30, 2019).

Bone Fractures:

The question of whether PPI use reduces bone density and increases the risk of fractures is contentious. Data from almost 80,000 women in the Nurses’ Health Study show that those taking PPIs were more likely to break a hip (BMJ, Jan. 31, 2012). The rate among those taking a PPI was 2.02 per 1000 person-years, compared with the rate among those not taking such drugs of 1.51 per 1000 person-years. That’s 35% increased relative risk.

A relatively recent review concurred that most of the evidence points to more fractures among PPI users (International Journal of Environmental Research and Public Health, May 5, 2019). The investigators conclude:

“Therefore, patients on long-term PPI treatment should pay attention to bone health status and consider prophylaxis to decrease fracture risk.”

Cardiovascular Complications:

Studies indicate that people taking PPIs are more susceptible to heart attacks (PLOS One, June 10, 2015). Epidemiological research on nearly 3 million individuals found that those taking a PPI were 16% more likely to suffer one than individuals taking H2 blockers instead. A recent review of FDA safety data suggests that esomeprazole may carry the highest risk (Journal of Research in Pharmacy Practice, Oct. 16, 2019). PPIs indirectly reduce production of a natural compound, nitric oxide, that helps relax blood vessels (Circulation, July 3, 2013). Perhaps this action explains the cardiovascular complications that are associated with PPIs.

Dementia:

German researchers reported a few years ago that patients on regular PPI medication were more likely to develop dementia (JAMA Neurology, April 2016). They suggested “The avoidance of PPI medication may prevent the development of dementia.” However, they acknowledged more studies are needed.

Now Swedish investigators have turned up a possible explanation (Alzheimer’s & Dementia, May 8, 2020). Certain PPIs inhibit the enzyme the body uses to make the neurotransmitter acetylcholine. Without acetylcholine, brain cells cannot communicate well. This may well help to explain the link between PPI use and cognitive dysfunction.

Esophageal Cancer:

Barrett’s esophagus (BE) is a condition for which doctors often prescribe PPIs for months or years (Digestive Diseases and Sciences, Aug. 2018). In this condition, cells lining the esophagus (swallowing tube) change and become similar to cells lining the intestines. They also may proliferate, setting the stage for cancer of the esophagus. People with Barrett’s do have a higher risk for esophageal cancer.

The American Gastroenterological Association encourages its members to prescribe proton pump inhibitors to prevent Barrett’s esophagus from turning into esophageal cancer (Gastroenterology, March, 2017). How solid is the evidence? A study in PLOS One did not find a significant reduction in cancer risk (Jan. 10, 2017).

Perhaps more worrisome were the findings from a large Danish epidemiological study (Alimentary Pharmacology and Therapeutics, May, 2014). The researchers tracked all patients diagnosed with Barrett’s esophagus between 1995 and 2009. They actually found an increased risk of adenocarcinoma of the esophagus associated with PPI therapy. Swedish researchers have also reported an association between PPIs and cancer (Cancer Epidemiology, Oct. 2019):

“PPI use was associated with an increased risk of gastric and oesophageal cancer and the risk remained increased over follow-up. These results support our original hypothesis that use of PPIs may be a risk factor for gastric and oesophageal cancer in the general population of maintenance users, independent of underlying indications.”

This Man Bites Dog Story Is Hard to Swallow:

We would like you to pause for a moment or two so you can ponder what you have just read. Most gastroenterologists believe that just about everyone with a diagnosis of Barrett’s esophagus needs to be on a proton pump inhibitor like esomeprazole or lansoprazole for years, if not decades. We suspect that many would insist that a diagnosis of BE requires lifelong acid suppression to prevent gastrointestinal cancers from developing.

But what if PPIs contribute to gastrointestinal cancers? We know that is a heretical concept for most GI experts, but it is not without some supporting data. A review in the journal Cancers (Basel), July, 2022 reviewed the medical literature. The authors concluded:

“The findings of this updated meta-analysis suggest that the risk of gastric cancer is increased in patients treated with PPIs compared with patients not taking PPIs.”

They offer an explanation. Because PPIs are so effective at blocking the production of stomach acid, the body tries very hard to compensate. It does this by producing a substance called gastrin. This peptide hormone has a crucial job. It stimulates the production of hydrochloric acid. Remember, the human body tries very hard to create stomach acid. When acid levels drop because of PPIs, gastrin is produced in excess to try and kick start the process. Think of it a bit like a fountain that doesn’t turn off. Water will continue to flow even after it spills over the edge. When gastrin is created in excess it is called hypergastrinemia.

Gastrin also stimulates stomach motility. Think of that like a mixing bowl, churning food around and helping the stomach send it towards the small intestines. Gastrin also triggers cellular growth in the lining of the upper GI tract.

An article in Frontiers in Oncology, Oct. 24, 2023) was titled “The Central Role of Gastrin in Gastric Cancer.” The authors sum up their concerns:

“Long-term PPI treatment induces the risk of gastric NETs (neuroendocrine tumors) and also gastric cancer, presumably via a reduction in gastric acidity and hypergastrinemia…In a very recently published paper with the title ‘Proton pump inhibitors and increased risk of gastric cancer: how much more evidence is needed?’, Brusselaers and Simin concluded that, currently, a significant proportion of gastric cancers in the Western world could be due to PPI use. Moreover, there is every reason to fear that in the future the scale of this problem will only increase.”

The story on esophageal cancer is more complex. Again, most gastroenterolgists believe that PPIs protect the esophagus from cancer. But an article in the Journal of Gastroenterology (Oct. 18, 2022) offers a different perspective:

“In conclusion, this large population-based cohort study indicates that discontinuation of long-term PPI therapy is associated with a decreased risk of both gastric adenocarcinoma and oesophageal adenocarcinoma, although residual confounding cannot be excluded. In the absence of a clear indication for long-term PPI therapy, the need for PPI therapy should be reconsidered to avoid unnecessary cases of gastric and oesophageal adenocarcinoma.”

The European spelling of esophageal is oesophageal. This Swedish research has challenged American gastroenterologists. We make no recommendations. This controversy requires a candid conversation between patients and their clinicians and a recognition that there are still more questions than answers when it comes to the long-term safety of PPIs. That is especially true regarding gastrointestinal cancers.

Infections:

Among the earliest complications recognized was a higher risk of infections. Apparently, stomach acid helps to keep many pathogens from getting into the body and causing trouble. Suppressing it may leave people vulnerable to infectious diarrhea (British Journal of Clinical Pharmacology, Jan. 5, 2017). The C. diff and Campylobacter infections researchers have noticed can lead to hospitalization for dangerous dehydration.

When you are taking a drug for heartburn or GERD, diarrhea may not be completely unexpected. However, PPI use has also been associated with a greater likelihood of community-acquired pneumonia (PLOS One, June 4, 2015). This shows up among people who have been taking their heartburn drug for a short period of time (Expert Review of Clinical Pharmacology, May 2012).

Kidney Injury:

Other researchers who analyzed FDA safety data (FDA Adverse Event Reporting System, or FAERS) found evidence that PPIs are linked to a higher risk for kidney stones and damage to the kidneys (Scientific Reports, Feb. 19, 2019). Importantly, the people who developed kidney problems in this study were not taking other medications that could could cause kidney injury. Possibly due to disturbances of kidney function, the investigators also found that people taking PPIs were more likely to have low levels of magnesium and calcium in their bodies.

Liver Damage:

Although Americans don’t spend much time thinking about their livers, scientists have considered the impact of PPIs on liver health. People who have compromised liver function due to hepatitis C infection (Alimentary Pharmacology & Therapeutics, Jan. 2018) or regular excess alcohol consumption (Nature Communications, Oct. 16, 2017) seem to fare worse when they also take one of these heartburn medications. In addition, people taking a PPI seem to be two to three times more likely to develop liver cancer known as hepatocellular carcinoma (Alimentary Pharmacology & Therapeutics, Aug. 2018). A recent review suggests that people with chronic liver disease are at increased risk of liver cancer and death if they take PPIs (European Journal of Clinical Pharmacology, June 2020).

Thyroid Treatment:

Some time ago, we received a question from a reader who wondered why the levothyroxine prescribed to treat hypothyroidism wasn’t working well. We discovered documentation that PPIs can reduce absorption of this medication (Clinical Drug Investigation, March, 2015). Stomach acid is important for the proper absorption of levothyroxine as well as certain other drugs. If you must take a PPI, you may need the doctor to adjust the dose of thyroid hormone.

Premature Death:

Scientists in St. Louis published data from the Veterans Administration showing that PPI use is linked to premature death from a variety of causes (BMJ, May 30, 2019). Some doctors were alarmed, while others were skeptical. However, many physicians now recognize that PPIs do have serious adverse effects and that they should not be used for a long time (American Journal of Gastroenterology, May 2020). The authors point out that some conditions do call for long-term use of these drugs and call for “ensuring that PPIs are prescribed appropriately according to individual risks and benefits.”

Rebound Hyperacidity:

We started hearing from readers of our syndicated newspaper column that if they stopped a PPI suddenly their hearburn returned with a vengeance. Many prescribers believed that this was just their regular reflux returning. These doctors made it clear that such patients needed to get back on the acid suppressors pronto. But a study published in Gastroenterology (July, 2009) proved that even healthy people without a history of heartburn could develop rebound hyperacidity after taking PPIs:

“PPI therapy for 8 weeks induces acid-related symptoms in healthy volunteers after withdrawal. This study indicates unrecognized aspects of PPI withdrawal and supports the hypothesis that RAHS [rebound acid hypersecretion] has clinical implications.”

The bottom line seems to be that after a few weeks on a proton pump inhibitor the body’s acid making machinery goes into overdrive. If the PPI is stopped, the symptoms of heartburn can be unbearable for a considerable length of time.

Getting Off a PPI:

The Food and Drug Administration has been surprisingly slow to recognize what is now called sudden discontinuation syndrome. Physicians and pharmacists have not been adequately alerted to withdrawal symptoms when patients stop anti-anxiety agents like alprazolam (Xanax), antidepressants such as venlafaxine (Effexor) or a pain reliever like tramadol (Ultram, Ultracet). Drug companies have not been required to develop protocols for gradual tapering of these medications or for proton pump inhibitors.

So how do you stop taking a PPI? As we explained above, it can be difficult. Studies suggest that tapering the dose gradually is better than stopping cold turkey (Family Practice, Dec. 2014). Unfortunately, doctors have not reached a clear consensus on the best way to stop taking one of these drugs (International Journal of Molecular Sciences, Nov. 2, 2019). However, here are the tactics we have gleaned (Current Gastroenterology Reports, May 16, 2018). Plan on the withdrawal taking at least six weeks. Some people may be able to move more quickly, but others will have to take things more slowly, perhaps as long as six months.

• Reduce the dose very gradually. Doctors often suggest that people go from once daily to once every other day for a few weeks. Then once every three days until eventually phasing off completely.
• Such instructions are woefully inadequate. Some people need to reduce the dose much more slowly. They might find an oral disintegrating tablet helpful because it can be broken into pieces. That way you could go from a whole tablet to 3/4 of a tablet for several weeks, then to half a tablet and eventually to a quarter of a pill before skipping any pills.
• Some PPIs come in capsules that contain “sprinkles.” The manufacturer recommends opening the capsule and adding the sprinkles to applesauce or yogurt. You could gradually cut down on the proportion of the capsule that you take in this manner.
• You may still have some heartburn symptoms as you cut back on the PPI. Consider adding an H2 blocker such as cimetidine or famotidine when you have acid reflux symptoms.
• Antacids could also help control symptoms.
• Some people report that a very low-carb diet can reduce heartburn symptoms significantly. This was confirmed in a study (Digestive Diseases and Sciences, Aug. 2006).
• If a very low-carb approach does not appeal to you (or if you try it without success), increasing the fiber in the diet is an alternative (World Journal of Gastroenterology, June 7, 2018). That means concentrating on whole grains and vegetables (at least 5 servings daily) and skimping on sweets.
• Experiment with DGL (deglycyrrhizinated licorice). This botanical medicine helps protect the stomach lining by increasing natural mucus secretion (European Journal of Pharmacology, June 19, 1981). Naturopathic doctors have used it as an alternative to PPIs or H2 blockers for acid reflux (Integrative Medicine, Aug. 2018). The recommended dose is 760 mg 20 minutes before a meal. Take it on the days you do not take the PPI.
• Sip persimmon tea with cinnamon and ginger. This is traditionally served sweetened; for medicinal purposes, you will want to use the minimum amount of sugar you find palatable. To make it, bring 2 quarts of water to a boil with 2/3 cup fresh ginger root, peeled and sliced, and 3 cinnamon sticks. Simmer it for 30 minutes. Strain and add honey to taste and 1/2 fresh persimmon, washed and sliced. If fresh persimmon is not in season, 1/2 cup sliced dried persimmon may be substituted. Refrigerate the tea and take 2 ounces before each meal to ease PPI withdrawal.
• A good probiotic would be a sensible addition during the time you are getting off the PPI. Acid-suppressing drugs can alter the gut microbiota (Neurogastroenterology and Motility, April 21, 2020), so a probiotic may help with recovery. ConsumerLab.com has tested several; the popular brands Culturelle and Florastor performed well in their test.
• Take ginger capsules to treat occasional heartburn symptoms.

Flatulence

Everybody passes gas. Most people do so 14 times per day on average. Michael Levitt, MD, one of the world’s leading flatologists, has said that 22 or fewer flatus events per day is normal, and doesn’t require any special action.

As in all areas of life, however, there are always some overachievers. We once heard about a man whose output was so impressive— and so distressing, to him, and no doubt to others—that Dr. Levitt encouraged him to keep a “flatulographic record” (aka a fart chart) in order to figure out which items in his diet might be triggering his problem. By making note of every time he had a “flatus event,” he soon found out that milk was the culprit. When he went on a plain milk diet, he passed gas 141 times in a single day! In fact, he farted 70 times in a single four-hour period—in other words, once every 3.4 minutes.

One maddening thing about flatulence (besides the obvious) is that everyone’s triggers are different. There’s no easy way to know what might be causing your discomfort without keeping a careful record of what you consume (and thus create). There are, of course, some common offenders. Perhaps you have heard the grade-school verse that goes, “Beans, beans, good for the heart, the more you eat, the more you fart.” But what about wheat, barley, and rye? Or, more surprising still, the drugs paroxetine (Paxil) or atorvastatin (Lipitor)?

Digestive discomforts can come from the unlikeliest places. But luckily, there are also some unlikely-sounding remedies that may ameliorate the problem, or at least help trap the odor. Have you ever considered sipping fennel seed tea for gas? Or experimenting with carbonized underclothes to keep bad smells at bay? Cutting back on the foods that cause you trouble seems sensible. But which ones are they?

A good place to start is with the aforementioned fart chart. It’s a diary of everything you eat—and the medications you take—and every time you fart. Creating this kind of record can help gas-prone people determine which things are triggering their flatulence. You might think the answer is just to hold it in. Not everyone can do this—some people’s sphincters are stronger than others. But even if you can hold it like a pro, we don’t recommend it. As most practitioners have no doubt noticed, holding gas in can lead to painful cramping, pressure, bloating, and even colic.

We know there’s a social stigma attached to farting in public, but we say: let ’em rip. It will keep the pain away. Of course excuse yourself to the bathroom when you can, and sometimes you may feel it’s necessary to hold it in. We agree that a board meeting is not necessarily the time to let out a loud, smelly fart. But try not to get in the habit of squeezing farts away. Instead, figure out your triggers.

Drug-Induced Flatulence

When was the last time your physician warned you that one of the drugs she was prescribing could give you gas? And yet there are hundreds of medications that can cause flatulence. Part of the reason for this is that lactose is a filler in some drugs. For those who are lactose intolerant, this could certainly cause a problem.

Below, you’ll find a list of some of the medications that have commonly been linked to flatulence, but it’s by no means exhaustive. You may want to check with your physician if you’re still having trouble after keeping a fart chart, watching your diet, and taking other measures. It could be that the problems you’re having are linked to your medications.

Getting Rid of Gas

Of course there are lots of foods that cause gas which we shouldn’t avoid because of their wonderful nutritional properties: legumes like beans and lentils, and vegetables like broccoli, kale, and cauliflower. So what can you do to keep the gas at bay while still consuming the foods that you should eat to stay healthy?

Beano

There’s no shortage of products on the market that claim to help get rid of gas. But there is a shortage of clinical evidence to back those claims. With one exception. There is some degree of scientific support indicating that Beano can help stop gas in its tracks. Italian researchers report that it helps control flatulence in children (BMC Gastroenterology, Sep. 24, 2013). Scientists have also tested it in adults, providing a test meal of cooked beans and tracking flatus events afterward (Digestive Diseases and Sciences, Jan. 2007). The test pills performed significantly better than placebo.

Beano was created by Alan Kligerman, who grew up delivering milk for his family’s New Jersey dairy. This dairy man cum inventor was also the creator of Lactaid, a godsend for people with lactose intolerance. Lactose intolerance commonly causes bloating and gas, so Lactaid is likely to be useful for flatulence for many of those individuals.

Beano contains alpha-galactosidase, the enzyme that helps break down the complex sugars in beans and veggies like cauliflower and cabbage. Some people swear by it; others say it hardly has any effect. At $10 to $15 for 100 pills, it may at least be worth a try; it doesn’t seem to produce undesirable side effects. Take Beano with foods that tend to give you gas, and don’t skimp. A normal dose is 3 or 4 Beano pills, although you may need only 2 or 3 of the Ultra800 higher-dose formulation.

Simethicone or Charcoal

The active ingredient in many widely advertised gas-busting products is simethicone, a defoaming agent. However, its benefits have yet to be proven scientifically.

Another common ingredient in over-the-counter fart-fighters is charcoal. Activated charcoal is used in water filters, gas masks, and air filters to suck up harmful toxins, and it’s also long been marketed as a gas guzzler (so to speak). The data are mixed on whether or not taking charcoal orally can cut down on flatulence. What’s more, it can also interact with a lot of meds, including aspirin.

On the other hand, cushions, pads, and even underwear containing charcoal do seem to work quite well, acting as a filter for your derriere. Underwear made of activated carbon cloth won’t stop you from farting. But according to gas expert Michael Levitt, MD, it can block 95 to 99 percent of bad odors. A few brands you will find are made by Under-Tec and Shreddies.

Another—though less effective—option is carbon-based pads that you secure into your regular underwear. Brands include Flat-D and UnderEase and filter about 50-75 percent of smells. And the Flat-D Cushion is roughly 60 percent effective at trapping odors.

Pepto Bismol

You’re probably already familiar with Pepto Bismol, the pink stuff known for helping alleviate diarrhea. But maybe you didn’t know that it can also take away stinky gases. When Dr. Levitt and his colleagues tested it, they found that it could banish 95 percent of bad smells.

That said, we don’t advocate regular consumption of Pepto Bismol. Too much of its active ingredient, bismuth subsalicylate, could lead to bismuthism, which is not good. Symptoms of bismuth poisoning include nausea, vomiting, stomach pain, diarrhea, mouth ulcers, skin rash, and kidney damage. Pepto Bismol also shouldn’t be taken with blood thinners like warfarin (Coumadin). Please follow the instructions for use on the label, and be moderate. Occasional use after a very smell-inducing meal would be fine.

Probiotics

Probiotics might help repopulate our small intestines with good bacteria, which shoulder out the bad guys that are responsible for producing gas. It seems logical that they should help get rid of malodorous fumes, but the jury’s still out. A review of research found that people with lactose intolerance often benefit from probiotics (Nutrients, May 20, 2020). Another review found that multi-strain probiotics can diminish symptoms of irritable bowel syndrome such as pain, bloating, and flatulence (International Journal of Surgery, May 2020). You can find Lactobacillus rhamnosus GG strain in capsule form. Some brands of yogurt, like Dannon’s Activia brand, also contain probiotic strains added above and beyond the cultures used to ferment the milk.

Spices and Herbs

Asafoetida

Asafoetida is a resin from the underground portions of the plant Ferula asafoetida. It has been referred to in English as stinking gum or devil’s dung, suggesting its strong unpleasant odor.

In traditional Indian herbal medicine, asafoetida is used for lung conditions as well as digestive disorders. It contains compounds that prevent blood clotting and lower blood pressure (Pharmacognosy Reviews, July 2012).

We understand that Indian cooks add hing to dishes that might otherwise cause flatulence and that it is valued as a culinary spice. Apparently it also has antifungal and anti-inflammatory activity and can be used to lower blood sugar (Journal of Ethnopharmacology, Mar. 8, 2011).

Fennel

One herb that’s long been used to get rid of gas is fennel seed. It has a nice, licorice-y smell (although it’s not licorice and doesn’t have the same medicinal properties or side effects), and it can be found on the spice shelf of most supermarkets. To tame smelly gas, you can get it in capsule form (look for it in health-food stores), or you can make tea from its seeds. To make fennel seed tea, start with a teaspoon of fennel seeds. Crush them slightly with the back of a spoon or a mortar and pestle. Pour 8 to 10 ounces of boiling water over the bruised seeds, and let them steep for about 5 minutes. Then strain out the seeds, and sweeten if you like (though keep in mind that some sugar-free sweeteners can make gas worse). You can drink up to three cups per day.

Bitters

Along with fennel, there are lots of other herbs and spices that have anti-flatulence properties. Some herbal mixtures called “bitters” were designed specifically to ease digestive discomfort. Many people find that a few drops of Swedish or Angostura bitters in water can help with gas and indigestion.

Other Spices

Other long-popular herbal remedies for digestive issues are turmeric, the yellow herb often used in South Asian food, and ginger. This can be tossed into cooking (i.e. beans), sipped as a tea, or even ingested as candy.

In the Hispanic community, epazote (Dysphania ambrosioides) or yerba buena (Mentha citrata) are both popular.

De-Gassing Beans

One of our faithful readers, Parker Enwright, from Orlando, Florida, sent us a way to “eliminate gas-producing sugars before eating beans.” Enclosed was a note from a food seminar in Canada. Parker insists this “really works–I have used it with complete success for about two years. (My bean soups are famous among friends as “no f— beans!)”

To prevent flatulence from beans, put beans in water to cover and boil three minutes. Remove from heat and let beans soak in this water, at room temperature, for at least four hours. Pour off and discard the water. Use fresh water to cook beans. Discarding this water after the quick boil and soaking rids the beans of two sugars (raffinose & stacchyose) that cause flatulence.

Pulse Crop Development Board
Saskatchewan, Canada, 1989

Celiac Disease

Sometimes, gas can be the symptom of something more serious. One possible cause is celiac disease, which affects far more people than once thought. It used to be that doctors believed only 1 in 5,000 people were likely to have the illness, whereas now they think that it may be as common as 1 in 100, or even as high as 1 in 22 in families prone to the condition.

People with celiac disease can’t tolerate gluten, which is found in the grains wheat, rye, and barley. When they eat gluten, they experience an immune reaction that kills off cells in their small intestines. Not surprisingly, this can lead to all sorts of uncomfortable abdominal symptoms (listed below), and it also makes it difficult to absorb calcium, magnesium, iron, and other nutrients that the body needs.

Lots of doctors practicing today were never taught about the wide array of problems that celiac disease can cause, like migraines or peripheral neuropathy. With new evidence of its ubiquity, we think more patients should be tested for this condition.

If you have several of the symptoms on the list below, ask your doctor for EMA (endomysial antibody) and tTG (tissue transglutaminase) blood tests. People with celiac disease MUST avoid all foods and beverages containing gluten (like wheat-based pizza, bread, bagels, pretzels, pasta, and beer), which should help clear up a lot of digestive problems.

Some Signs and Symptoms of Celiac Disease:

• Anemia (iron deficiency)
• Bloating
• Bruising
• Dementia
• Diarrhea or runny stools (They may float and smell terrible)
• Fatigue
• Gas and flatulence
• Headaches and migraines (frequent)
• Heartburn
• Itchy skin rash
• Numbness or tingling (hands and feet)
• Osteopenia (weakened bones), osteoporosis
• Reflux

Many doctors believe that celiac disease mostly affects children, but more recent research shows that people past middle age can be diagnosed for the first time with celiac disease (BMC Gastroenterology, June 29, 2009; Gastroenterology Clinics of North America, Sep. 2009).

Following a Gluten-Free Diet:

Food labels have gotten better at identifying gluten as an ingredient than they were decades ago. Still, US manufacturers are not as good about this as European manufacturers. People who must follow a gluten-free diet need to make sure they are getting proper nutrition from a range of vegetables and fruits as well as protein such as eggs, fish, chicken or meat (European Journal of Nutrition, March 2017). None of those foods in their natural state contain any gluten, but vegetarians need to read the labels carefully if they use meat substitutes. Many contain gluten.

Constipation

People around the world are concerned about regularity, and have been so for a very long time. The ancient Egyptians used aloe vera as a laxative, while Arab healers in the ninth century used senna for that purpose. The lasting power of laxatives can be seen by the fact that more than a thousand years later, the popular laxative Ex-Lax contains senna-derived compounds.

When constipation is defined in terms of regularity, no single standard determines what is normal. Some people do well with two or three bowel movements a week, while others may visit the bathroom three times a day. Effort counts, too, and so does the consistency of stool. Passing “bricks” can be distressing.

If bowel movements suddenly become infrequent or difficult, or if increased fluid and fiber don’t help, it is appropriate to check with a doctor. An underlying medical problem, such as Parkinson’s disease or an underactive thyroid gland, requires treatment. When there is no apparent medical cause, physicians may dismiss constipation as a minor complaint. Patients don’t see it that way. One man suffering from heart disease, failing vision, and prostate enlargement still rated constipation as one of his most troublesome health problems.

Medicines That Cause Constipation

Physicians may sometimes contribute to constipation unintentionally and without informing their patients. Quite a few medications may cause constipation as a side effect. Narcotic pain medicines and older antidepressants are especially notorious in this regard, and some anti-cancer medicines and AIDS drugs can also be constipating. If this happens to you, don’t stop taking your medicine. It may be a lifesaver. But do discuss the situation with your doctor. In some cases there may be an alternative that is less likely to produce this complication. Here is a short list of constipating drugs. It represents just the tip of the figurative iceberg.

As mentioned above, this is just the proverbial tip of the iceberg. If you are taking older-generation antihistamines (such as diphenhydramine or chlorpheniramine, medicines for overactive bladder like oxybutynin, older antidepressants (amitriptyline, doxepin, etc) blood pressure meds such as beta blockers like metoprolol or calcium channel blockers such as amlodipine, the cholesterol-lowering med cholestyramine or prescription pain relievers like tramadol, constipation could be your companion. Please check with the prescriber if any of your medications are be causing you digestive difficulties.

Overcoming Constipation

High Fiber Foods

All-Bran
apples
bananas
barley
beans
blackberries
bran
Bran Buds
Bran Flakes
broccoli
bulgur wheat
chickpeas
Fiber One
figs
lentils
lima beans
Mother’s Oat Bran
Nabisco 100% Bran
pears
peas
popcorn
prunes
Raisin Bran
raisins
Shredded Wheat’n Bran
split peas
Uncle Sam cereal
winter squash

The first rule in preventing constipation is to get plenty of fiber and fluid. Here’s how: make sure you drink six to eight 8-ounce glasses of water or juice daily. Eat five to ten servings of vegetables and fruits. One reader found that four ounces of prune juice with pulp daily solved her problem.

For extra fiber, whole bran or bran cereal is useful, and so is psyllium (Metamucil, Perdiem Fiber, Reguloid, Serutan and similar products). Fiber can cause bloating or flatulence, though, so it is best to start with a little and increase the dose gradually. Be sure to wash such products down with plenty of water.

Bulk-producing laxatives such as polycarbophil or methylcellulose work in a similar fashion to fiber. Brands such as Citrucel, FiberCon, Fiber-Lax, Konsyl Fiber, or Mitrolan should be taken according to instructions. Neither bulk-forming laxatives nor any other laxative should be used if a person has nausea, vomiting, fever or severe abdominal pain that might indicate appendicitis or intestinal blockage. Such conditions require urgent medical attention.

Recipes for Relief

Power Pudding

Mix:

• 1 cup coarse unprocessed bran*
• 1 cup applesauce
• 3/4 cup prune juice

The mixture will be very thick. Take 1 or 2 tablespoons daily, washed down with plenty of water. Refrigerate unused portion. If there are no results within a week, increase the dose by 1 tablespoon. Do not exceed 6 tablespoons daily.
*found in the cereal section

Pumpkin Bran Muffins

Preheat oven to 400 degrees.

Combine:

• 1 cup whole wheat flour
• 1 1/2 teaspoons baking powder
• 1/2 teaspoon baking soda
• 1 teaspoon cinnamon
• 1/2 teaspoon ground ginger
• 1 teaspoon nutmeg

in a large mixing bowl and set aside.

In another bowl, combine:

• 2 cups bran cereal
• 1 1/4 cups reduced fat milk
• 1/3 cup dark brown sugar
• 1 egg (large)
• 1/2 cup canned pumpkin
• 3/4 cup raisins
• 1/2 cup diced dried apple and stir well.

Let the bran mixture sit for approximately five minutes to allow bran to soften. Stir it into the dry ingredients (waiting in the large bowl) just enough to blend. (Don’t overmix.) Drop the batter into muffin pans lightly oiled and lined with cupcake papers. Bake at 400 degrees for about 18 to 20 minutes, until a toothpick inserted in the center of a muffin comes out barely clean.
Thanks to Kit Gruelle for this recipe.

If the principal problem is a hard stool, or if recovery from surgery makes it uncomfortable to strain at all, a stool softener such as docusate (Colace, Dialose and others) may be recommended. Mineral oil is sometimes taken to lubricate the stool and make it easier to pass, but this product interferes with absorption of nutrients, especially fat-soluble vitamins, and its regular use is not recommended.

When confronted with especially stubborn constipation, gastroenterologists sometimes resort to osmotic laxatives. These substances attract water into the colon, softening stool and triggering movement. Perhaps the best known are Milk of Magnesia (magnesium hydroxide) and Epsom Salt (magnesium sulfate). Such products may upset the balance of fluid and minerals in the body, and should not be given to children or people with chronic disease except under medical supervision. Certain sugars that are not well absorbed, especially sorbitol and lactulose (Chronulac, Duphalac, etc.) also act as osmotic laxatives. (This is why sugar-free gum or candy containing sorbitol or mannitol can cause diarrhea for some people.)

For some people who must take strong pain medicines, constipation can be agony. One reader confessed: “I have used over-the-counter harsh laxatives from childhood and have tried just about every herbal laxative known to man. I am on numerous prescription painkillers that cause constipation, so I’m in a lose-lose situation. I’ve gone 14 days without relief, and when I do have a movement, it is too painful to describe.” MiraLax (polyethylene glycol 3350) may be helpful in such a difficult situation. It is an osmotic laxative similar to the products used to clean the colon prior to a colonoscopy. It should never be used more than once a day.

Tips to Combat Constipation

Many readers have shared their practical wisdom with us. One woman in Seattle, Washington, reminds us that some people experience difficulties with constipation after eating specific foods. Mango has this effect for one person in her family, and many people know that cheese has this reputation. She warns that peanut butter can also slow the system down. Other readers, keeping in mind that coconut macaroons seem to be a helpful antidote for diarrhea, avoid coconut when they are troubled with constipation.

People have special favorites when it comes to foods for fighting constipation. One reader proclaims, “The VERY BEST fibers are leafy green vegetables, like SPINACH.” Another swears by prune juice with pulp, a traditional stand-by. Prunes have a well-deserved reputation for combatting constipation. In additional to the natural fiber in this fruit, scientists have found a compound in prunes that is similar to a laxative used in the 1950s. This drug, oxyphenisatin, was taken off the market because it was associated with liver problems. It seems unclear whether prunes really contain this compound, but if they do, it would be smart to follow the advice of the Harvard Health Letter: “It is unlikely that moderate consumption would cause any problems, but prune use, like everything else, should be prudent.”

Another old-fashioned approach to constipation is “hot lemonade”— hot water with a big squeeze of lemon juice first thing in the morning. If you prefer coffee, there is evidence that about three cups of your favorite brew can get things going (Diseases of the Colon and Rectum, Aug. 2019). Dates and apples are popular, too. Another is blackstrap molasses. According to a reader, “I take 3 spoonfuls 4 every other day and I no longer need laxatives. It is not a laxative but it works. When I need extra help, I eat some black licorice.”

Flax seed can be beneficial in avoiding constipation. We like this reader’s description of how she uses it:

“Some time ago you had a question from a person who wanted to know how to use flax seed to relieve constipation. I purchase it in bulk at a health food store for about $1.50 per pound. I put three quarts of water on to boil, add two tablespoons of flax seed and simmer for fifteen minutes. Then I cool it and strain it into containers. (It makes just over two quarts.) With two ounces in my orange juice every morning, I am more than satisfied.”

Several herbs may be useful, though we don’t recommend regular use of the usual laxative herbs like senna. Ginger, on the other hand, can stimulate digestive tract action. It is not habit forming and is said to ease flatulence as well. Milk thistle, an herb used to protect the liver, has given one reader relief: “I’m 75 and I’ve had trouble all my life. A few months ago, a doctor told me about milk thistle. His wife takes it so I tried it. Milk thistle works wonders.” Dong quai also has laxative action.

Dietary supplements sometimes cause diarrhea as a side effect. At high doses, vitamin C can cause diarrhea, and some readers have used this to fight constipation. Others utilize the mineral magnesium. After all, milk of magnesia, a magnesium salt, is a time-honored laxative. Taking magnesium with calcium can ease the constipation sometimes associated with calcium supplements.

If these remedies don’t help, and constipation is a persistent problem, please get medical attention. Constipation could be a symptom of something more serious that requires prompt treatment.

Joe & Terry’s Ten Tips to Combat Constipation

• Lots of fiber & fluid
• Bran-apple-prune mix
• Flax seed
• Sugarless gum
• Psyllium
• MOM (milk of magnesia)
• Unifiber (cellulose)
• Pumpkin bran muffins
• Vitamin C
• Ginger

Diarrhea

Diarrhea has probably been one of the most common complaints of humans from time immemorial. Just imagine what hunters and gatherers had to eat just to survive. A lot of what was consumed would likely be considered inedible today. But in times of famine, our ancestors couldn’t be picky. Remember, there was no such thing as refrigeration, vacuum sealing or chemical preservatives to keep food from spoiling. As a result, people likely suffered from all sorts of intestinal infections and diarrhea would have been an obvious consequence.

There are lots of names for diarrhea, especially if it occurs while traveling: Montezuma’s revenge, turista, Delhi belly, Turkey trots and Katmandu crud to list a few. Traveler’s diarrhea can be brought on by a range of nasty organisms. Bacteria, parasites or viruses can all trigger gastrointestinal symptoms. We’ll tackle traveler’s diarrhea shortly.

Diarrhea can be short lived, lasting only a few miserable hours. It can also be chronic, lasting for months or even years. If it is caused by food poisoning, a laboratory may be able to identify the culprit in a stool sample. Not infrequently, though, diagnosis can be challenging. Here are just a few of the things that can cause diarrhea:

• Bacterial infections of the intestinal tract
• Viral infections of the intestinal tract
• Parasites
• Drug reactions
• Irritable Bowel Syndrome
• Inflammatory Bowel Disease
• Food allergy (sulfite, peanuts, etc.)
• Lactose intolerance
• Celiac disease (intolerance to gluten)
• Sorbitol, mannitol, xylitol (the sweeteners in sugarless chewing gum and many low-cal goodies)

Drug-Induced Diarrhea:

Many cases of chronic diarrhea can be caused by medications. There are over 500 different drugs that can cause loose stools. The popular diabetes drug metformin, for example, can cause a range of gastrointestinal symptoms, including nausea and diarrhea. A few other culprits include the osteoporosis medication risedronate (Actonel), the anticonvulsant lamotrigine (Lamictal) and the antidepressants citalopram (Celexa) and desvenlafaxine (Pristiq). These represent a tiny fraction of the hundreds of medications that can disrupt your digestive tract. If your diarrhea has persisted, always ask your physician and pharmacist whether one or more of your medications might be contributing to the problem. There may be an alternative that doesn’t affect your GI tract.

Sometimes drug-induced diarrhea can be life threatening. The antibiotic clindamycin, for example, may trigger an imbalance in the bacterial microbiome of the GI tract. If someone develops a Clostridioides difficile (C. diff) infection from this drug, it can be devastating. (You might recognize its previous name better: Clostridium difficile.)

Ellen offered her experience as a cautionary tale:

“I was given IV clindamycin during hip replacement surgery. Five days later, I woke up in the middle of the night with severe diarrhea, and I hurt really badly all over. On the second day of diarrhea I saw the doctor, who said it was just an intestinal bug. On the third day I was disoriented, but I remember saying I just wanted to die.

“My husband came home from work that night, took one look at me and said, ‘We are going to the hospital.’ I was diagnosed with C. diff. It was affecting my heart and my breathing. I was very dehydrated and my potassium was too low. I was extremely disoriented, and I remember very little of two or three days in the hospital. I was finally able to go home after four days, although I was still weak and still had diarrhea.

“Six months later, I saw a new doctor who was shocked that I still had diarrhea. I tested positive for C. diff and just finished a round of vancomycin. Now my stools are mushy. I’m hoping that they will return to normal, but I don’t know what to do when I need antibiotics again. I am allergic to amoxicillin and will NOT take clindmycin again.”

Dentists frequently prescribe clindamycin to manage infections in the mouth.

This can have unexpectedly severe consequences, as Janet related:

“In December, 2010, I had a colonoscopy and the results were very good. Toward the end of January, 2011, I had a root canal. The dentist had to remove an old silver filling I’d had in that tooth when I was a child. She disturbed some bacteria when she was cleaning the tooth out in preparation for the root canal.

“The next evening, my tooth began to hurt. I texted my dentist and she prescribed the antibiotic clindamycin. I picked it up from the pharmacy and took one of the pills before I left the pharmacy.

“I took one more that night before going to bed and continued on clindamycin for the next two days. Then I started having severe abdominal pain. I texted my dentist and told her about the pain and she told me to stop taking the clindamycin.

“The pain started getting worse, so my medical doctor told me to go to the clinic ASAP. When I got there, I was sent across the street to the emergency room in the hospital where I was diagnosed with C. diff. My colon was very inflamed. I was kept in the hospital for six days and I had to stay at home after being discharged from the hospital for an additional 8 days (a total of 14 days away from work). It has been several years and I am still not really back to normal.”

The problem with C. diff is that the antibiotics can disrupt the usual balance of microbes in the digestive tract. If beneficial bacteria die off, C. diff is ready to jump into the vacant ecological niche and multiply like crazy. Think of your digestive tract a little like a garden. The soil has to be nurtured with nutrients. That’s the food you eat. If you are a junk food junkie, the gut environment will suffer. Fiber is the fuel for your microbiome. Most Americans don’t get nearly enough fiber in their diet. So too, a garden that is depleted of nitrogen, phosphorus, potassium, calcium, magnesium and sulfur will not flourish.

Now imagine if you overdid it on the weedkiller. Too much herbicide on a garden might kill off the good plants along with many of the weeds. Over time, though, the hardiest weeds might come back before the vegetables and flowers can get a foothold. After several weeks the weeds might take over. That can happen very fast in the digestive tract when powerful antibiotics kill off the natural balance of bacteria.

FMT: Fecal Microbiota Transplantation:

That’s probably why one of the most effective treatments for C. diff overgrowth that causes intractable diarrhea is a fecal microbiota transplant. OK, we know that sounds kind of gross. But if you have been fighting intractable diarrhea for weeks or months because your bacterial balance is out of whack, you might seriously consider a reseeding of your colon with a healthy balance of microbes. Here is what the experts have to say about this approach:

“Fecal microbiota transplantation (FMT) is a procedure involving transfer of stool from a healthy donor into the intestinal tract of a diseased recipient to restore intestinal microbial composition and functionality. FMT’s tremendous success in recurrent and refractory Clostridioides difficile infection (CDI) catalyzed gut microbiota research and opened the door to microbiome-based therapy for various gastrointestinal and other disorders. Expert opinion: FMT as the best tool for treatment of antibiotic-refractory CDI has gained immense popularity over the last decade” (Expert Opinion on Biological Therapy, Jan. 2020).

There are benefits and risks of all drug therapies. That’s also true of FMT. Donor screening is crucial to prevent the risk of “catching” some other intestinal infection from the FMT. A gastroenterologist who is skilled in this approch can guide you through the process.

Garden-Variety Diarrhea:

We suspect that the underlying causes of most cases of “common” diarrhea rarely get diagnosed. You let something go too long in the refrigerator and goodness knows what started growing. Uncle Arthur’s special barbecue sauce might have contained something that just didn’t agree with you. Symptoms can last a few hours or a few days. They can be mild or severe.

Diarrhea can be the sign of a dangerous illness, and doctors often treat it seriously. Even if it isn’t caused by something life-threatening, it can result in dehydration and weakness. Prolonged diarrhea is certainly a reason to get to the doctor fast.

Treatment:

The Mayo Clinic website pretty much sums up the mainstream medical perspective on garden-variety diarrhea:

“Most cases of diarrhea clear on their own within a couple of days without treatment. If you’ve tried lifestyle changes and home remedies for diarrhea without success, your doctor might recommend medications or other treatments.”

Loperamide (Imodium):

The doctor’s go-to diarrhea drug is often loperamide (Imodium). It has been around since the 1970s. By the 1980s it was the most prescribed antidiarrhea drug in the US. The FDA approved loperamide for over-the-counter sale as Imodium A-D (A-D presumably short for anti-diarrhea) in 1988. Loperamide is now available in generic form at relatively low cost.

How does loperamide work? Anyone who has ever had to take opioids for pain relief knows that one frequent complication of drugs like hydrocodone or oxycodone is constipation. Opioids slow down the digestive tract. The official prescribing information notes that:

“Loperamide binds to the opiate receptor in the gut wall. Consequently, it inhibits the release of acetylcholine and prostaglandins, thereby reducing peristalsis, and increasing intestinal transit time.”

The neurochemical acetylcholine controls muscular contractions that cause peristalsis (wavelike squeezes that move food and waste through the digestive tract). Take away action of acetylcholine and you slow down the GI tract and help control diarrhea. The maximum dose for prescription-strength loperamide is 16 mg per day. The OTC dose is 8 mg per day.

In 2018, at the height of the opioid crisis, the FDA decided to limit the amount of loperamide that could be sold OTC. The agency had heard that some people were “abusing” this diarrhea medicine. To accomplish this, though, requires very high doses (50 to 100 pills). At that level the drug can disrupt heart rhythms. To prevent abuse, the FDA has limited OTC sale to 48 mg, or a six-day quantity.

Side effects of loperamide include, not surprisingly, constipation. If you shut down the normal movements of the GI tract that is a likely outcome. Of course, if you are suffering from diarrhea, a little constipation might not be so terrible, as long as it is short lived. Other adverse reactions include drowsiness, dizziness nausea and cramps. It may also be harder to pee if you take too much loperamide.

Diphenoxylate/Atropine (Lomotil):

This prescription combination diarrhea medicine has been around since 1960. Diphenoxylate is an opioid that works in a somewhat similar manner to loperamide. Atropine is a powerful anticholinergic drug. That means it interferes with the action of acetylcholine. Together, these drugs slow down muscular contractions within the digestive tract. Side effects include drowsiness, confusion, dizziness, nausea, vomiting, loss of appetite, dry mouth, headache, depression, sedation, rash and itching.

Non-Drug Diarrhea Remedies:

The very first remedy for “common” diarrhea is not a remedy at all. It is, however, appropriate for various forms of diarrhea. We’re talking fluids. That’s because diarrhea can often lead to dehydration. We are particularly fond of liquids with the appropriate electrolyte balance. When children develop diarrhea, pediatricians frequently recommend Pedialyte. This rehydration liquid has also become popular with athletes because it has a good balance of sodium, potassium, chloride and zinc. We suggest having some on hand just in case.

Probiotics:

Interest in probiotics is intensifying. There is a growing recognition that not all bacteria are bad and that we need to create a delicate balance to have a harmonious environment within the digestive tract. “Antibiotics” can upset that balance. “Probiotics” may be able to reestablish harmony. Lactobacillus acidophilus and Bifidobacteria bifidum seem to help relieve diarrhea. The normal dose ranges from one to ten billion of these good bacteria daily. Many stores carry milk or yogurt with active acidophilus cultures. You will find acidophilus and bifobacter pills at your local health food store.

While diarrhea generally corrects itself, there are some conditions under which you do not want to fool around before seeking medical assistance. These would include diarrhea in an infant or toddler, any bloody diarrhea, and diarrhea that persists for more than a couple of days.

Pectin

A time-honored remedy for diarrhea is pectin, the soluble fiber found in fruits and vegetables. If the brand name diarrhea medicine Kaopectate sounds familiar, it is because “pectate” means pectin. The original formula for this remedy has changed, however. It no longer contains kaolin and pectin. Today’s Kaopectate Anti-Diarrheal medicine contains the same active ingredient found in Pepto-Bismol, bismuth subsalicylate.

You can find pectin in a variety of preparations. We suggest you look up our “purple pectin” recipe for arthritis. It contains liquid pectin from Certo (found in the home canning department of your grocery store).

Pectin is a thickening agent that is used to make jams and jellies. It does much the same thing in the digestive tract. A side benefit is its ability to lower cholesterol levels. A home made way to get extra pectin would be to cook some apples, mash them, and make your own applesauce. Apples are quite high in pectin and applesauce is an old-fashioned diarrhea remedy.

A reader of our newspaper column sent in this diarhea recipe that indirectly involves pectin:

Recipe: Old Scandinavian Diarrhea Remedy

• Core and peel a tart apple (Granny Smith or MacIntosh)
• Using the tines of a fork, mash the apple
• Let the apple pulp sit for 15 min. or until browned
• Eat the browned pulp. It works for me!

“I learned this from my mother who learned it from hers. My grandmother was from Denmark which is why I think the remedy may have Scandinavian roots.”

Herbs:

Berberine:

One of the most overlooked yet well tested herbal diarrhea remedies is a substance called berberine, an alkaloid which is found in barberry (also known as jaundice berry and pepperidge bush), goldenseal, and Oregon grape, an ornamental, holly-like plant common in the Pacific Northwest. Several clinical studies found that berberine was equal to or more effective than antibiotics in quelling diarrhea associated with bacterial gastroenteritis. For example, one study involved 200 adults whose diarrhea was treated with either a standard antibiotic regimen, or antibiotic plus berberine (150 milligrams/day). The patients receiving the berberine recovered more quickly (J. Assn. Physicians India 1967). By the way, 30 patients received only berberine, which put a stop to the diarrhea for all 30 with no undue side effects. The normal dose is five to ten milligrams per kilogram per day.

Berberine has been shown to have activity against amoebas, E. coli, giardia, salmonella and shigella. It has also been found to work against diarrhea associated with irritable bowel syndrome (Phytotherapy Research, Sept 24, 2015). This randomized double‐blind placebo‐controlled clinical trial reported:

“The effects of berberine hydrochloride on IBS‐D [irritable bowel syndrome-diarrhea], defined by a reduction of diarrhea frequency, abdominal pain frequency and urgent need for defecation frequency, were significantly more pronounced in the berberine group than the placebo group in the 8 weeks of treatment…So we concluded that berberine hydrochloride is well tolerated and reduces IBS‐D symptoms, which effectively improved patients QOL [quality of life].”

We suggest that anyone with bacterial diarrhea be treated by a physician who can monitor progress. Remember that fluid and electrolyte replacement is crucial in such situations.

Tannins:

Native American healers knew that certain herbal ingredients could calm an inflamed intestinal tract. The root of the wild geranium (also known as alumroot and spotted cranesbill) contains a high concentration of tannins, which act as an astringent when used externally, and which are said to be effective against diarrhea when ingested.

Tannins also appear in high concentrations in blackberry, raspberry, and blueberry leaves which are often put forward as diarrhea aids, generally in the form of teas, or combined in capsules with other astringent ingredients. Let the berry leaves steep for about 10 to 15 minutes. Drink a cup four to six times daily to calm the digestive tract. Even regular black tea can provide some relief since it too is high in tannins.

One reader shared this remedy:

“A medication my husband had to take gave him chronic diarrhea. Our doctor suggested psyllium (Metamucil), but it was ineffective. I remembered that my mother gave us blackberry wine (2 oz) or blackberries. I bought blackberries and gave my husband 3/4 cup each morning with his cereal. In three days the diarrhea had disappeared. When we told the doctor he just smiled. Believe me when I say it really worked!”

Coconut as a Home Remedy for Diarrhea:

Speaking of home remedies for diarrhea, one of our favorites is coconut! We first heard from Donald Agar in 1998. Donald lived in Pittsfield, Massacnusetts. He was born on August 6, 1932. When his beloved wife Joan died, Don had to fend for himself. That meant shopping and cooking for himself. It was his choice of dessert that led to this letter to The People’s Pharmacy:

“I have had Crohn’s disease for 40 years, and during that time I have had a never-ending battle with diarrhea. Lomotil helps some, but it doesn’t eliminate the problem.

“Three months ago, I bought a box of Archway Coconut Macaroon cookies. I’ve been eating two a day and I have not experienced diarrhea in that time. If by chance I eat three in a day, I get constipated. Believe me, I have a new life now.

“My brother-in-law has a friend who just had cancer and suffered diarrhea as a consequence of the operation. We told him about the cookies and they corrected his diarrhea. I would be delighted if others were helped by my discovery, too.”

We chuckled when Donald’s letter arrived. Cookies for diarrhea, what a joke. And yet Crohn’s is no laughing matter. Inflammatory bowel disease can be a life and death condition with surgery and removal of portions of the large intestine a not uncommon complication. This disorder often leads to industrial strength diarrhea. It is a persistent condition that can last for decades if not a lifetime. We were rather skeptical that Donald’s unorthodox approach would help anyone else. Like many other chronic ailments, symptoms of Crohn’s disease can come and go. Perhaps, we thought, the cookies were a coincidence.

We certainly could not explain why two Archway Coconut Macaroons could be helpful for such a serious problem. These cookies are high in fat and contain modified starch, egg white, soy lecithin, sweeteners, and coconut. It seemed so bizarre, and yet we could not resist sharing his experience with our readers. To our surprise the letters started pouring in. Over the last couple of decades we have received so many messages that we have lost count. Here are just a few representative samples:

One anonymous reader developed diarrhea after gallbladder surgery, a not uncommon consequence:

“After gallbladder removal in 2014, I started having bouts of bad diarrhea leading to nausea and dehydration and then to hospital. I could no longer go to meetings or even shop safely.

“Then I remembered reading about the stories from this column and decided to try the coconut cookies. Two Archway Coconut Macaroon cookies a day plus a cup of ginger tea solved most of the problem.

“I no longer miss meetings or have to stay at home all the time. It is not a perfect cure, but it does work well for me and I am grateful to know about it.”

A mother tried the cookies for her son:

“After reading about coconut macaroon cookies for diarrhea in your newsletter, I had my son try this remedy. He has had diarrhea every day for a couple of years.

“I bought him some Trader Joe’s Coconut Macaroons. They worked on day one of the trial and have worked every day for a month.

“His stools are soft but with no diarrhea. Placebo? Well, just yesterday he told me he forgot to eat the cookies two days in a row. His diarrhea came back on the second day. A daily macaroon cookie is one “pill” he now remembers to take!”

For those who wish to make their own coconut macaroon cookies, here is a recipe a listener of our radio show shared. Her grandchildren love these cookies! You can cut back on the sugar if you prefer cookies that are less sweet.

Mix 2 2/3 cup shredded coconut, 2/3 cup sugar, ¼ tsp. salt, 1 tsp. almond extract, 4 egg whites. Drop by teaspoonfuls on a greased cookie sheet and bake for 20 minutes at 325 degrees or until lightly brown.

Patty corrected this recipe with this suggestion:

“Readers need to know that the recipe is missing an important step – whisk the eggs and everything else (except the coconut) together until very frothy before mixing in the coconut just enough to moisten it. A Google search will give you detailed instructions for those who need them.

“I’d read on the People’s Pharmacy website about eating coconut macaroons for diarrhea. I was skeptical, thinking that if my stomach was that upset, the cookies would make it worse. I’ve tried it and it works every time! I’ve been on some antibiotics and the cookies allow me to go once or twice daily instead of all day long. I use Jenny’s Macaroons I buy from my favorite vitamin and natural foods site online. Jenny’s, though sweet, contain more sulfite-free coconut than anything else. Chewy and delicious. They are moist and gooey and come in a re-sealable can. Archers’, though tasty, are way too sweet for me and more like a regular crunchy cookie in texture.”

Jim says it doesn’t have to be coconut macaroon cookies:

“On several occasions, I have found a tablespoon of shredded coconut (unsweetened) from the health food store stopped watery diarrhea literally in its tracks. Cost is perhaps $3/lb. and it can be stored in the freezer. In my opinion, anyone with that problem should give it a try. Mix it in orange juice, oatmeal, cereal, etc. Obviously, this does not address the issue of gut bacteria destruction by antibiotics but may help with the major symptom.”

Is there any science to support coconut vs. diarrhea?

A research report presented at the Digestive Disease Week Conference in June, 2017, supported the role of coconut oil and cocoa butter against intestinal inflammation. A study in mice suggests that changing the diet might be beneficial in treating Crohn’s. These mice with intestinal inflammation were fed a high-fat diet. The fats used were derived from plants and included coconut oil and cocoa butter. This diet changed their microbiome (bacterial ecology) significantly and reduced the inflammation found in their digestive tract.

So far, this research has been done only in mice. The researchers anticipate identifying the beneficial bacteria and offering them as probiotics to Crohn’s disease sufferers. They will also be conducting research to see whether coconut oil or cocoa butter are helpful in the diet of these patients.

In the study, mice got either standard lab chow or high-fat chow laced with coconut oil and cocoa butter. Mice that were fed the high-fat chow had better bacterial ecology in their GI tracts and less inflammation. They had less variety of microbes in their intestines, however, which might not be beneficial over the long term.

Readers have long suggested that there is something in coconut oil that has anti-bacterial activity. They speculated that this compound might suppress the microbes that were causing an overactive immune reaction. Lest you think this is all nonsense, here is a link to an article demonstrating that virgin coconut oil (VCO) does indeed have antibacterial activity against the bad actor Clostridium difficile (C. diff). It was published in the Journal of Medicinal Food (Dec. 2013).

A study published in the journal Frontiers in Microbiology, Jan. 17, 2018 found that lauric acid, a componenet of coconut oil, could be beneficial against C. diff infections:

“Collectively, the results of this study indicate that lauric acid exhibits potent antibacterial activity against C. difficile, and lauric acid prophylaxis may substantially decrease the level of inflammation induced by infection with C. difficile in vivo. The beneficial effect of lauric acid as a food supplement or as an adjunct therapy for CDI [C. difficile infection] should be considered.”

In their animal model the researchers reported that “lauric acid intake significantly reduced the severity of diarrhea and intestinal inflammation associated with CDI.” The bottom line seems to be that ingredients in coconut do indeed appear to have biological activity that could explain the reader observation that this food helps against some types of diarrhea. Sometimes it takes the scientists awhile to catch up to the reasons a home remedy might work. We doubt that it will work for everyone because diarrhea can be brought on by so many different things.

Irritable Bowel Syndrome

Gastroenterologists often refer to irritable bowel syndrome (IBS) as a “functional digestive disorder.” That’s because they can’t blame any specific germ or immune system problem for the difficulties that sufferers experience. Symptoms like severe abdominal pain, flatulence, bloating and either diarrhea or constipation can be debilitating. Sometimes they seem to come from nowhere, although at other times the trouble is triggered by stress or even particular foods.

Evidence is growing that these symptoms may actually be caused by disruptions in the balance of bacteria in the digestive tract (Pimentel & Lembo, “Microbiome and Its Role in Irritable Bowel Syndrome,” Digestive Diseases and Sciences, March 2020). Sometimes an intestinal infection is the first sign of IBS, with changes in the gut microbiota later. Scientists have identified overgrowth of the small intestine with bacteria causing diarrhea (IBS-D). A different type of microbial imbalance results in the predominance of constipation among the symptoms (IBS-C).

Simple Remedies for IBS

Psyllium

Surprisingly, there is one remedy that appears to be helpful for both forms of irritable bowel syndrome. You may think of psyllium (eg, Metamucil) as a laxative. Indeed, it can help people who are constipated, but it is also quite useful in calming diarrhea (Surdea-Blaga et al, “Dietary interventions and irritable bowel syndrome – what really works?” Current Opinion in Gastroenterology, online Dec. 16, 2020).

Probiotics

If the main cause of IBS is a disruption of the gut microbes, wouldn’t probiotics be an obvious therapy? Some investigators have put them to the test. In a review of 15 randomized, placebo-controlled trials of probiotics (Didari et al, “Effectiveness of probiotics in irritable bowel syndrome: Updated systematic review with meta-analysis,” World Journal of Gastroenterology, March 14, 2015), the authors concluded:

“Probiotics reduce pain and symptom severity scores. The results demonstrate the beneficial effects of probiotics in IBS patients in comparison with placebo.”

The hitch in this review is that we don’t learn which specific strains of probiotic are most beneficial. A Chinese trial is currently underway testing a combination of four strains of Bifidobacterium for treating IBS-D (Bai et al, “The efficacy of Bifidobacterium quadruple viable tablet in the treatment of diarrhea predominant irritable bowel syndrome: protocol for a randomized, double-blind, placebo-controlled, multicenter trial,” Trials, June 30, 2020). We will be very interested in reading the published results when this study is completed.