 Hi, this is Dr. Ruscio. Are PPIs or Acid Suppressing Medications bad for your health and might they even be linked to an increased risk of death? Let's take a look at a recent study that's fairly damning against the potential detriments from using Acid Suppressing Medications. Let's go through this point by point. In this following study published in the BMJ in 2019 entitled, Estimates of All Cause Mortality or Death and Specific Cause Mortality associated with proton pump inhibitors among U.S. veterans, a cohort study. The researchers were attempting to look in a prospective cohort fashion, meaning we take a group of people and we track them going forward in time to evaluate if there's an association between the use of PPI medications, Acid lower medications and any type of mortality or death. Let's look at what they found. In this group of 157,000 users of PPIs and 56,000 H2 blockers, H2 blockers are a more mild form of Acid Suppressing Medication. They're known as histamine receptor 2 antagonists. So they block the histamine 2 receptor or the participants or the groups that were tracked. So we have very compelling, very large sample sizes that are being tracked. Let's look at what they found. Conclusion. Taking PPIs is associated with a small excess of cause specific mortality that means death due to certain causes, including death due to cardiovascular disease, chronic kidney disease and upper gastrointestinal cancer. The burden was also observed in patients without an indication for PPI use. What they are indicating here is that if someone needs a PPI it could be the underlying pathology, the underlying process in the body requiring the PPI that leads them to have that increased likelihood of death and perhaps not the medication itself. The medication might be an innocent bystander. What they're describing here is even those who didn't have a clinical need for PPI's but who were using them still saw this increased risk of specific causes of death. Continuing their conclusion, heightened vigilance in the use of PPI's may be warranted. So that's some pretty damning evidence urging us to be cautious with the indiscriminate use of PPI's or acid lowering medications. Now we should necessarily throw the baby out with the bathwater, meaning there is good evidence for clinical utility, the ability to heal gastric and duodenal ulcers when PPI's are used for four to eight weeks. So there does going to be good evidence and we should be open minded to a short term application of using acid lowering medication. But it's a long term use and risk associated with the long term use that we really could improve upon. What causes reflux? In my experience the most common causes are food triggers, excessive gas production or immune activation. And oftentimes these three are intertwined in this causal web. Now regarding dietary triggers, this is not an exhaustive list but it's a starting point. Things like gluten, dairy, soy, processed foods, spicy foods, caffeine, soy, I believe are so that can be a problem. And what one could do is perform a trial on an elimination diet. There are different iterations of elimination diet. There's something known as a six food elimination and eight food elimination. There's a paleo diet. There's a Mediterranean diet. I like the paleo diet because that will remove many common inflammatory or irritating foods. The good news is you only need to try this for about two to three weeks and then you should be noticing either a clear benefit or if you're not sure that tells you that that's probably not getting to the dietary triggers or the underlying causes of your reflux. Now regarding excessive gas production, a diet that can be very helpful there is the low FODMAP diet and there's been at least one study showing that a low FODMAP diet can improve reflux or GERD and a low FODMAP diet essentially is a diet that will limit foods that are powerful at feeding intestinal bacteria. Remember that intestinal bacteria eat some of the food that goes through your intestinal tract and as a by-product of eating, just like we sometimes fart and burp, so do these bacteria and they release gases and these gases can be part of what underlies GERD or reflux. Now probiotics can be helpful because they can actually help to reduce gas levels and this ties in with another potential cause of excessive gas which could be excessive bacteria because remember, bacteria eat substrate in the gut and as a by-product of their metabolism release gas so it stands to reason that there could be two ways in which you could rectify this problem. One, stop feeding the bacteria so much so they produce less gas that's the low FODMAP diet. The other, if you have too much bacteria, use a method to help reduce that bacterial overgrowth. This is where probiotics can be quite helpful and there has been one trial showing, at least strongly suggesting that probiotics can help to improve reflux and there's strong evidence showing that probiotics can help to reduce bacterial overgrowth so probiotics when appropriately use and I would highly recommend our three probiotic protocol to really support the different niches in the gut that different types of probiotics can support but the probiotics might end up doing is helping to combat this high level of bacteria, less bacteria, less gas and less reflux. Tying back into the immune system component of this, if you have a bacterial overgrowth we know that that can irritate the immune system and cause the immune system to activate to try to crop out this overgrowth of bacteria. We also know that a low FODMAP diet can reduce immune system activation, namely through a measure on a cytokine so we see less of the inflammatory signaling molecules the immune system uses when one follows your low FODMAP diet. Also we see the same type of phenomenon when one uses probiotics so if the immune system overactivation is the root cause of the reflux some of these same therapies can also be helpful. Now how does the immune system tie in? Well we know that part of the signaling used by the immune system is histamine and so if we know that one of the medical treatments for reflux are histamine antagonists or histamine blockers another way of coming at this could be to use for example a low FODMAP diet or a probiotic both which have been shown to lower histamine and we have preliminary evidence showing either of these therapies can improve reflux. So whether the cause of the factor is a food trigger, gas or the immune system some of these kind of keystone dietary or I should say gut therapies, diet and probiotics can be quite helpful in improving the underlying cause of this syndrome of reflux and finally one may want to consider a trial on a low histamine diet and a low histamine diet instead of limiting the production of histamine as you would by going low FODMAP or using probiotics you would actually in this case limit your dietary intake of histamine because some foods are higher in histamine than others. So if we zoom way out fairly compelling evidence that we should be very cautious with the long term use of acid suppressing medication whether that's a PPI or a H2 histamine blocking agent. Fortunately things like diet and looking at the use of probiotics can be very helpful in not only reducing the symptoms of gut or reflux but also helping to fix the underlying cause of that symptom because remember we want to use our interventions to get to the root cause not just suppress the symptom and I think it's fairly tenable to argue that a PPI or a histamine antagonist are not really treating the cause of the problem. Now there's certainly a time and a place for symptomatic palliative measures however if we can get to the root cause of the high histamine levels by using a diet that reduces inflammatory foods or a low FODMAP diet which reduces both gas and histamine or by using a probiotic which can reduce gas and histamine production. Now what we're doing is we're opening up the chance to see not only a reduction in the chief complaint or reflux but you may sleep better, you may have less joint pain, you may have clearer skin or you may have clearer thinking. As an example we know that when histamine levels are too high that can be correlated with impairment of cognition. People can feel kind of foggy when histamine is high just as one of many examples. So in summary, caution with long-term use of acids or pressing medication is quite warranted. Fortunately there are other therapies that can be used namely diet, an elimination diet like a palliative diet or a low FODMAP diet and probiotics are some very simple interventions that one can use to get to and address the root cause of the reflux, thus not needing an acid lower medication and potentially even reaping side benefits like less joint pain or improved cognition as a byproduct again of treating the underlying cause of the imbalance. So hopefully this helps you get healthy and get back to your life and find a way to get off of an acid-depressing medication.