DIETARY MODIFICATIONS

The main offending foods to avoid in typical American diet are outlined below. We have also provided a detailed food list for patients who remain symptomatic in spite of following this outline.

Breakfast - The usual breakfast of coffee, orange juice, milk, bacon and egg, and banana are the most offending foods in causing heartburn. Eat toast and jelly with small amount of butter and a cup of tea. If you are going to have orange juice, have 4 ounces of sweet fresh squeezed orange juice. Add a small amount of skim milk to your cereal or have your cereal with your orange juice instead of the milk, try it, it is good. Boiled egg is better than fried or scrambled.

Lunch - Avoid French fries, potato chips, hot dogs, and cold cut meats with high fat contents. If you must add relish, catsup, mustard, barbecue sauce and mayonnaise, add only a touch. In your salad avoid raw onion, carrot, cucumber, broccoli, cauliflower, and vinaigrette based dressing. Use regular (non-carbonated) water for beverage.

Dinner - Avoid deep-fried foods like fried chicken, fried clam, cheese dishes like musaka (ground beef, cheese and eggplant), barbecued ribs, fatty foods, creamy soups like clam chowder, heavy meals like meatloaf, and large meals no matter what. Go light on vegetables specially if raw, chocolate containing deserts, and alcoholic beverages. Stop eating at least three hours before retiring.

What is O.K. to eat?   White meats like chicken without fat and skin, fish and seafood, and lean red meats either broiled or grilled. Rice, baked or mashed potato, pasta, steamed or cooked vegetables, and mild tomato sauce.

RELAX - In patients with heartburn and GERD medications are primarily used to control symptoms. While on medications you may be able to eat most foods and beverages without becoming symptomatic. While this is not recommended most people practice this and get away with it.

Detailed list of foods:

A useful way of thinking about foods which may cause heartburn is "after dinner foods", that is to say, mints, coffee, tea and fatty foods such as cake, ice cream, and chocolates. These are definitely foods that cause heartburn. Avoid foods and beverages that cause heartburn, for example:.

• Tea and Coffee (including the decaffeinated variety)

• Fruit and vegetable juices such as orange juice, grapefruit juice, pineapple juice, V8 juice, tomato juice

• Carbonated beverage of all types (regular water is the best drink)

• Milk and buttermilk

• Beer, wine, and hard liquors

• Oatmeal and other fibrous breakfast cereals

• Fruits such as kiwis, apples, melons and bananas, raw peaches, plums, and strawberries

• Vegetables such as raw onions, carrots, radishes, tomatoes, cucumbers, broccoli, pepper, turnip, eggplant

• Fatty foods such as bacon, eggs, sausage, hotdog, cold cuts (i.e. bologna, salami, pepperoni), Italian sandwich, hamburger, meatloaf, gyro, stews, shepherd's pie, pizza

• Deep-fried foods such as french-fries, potato chips, hash browns, fried clams

• Spicy foods like burritos, tacos, curry, homos, Cajun foods

• Sauces such as tomato sauce, mayonnaise, ketchup, mustard, horseradish, gravy, salsa, salad dressings containing lime/lemon juice and vinegar

• Most Mexican, Indian, and Chinese foods served in restaurants due to their beans, spices, and fat content

• Hot & sour soups, thick soups, bean soups, cream based soups, soups containing beans and legumes

• Pickled foods, dehydrated foods such as dates

LIFESTYLE MODIFICATIONS

• Elevate the head of your bed at least six inches by putting a couple of bricks or old books under the top legs of your mattress frame. You can also purchase special foam wedge pillow made for this purpose from your local pharmacy supply store, or try a more  advanced pillow by contacting www.propuppillow.com. This will reduce the return of stomach acidity and semi-digested food into your esophagus, throat, mouth and potentially your lungs when you are sleep.

• Avoid exercising at least for one to two hours after each meal. Do not bend from the waist down for 1-2 hours after each meal.

• Avoid eating or drinking except water and medications for 2-3 hours before going to bed (go to bed with an empty stomach to reduce the chance of reflux).

• Avoid wearing tight belts, pants or corsets.

• Stop drinking alcoholic beverages.

• Stop smoking.

• Avoid large meals. If necessary eat smaller amounts more frequently.

• Reduce your weight to diminish reflux.

MEDICATIONS THAT ADVERSELY AFFECT GERD

Medication belonging to the following pharmacological classes cause or increase heartburn by relaxing  the lower esophagal sphinctere:  Nitrates, Anticholinergics, Beta-adrenergic agonists, Alpha-adrenergic antagonists, Aminophyllines, Benzodiazepines, Calcium channel blockers, Nicotine derivatives, Tricyclic antidepressants, and chlorpromazines.

OVER-THE-COUNTER SELF MEDICATIONS

The best news for chronic reflux sufferers is Prilosec going over-the-counter. Prilosec(Omeprazole) has been around for a long time and has an excellent safety record similar to other PPIs (Omeprazole = Prilosec, Esomeprazole = Nexium, Lansoprazole = Prevacid, Pantoprazole=Protonix, and Rabeprazole = Aciphex). It is offered however, for reasons unkown to me, much cheaper than prescription PPIs (typically $1 vs. $3-4/tablet or capsule of similarly effective PPI) even though it is as strong, as good and as safe.

Zantac (Ranitidine) 150 mg is over the counter now; last time I checked the cost of 60 tablet package was $22 at my local pharmacy. The usual dose is 150 mg twice daily.

Prilosec 20 mg is also over the counter and 14 tablets cost $11. Therefore, one month supply of either one costs about $22. In patients who need to take 2 Zantac tablets daily it is more convenient and more effective to take one Prilosec OTC.

Indeed, in my experience Prilosec 20 mg (omeprazole) is as effective as Prevacid 30 mg (lansoprazole) and in most patients as effective as Nexium 40 mg (esomeprazole) and Aciphex 20 mg (rabeprazole) and more effective than Protonix 40 mg (pantoprazole).

Most of the time patient co-pay is equal or more than the cost of one month Prilosec OTC. Again based on my experience, Protonix (panntoprazole) that is the least effective of all PPIs has the lowest co-pay and is preferred by most HMOs.

Zantaz 150 mg and Prilosec 20 mg, do not require prescription to buy.

Histamine Receptor Antagonist (H₂-RA) - Over-the-counter histamine receptor blockers like Tagamet HB, Pepcid AC and Zantac75 reduce gastric acid formation in response to a meal, therefore they should be taken before each meal and by the same reason they do not provide immediate relief of heartburn as antacids do. Based on my clinical experience, Axid (nizatidine) is the least effective of the H₂-blockers. H₂-RAs are relatively safe, but if you need to take them regularly or more than 2 daily you should consult your physician. 

Pepcid Complete (over-the-counter) - a combination of Pepcid AC (Famotidin) and a calcium carbonate antacid. Famotidin is an H₂-blocker which reduces acid secretion within 45 minutes to an hour of ingestion. The calcium carbonate acts immediately to neutralize the acid already present in the stomach. This combination provides both short term and long term relief.

Surpass (an antacid chewing gum) - Recently, Wrigley Healthcare has released a chewing gum that is coated with 450mg of calcium carbonate. Calcium carbonate neutralizes the acid and relieves heartburn immediately. While continuing to chew gum will produce saliva, and since Saliva's pH is alkaline, the swallowed saliva will continue to neutralize the remaining acid. Like Tums, Surpass may be used as calcium supplement as well.