Transcription:
Treating GERD with Dietary Therapies

Melanie Cole, MS (Host):  Welcome. Today we’re talking about treating GERD with dietary therapies. My guests in this panel discussion are Dr. John Pandolfino. He’s a Hans Popper professor of medicine and chief of gastroenterology and hepatology. And Bethan Doerfler. She’s the clinical research dietician in the division of gastroenterology and they're both at Northwestern Medicine. I'm so glad to have you both with us today. Dr. Pandolfino, I’d like to start with you. Please speak briefly about the pathophysiology of GERD and what determines disease severity.

John Pandolfino, MD (Guest):  Yeah. So the pathophysiology of gastroesophageal reflux disease is actually more complicated than people think. Typically people think of this as an acid disease mostly, but actually when you look at normal people and people with GERD, they have about the same amount of acid in their stomach. Really what it is, it’s actually a disorder of delivery of that acid from the stomach into the esophagus. So it’s really abnormalities in anatomy and physiology that really dictate how much acid gets into the esophagus and above and sits in the esophagus and injuries the esophagus and causes all those symptoms. So it’s really more of a motility and an anatomical problem than an acid problem, but most of the time at least medically we focus on suppressing the acid. I think that really lays into the whole idea of the talk today and the discussion today in that we’re focusing on how obesity and how diet effects reflex. But again, it does have a very important role of the physiology of reflux disease.

Host:  Well then doctor, what has been the standard treatments for GERD? What do you most typically do?

Dr. Pandolfino:  So most typically what we usually start with is some very mild lifestyle modifications where we’ll ask them to identify some triggers and to avoid those. We’ll also advocate for weight loss. It doesn’t take a lot of weight loss. Studies suggest that even five to ten pounds to weight loss can lead to a dramatic reduction in symptoms in reflux. So we ask the patient to try to lose a little bit of weight. Then depending on how severe their symptoms are, we’ll start with medical management. Really the state of the art right now has been proton pump inhibitors. So if people have pretty significant symptoms and they have a really reduced quality of life, we’ll start right off the bat with a proton pump inhibitor. Something like omeprazole, lansoprazole, anthroposol. Those are some of the older ones that have been around for a while and are generic. Those really focus on blocking the pumps that secrete acid. They actually are very effective in treating most people who have acid related symptoms.

Host:  Beth, as Dr. Pandolfino mentioned obesity mentioned a few times and how that is one of the first lines of defense, how important is obesity as an independent risk factor for GERD?

Bethany Doerfler, MS, RDN (Guest):  Yes, that’s an excellent question. In the last several decades, we have seen the obesity epidemic in the U.S. take off. We’ve been able to see that weight gain independently predicts the onset of GERD and reflux symptoms. Conversely as Dr. Pandolfino mentioned, we see that when people lose weight, not only do we see that their GERD symptoms improve but actually even their PPI medications can work better. Some studies that we can talk about have showed as little as a five pound weight loss up to more like a 10 to 12% of body weight loss. So really we can see a lot of substantial changes. More than 66% of Americans are either overweight or obese. When we think about the physiology of GERD, when individuals gain weight they have a tendency to gain weight around their midsection. That increases the pressure at the base of the esophagus also making reflux worse.

Host:  So Beth, based on that, does the current healthcare system effectively promote weight reduction in patients with obesity and GERD? Do you feel that this is new and that we’re learning more about it as an independent risk factor? Do you feel that it’s been concentrated on before?

Bethany:  I would say that weight loss as a primary lifestyle treatment tool for reflux is only recently receiving it’s due attention in the GI world. Weight loss has primarily been viewed as first line therapy for treating cardiovascular disease, diabetes, hypertension. We’re starting to see that some of the elements of the diet that help facilitate weight loss…Weight loss is important because not only does it help reflux but some of the foods that we encourage people to eat to promote weight loss also may have a real functional role in helping to protect the esophagus and the overall wellness.

Host:  Well I'm going to stick with you just a minute since you are a dietician. What role does diet play? Is dietary therapy—what we’re going to be discussing a little more here today—is that an effective long term treatment modality?

Bethany:  Diet therapy is a very effective modality to treat GERD for several reasons. I think historically our focus on nutrition to treat GERD has focused more on types of foods that people shouldn’t eat. People have often been given some pretty basic advice about limiting acidic foods. As Dr. Pandolfino mentioned, it’s really not purely about the acid. It’s more about kind of the physiology and the acid clearance of the esophagus. So we’re starting to shift our focus in nutrition not only to look at what people are eating but kind of how they're eating. How do we reduce portion size? How do we include certain foods that empty faster from the esophagus and the stomach? What types of fiber and antioxidants can be good for the esophageal mucosa? We’re really getting away from globally telling people that they can't eat certain foods. We’re really trying to play up eating more of certain types of foods that will contribute not only to wellness but also to weight loss.

Host:  Well, thank you for that answer. So Dr. Pandolfino, tell us about The Reflux Improvement and Monitoring, the TRIM program. What is it? Has it proven to be an effective weight loss intervention? Tell us about your recent study, some of the results, and some of the methods that you used.

Dr. Pandolfino:  Yeah. So the TRIM study was really in response to kind of this overarching plan to really involve diet and weight loss more in the upfront treatment of reflux disease. Really, when you look at it, an important quality measure of how well we’re doing in terms of gastroenterology is are we effectively educating our patients and giving them advice and treatment outline, focus on weight loss and diet in GERD. We can give people, as Beth mentioned, these lists of things to not do, but we really need to be a little bit more proactive with the patients. So what we decided to do at Northwestern was we designed this platform in our electronic health record where if you are overweight and you are on an acid medicine for reflux, you were contacted by a health coach. This health coach helped you along with some very solid standard advice to lose weight, maybe exercise a little bit more. Then helped you actually try to get off your acid medicine.

We were astounded by the results. We saw that when we actually looked at this, over 50% of the people actually hit their weight loss target of 10 to 15 pounds. We saw a huge reduction in symptoms for many of the patients. Also a big proportion of these patients actually were able to get off their acid medicine. Which, you know, anytime you take a medicine, it’s expensive. It interrupts your life because you have to work that into your daily practice and daily activities. Then, of course, any medicine can have some side effects. You want to reduce that. If you can get people off a medicine by having them live a healthier lifestyle, it’s really important.

With that, we’ve kind of now implemented this TRIM program across the system and not just in the esophageal group and the reflux group, but really trying to indoctrinate it across all of primary care because the results were so good. They were really done in a way that was not intrusive in terms to the way a physician practices and also for the patient’s life. I think they really enjoyed having this advocate.

Host:  Well, I'm sure they did. What a great program, what a great study. So Dr. Pandolfino, tell us a little bit about the esophageal center at Northwestern Medicine that you developed. What can refer providers expect?

Dr. Pandolfino:  Yeah. So at Northwestern, we’ve always had a strong tradition of excellence in the esophagus. It started with Peter Kahrilas who really was the person who brought the physiology and science to Northwestern. We’ve really built this program to the point where now we have six/seven practitioners. Beth is one of our main dieticians. We have psychologists. It’s a really complementary integrated program where we focus on providing a personalized precision model in a very integrated practice unit format. So we tried to really expedite your workup. So we really truly understand the pathology and the pathophysiology behind what's driving your symptoms. Because even reflux can be very complex. There are some patients that have more of a belching pattern with reflux. There are other people that have stream patterns that may be related to obesity. There are other patients who have a really defective anti-reflux barrier. They may have a hiatal hernia. You have to tailor the therapy individually for patients.

So when we actually see you, we’ll actually sit there and say, “Okay. This is the actual symptom that you're worried about and we’re going to focus on that. This is the diet and the lifestyle modifications that will effectively help you with this particular symptom and this pathophysiology. This is the right treatment.” So it’s a really head to toe precision approach to anyone who comes in with an esophageal complaint. As I mentioned, GERD is something that fits a precision personalized model very well.

Bethany:  I would also like to add that the results that we received from the TRIM study and because of the research going on within the esophageal center, our group has also recently initiated a new diet study for our patients with reflux where we are randomizing people to receive one of three different diets. We think all of them are helpful in reflux. We’re looking at outcomes. We have designed very specific resources for patients including sample menus and shopping guides, meal ideas, because we’re really trying to home in on what dietary therapies—Again, not restricting what people eat but specifically telling people what they should eat to improve their symptoms. So stay tuned. There should be more to come down the line on the results of that.

Host:  Well, thank you for telling us about that. It is such a multidisciplinary comprehensive approach, as you said. So Beth, I’d like you to give us this first last word. Tell us what you would like other providers to know about the trim program, about dietary therapies, the role that diet plays in esophageal reflux disease, and how you can help them at Northwestern. Help their patients and what you can do for them.

Bethany:  One thing I would like to tell other practitioners is that patients want diet and lifestyle advice. If they can't get it in their medical visit, they will try to find it on their own. Many of the things that we provide to patients that I would give as clues to providers is that patients do best in the TRIM study and also in our clinical practice. People do best when they have an abundance of resources. We’re really moving away nutritionally from telling people what they shouldn’t eat and we’re really focusing on these are the key things we want you to eat that will help improve the way that your gut empties, the sensations in your gut, and ultimately how we can reduce reflux. People really want an action plan, and we try to offer that to them when they come. I would also suggest to other providers that they need to provide a similar type lifestyle action plan with very detailed resources to help people feel they have this very structured approach. What people eat is very important and how people eat—eating behaviors—is equally important.

Host:  Well, certainly it is. So Dr. Pandolfino, wrap it up for us. What are your top recommendations that you’d like other gastroenterologists, other providers to consider when they're treating patients with GERD and about the TRIM program and new research that Beth mentioned. Give us a good summary.

Dr. Pandolfino:  Yes. So I think really when people are thinking about reflux they just need to think about it as a chronical medical disorder that has a multitude of potential treatments, and that you really have to target the treatments for the patient, specifically their lifestyle. Then, of course, their pathophysiology and then the medicines and the procedures that can effectively treat them. I also want to let the providers know that when your patients have these significant symptoms, it does affect their quality of life. It’s extremely important to also deal with the stress and anxiety that’s related with that. The food avoidance, the anxiety related to going out to dinner. All these things matter to patients and they shouldn’t be discounted. So when you're thinking about your patient, think about the whole patient and how this is effecting their quality of life.

Last, there is still a small association of gastroesophageal reflux disease with esophageal cancer. If your patient is having chronic symptoms and they are requiring a chronic maintenance therapy with acid suppressive medicines like proton pump inhibitors, they really should be screened for esophageal cancer. I think, once again, it’s not a huge risk. People shouldn’t be scared to death about cancer with GERD, but the first and most important thing you can do is get to your doctor, get an endoscopy, get it ruled out that you're at risk for this and then you can go on and really just focus on treating the symptoms. So really important just not to forget that part. Once again, it’s a multidisciplinary approach that really does the best job when you're treating gastroesophageal reflux disease.

Host:  Well it certainly is. What a great episode. Such an interesting topic that so many millions of people suffer from. So thank you so much for coming on, both of you, today and sharing your expertise and telling us about some really interesting studies. That wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at nm.org to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.