While many people experience occasional heartburn or mild acid reflux, when these symptoms occur at least twice a week or interfere with everyday life, you may be diagnosed with Gastroesophageal reflux disease (GERD).
GERD causes symptoms or injury to the esophagus by frequent acid reflux—the backwash of stomach acid and bile salts that flood the esophagus.
“It’s primarily due to the dysfunction of the muscles and nerves that control normal esophageal functions and normal gastric emptying,” says James C. Reynolds, MD, AGAF, FACP, FACG , a gastroenterologist, and professor of medicine at Penn Medicine. “But the good news is that GERD is treatable and can be cured.”
Because GERD is related to both neuropathy or nerve damage and obesity, people with diabetes have an increased risk of developing acid reflux disease. According to one 2013 study, “the prevalence of gastroesophageal reflux symptoms in diabetes could be as high as 41%.”
“For people with type 1, the mechanism is entirely related to nerve damage caused by years of inadequate glycemic control,” says Dr. Reynolds. “Type 1 has clearly shown to be a risk factor for developing problems in the gastrointestinal tract, including constipation, diarrhea, gastroparesis and GERD, all of which can be improved by better glycemic control.”
When it comes to type 2, obesity is a huge risk factor for GERD, ulcers in the esophagus and the most serious complication—Barrett’s esophagus, a risk factor for developing esophageal cancer.
“If you add poorly managed diabetes, which can cause damage to nerves, then the risk for all of those conditions increase exponentially for type 2’s,” says Dr. Reynolds.
“Additionally, if you have retinopathy or trouble with your feet, chances are that you also have esophageal problems as well,” he adds. That’s because both can be caused by nerve problems, and may signal that other parts of the body are similarly affected.
GERD develops when the sphincter muscle that separates entry to the stomach from the esophagus becomes weak or relaxes when it shouldn’t.
Usually, this sphincter remains in a closed position. When you eat the sphincter opens to allow food to pass into the stomach. With GERD, however, the sphincter doesn’t close completely after eating, allowing acid to flow backward into the esophagus.
The lining of the esophagus is ill-equipped to handle the acidic contents of the stomach contents, which leads to a burning sensation in the throat and mouth. In addition, prolonged exposure to acid in the lining of the esophagus can change cells so that they no longer resemble esophageal cells, but instead, take on the appearance of stomach cells. This condition is known as Barrett’s esophagus.
There are a variety of medications for GERD.
They include over-the-counter antacids, histamine-2 blockers, and proton pump inhibitors (PPIs) that you can take to reduce the amount of acid in your stomach. If stomach emptying is an issue, doctors may recommend a course of prokinetics or antibiotics. About two weeks of PPIs may be all that is needed to heal any esophageal erosion for some people; others may require long-term management with prescription medication.
While several negative effects have been linked with long-term use of PPIs—including kidney disease, dementia, fractures, infections and vitamin/mineral deficiencies—the actual risk of developing these complications is low to very low.
For difficult cases, surgery may be prescribed.
Reflux often occurs if the muscles where the esophagus meets the stomach do not close tightly enough. A hiatal hernia can make GERD symptoms worse. It occurs when the stomach bulges through this opening into your chest.
The most common surgery to address these problems is Nissen Fundoplication, where a surgeon repairs a hiatal hernia if present and then goes on to wrap the upper part of the stomach around the end of the esophagus with stitches.
This helps prevent stomach acid and food from flowing upward from the stomach into the esophagus.
This can be done with a surgical cut or laparoscopically.
Another, less employed option, is an endoluminal fundoplication, where an endoscope—a special camera on a flexible tool—is passed into your mouth and down your esophagus. Using this tool, the doctor will put small clips in place at the point where the esophagus meets the stomach. These clips help prevent food or stomach acid from backing up.
While heartburn and other symptoms should improve after surgery, some people may have to continue to take drugs. In some cases, if symptoms return, if the stomach was wrapped too tightly, or if a new hiatal hernia develops, individuals may require a second surgery.
In the case of obesity, losing weight can help reduce GERD, as can quitting smoking and avoiding large, fatty meals.
“Fat is the most difficult thing to empty out of your digestive tract in general,” says Dr. Reynolds. “If your stomach isn’t emptying well because you ate a fatty meal, there is more opportunity for acid juice in the stomach to bubble up in the digestive tract.”
Dr. Reynolds says that low-fat meals are good for several reasons, including allowing the stomach to empty better and helping to keep your weight down so you don’t gain pounds and worsen your diabetes.
“Perhaps the best advice, however, is not to lay down soon after eating,” says Dr. Reynolds. “Because the stomach isn’t emptying as it should, if you go to bed before you’ve digested your meal, stomach acids have the opportunity to flood the esophagus, making GERD worse.”
This can pose a problem for people with diabetes who may be instructed to eat snacks before bed, which Dr. Reynolds says is “definitely a no-no.” To deal with this issue, the Joslin Diabetes Clinic suggests that people with certain insulin regimens or who have a history of early morning low blood glucose levels to talk to their healthcare provider to see if they can cut the amount of insulin they take or change the time they take it.
If a snack remains necessary, Dr. Reynolds recommends limiting it to foods that are very low in fat.
For some people, a diet that eliminates certain foods may help the condition, although Dr. Reynolds notes that trying to stay on a restrictive eating plan can be difficult. So save for avoiding fatty foods, he often recommends that patients go easy on dietary restrictions.
“It turns out that the medicines for acid reflux are so effective and that controlling your life by eliminating a whole list of food can be really damaging to your social and family life,” he says. “But if someone really wants to do it, it can be very helpful.”
For those interested in seeing if certain foods aggravate their condition, On Track Diabetes Editorial Board Member Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDE offered suggestions on foods to avoid, including:
Hess-Fishl also recommends increasing the amount of fiber and vegetables in the diet and choosing lean meats and healthy fats (avocado, walnuts, flaxseed, and olive oil).
And while exercise is recommended, routines that put pressure on the abdominal cavity, such as sit-ups or weight lifting should be avoided, particularly immediately following meals.
“Taking a small walk after meals will help with digestion, help burn calories and possibly aid in losing some weight—all of which will reduce GERD symptoms,” says Hess-Fischl.