• Why acids leave the stomach and enter the esophagus
• The harmful effects of taking antacids and acid stopping drugs
• How antacids perpetuate heartburn and actually make it worse over time
• The role of stomach acid in digestion
• The bacterial component in acid reflux
• Why you get gas and belch
• Which nutritional deficiencies are common with acid reflux
• The association between acid reflux and IBS, Crohn’s, and other intestinal diseases
• Which inexpensive supplement will help reduce indigestion
• Which foods cause heartburn
• Which foods you should eat to heal the gut

Click here to listen to the MP3 file, or right-click to download it.

Related posts:

1. Get rid of heartburn and GERD forever in three simple steps
2. What Everybody Ought To Know (But Doesn’t) About Heartburn & GERD
3. The hidden causes of heartburn and GERD

In this final article of the series, we’re going to discuss three steps to treating heartburn and GERD without drugs. These same three steps will also prevent these conditions from developing in the first place, and keep them from returning once they’re gone.

To review, heartburn and GERD are not caused by too much stomach acid. They are caused by too little stomach acid and bacterial overgrowth in the stomach and intestines. Therefore successful treatment is based on restoring adequate stomach acid production and eliminating bacterial overgrowth.

This can be accomplished by following the “three Rs” of treating heartburn and GERD naturally:

1. Reduce factors that promote bacterial overgrowth and low stomach acid.
2. Replace stomach acid, enzymes and nutrients that aid digestion and are necessary for health.
3. Restore beneficial bacteria and a healthy mucosal lining in the gut.

Reduce factors that promote bacterial overgrowth and low stomach acid

Carbohydrates

As we saw in Part II and Part III, a high carbohydrate diet promotes bacterial overgrowth. Bacterial overgrowth – in particular H. pylori – can suppress stomach acid. This creates a vicious cycle where bacterial overgrowth and low stomach acid reinforce each other in a continuous decline of digestive function.

It follows, then, that a low-carb (LC) diet would reduce bacterial overgrowth. To my knowledge there have only been two small studies done to test this hypothesis. The results in both studies were overwhelmingly positive.

The first study was performed by Professor Yancy and colleagues at Duke University. They enrolled five patients with severe GERD that also had a variety of other medical problems, such as diabetes. Each of these patients had failed several conventional GERD treatments before being enrolled in the study. In spite of the fact that some of these patients continued to drink, smoke and engage in other GERD-unfriendly habits, in every case the symptoms of GERD were completely eliminated within one week of adopting a very low carbohydrate (VLC) (<20 grams/day) diet! The patients were able to stop all antacids and prescription stomach medicines and this improvement continued even after they liberalized their carbohydrate intake to a more tolerable 70 grams per day.

The second study (PDF) was performed by Yancy and colleagues a few years later. This time they examined the effects of a VLC diet on eight obese subjects with severe GERD. They measured the esophageal pH of the subjects at baseline before the study began using something called the Johnson-DeMeester score. This is a measurement of how much acid is getting back up into the esophagus, and thus an objective marker of how much reflux is occurring. They also used a self-administered questionnaire called the GSAS-ds to evaluate the frequency and severity of 15 GERD-related symptoms within the previous week.

At the beginning of the diet, five of eight subjects had abnormal Johnson-DeMeester scores. All five of these patients showed a substantial decrease in their Johnson-DeMeester score (meaning less acid in the esophagus). Most remarkably, the magnitude of the decrease in Johnson-DeMeester scores is similar to what is reported with PPI treatment. In other words, in these five subjects a very low carbohydrate diet was just as effective as powerful acid suppressing drugs in keeping acid out of the esophagus.

All eight individuals had evident improvement in their GSAS-ds scores. The GSAS-ds scores decreased from 1.28 prior to the diet to 0.72 after initiation of the diet. What these numbers mean is that the patients all reported significant improvement in their GERD related symptoms. Therefore, there was both objective (Johnson-DeMeester) and subjective (GSAS-ds) improvement in this study.

It’s important to note that obesity is an independent risk factor for GERD, because it increases intra-abdominal pressure and causes dysfunction of the lower esophageal sphincter (LES). The advantage to a low-carb diet as a treatment for GERD for those who are overweight is that LC diets are also very effective for promoting weight loss.

I don’t recommend VLC diets for extended periods of time, as they are unnecessary for most people. Once you have recovered your digestive function, a diet low to moderate in carbohydrates should be adequate to prevent a recurrence of symptoms.

An alternative to a VLC is something called a “specific carbohydrate diet” (SCD), or the GAPS diet. In these two approaches it is not the amount of carbohydrates that is important, but the type of carbohydrates. The theory is that the longer chain carbohydrates (disaccharides and polysacharides) are the ones that feed bad bacteria in our guts, while short chain carbohydrates (monosacharides) don’t pose a problem. In practice what this means is that all grains, legumes and starchy vegetables should be eliminated, but fruits and certain non-starchy root vegetables (winter squash, rutabaga, turnips, celery root) can be eaten. These are not “low-carb” diets, per se, but there is reason to believe that they may be just as effective in treating heartburn and GERD. See the resources section below for books and websites about these diets, which have been used with dramatic success to treat everything from autism spectrum disorder (ASD) to Crohn’s disease.

Be careful to avoid the processed low-carb foods sold in supermarkets. Instead, I suggest what is known as a “paleolithic” or “primal” approach to nutrition. Mark’s Daily Apple is a great online resource for this approach, and his book “Primal Blueprint” is a good summary of the principles.

Fructose and artificial sweeteners

As I pointed out in Part II, fructose and artificial sweeteners have been shown to increase bacterial overgrowth. Artificial sweeteners should be completely eliminated, and fructose (in processed form especially) should be reduced.

Fiber

High fiber diets and bacterial overgrowth are a particularly dangerous mix. Remember, Almost all of the fiber and approximately 15-20% of the starch we consume escape absorption. Carbohydrates that escape digestion become food for intestinal bacteria.

Prebiotics, which can be helpful in re-establishing a healthy bacterial balance in some patients, should probably be avoided in patients with heartburn and GERD. Several studies show that fructo-oligosaccharides (prebiotics) increase the amount of gas produced in the gut.

The other problem with fiber is that it can bind with nutrients and remove them from the body before they have a chance to be absorbed. This is particularly problematic in GERD sufferers, who may already be deficient in key nutrients due to long term hypochlorydria (low stomach acid).

H. pylori

In Part III we looked at the possible relationship between H. pylori and GERD. While I think it’s a contributing factor in some cases, the question of whether and how to treat it is less clear. There is some evidence that H. pylori is a normal resident on the human digestive tract, and even plays some protective and health-promoting roles. If this is true, complete eradication of H. pylori may not be desirable. Instead, a LC or specific carbohydrate diet is probably a better choice as it will simply reduce the bacterial load and bring the gut flora back into a state of relative balance.

The exception to this may be in serious or long-standing cases of GERD that aren’t responding to a VLC or LC diet. In this situation, it may be worthwhile to get tested for H. pylori and treat it more aggressively.

Dr. Wright, author of Why Stomach Acid is Good For You, suggests using mastic (a resin from a Mediterranean and Middle Eastern variety of pistachio tree) to treat H. pylori. A 1998 in vitro study in the New England Journal of Medicine showed that mastic killed several strains of H. pylori, including some that were resistant to conventional antibiotics. Studies since then, including in vivo experiments, have shown mixed results. Mastic may be a good first-line therapy for H. pylori, with antibiotics as a second choice if the mastic treatment isn’t successful.

Replace stomach acid, enzymes and nutrients that aid digestion and are necessary for health

HCL with Pepsin

If you have an open-minded doctor, or one that is aware of the connection between low stomach acid and GERD, ask her to test your stomach acid levels. The test is quite simple. A device called a Heidelberg capsule, which consists of a tiny pH sensor and radio transmitter compressed into something resembling a vitamin capsule, is lowered into the stomach. When swallowed, the sensors in the capsule measure the pH of the stomach contents and relay the findings via radio signal to a receiver located outside the body.

In cases of mild to moderate heartburn, actual testing for stomach acid production at Dr. Wright’s Tahoma clinic shows that hypochlorydria occurs in over 90 percent of thousands tested since 1976. In these cases, replacing stomach acid with HCL supplements is almost always successful.

Although testing actual stomach acid levels is preferable, it is not strictly necessary. There is a reasonably reliable, “low-tech” method that can be performed at home to determine whether HCL supplementation will provide a benefit. To do this test, pick up some HCL capsules that contain pepsin. HCL should always be taken with pepsin because it is likely that if the stomach is not producing enough HCL, it is also not producing enough pepsin.

To minimize side effects, start with one 650 mg capsule of HCL w/pepsin in the early part of each meal. If there are no problems after two or three days, increase the dose to two capsules at the beginning of meals. Then after another two days increase to three capsules. Increase the dose gradually in this stepwise fashion until you feel a mild burning sensation. At that point, reduce the dosage to the previous number of capsules you were taking before you experienced burning and stay at that dosage. Over time you may find that you can continue to reduce the dosage, or you may also find that you may need to increase the dosage.

In Dr. Wright’s clinic, most patients end up at a dose of 5-7 650 mg capsules. In my more limited experience, 3-4 capsules is the norm.

Bitters

Another way to stimulate acid production in the stomach is by taking bitter herbs. “Bitters” have been used in traditional cultures for thousands of years to stimulate and improve digestion. More recently, studies have confirmed the ability of bitters to increase the flow of digestive juices, including HCL, bile, pepsin, gastrin and pancreatic enzymes. ¹

Unsurprisingly, there aren’t many clinical studies evaluating the therapeutic potential of unpatentable and therefore unprofitable bitters. However, in one uncontrolled study in Germany, where a high percentage of doctors prescribe herbal medicine, gentian root capsules provided dramatic relief of GI symptoms in 205 patients.

The following is a list of bitter herbs commonly used in Western and Chinese herbology:

• Barberry bark
• Caraway
• Dandelion
• Fennel
• Gentian root
• Ginger
• Globe artichoke
• Goldenseal root
• Hops
• Milk thistle
• Peppermint
• Wormwood
• Yellow dock

Bitters are normally taken in very small doses – just enough to evoke a strong taste of bitterness. Kerry Bone, a respected Western herbalist, suggests 5 to 10 drops of a 1:5 tincture of the above herbs taken in 20 mL of water.

An even better option is to see a licensed herbalist who can prescribe a formula containing several of the herbs above as appropriate for your particular condition.

Apple cider vinegar, lemon juice, raw (unpasteurized) sauerkraut and pickles are other time-tested, traditional remedies that often relieve the symptoms of heartburn and GERD. However, although these remedies may resolve symptoms, they do not increase nutrient absorption and assimilation to the extent that HCL supplements do. This may be important for those who have been taking acid suppressing drugs for a long period.

It is also important to avoid consuming liquid during meals. Water is especially problematic, because it literally dilutes the concentration of stomach acid. A few sips of wine is probably fine, and may even be helpful.

Finally, for those who have been taking acid stopping drugs for several years, it may be necessary to replace the nutrients that are not absorbed without sufficient stomach acid. These include B12, folic acid, calcium, iron and zinc. It’s best to get your levels tested by a qualified medical practitioner, who can then help you replace them through nutritional changes and/or supplementation.

Restore beneficial bacteria and a healthy mucosal lining in the gut

Probiotics

Because bacterial overgrowth is a major factor in heartburn and GERD, restoring a healthy balance of intestinal bacteria is an important aspect of treatment. Along with performing several other functions essential to digestive health, beneficial bacteria (probiotics) protect against potential pathogens through “competitive inhibition” (i.e. competing for resources).

While I haven’t seen any specific research on probiotics in the treatment of GERD, numerous studies have demonstrated their effectiveness in treating a variety of G.I. conditions.

Researchers in Australia have shown that probiotics are effective in reducing bacterial overgrowth and altering fermentation patterns in the small bowel in patients with IBS. Probiotics have also been shown to be effective in treating Crohn’s disease, ulcerative colitis, and other digestive conditions.

I am often asked what type of probiotics I recommend. First, I am not a big believer in supplements. I think we should always attempt to get the nutrients we need from food. This is also true for probiotics. Fermented foods have been consumed for their probiotic effects for thousands of years. What’s more, contrary to popular belief and the marketing of commercial probiotic manufacturers, foods like yogurt and kefir generally have a much higher concentration of beneficial microorganisms than probiotic supplements do.

For example, even the most potent commercial probiotics claim to contain somewhere between one and five billion microorganisms per serving. (I say “claim” to contain because independent verification studies have shown that most commercial probiotics do not contain the amount of microorganisms they claim to.) Contrast that with a glass of homemade kefir, a fermented milk product, contains as many as 5 trillion beneficial microorganisms!

What’s more, fermented milk products like kefir and yogurt offer more benefits than beneficial bacteria alone, including minerals, vitamins, protein, amino acids, L-carnitine, fats, CLA, and antimicrobial agents. Studies have even shown that fermented milk products can improve the eradication rates of H. pylori by 5-15%.

The problem with fermented milk products in the treatment of heartburn and GERD, however, is that milk is relatively high in carbohydrates. This may present a problem for people with severe bacterial overgrowth. However, relatively small amounts of kefir and yogurt are therapeutic and may be well tolerated. It’s best to make kefir and yogurt at home, because the microorganism count will be much higher. Lucy’s Kitchen Shop sells a good home yogurt maker, and Dom’s Kefir site has exhaustive information on all things kefir. If you do buy the home yogurt maker, I suggest you also buy the glass jar that Lucy’s sells to make it in (rather than using the plastic jar it comes with).

Another option is to eat non-dairy (and thus lower-carb) unpasteurized (raw) sauerkraut and pickles and/or drink a beverage called kombucha. Raw sauerkraut can easily be made at home, or sometimes found at farmer’s markets. Bubbies brand raw pickles are sold at health food stores, as is kombucha, but both of these can also be made quite easily at home.

If you do choose to take capsules, make sure the brand you choose is reputable and the viability of their product has been independently verified. Natren is such a brand in the US.

Bone broth and DGL

Restoring a healthy gut lining is another important part of recovering from heartburn and GERD. Chronic stress, bacterial overgrowth, and certain medications such as steroids, NSAIDs and aspirin can damage the lining of the stomach. Since it is the mucosal lining of the stomach that protects it from its own acid, a damaged stomach lining can cause irritation, pain and ultimately, ulcers.

Homemade bone broth soups are effective in restoring a healthy mucosal lining in the stomach. Bone broth is rich in collagen and gelatin, which have been shown to benefit people with ulcers. It’s also high in proline, a non-essential amino acid that is an important precursor for the formation of collagen. Bone broth also contains glutamine, an important metabolic fuel for intestinal cells that has been shown to benefit the gut lining in animal studies. See this article and this one for more information about the healing power of bone broth, and how to make it.

Although I’m not big on supplements, as I explained above, I’m not averse to using them when they can be helpful – especially for short periods. Deglycyrrhizinated licorice (DGL) has been shown to be effective in treating gastric and duodenal ulcers, and works as well in this regard as Tagamet or Zantac, with far fewer side effects and no undesirable acid suppression. In animal studies, DGL has even been shown to protect the stomach lining against damage caused by aspirin and other NSAIDs.

DGL works by raising the concentration of compounds called prostaglandins, which promote mucous secretion, stabilize cell membranes, and stimulate new cell growth – all of which contributes to a healthy gut lining. Both chronic stress and use of NSAIDs suppress prostaglandin production, so it is vital for anyone dealing with any type of digestive problem (including GERD) to find ways to manage their stress and avoid the use of NSAIDs as much as possible.

Conclusion

The mainstream medical approach to treating heartburn and GERD involves taking acid stopping drugs for as long as these problems occur. Unfortunately, because these drugs not only don’t address the underlying cause of these problems but may make it worse, this means that people who start taking antacid drugs end up taking them for the rest of their lives.

This is a serious problem because acid stopping drugs promote bacterial overgrowth, weaken our resistance to infection, reduce absorption of essential nutrients, and increase the likelihood of developing IBS, other digestive disorders, and cancer. The manufacturers of these drugs have always been aware of these problems. When acid-stopping drugs were first introduced, it was recommended that they not be taken for more than six weeks. Clearly this prudent advice has been discarded, as it is not uncommon today to encounter people who have been on these drugs for decades – not weeks.

What is especially disturbing about this is that heartburn and GERD are easily prevented and cured by making simple dietary and lifestyle changes, as I have outlined in this final article.

Unfortunately, the corruption of our “disease-care” system by the financial interests of the pharmaceutical companies virtually guarantees that this crucial information will remain obscure. Drug companies make more than $7 billion a year selling acid suppressing medications. The last thing they want is for doctors and their patients to learn how to treat heartburn and GERD without these drugs. And since 2/3 of all medical research is sponsored by drug companies, it’s virtually guaranteed that we won’t see any large studies on the effects of a low-carb diet on acid reflux and GERD.

So once again it’s up to us to discover the truth and be our own advocates. I hope this series of articles has served you in that goal.

I have created a “myth busing report” page for heartburn and GERD which contains an index of these articles, as well links to books and other offsite resources. If anyone you know is suffering from heartburn and GERD, please direct them to http://thehealthyskeptic.org/heartburn.

Related posts:

1. Audio interview on how to cure heartburn and GERD without drugs
2. The hidden causes of heartburn and GERD
3. What Everybody Ought To Know (But Doesn’t) About Heartburn & GERD

After today’s post I’m going to move on to some new topics. There are so many mainstream health myths out there it’s hard to cover them all! In the next few months we’re going to shift our attention to the digestive system. We’ll talk about the real cause of acid reflux (GERD), the high rates of gluten intolerance in the US and its consequences when undiagnosed and untreated, the hidden problem underlying Irritable Bowel Syndrome (IBS), and more.

As you know if you’ve been following this blog, heart disease is primarily caused by inflammation and oxidative damage. This is now well-accepted amongst medical researchers, though many physicians and medical professionals are still unfortunately focused on cholesterol.

It follows, then, that to prevent heart disease our primary goal should be to reduce inflammation and oxidative damage. How do we do that? Follow these nine steps:

1. Don’t eat industrial vegetable oils.

Industrial vegetable oils like corn, soy, cottonseed, sunflower, and safflower are high in omega-6 polyunsaturated fatty acids (n-6 PUFA). Countless studies show that n-6 PUFA promote both oxidative damage and inflammation, and significantly raise the risk of heart disease. Industrial vegetable oils are found in nearly all processed and packaged foods, and in most foods cooked in restaurants. My rule here is simple: if it comes in a package, don’t eat it. And make eating out a special occasion, not a daily ritual.

For more on the danger of vegetable oils, see How to Increase Your Risk of Heart Disease.

2. Eat traditional, saturated fats.

For more than five decades we’ve been brainwashed to believe that saturated fat causes heart disease. It’s such a deeply ingrained belief that few people even question it. It’s just part of our culture now.

But several recent studies have confirmed what many researchers have known all along: that eating saturated fat doesn’t cause heart disease. Saturated fats are protected against oxidative damage – one of the primary causes of heart disease. What’s more, saturated fats have numerous health benefits.

For more on this, see New Study Puts Final Nail in the “Saturated Fat Causes Heart Disease” Coffin, and The Most Important Thing You Probably Don’t Know About Cholesterol, and Have Some Butter with your Veggies!

3. Eat less sugar (including simple carbs).

Most people know that eating sugar wreaks havoc on their health. But what many don’t understand is that all carbohydrates eventually break down into sugar in the body. Simple carbohydrates such as rice, potatoes, pasta and bread can cause spikes in blood sugar and insulin, both of which contribute to oxidative damage and inflammation – and consequently increase the risk of heart disease.

For decades the American Heart Association and American Diabetes Association have been promoting a low-fat, high-carb diet. Research has shown that this diet actually increases the risk of both heart disease and diabetes! If you want to steer clear of these conditions, a high-fat, low-carb diet is your best choice.

The average American gets 57% of his/her calories from highly refined cereal grains and polyunsaturated (PUFA) oils. The #3 source of calories, behind grains and PUFA, is sugar and high-fructose corn syrup. Refined grains, polyunsaturated oils and sugar are all major contributors to both inflammation and oxidative damage. Clearly the low-fat, high-carb diet has been a failure.

For more on this, see The Most Important Thing You Probably Don’t Know About Cholesterol and, Low-Carb Diet Best for Weight Loss.

4. Eat nutrient dense foods (especially organ meats and egg yolks!)

The key to proper nutrition is eating nutrient-dense foods. Most people think about vegetables when they think of vitamins and minerals. However, a serving of beef liver has between 10-100 times the amount of key vitamins and minerals than those found in carrots or apples.

Egg yolks are another of nature’s superfoods. One egg provides 13 essential nutrients, all in the yolk (contrary to popular belief, the yolk is far higher in nutrients than the white). And despite conventional wisdom, it’s entirely safe to eat three eggs a day. In fact, studies show that egg consumption actually increases large, buoyant LDL cholesterol – which is the type that doesn’t cause heart disease!

Grass-fed, organic animal products and raw dairy (butter, milk) are also high in health promoting nutrients, and should be eaten liberally.

For more on this, see Three Eggs a Day Keeps the Doctor Away, Cholesterol Doesn’t Cause Heart Disease and Liver: Nature’s Most Potent Superfood.

5. Eat fermented foods.

Almost all healthy, traditional cultures that have been studied regularly consume fermented foods like yogurt, kefir, sauerkraut, kim chi and kombucha. These foods have numerous health benefits, but in the context of heart disease one of the most important reasons to include them in the diet is that they are one of the few dietary sources of vitamin K2.

Unfortunately, many people are not aware of the health benefits of vitamin K2. The K vitamins have been underrated and misunderstood up until very recently in both the scientific community and the general public. While K1 is preferentially used by the liver to activate blood clotting proteins, K2 is preferentially used by other tissues to deposit calcium in appropriate locations, such as in the bones and teeth, and prevent it from depositing in locations where it does not belong, such as the soft tissues.

A 1993 study showed that those in the highest third of vitamin K2 intake were 52 percent less likely to develop severe calcification of the arteries, 41 percent less likely to develop heart disease, and 57 percent less likely to die from it.

For more on this, see Vitamin K2: The Missing Nutrient.

6. Take your high-vitamin cod liver oil.

Cod liver oil is one of the only supplements I recommend to people. It’s a great source of long chain omega-3 fatty acids (EPA and DHA), which protect against inflammation. But even more importantly, cod liver oil is one of the few dietary sources of vitamin D. Low vitamin D levels associate with nearly every common non-communicable disorder, including obesity, diabetes, cardiovascular disease, autoimmune disease, osteoporosis and cancer.

But not all cod liver oils (CLOs) are created equal. Most commercially available CLOs are processed with heat and chemicals. Because heat and chemicals destroy the naturally occurring vitamins, synthetic vitamins are then added back in. Synthetic vitamins don’t have the same benefits as naturally occurring vitamins, and in fact they can be toxic at high doses (hence the hysteria of vitamin A toxicity from taking too much cod liver oil).

The only brand I know of that is cold-processed and contains the naturally occurring vitamins A & D in high amounts is Green Pastures Fermented Cod Liver Oil. Even better, because it’s fermented you’ll also get vitamin K2, which we know from step #5 protects against heart disease.

For more on this, see Separating Fact from Fiction on Cod Liver Oil, and Vitamin D: The New Super-Nutrient?.

7. Be active & go outside.

Physical inactivity is likely a major causative factor in the explosive rise of coronary heart disease in the 20th century. During the vast majority of evolutionary history, humans have had to exert themselves to obtain food and water. Even at the turn of the 20th century in the U.S., a majority of people had jobs that required physical activity (farmers, laborers, etc.) Now the majority of the workforce has sedentary occupations with little to no physical activity at all.

Currently more than 60% of American adults are not regularly active, and 25% of the adult population is completely sedentary. People that are physically inactive have between 1.5x and 2.4x the risk of developing heart disease.

On the other hand, regular exercise reduces both inflammation and oxidative damage. Even relatively low levels of activity are protective – as long as they are consistent. A public review at Harvard University showed that 30-minutes of moderate physical activity on most days of the week decreases deaths from heart disease by 20-30%.

It’s also important to spend time outdoors and get some sun. In addition to the obvious psychological and even spiritual benefits, sunlight exposure will boost your vitamin D levels. Just remember that sunscreen blocks your body from making vitamin D from sunlight.

For more on this, see Throw Away the Sunscreen!

8. Maintain a healthy weight (not too fat or thin)

Countless studies show that obesity causes both inflammation and oxidative damage, and significantly raises the risk of heart disease. For those who are obese, losing weight is perhaps the most important first step to take to reduce their risk profile.

However, most people aren’t aware that being too skinny can also increase the risk of heart disease.

It is also important to keep in mind that where you store body fat is probably more important than how much body fat you have. For example, body fat stored in the legs has consistently been shown to protect against metabolic risk in longitudinal studies. In contrast, abdominal fat, and in particular visceral fat, is independently associated with increased risk of morbidity and mortality.

For more on this, see this excellent offsite article: Get Fat, Live Longer.

9. Don’t smoke and minimize exposure to other toxins

Smoking promotes both oxidative damage and inflammation. Smoking as few as one cigarette a day can increase the risk of heart disease by 40 percent, while smoking 40 cigarettes a day increases the risk by 900 percent.

Over 70,000 synthetic chemicals are used commercially and approximately 1,000 new chemicals are introduced into our environment each year. These include insecticides, herbicides, gasoline, dry cleaning chemicals, personal care products, and more.

Environmental toxins cause both inflammation and oxidative damage, which as you certainly know by now, cause heart disease. Avoid exposure to these toxins as much as possible. Using environmentally friendly cleaning and personal care products in your home is a great start.

10. Manage stress & enjoy life

In the famous INTERHEART study, stress tripled the risk of heart disease. This was true across all countries and cultured that were studies. The primary mechanism by which stress causes heart disease is by dysregulating the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is directly intertwined with the autonomic nervous system, and it governs the “fight-or-flight” response we experience in reaction to a stressor.

Continued activation of this “fight-or-flight” response leads to hyper-arousal of the sympathetic nervous system, which in turn leads to chronically elevated levels of cortisol. And elevated levels of cortisol can cause both inflammation and oxidative damage.

Stress management, then, should be a vital part of any heart disease prevention program. In fact, some researchers today believe that stress may be the single most significant factor in the cause and prevention of heart disease. There are several proven methods of stress reduction, including mindfulness-based stress reduction (MBSR), acupuncture and biofeedback. It doesn’t matter which method you choose. It just matters that you do it, and do it regularly.

If you follow these ten steps, you will dramatically reduce your risk of not only heart disease, but also diabetes, metabolic syndrome and almost every non-communicable modern disease. You’ll also have more energy, sleep better and improve your quality of life. So what do you have to lose? Sure beats taking dangerous statin drugs.

Related posts:

1. Preventing heart disease without drugs
2. Inflammation worsens danger of heart disease
3. How to increase your risk of heart disease

A graduate of Harvard Medical School and the founder and director of The Center for Mind-Body Medicine in Washington, DC, Dr. Gordon has been helping people to recover from depression without drugs for almost 40 years. If what you’ve been learning on The Healthy Skeptic about depression and antidepressants rings true, you’ll love Dr. Gordon’s work.

The web-based series, called “A Natural Approach for Treating Depression,” will include video lessons focused on four of Dr. Gordon’s main themes to treating depression and is based on Dr. Gordon’s treatment program, which he developed and has been teaching around the world for almost 40 years.

Dr. Gordon’s program asserts that prescription antidepressants are often ineffective and create significant side effects. He teaches natural self-care techniques, such as relaxation exercises, physical exercise, proper nutrition and others, that have been proven to successfully treat depression and its symptoms. The program allows the patient to take an active, effective role in their own healing. The series and its related downloadable resources for participants are free.

If you or anyone you know is suffering from depression and could use some extra guidance, I would highly recommend this program. Dr. Gordon writes with clarity, compassion and decades of firsthand experience in treating patients with depression. Although I haven’t yet heard him speak or teach, I can say with confidence from reading his book that his online program will be an invaluable resource to those struggling with depression.

For more information and to sign up, follow this link.

Related posts:

1. Upcoming talk: Holistic Treatment of Depression
2. Treating depression without drugs – Part I
3. Treating depression without drugs – Part II

They’re for depression.

Last year doctors wrote $232.7 million prescriptions for antidepressants. That’s an increase of 25 million prescriptions since 2003 and translates into an estimated 30 million patients in the United States who spent $12 billion on antidepressants in 2007.

With numbers like these, a person might make these assumptions:

• Antidepressants are effective treatments for depression
• There are few, if any, effective alternatives to antidepressants

As reasonable as these assumptions would be based on the popularity of antidepressants, they are both wrong.

In my preceding articles in this ongoing series on depression and antidepressants, I’ve presented clear evidence that antidepressants are not effective for treating depression.

In this article and the following two, I will present evidence that several non-drug treatments for depression are at least as effective as antidepressants, with few (if any) of their side effects, risks and costs.

As you may recall from the previous articles in this series, recent meta-analyses have shown that antidepressants have no clinically meaningful advantage over placebos. What I have not yet pointed out is that the effectiveness of antidepressant drugs has probably been overstated due to methodological factors in the studies.

In the studies performed on antidepressant drugs, the people taking the drugs also received supportive weekly visits with doctors or researchers along with the medication. The resulting “therapeutic alliance” may have enhanced the efficacy of these drugs and given an inaccurate picture of their effectiveness in a managed care environment where antidepressants are often delivered in conjunction with infrequent visits to a physician or mental health professional.

We know from placebo research that the contact which occurs between the patient and practitioner can be a powerful treatment in itself. Therefore, the supportive visits that patients received during the drug trials could have easily amplified the effect of the drug and made it seem far more effective than it would be in a “normal” clinical situation where visits to a physician or psychiatrist are not regular or frequent.

With this in mind, it is very likely that antidepressants are less effective than placebos in normal clinical practice. Indeed, researcher Joanne Moncrieff has repeatedly pointed out that the term “antidepressant” is a misnomer. The drugs collectively referred to as “antidepressants” do not specifically treat depression (any more than placebo), and therefore should not be called “antidepressants” at all.

What are the alternatives, then, to treating depression? Imagine having a choice between five treatments. Treatment A produces a therapeutic response but also a large number of adverse effects including diarrhea, nausea, anorexia, sweating, forgetfulness, bleeding, seizures, anxiety, mania, sleep disruption and sexual dysfunction. Treatments B, C, D & E produce therapeutic responses similar to Treatment A, but with far fewer adverse effects and costs. Treatments B & C, in fact, have no adverse effects at all and have been shown to be significantly more effective than Treatment A in the long-term.

This is not, of course, simply a hypothetical question. Treatment A corresponds to the selective serotonin reuptake inhibitors (SSRIs) that have become so overwhelmingly popular. Treatment B is psychotherapy, which is as effective as antidepressants in the short term (even for serious depression), and is more effective in the long term. Treatment C is exercise, which has been reported to have lasting therapeutic benefits in the treatment of major depression with no “side effects” except for improved physiological and mental health. Treatment D is light therapy, which has been recently assessed in several clinical studies and is just as effective as antidepressant medication. Treatment E is St. John’s Wort, an herb that has been extensively studied and shown to be similar in efficacy to antidepressants with 10 times fewer adverse effects.

As depression researcher David Antonuccio points out, “whether one subscribes to the Hippocratic dictum ‘first do no harm’ or takes a cost-benefit approach to treatment, it is impossible to ignore the fact that antidepressants are not medically benign treatments. Antidepressants have serious side effects (listed above) as well as medical risks (including increased risk of dying) when combined with other medications – as is often the case in clinical settings. Antidepressants have been shown to cause potentially permanent changes to the brain that can predispose a patient to depression in the future, and the withdrawal symptoms of SSRIs are substantial for many, if not most, patients.

A frequent argument made by supporters of antidepressants is that patients with serious depression need antidepressants to stave off suicide. However, there is no evidence whatsoever that antidepressants reduce the risk of suicide or suicide attempts in comparison with placebo in clinical trials. On the contrary, in a recent analysis of the data that compensated for erroneous methodologies, Dr. Grace Jackson found that antidepressants increased the risk of suicide by two to four times in adults, and by three times in children (Jackson 2005, p.122)

It has also been demonstrated that recent sharp increases in antidepressant use have been accompanied by increased prevalence and duration of depressive episodes and rising levels of sickness absence (Patten 2004). Naturalistic studies have also shown that depressive episodes are more frequent and last longer among antidepressant users than among nonusers, and that sickness absence is more prolonged (Moncrieff 2006). Finally, long-term follow-up studies show very poor outcomes for people treated for depression with drugs, and the overall prevalence of depression is rising despite increased use of antidepressants (Fombonne 1994).

Please allow me to summarize the research and simplify the preceding paragraphs:

Antidepressants don’t work. If anything, they make things worse.

Now that we have firmly established the ineffectiveness and dangers of antidepressants, let’s look more closely at the alternatives. We will evaluate each treatment based on Antonuccio’s criteria above:

• Does the treatment do any harm?
• How do the “costs” compare with the “benefits”?

and we will also compare their efficacy with that of antidepressants.

Psychotherapy

Several studies show that psychotherapy (particularly cognitive therapy, behavioral activation, and interpersonal therapy) compares favorably with medication in the short-term, even when the depression is severe, and appears superior to medications over the long term (Antonuccio 2002). When medical cost offset, relapse and side effects are considered in a cost-benefit analysis, psychotherapy can be very cost-effective – particularly in a psychoeducational (e.g. therapist-assisted bibliotherapy) or group format (Antonuccio et al. 1997). Finally, studies show that most patients prefer psychotherapeutic intervention to drugs when given the choice. (Unfortunately, they are rarely given the choice; today, fewer than 10% of psychiatrists offer psychotherapy to their patients.)

It is important to note that several studies have shown that combined treatment (psychotherapy + medication, exercise + medication) produces inferior results when compared to the non-drug modality alone (Hollon et al. 1992). The failure of this combined approach is not surprising when one considers the counter-productive effects of invasive chemical interventions (e.g. suppression of REM sleep, elevation of cortisol, induction of mania).

Unfortunately, the mental health profession remains largely ignorant to this “tragedy of its own making”:

Exercise

Several studies have shown that aerobic exercise is at least as effective as antidepressants in treating depression. For example, one recent study published in the American Journal of Preventative Medicine in 2005 indicated that the “public health dose” (5x/week frequency burning 17.5 kcal/kg/week) of exercise led to remission rates of 42%. For the sake of comparison, the Collaborative Depression Study, conducted by the National Institute for Mental Health, indicated remission rates of 36% for cognitive behavioral therapy and 42% for antidepressant medication.

A frequent criticism of exercise as a treatment for depression is the supposed lack of compliance in patients. The argument is that people who are depressed are too depressed to exercise. While this may be true in some cases, adherence rates in exercise studies were comparable to many medication trials, where rates vary from 60%-80%. Thus, evidence does not support the notion that exercise is not a feasible treatment for depressed patients.

Another benefit of exercise as a treatment for depression is that the only “side effects” are improved physiological and mental health. In contrast to antidepressants, exercise has no adverse effects whatsoever. Instead, it has a moderate reducing effect on anxiety, can improve physical self-perceptions and in some cases global self-esteem, and can enhance mood states and – in older adults – improve cognitive function.

In a study published in Psychosomatic Medicine in 2000, another important advantage of exercise over antidepressants was revealed. Participants in the exercise group were less likely to relapse than participants in the two groups receiving medication. Other studies have confirmed this effect, demonstrating that aerobic exercise is especially helpful in the prevention of relapse and recurrence of depression.

Once again, as was the case with psychotherapy, there was no benefit when combining antidepressant drugs with exercise. In fact, the opposite was the case, at least with respect to relapse for patients who initially responded well to treatment. According to the authors of the study:

The authors go on to speculate on why antidepressant drugs would decrease the exercise’s beneficial effects on depression:

It is also possible that the metabolic and physiological effects of antidepressants described above (suppression of REM sleep, elevated cortisol levels, etc.) could counteract the positive benefits of exercise to a certain degree.

In part II of this article I will discuss light therapy, St. John’s Wort and acupuncture as treatments for depression. In Part III I will examine other lifestyle modifications that can both prevent and treat depression, such as proper nutrition, stress management, getting adequate sleep, the experience of pleasure and prayer or spiritual practice.

Related posts:

1. Treating depression without drugs – Part II
2. Treating depression without drugs – Part III
3. Upcoming talk: Holistic Treatment of Depression

Last week I mentioned the INTERHEART study, which looked at the relationship between heart disease and lifestyle in 52 countries around the world. What this study revealed is that approximately 90% of heart disease could be prevented by simple changes to diet and lifestyle.

Let’s just make this crystal clear: 9 out of 10 cases of heart disease are completely preventable without drugs. With sales of statin drugs reaching close to $30 billion this year with Lipitor alone bringing in close to $14 billion, this might come as some surprise. But the pharmaceutical companies are, quite literally, invested in people taking their cholesterol-lowering drugs in spite of the complete lack of evidence that lowering cholesterol prevents heart disease.

In order to understand the changes we need to make to prevent heart disease, we have to briefly examine what causes it. By now you know that the answer is not “cholesterol”. In fact, as I mentioned briefly in last week’s article, the two primary contributing mechanisms to heart disease are inflammation and oxidative damage.

Inflammation is the body’s response to noxious substances. Those substances can be foreign, like bacteria, or found within our body, as in autoimmune diseases like rheumatoid arthritis. In the case of heart disease, inflammatory reactions within atherosclerotic plaques can induce clot formation.

When the lining of the artery is damaged, white blood cells flock to the site, resulting in inflammation. Inflammation not only further damages the artery walls, leaving them stiffer and more prone to plaque buildup, but it also makes any plaque that’s already there more fragile and more likely to burst.

Oxidative damage is a natural process of energy production and storage in the body. Oxidation produces free radicals, which are molecules missing an electron in their outer shell. Highly unstable and reactive, these molecules “attack” other molecules attempting to “steal” electrons from their outer shells in order to gain stability. Free radicals damage other cells and DNA, creating more free radicals in the process and a chain reaction of oxidative damage.

Normally oxidation is kept in check, but when oxidative stress is high or the body’s level of antioxidants is low, oxidative damage occurs. Oxidative damage is strongly correlated to heart disease. Studies have shown that oxidated LDL cholesterol is 8x greater stronger a risk factor for heart disease than normal LDL.

Since there may be some confusion on this point, I want to make it clear: normal LDL cholesterol is not a risk factor for heart disease in most populations, but oxidated LDL cholesterol is. This points to oxidation as the primary risk factor, not cholesterol. Why? Because when an LDL particle oxidizes, it is the polyunsaturated fat that oxidizes first. The saturated fat and the cholesterol, hidden deep within the core of the lipoprotein, are the least likely to oxidize.

It follows, then, that if we want to prevent heart disease we need to do everything we can to minimize inflammation and oxidative damage.

By focusing on reducing or completely eliminating, when possible, the factors in our life that contribute to oxidative stress and inflammation, we can drastically lower our risk for heart disease. Let’s take a brief look at each risk factor.

Stress

In the INTERHEART study, stress tripled the risk of heart disease. This was true across all countries and cultured that were studies. The primary mechanism by which stress causes heart disease is by dysregulating the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is directly intertwined with the autonomic nervous system, and it governs the “fight-or-flight” response we experience in reaction to a stressor.

Continued activation of this “fight-or-flight” response leads to hyper-arousal of the sympathetic nervous system, which in turn leads to chronically elevated levels of cortisol. And elevated levels of cortisol can cause both inflammation and oxidative damage.

Stress management, then, should be a vital part of any heart disease prevention program. In fact, some researchers today believe that stress may be the single most significant factor in the cause and prevention of heart disease. There are several proven methods of stress reduction, including mindfulness-based stress reduction (MBSR), acupuncture and biofeedback. It doesn’t matter which method you choose. It just matters that you do it, and do it regularly.

Smoking

I assume that you are already well aware of the dangers of smoking, so I won’t spend much time on this one. For the purposes of this discussion, I will point out that smoking as few as 1-4 cigarettes a day has been shown to increase the risk of heart disease by 40%. But smoking 40 cigarettes a day increases that risk by 900%.

So if you smoke and you’re concerned about heart disease – quit.

Nutrition

Over the past century we’ve seen a consistent decline in the consumption of traditional, nutrient-dense foods in favor of highly processed, nutrient-depleted products. The flawed hypothesis that cholesterol causes heart disease has wrongly identified health-promoting foods like meat, organ meats, eggs and dairy products as harmful, and replaced them with toxic, processed alternatives such as chips, white breads, pastries, crackers, cookies, frozen foods, candy and soda.

There are two ways that nutrition contributes to heart disease: too much of the wrong foods, and not enough of the right ones.

The average American gets 57% of his/her calories from highly refined cereal grains and polyunsaturated (PUFA) oils. The #3 source of calories, behind grains and PUFA, is sugar and high-fructose corn syrup. Refined grains, polyunsaturated oils and sugar are all major contributors to both inflammation and oxidative damage.

Not only do refined carbohydrates, vegetable oils and sugar contribute to inflammation and oxidative damage, they are also completely devoid of micronutrients that would protect us from these processes. Meats, fruits and vegetables are all high in antioxidants that prevent oxidative damage, and rich in other micronutrients that play important roles in preventing heart disease.

More than 85% of Americans are not getting the federally recommended five servings of fresh fruit and vegetables each day. The intake of dark leafy green or yellow/orange veggies for the average American is equivalent to 18g – one-half of one small carrot. Iceberg lettuce, tomatoes, french fries, orange juice and bananas constitute 30% of fruit and vegetable intake for most Americans.

Many people know that the “Standard American Diet” is extremely unhealthy. But what most do not know is that the so-called “heart-healthy” diet that has been vigorously promoted for decades actually contributes to heart disease! The “heart-healthy” diet is high in refined carbohydrates and polyunsaturated oils, which, as we have seen, cause inflammation and oxidative damage.

On the other hand, saturated fats (which have been demonized by the medical mainstream) such as butter, coconut oil, lard, tallow and ghee are protected against oxidation and possess many other important health benefits. These fats are the ones we need to be eating to protect ourselves from heart disease.

It is extremely important to buy organic meat, eggs and dairy products that come from animals that have been raised on fresh pasture rather than in commercial, factory feedlots. See this article and this one for more information on why this is so essential.

Finally, it must be pointed out that not all “organic” products are healthy. Most packaged food (including organic cereals, crackers, chips and so-called “nutrition bars”) are full of highly refined carbohydrates, sugar, and vegetable oils. And by now, I don’t need to tell you what that means!

So what would a truly heart healthy diet look like, then? Download my Guidelines for Natural Prevention of Heart Disease to find out.

Physical Inactivity

Physical inactivity is likely a major causative factor in the explosive rise of coronary heart disease in the 20th century. During the vast majority of evolutionary history, humans have had to exert themselves to obtain food and water. Even at the turn of the 20th century in the U.S., a majority of people had jobs that required physical activity (farmers, laborers, etc.) Now the majority of the workforce has sedentary occupations with little to no physical activity at all.

Currently more than 60% of American adults are not regularly active, and 25% of the adult population is completely sedentary. People that are physically inactive have between 1.5x and 2.4x the risk of developing heart disease.

On the other hand, regular exercise reduces both inflammation and oxidative damage. Even relatively low levels of activity are protective – as long as they are consistent. A public review at Harvard University showed that 30-minutes of moderate physical activity on most days of the week decreases deaths from heart disease by 20-30%.

The best strategy for people struggling to find time to exercise is to make it part of their daily life (i.e. riding a bike or walking to work, choosing the stairs over the escalator or elevator, etc.)

When combined, the four strategies listed above will significantly reduce your chances of getting heart disease – without taking a single pill of any kind.

If you already have heart disease, or you are at high risk for heart disease (overweight, high blood pressure, diabetic, etc.), then you may need additional support. See my

• Natural Prevention of Heart Disease Guidelines
• The Truth About Cholesterol Brochure
• Resources for further learning
• Recommended tests for heart disease
• Recent New York Times article questioning efficacy of cholesterol-lowering drugs

Related posts:

1. Ten steps to preventing heart disease naturally
2. Inflammation worsens danger of heart disease
3. Cholesterol doesn't cause heart disease