Most of us will have experienced the burning sensation that can creep up from the middle of our chest into the throat following an indulgent meal, drinking wine or coffee, consuming chocolates or simply eating too late before bedtime.
When heartburn or acid reflux strikes, antacids and PPIs will provide quick symptom relief. But they do not address or resolve the underlying causes, so the gnawing feeling returns and people can end up taking medications for years.
PPI use has significantly increased over the past decades with data from 2023 showing that nearly one quarter of adults globally use a PPI, with 25% of people continuing use for over a year and 28% extending beyond 3 years. This is despite current NICE guidelines that recommend PPIs to be given for the shortest time possible.
In this blog I want to raise awareness of the benefits of PPIs but more importantly the hidden health risks associated with prolonged PPI use and suggest some steps you can take to improve the situation.
What are PPIs and how do they work?
PPIs stand for Proton Pump Inhibitors. They are medications that offer quick and effective relief by reducing stomach acid in conditions like heartburn, gastro-oesophageal reflux disease (GORD), silent reflux, hiatus hernias, peptic ulcers and pregnancy. In addition to symptom relief, they do the important job of protecting the delicate lining of the oesophagus (food pipe) from on-going damage. This damage is linked to an increased risk of developing cancer so it is important that you do not simply stop taking your PPI medication without taking other steps to minimise this risk.
There are different types of these medications like Omeprazole, Lansoprazole etc. (all ending with ‘prazole’). They all work in similar ways although their formulations and dosing regimens may vary. Some are available over the counter and others are prescription only.
The proton pump is a specific enzyme in the stomach that is responsible for the final step in the production of stomach acid, releasing hydrogen ions (or protons). Stomach acid is essential for breaking down food during the digestion process. It also kills off harmful bacteria that you may have ingested. PPIs bind to this enzyme, stopping it from releasing further hydrogen ions, and thereby rendering it permanently ineffective.
Taking a morning and an evening dose 30 minutes before a meal will result in about 80% inhibition of stomach acid production, not accounting for other factors that can have an impact such as stress. Over the next 24 hours, the body will replace about 25% of the destroyed pumps. Some people will experience side effects in the form of IBS like symptoms such as diarrhea, constipation, fatigue, cramps, headaches and more.
An interesting fact that not many people are aware of is that PPIs can only gain access to the enzyme if there is food in the stomach. This means taking PPIs just before going to bed to help with reflux, which is usually a few hours after your last meal, will be ineffective and not bring any relief.
There are other reasons why your doctor may be prescribing PPIs. For example, in order to protect your stomach from medications that impact the protective mucus production and are known to cause gastric ulcerations and erosions like NSAIDs, blood thinners, SSIRs etc.
What are some of the hidden unintended consequences of long-term PPI use on your health?
PPIs are mainly intended for short-term use to manage acute symptoms due to acid related conditions. They do not resolve underlying issues such as food sensitivities, poor digestion, physical issues like hiatus hernia or stress. These need to be addressed with diet and life-style changes, or over time they are likely to get worse.
Long-term use, especially more than 8 weeks, is linked to a range of health issues that can appear to be unrelated.
Nutrient deficiencies
Stomach acid plays a crucial role in food breakdown and absorption. One of my favourite sayings is ‘we are not what we eat but what we are able to absorb’. We know that PPIs reduce stomach acid levels and long-term use can interfere with the absorption of critical nutrients.
Nutrient | Role in Body | Impact of deficiency | Symptoms/Health Risk |
Calcium | Vital for bone health, muscle function, and nerve signalling | Reduced calcium absorption increases the risk of bone loss and osteoporosis | Increased fracture risk, muscle weakness, dental issues, and potential development of osteoporosis |
Magnesium | Crucial for muscle/nerve function, heart health, and bone strength | Impaired magnesium absorption can cause chronic low magnesium levels) | Muscle cramps, irregular heartbeat, fatigue, seizures, and potential worsening of cardiovascular conditions |
Vitamin B12 | Essential for red blood cell production and nerve function | Decreased stomach acid reduces the release of B12 from food, leading to deficiency | Anaemia, nerve damage, memory problems, mood disturbances, and cognitive decline |
Iron | Critical for oxygen transport in the blood | Lower stomach acidity inhibits conversion of dietary iron to its absorbable form | Fatigue, shortness of breath, weakened immunity, and development of iron-deficiency anaemia |
Zinc | Important for immune health, wound healing, and enzyme function | Stomach acid is essential for the proper absorption of zinc from dietary sources | Impaired immune response, delayed wound healing, hair loss, and changes in taste or smell |
Proteins | Building blocks of tissues, enzymes, and hormones | Reduced stomach acid impairs protein breakdown into absorbable amino acids | Impaired muscle repair, weakened immunity, slower healing, and diminished enzyme/hormone production |
There are other nutrient deficiencies that can develop due to PPI use that can significantly impair every aspect of quality of life by impacting energy levels, mood, quality of sleep, resilience, libido and much more.
Disrupted gut health
Stomach acid acts as a barrier against harmful bacteria entering the digestive tract. Prolonged suppression of stomach acid can disrupt the natural balance of your gut microbiome, impacting digestion, immunity and overall health. Reducing stomach acid can create an environment that allows an overgrowth of potential harmful bacteria, fungi or virus and a reduction on our friendly bacteria, also referred to as dysbiosis.
Dysbiosis can lead to increased susceptibility to gastrointestinal infections such as Clostridium difficile and small intestinal bacterial overgrowth (SIBO). It also compromises the gut’s ability to produce and absorb essential nutrients, weakens the intestinal barrier (leaky gut) where toxins, pathogens, or partially digested proteins enter the bloodstream activating the immune system and exacerbating system inflammation.
This can lead to bloating, gas, diarrhea, constipation or abdominal discomfort as well as potentially contributing to conditions such as IBS, IBD, obesity, diabetes, depression, anxiety, skin issues and more.
Rebound hypersecretion when trying to stop
If you stop taking your PPIs ‘cold turkey’, you are likely to experience a rebound reaction where the stomach acid production and associated symptoms will temporarily increase. People often take this as a sign that their reflux has deteriorated and that they need to continue taking PPIs, often in higher doses.
What is actually happening is that the body has upregulated the chemicals that initiate stomach acid production. When you stop taking PPIs, the proton pumps start to regenerate in larger quantities. But the increased signals trying to produce more stomach acid are still hanging around in the stomach also. It is bit like water held behind a dam - when the dam opens (increased proton pumps), the water comes flooding through (increased stomach acid). It takes our bodies between a few days to a few weeks to recalibrate and adjust. This rebound reaction can occur in as little as 4 – 5 days use of PPIs.
It is very important that you take appropriate measures (like Gaviscon) to protect your oesophagus during this adjustment period.
The surprising connection between acid reflux and your nervous system
Acid reflux is driven not only by what we eat but how we eat is just as important. So, rather than taking medications that mask symptoms, we need to mindful and improve the process of digestion.
Digestion is controlled by our nervous system. There are two branches, the sympathetic or ‘fight or flight’ stress reaction and the parasympathetic ‘digest and rest’ response. These are mutually exclusive which means if we are stressed, we cannot digest and this can lead to a range of digestive complaints including reflux. Stress can take many forms from emotional and psychological stressors to blood sugar imbalances, under/over-exercise, acute and chronic inflammation, pain, infections, disturbed sleep and more.
Luckily, there are ways that we can switch into a parasympathetic state – it just takes practice. Meet the Vagus nerve! It is the largest nerve in our body and connects the gut to the brain. It has many functions but also controls the movement of food and the release of digestive enzymes. A poorly functioning vagus nerve due to stress, nerve damage, or other factors, can weaken the lower oesophageal sphincter (ring muscle between the stomach and diaphragm) resulting in reflux symptoms.
Thinking about the digestive process, the vagus nerve gets activated by the sight, smell and taste, and even just thinking about what the food we are about to eat. This anticipation, also called the cephalic phase, leads to the production and release of enzymes, bile, and gastric juices to support our digestion but takes about 15 – 20 minutes to kick in. That is why eating on the run, ‘inhaling’ our food, or multi-tasking when eating is not conducive to good digestion.
Other strategies like being more mindful before and during eating, taking your time and chewing our food properly (the stomach doesn’t have teeth) helps to mechanically break down our food and takes the burden off our stomachs.
As Nutritional Therapists we often encourage our clients to incorporate activities that over time will improve vagal tone i.e. the strength and efficiency of this vital nerve. Benefits are cumulative. Therefore, the more consistently you engage in activities that boost vagal tone, the more robust and enduring the improvements in digestive health and overall bodily function
Some examples of recommended activities include:
Mindfulness and mediation
Deep breathing like alternate nostril breathing or box breathing (used by the Navy Seals to reduce stress levels in difficult situations
Cold water exposure (finish shower with cold water, splash your face with cold water, cold water swimming etc)
Throat innervation like singing, humming, gargling, chanting
Regular physical exercise like walking, cycling, yoga, swimming, running
Anything that makes you laugh or helps you relax
Strategies to take control of your symptoms
Keeping a food and symptom tracker – this can help to identify specific triggers such as spicy foods, caffeine, chocolate, citrus or tomato based foods, alcohol etc. Other triggers include stress, meal timings and imbalances in your gut health.
Work on your digestive process – focus on not just what you eat, but how you eat.
Improve your vagal tone – Heart Rate Variability (HRV) is a practical way to measure vagal tone. There are many devices and apps at different prices that will provide you with data that will show how different activities and lifestyle changes can affect your vagal tone and overall health.
Work with a qualified nutritionist or health coach that can provide you with personalised nutrition, lifestyle & supplement recommendations and keep you on track
How can I help?
Last summer I became an accredited reflux practitioner with a new initiative called Digestion with Confidence spearheaded by Pharmacist & Nutritional Therapist Debbie Grayson who is also my mentor. Debbie is currently receiving a lot of coverage in the national press as her #refluxrevolution is gathering momentum.
Although I have been supporting clients with reflux issues for years, I now have a better understanding of the mechanisms of PPI medication and its effect on the body. And more importantly, I know how to help you wean off them safely (with your doctor’s approval), if you choose.
There is also an on-line course in development that will be launching later this year. If you are interested, please send me your email address so you will one of the first people to find out more.
In the meantime, you can download my free download ‘Drinks & Reflux’ ebook from my homepage as the impact of drinks is often overlooked in relation to acid reflux.
Thank you for reading this blog and found it informative. Please click here to either complete an enquiry form or book a call. Looking forward to hearing from you.
In support of your health and wellness,
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