The previous post I wrote about small intestinal bacterial overgrowth (SIBO) was simply a lead in to the post I really wanted to write. But the post I really wanted to write wouldn’t have made sense without the first post, which was, I suppose, the prologue.
A while back I was wading through the latest Medscape* had to offer when I came upon an article that almost put me over the edge. The offending piece was a video presentation by a Dr. Johnson, an academic gastroenterologist from a medical school in Virginia. The doctor was basically giving his top ten take aways from a recently published paper on the guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD). Although the doc delivered his presentation in a collegial doctor to doctor tone, it was the subject matter that drove me nuts, especially his selection of the number one take away item from his list.

A little background…

If a patient were to present to me with a medical problem, the first thing I would think of is how (or if) the problem could be treated nutritionally. If a nutritional treatment is appropriate, then pursuing that therapeutic option is the epitome of the first pillar of the practice of good medicine: Primum non nocere. First, do no harm.

It should be obvious, but just in case it isn’t, that nutritional therapy wouldn’t be the first thing flitting to my mind, if presented with victims of a car wreck, someone experiencing an acute heart attack, our kid showing up with a bleeding gash in his head, or a person in severe respiratory distress. But it is surprising how many chronic problems can be treated – or at the very least made better – by nutritional means. So in those disorders that can be improved by a change in nutrition, that is my default position.

Not so for the vast majority of physicians out there practicing mainstream medicine. For that lot, the default position is pharmaceuticals. Presented with a problem, they think drugs. Our professor in the Medscape video is a case in point.
In the last post, I discussed my experiences treating GERD using a low-carbohydrate diet, and I also described Dr. Norm Robillard’s research into SIBO as a driving force for GERD and irritable bowel syndrome (IBS) along with his methods of treatment using both high- and low-carb diets. Both his method and my method have proven successful in the vast majority of cases of GERD. Simple nutritional strategies.

Now let’s take a look at how the mainstream folks treat GERD.

Most of them immediately prescribe a proton pump inhibitor (PPI), a type of drug that produces a profound reduction in the stomach’s production of gastric acid (stomach acid). These PPI’s (Nexium, Prilosec, Prevacid, etc.) are potent inhibitors of stomach acid secretion, in fact, they’re the most potent drugs for this purpose so far developed.

Remember, GERD takes place when stomach acid is gets through the sphincter at the bottom of the esophagus and burns the delicate tissues of the esophageal lining, which, unlike the lining of the stomach, don’t have a thick coat of protective mucus. When the acid hits these tissues, it causes a variety of symptoms as described in the previous post.

For years, the mainstream way of treating GERD (also called acid reflux and heartburn) has been by reducing the acid content in the stomach’s digestive juices, so that when these juices get into the esophagus, they don’t burn the tissues—or cause symptoms—because the acid has been neutralized.

The first line of treatment, from as far back as the 1800s and still often used today, was antacids. If you have heartburn, you drink some bicarbonate of soda or pop a few Tumms or Rolaids or other antacids, which neutralize the acid in the stomach. About 35 years ago or so, pharmaceutical research scientists developed a new class of drugs called H2-receptor agonists (Tagamet, Pepcid, Zantac), which was the first major breakthrough in the treatment of ulcers, gastritis and even GERD. These new drugs reduced stomach acid by an order of magnitude as compared to simple antacids. And they offered the advantage of patent protection to the pharmaceutical industry, so they were widely advertised and prescribed. These medicines were the most effective treatment for years until the PPIs came on the scene, and now these newer drugs are some of the most prescribed on the planet.

Seems like the perfect treatment. You have symptoms caused by acid getting into your esophagus, so let’s take a PPI, reduce stomach acid production, and Voila! your symptoms vanish. All fine and dandy except for one little thing. Your stomach is full of acid for a reason. And if nature put stomach acid there for a reason, you can bet getting rid of it can cause problems. Let’s take a look at what stomach acid does.

It starts the digestive process of breaking down food into smaller particles

  • It activates the enzymes needed for protein digestion
  • It sends a message to the pancreas to begin producing and releasing digestive juices into the small bowel
  • It initiates the process of peristalsis, the rhythmic contractions of the small bowel that moves food through the digestive process
  • It is essential for the absorption of vitamin B12
  • It is the first line of defense against bacteria and parasites found in food, water and the air we breathe.

This last function is one most people don’t understand. At least as it applies to the infectious agents in the air we breathe. How can stomach acid prevent respiratory infections? Let me explain.

When we take a breath, the air travels down the bronchial passages of the respiratory tract. These tubes, like the branches of a tree, get progressively smaller as they head deeper into the lungs, and they are lined with a coat of sticky mucus, which traps bacteria and other noxious substances. Tiny hairs, called cilia, on the inner surface of these tubes keep the crud-laden mucus moving up the bronchi where it is ultimately dumped into the back of the throat. When we swallow, we redirect this mucus down the esophagus and into the stomach where the stomach acid then kills the bacteria that actually came in through our respiratory tract.

Although the respiratory and digestive tracts are separate, both originate in the mouth. During sleep, refluxed stomach contents can make their way up through the esophagus and ‘spill’ into the nearby respiratory tract. Since, thanks to neutralization of the stomach acid by PPIs, bacteria are more likely to proliferate in the stomach contents and can thus cause an infection when they reach the respiratory tract.

That last bit may make you suppose that people who are on PPIs and other acid-suppressing drugs might have increased rates of respiratory infections. As it turns out, they do. Long term PPI therapy is associated with an increase in the incidence of pneumonia.

Understand all this, and you should realize why neutralizing stomach acid could lead to problems. Which indeed it does. And it should make clear why it is much better to treat GERD by eliminating the cause and preventing stomach acid from getting where it doesn’t belong instead of simply neutralizing it so it doesn’t burn when it gets there.

Most people who have GERD, have it for the long term. It’s not something that comes and goes. So these folks go on GERD therapy for the long term, and the most prescribed medications for long-term GERD treatment are PPIs, which, you now know, keep stomach acid neutralized for the long term, and, as you might imagine, creates a host of problems.

The scientific literature has shown long-term PPI therapy to be related to the following conditions:

  • Anemia
  • Pneumonia
  • Vitamin B12 deficiency
  • Impaired calcium absorptionImpaired magnesium absorption
  • Increased rate fractures, especially hip, wrist and spine
  • Osteopenia
  • Rebound effect of extra-heavy gastric acid secretion
  • Heart attacks

Of all these disorders associated with PPI therapy, the one most well known by the general public is the increase in rates of fractures. Which is why I got so annoyed with the doc in the video below. He gives his top ten guidelines for dealing with GERD. And his #1 guideline is to blow off any worries about increased rates of fracture. He says the number one question patients ask him about PPI therapy is about fractures. He even says he is dismissive of them as he basically blows off their concerns. Remember, though, not to be too hard on this guy because he is talking to other docs, not giving a talk to patients or even the general public.

This is a doctor to doctor platform. Still…

His top ten list was derived from a paper discussing 54 guidelines for the diagnosis and management of GERD. In the entire list of 54, there were only two that involved lifestyle changes. One was a recommendation to lose weight. The other was the

Routine global elimination of food that can trigger reflux (including chocolate, caffeine, alcohol, acidic and/or spicy foods) is not recommended for the treatment of GERD.

Which to me beggars belief since, as I pointed out in the last post, GERD is easily treated with a low-carb diet.

In another paper in the same journal, the authors actually asked patients what made their IBS symptoms worse. Since IBS, like GERD, can be caused by SIBO, the problematic foods are likely the same. When queried, the #1 cause of symptoms in the vast majority of patients (70%) were “food items with incompletely absorbed carbohydrates.”

So patients tell us carbs make their symptoms worse. Physicians who treated patients with low-carb diets experience almost 100 percent success. Patients who go on low-carb diets almost always find relief from their symptoms. Dr. Robillard has developed a reasonable hypothesis to explain the above results. So, on the one hand, we have a therapy that works without side effects.

On the other hand, it is well known that long-term PPI therapy can cause problems in varying degrees of severity. And PPIs are not free; they are expensive. And, behind psychotropic medications and statins are the third most commonly prescribed drugs in the United States. Vastly more people are on PPIs than are on low-carb diets. More is the pity.

And it bugs me to the max that docs, such as the one on the video below, tell other physicians to tell their patients to blow off fears of fractures and go full speed ahead on an expensive treatment regimen fraught with the potential for multiple serious side effects.

Here is the very short excerpt of the video that so riled me up.
If you want to see the entire thing, here are Dr. Johnson’s Top Ten Gerd Guidelines in Medscape.*

*Medscape is a free online subscription service to physicians to keep them abreast of all the latest medical breakthroughs and recommendations. Though Medscape was created for and is mainly read by physicians, anyone can subscribe. Just go to Medscape and register as a non-physician guest. Then you, too, can keep up.


  1. It has been pointed out (by Balint M 1961, The Lancet, “The Other Side of Medicine”) that the more an illness resembles an accident (e.g. most infections) the more effective will be so-called scientific treatments and the more applicable will be the double-blind experiment in evaluating therapy: but where illness can be due, wholly or partly, to lack of integration between individual and environment (e.g. anxiety, depression, asthma, eczema, hay fever, ulcerative colitis) the more treatment has to be related to the individual’s life history…and then drugs may take second place or not be needed at all.
    Clinical Pharmacology, D. R. Laurence 1966
    Balint was making the case for psychotherapy in medical practice, but his words – and the examples given – are even more appropriate applied to nutritional therapies.

  2. I was one of the PPI long time users. I think I had been on them for over 13 years and my doctor always told me that I’d always need to take them due to my having a hiatus hernia. I have commented before to you regarding this – you had previously asked me to let you know how I got on after reading the book on GERD that you previously linked to.
    It took me a long time because PPI’s are so addictive, when you try to stop, even after being on a very low dose, you get bad acid reflux. I finally managed to kick the habit after reading an article by Dr Mercola by taking Zantac as needed – now I only need to take one about once a fortnight. I’m sure this is better than a daily PPI. I also, of course, eat a very low carb diet which is why I only have to take a minimal dose of medication (Zantac or Milanta) now.
    Here is the link for anyone interested:

  3. Hi Mike. Great to see you back on the blog. I am probably the world’s worst blogger so I really appreciate the effort of others who do it well. You top that list, IMHO. And thanks for the thoughts on the aetiology of GERD. I have routinely recommended LCHF to my GERD patients without being able to tell them why. It is useful to provide a conceptual framework to help them understand why they get a therapeutic benefit. I think it improves compliance (but I don’t have a RCT to prove that). Also, nice to hear that all the hard work on sous vide is paying off.
    Best regards,

    1. Hey Jay–
      Great to hear from you. Hope things are well in the soon-to-be frozen North.
      Thanks for the props re the post.
      I just thought I worked hard as a doctor. Nothing prepared me for how much work is required to be an appliance salesman.

  4. Re respiratory infections – the first thing, it seems, that respiratory specialists do when a person presents with chronic cough is prescribe PPI’s ! This happened to me and I discovered that this is quite normal, they don’t bother to find the cause of chronic cough, they prescribe two months of PPi’s to see how the patient responds.
    I absolutely refused to take the PPi’s ! Luckily, as that made the respiratory guy do a bit more ‘work’ – he discovered by scan that I had small airways disease, probably due to pollution, and I’m now taking a steroid inhaler as living near London (UK) I cannot avoid pollution. This is still not a wonderful solution but my point is that I refused PPI’s because it seemed to me nonsense to take something a) when you don’t know the cause of the problem, and b) to reduce stomach acid when stomach acid is obviously essential to health – I mean it’s hardly there by mistake !

    1. Many people with sub-clinical GERD present with persistent coughs. As I think I mentioned in the previous post, acid refluxing up into the throat at night can cause irritation and a chronic cough. So it’s not a stretch to treat for GERD to see if that solves the problem. But I certainly wouldn’t start out with PPIs as the first step.

  5. This is for me a very interesting topic but my comment will be a long one which I hope you will excuse.
    In March 2003 I had a triple heart bypass operation. In December of that year at Christmas I had severe abdominal pain that to me was the repeat of my heart attack; the pain was accompanied with chest compressions & back ache. I was taken to an emergency centre where the medics did all the usual tests for cardiac problems but they were all negative; there was no evidence of heart attack. The pain ceased after about an hour & I then felt fine & relieved that it was not another heart attack.
    Over the following years I had similar episodes from time to time & on each occasion no cardiac problems were found but it was decided that my problem was GERD. Then in 2011 I was given an ultra sound scan which found that I had some small gall stones but no treatment was indicated as they were so small.
    Then in June this year I had another episode of severe pain as above but this time I also became jaundiced. My doctor referred me to hospital where I another ultra sound scan showed a clear gall stone problem. A couple of days later the stone was removed.
    It was suggested that I needed gall bladder removal but after MRI scan the surgeon said not further treatment was needed.
    During the years that I suffered from the supposedly GERD problem I was prescribed PPI but, having read some of the drawbacks about PPI, I did not take it.
    So now, having read your articles Dr Eades, I have some questions.
    Is it perhaps the case that some people being prescribed PPI are in fact having not GERD but gall stone problems?
    If this is the case what are the appropriate remedies for instance can gall stones be prevented from forming>
    Are there any dietary issues that need to be addressed such as to prevent gall stones forming?
    Are symptoms of GERD being confused with gall bladder difficulties & do PPI address this adequately?
    I am not a medic of any kind & I am not criticising doctors, who have such a difficult job made worse by the predations of pharma & political interference, but is it possible that the people I know who are being treated with PPI being treated for the wrong problem?
    Many thanks
    Vic Taylor

    1. Many disorders can mimic GERD, and GERD can mimic many other disorders. So, many cases of whatever may actually be GERD and vice versa.
      In your case, I find it curious you were told after ultrasound that you had only some small gallstones, which made treatment unnecessary. It’s the small gallstones that need to be treated. They’re the ones that can make their way down the biliary duct and into the common duct where they can create a surgical emergency, which they did for you.
      I’m certain that some people prescribed PPIs are having gall bladder problems.
      Gall bladder disease is too complex a disorder to be completely described in the answer to a comment.
      Usually keeping the fat intake up keeps the gall bladder free of bile. Eating a low-fat diet tends to allow the contents of the gall bladder to remain in place where ultimately stones can precipitate. Which is why a long-term low-fat diet is a risk factor for gall stones.
      If one has gall stones, a PPI shouldn’t make much difference in the symptoms.
      Hope this brief discussion helps.

  6. Dr. Eades, In 1992 I started taking a PPI (Prilosec), due to bad acid reflux, and IBS. The acid reflux stopped immediatly but the IBS continued. In 2011 I started a low carb diet and within 2 months was able to stop the PPI and the IBS was cured also. Good nutrition is the key.

  7. This medical myopia is so common it hardly surprises me any more. It does enrage me for the sake of the patient, but surprise… no.
    Watched a video on non-surgical options for back pain from a med school the other day. It was all about doing epidurals. No discussion of doing any soft tissue range of motion work first… anywhere… in an hour and a half lecture.
    Decision tree:
    Person has low back pain.
    1. Shall we operate? Y/N
    2. If not, where shall we inject?
    3. If they don’t want surgery or an injection, write them a scrip.
    End of story.
    My field of soft tissue work is ignored for the most part. When I get a new client who is considering surgery, I ask them if their doctor has assigned them any prehabilitation to prepare the injured area for the stress of surgery and the rehabilitation that will follow. Blank looks. No.
    I ask them if their doctor has advised them about switching to a lower inflammation diet to see if that may help reduce the pain in the affected joints. Blank looks. No.
    Primum non nocere. First, do no harm. Honored in the breach it seems. When the first line of defense is cutting, injecting with drugs, and prescribing drugs, and the last line of not even considered defense is conservative care with range of motion exercise and nutritional therapy, it’s no wonder people come to me in pain. Whether they’ve already had the surgery or not.
    So whether it’s GERD or chronic pain, conventional approaches all too often are not adhering to “evidence based” medicine. They adhere to “drugs and surgery based” medicine. And that blithely does harm, all too often.
    ​Be well,
    Ben Fury, CFT, MAISS
    Erasing pain for everyone – because no one should have to manage pain.

  8. Thanks for a great post, Mike – look forward to many more.
    That line from the doctor (really? are we sure?) about his wife taking a PPI regularly is suspiciously disingenuous, I think . . . either that or he’s really a medical disaster. How could he not know? Oh – right. I always forget – he listens to drug reps and has had about an hour’s worth of training in nutrition. Talk about Jesus weeping!

  9. Totally agree about the PPI’s – they are a poor solution. What I found out is ANY reduction of food, whether low carb or not (I am going the Weight Watchers way – not low carb) will cause GERD to go into remission if the person also selects according to a friendly to GERD diet i.e. low fat foods etc. No medical provider ever told me this – I discovered it by serendipity when I lost my appetite due to a life crisis – the first night when I had greatly reduced the food intake, I slept through for the first time since 1980! I stayed on WW after the crisis (in 2008), have no more GERD and oh – lost 110 lbs also, 97 of which I’ve kept off! Who’da known? 🙂

  10. I too, have experienced relief from digestive issues and reflux when going low carb. Unfortunately, low carb gives me severe dehydration, brain fog and other issues. I know Mark’s Daily apple recommends higher carb for women because of this, but I find that even 150g daily is not quite enough, and oddly, adding fruit is not as effective as other carbs. 200g plus 1-2 servings of fruit seems good, but is also problematic as I suffer from yeast infections. I am NOT diabetic. All that said, how low carb do I need to go? BTW, I had reflux even as a young child…

    1. Inflammation can be lessened by diet, but if there exists an outside agent – a virus, bacteria, parasite, splinter or other foreign body – diet alone won’t get rid of it until the offending agent is either killed or removed.

      1. I wonder if something with natural anti-viral properties like curcumin would be useful in some issues like this? Have you had any cases like that, Mike?

        1. It would seem like it would, but I’ve never used it specifically for that purpose nor have I seen any studies. Doesn’t mean there aren’t such studies, just that I haven’t seen them.

      2. Some viruses like HCV and HBV, and other intracellular parasites like Lyme disease can be hard to get rid of. They tend to alter both metabolism and immunity to survive, and this is both inflammatory and immunosuppressive (masking the specific pathogen).
        HCV is helped by high carb/insulin levels and by high omega 6 PUFA intakes. HCV is specifically inhibited by carbohydrate restriction, but inflammation from any virus is also inhibited when carbohydrate/insulin and linoleic acid are kept low, and saturated and monounsaturated fats and DHA (omega 3) are favoured.
        Viruses also sequester nutrients such as selenium and zinc and glutathione, so a diet rich in trace elements, protein, and antioxidants will also be anti-inflammatory.

  11. Hi Mike!
    Like Jay Wortman, it is great to see you blogging again. I always learn a lot and your blogs also get me thinking. . . so much to learn.
    I am seeing some stunning results with the athletes I work with just had a guy go under 12 hours for 100 miles and set a new American record. My program is all about Optimizing Fat Metabolism (OFM) and what we are seeing is not considered possible by conventional standards….I mention this runner b/c when we started working together he had serious gastrointestinal issues which have become history.
    Keep up the great work.

  12. About 17 years ago I had severe reflux. Never left home without Tums. Then I realized it occurred after I ate bread, so I stopped eating any kind of wheat. When I was Dx’d with DM a few years later, I stopped rice and corn etc. as well and have maintained LC diet since them. Reflux initially disappeared, along with mild arthritis. (My low-fat friends claimed it wasn’t the bread but the butter I put on the bread that was the culprit, but it happened even without butter.)
    Then about 4 years ago, after maintaining the LC diet, the reflux returned along with “chest pain.” An upper GI showed esophageal ulcer and a total lack of LES (probably genetic as my father had lifelong reflux problems), plus hiatal hernia.
    PPIs healed the ulcer, according to follow-up upper GI.
    So I think LC diets can put reflux into remission, but if you have strong risk factors, they can’t cure the condition. And one has the dilemma: Should I take PPIs that have bad side effects or should I live with reflux that has bad side effects? Histamine blockers aren’t as effective.
    One dietary problem is that fat is a trigger for reflux, and LC diets are high in fat. Protein raises BG via gluconeogenesis.
    I suppose the answer is a low-food diet.

  13. Hi Mike,
    What do you think of Dr. Campbell-McBride’s use of Betaine HCl to treat GERD as part of the GAPS protocol?

  14. I’ve been on PPIs since they were introduced.
    I used to get GERD from pepperoni pizza (even to the point where the PPIs weren’t enough), followed by a day on the toilet. So I cut out the pepperoni. Then the sauce. Then the cheese. Then the deep dish (because of the grease).
    To no avail.
    But when I’m following a low-carb diet, I can eat all of the pepperoni, sauce, cheese (and grease) I want, stop taking PPIs and have absolutely no GERD.

  15. I don’t have GERD unless I go do water exercise. The water pressure is what pushes my stomach contents through the sphincter.
    I think I need to limit the amount I eat before I get in the water. That may be the answer. I just need to discipline myself.

  16. Mike, welcome back.
    I once read some research, which I know can’t find, indicating that the LES muscle is sensitive to acid: it will close more tightly when the acid level is high than when the acid level is low. This makes intuitive sense: it would mean that the LES is relatively relaxed when you are eating and the entry of food into the stomach is decreasing the overall level of acidity in the stomach, and then tightens up again when the food is digested and the acidity level rises again. It would explain why many people report that they obtain GERD relief by taking ACV or another vinegar after meals. It also suggests that PPIs worsen the problem in yet another way: by decreasing the acidity level in the stomach, they make it more likely that what remains will be refluxed.

  17. More anecdotal support for nutrition over medications. I lived with GERD for a long time. Head of bed was elevated. No food later than six in the evening. It helped, but didn’t eliminate the problem. Docs prescribed Prilosec (or an equivalent) several times. I started the prescription. Within a day or two, my guts hurt too much to continue.
    Less than two years ago after reading Robb Wolf and Mark Sisson, I decided no more dairy, grains or legumes for a month. Within two weeks I wasn’t popping Tums after every meal. The GERD took a little longer. At the end of one month, I realized that after 71 years, that life didn’t mean daily heart burn and GERD. After that month, I reintroduced foods selectively to test my body’s reaction. Two years later there are no grains of any type or legumes. Dairy was reintroduced without a problem.
    Today my foods are some dairy, meats, vegetables and fruits. I’ve never felt better. No heart burn. No GERD.

  18. About 3-4 years ago, my brother introduced me to The Primal Blueprint by Mark Sisson. It all seemed to make sense to me and I gave a sort-of-paleo diet a try. I’m not hardcore about it, but I eat minimal complex carbohydrates now… I treat bread like ice cream.
    Over the next 18 months, I dropped about 35 pounds, which was great (I still have about 20 to go), but even more importantly, about 4 months in I noted that my reflux had gone away entirely. A couple of months later, I decided to try eliminating my daily 40mg Nexium for a few weeks to see what happened.
    The wonderful answer is: nothing. No reflux at all. Now, if I have a bread-heavy meal, eat a tomato-based sauce, or indulge in a soda, it doesn’t affect me. If I eat those things more than a couple of days in a row, though (I do go on the occasional PB&J bender), the GERD comes back.
    Drastically curtailing the more processed foods from my diet allowed me to get rid of a drug therapy I’d been on for over ten years!

  19. Thought I would comment since, as a third year pharmacy student, we just had our GERD lecture.
    Not sure what the med students are learning, but we are trained to absolutely counsel patients on lifestyle modifications before drugs – although the lifestyle mods are not supported by a plethora of data. Routine avoidance of foods is NOT recommended (although selective elimination is). Typical foods that we learned to target include spicy foods, coffee, chocolate, and caffeine products.
    Another big risk factor is being overweight, since that can decrease the lower esophageal sphincter pressure – and patients looovve being told to lose weight (but we’re trained to suggest it before PPI therapy).
    I’ve never heard of carbohydrate intake being related to GERD – will have to check into PubMed some more. Interesting stuff.

  20. After years of constant throat-clearing and what I thought was post-nasal drip, I was diagnosed with “silent”reflux.” Since I never had heartburn or other symptoms, I was skeptical. When the doc showed me a list of about 10 symptoms of laryngopharyngeal reflux, and I had most of them, I had to admit there might be something there. Of course, he prescribed a PPI. Never once during the exam did he ask me about lifestyle or diet, nor did the other doc in the practice that I saw when I went back for a follow-up. (I am totally disillusioned by “specialists.”)
    I did not want to take the PPIs, because it made no sense to inhibit stomach acids that were there to do a job if the real issue was the acid getting to my esophagus. The symptoms were just annoying and I could put up with them, but I sing in a choir and my singing voice was really taking a hit, along with my speaking voice. I always sound raspy, like I have a cold. So I did take the PPIs for a while, and my voice seemed to get better. Then I quit, and the voice issues came back, but worse. I went back to a low dose of omeprazole (20mg/day), but it’s not helping and I want to quit taking them.
    I do eat a low-carb diet (have been for a couple of years), but it’s not helping. I do drink coffee and alcohol, and have a very stressful job, which are likely adding to the issue. I’d appreciate any insights and suggestions.

    1. Interesting about how symptoms came back even worse when you quit taking the PPIs. One of the side effects of those meds is a rebound hypersecretion of acid after their discontinuance, which is doubtless what happened to you.
      I’ve had a handful of patients who had your symptoms. I sent them to ENT docs for evaluation and all were found to have vocal cord nodules as a consequence of sub-clinical GERD.
      GERD doubtless has multiple causes. I suspect the greatest percentage of cases are driven by SIBO, but that doesn’t mean all are.
      I can suggest a couple of things. First, you might want to check your carb intake against the tables in Dr. Robillard’s book to see if the carbs you are consuming are those that contribute to SIBO, and if so, change your diet. Second, if the carbs you are eating are not contributors to SIBO, you might want to try to severely restrict your carbs just to see what happens. If you sleep better, you may find that your other symptoms clear with an extremely low-carb regimen.
      You could also take a large dose of melatonin 4-8 g at bedtime along with some folate. Those, especially the melatonin, have been shown to improve LES integrity and reduce reflux.
      As a last resort, you could always take the meds. I wouldn’t use a PPI, though. I would probably take an H2 agonist such as Zantac or Pepcid, both OTC, because, although they are a little less effective than the PPIs, they don’t have the problem of rebound hypersecretion.

      1. Thanks for your reply. Both times I went to the ENT they put the scope through my nose and down my throat to check my vocal chords. They didn’t find any nodes, which I thought might be the case, nor inflammation. I will try your suggestions to see if they help.

  21. Linda,I have GERD, and for me, coffee (including decaf) is a big trigger. I can’t bring myself to quit, but I’ve cut way back. Then after no problems for a long time, the amount creeps up again, and I start feeling minor pangs and cut back again.
    I know how difficult it is to give up coffee, but you might try reducing the amount.
    Same with alcohol if that affects you. I can easily live without it.

  22. Over the past year or so I’ve let my mostly good LC diet slip into more trips in the crappy carby lane and had some of the classic GERD symptoms (sore throat in the a.m., burning sensation when lying down, feel like something was caught in my throat). A trip to my PCP scared me enough that I agreed to take the protonix med [esophageal cancer, yo!!!!]. I take a 40mg protonix tab every day and it has eliminated my GERD completely. But I absolutely remember not having the acidy stuff going on when I was more diligent with my diet. This is a good wakeup call to not let all those foods I know aren’t good for me creep back in. Thanks for the info about Dr R’s book, Dr Mike. Looks like I have some research to do so I can wean myself off the protonix.

      1. Ack, so far not so good. I woke with a burning raw sore throat today, very reminiscent of what I was dealing with prior to the PPI. I have had problems with tomato-based meals and GERD but had stopped paying attention since the PPI was eliminating the issue. Dinner last night was chili. Ding ding! I see your recommendation for a H2 blocker below and will have some of those on hand while I try to taper. I have an appointment with my PCP coming up soon, but I have a feeling she won’t be thrilled with my coming off the med, although she has been supportive of my low carb eating in the past.

  23. I have been low carb for 2 years. I have taken PPI for GERD for more than 10 years. Since going low carb I have tried stopping the PPI twice. On both occaisions I had unbelievable rebound hyperacidity. I tried to get my GI doc to suggest a taper strategy, since I figured my serum gastrin level was a gazillion and would take a while to normalize, but all I got from him was ” Don’t obsess about the PPI, just keep taking it.”. Not helpful…..
    Have you had sucess with a particular weaning strategy? I want off these PPI’s!

    1. One of the big problems with PPIs is the rebound hypersecretion of acid when they’re discontinued.
      I’ve never really weaned anyone off of a PPI simply because I’ve never put anyone on a PPI. I much prefer another class of drugs – the H2 blockers. These drugs aren’t as potent as the PPIs, but they also don’t have such fierce rebound hypersecretion problems. These drugs are sold under the trade names Zantac, Pepcid, Tagamet and a couple of others. My favorite is Pepcid AC, which is a pepcid along with an antacid. You might try weaning off that way. Switching Pepcid or one of the other H2 blockers to see what happens. Make sure to discuss it with your doctor.

      1. Thanks for the suggestion. Perhaps my internist, instead of my GI doc, will have some experience in the taper. PubMed search reveals that the process of returning to normal after the rebound hyperacidity can take 12 weeks. I will keep you posted on how my “taper” goes.

      2. Here we are 10 weeks after I discontinued PPI (I tapered for two weeks, then stopped). The rebound hyperacidity was truly horrible for about 6 weeks, mounds and mounds of antacids and PepcidAC every 4 hours. Finally, in the last two weeks or so, my acid has returned to normal. Lo and behold, on low card diet, I am not refluxing much and am only requiring the very occaisional antacid! Looks like that estimate of 12 weeks of hyperacidity rebound was about right……

  24. Back in October I commented about my problems with gall stones which gave me GERD symptoms. I did not mention in that comment that previously I found relief from occasional heartburn by taking a peppermint oil capsule before a meal; this worked well for me. I also recall that my late grand-father would always suck a peppermint just before turning in for the night. I guess this might have been for the same purpose, to counter reflux.
    Thanks for your clear explanation of how GERD is caused Mike.

  25. Have been taking prescription Prevacid at 40 mgs once a day for GERD for 13 months, and have EOE. Have had my throat dilated twice in 14 months, once for EOE, and once for acid at the bottom of my esophagus closing it up. My regular doc just put me on a low carb diet for pre-diabetes, and tryglicerides of 386. She said 9 carbs per serving, 6 sugars. I researched and found out it was low carb. Have done a ton of research and found this is the best thing for me to live on the rest of my life. BUT as soon as I started eating the 3 cups of vegies she told me to eat for lunch, my stomach quit. Went on strike. It bloats up so I look pregnant. Very uncomfortable, it rides up and hits my ribs. Or feels like it. Then diarrhea later. I have a baby hiatal hernia that does have an effect. I have decided the PPI is causing the issue with vegies, so have quit it 5 days ago. If I take some cider vinegar in water two three times a day it helps the heartburn, but I’m prepared to take Pepcid AC if needed. So it’s mostly an issue of one doc’s prescription messing up the other doc’s diet. I don’t want to take PPIs anymore, and I do want to stay on the diet. I am an 56 yo female, slightly overweight at 136 lbs,, 5’3 1/2″. tall,

    1. If the veggies cause a problem, I would avoid them. Were I in your shoes, I would try more protein and fat until I got things healed up.

  26. I had heart burn attack twice, took Famoditine for 24 hours, got off… then experienced LPR symptoms, tried Koufman’s for 3 days and re-experienced heart burn, then on to Robillard’s FT, no heartburn for three days, my throat feels better. Now my only symptoms are that my throat swells up immediately after eating and only calms down a few hours after. I wake up with virtually no symptoms but the minute I eat my throat swells. Its distressing. I am not working out as much because I am eating so little now.
    I know Dr. Robillard said it can take LPR to heal up to a month on FT so I hope and cross my fingers that it will clear up like the GERD did (3 days as he promised!)

  27. I wonder how Elle did with her LPR. I am on Dr. Robillard’s diet and as with Elle my GERD cleared up pretty quickly but the sorethroat is hanging in there. Did it eventually go away?

  28. I will read Dr Robillards book but I have on main concern cutting back carbs , which is cutting calories. I have been on PPI’s a few different times and currently, with Gerd and LPR causing me major pain. I am 50 yrs old and have trouble gaining weight, I know, no sympathy. But I have to eat 5 healthy meals a day to keep my 112lbs up. While eating healthy carbs now ,I cant imagine eating even less. How can I maintain my weight on this diet? Any input or suggestions?

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