Do You Have Silent Reflux? Why You Should Care and How to Recover

He stops eating at 11:00 AM because you're literally, your colon and everything, it takes 8 to 24 hours to completely empty. So 11:00 AM is pretty, um, extreme. I'm shooting for around 3 to 4:00 PM to eat my last big meal. And every meal— Hi, welcome back to the Mind Body Space Podcast. This is Dr. Juna Bobby MD, and it's the last Friday of the month when Dr. April Hershberg joins me to discuss stress management tips to improve everything about our lives. April and I are both mom MDs. I am a board-certified and I'm a fellowship-trained radiologist, and I spent decades seeing disease from the inside out. That was frustrating for me, so I wanted to learn everything I could to help prevent diseases and keep us well. And April?

And I am a psychiatrist at Mass General Hospital, board-certified in both lifestyle medicine and mind-body medicine. Happy to be here, Juna Bobby MD.

Our monthly conversations are to answer your questions, and we do our best to get our expert weigh-in and information that you can trust. We also toss in our opinions and life experiences once in a while, right, April?

Totally.

Because whenever we think it's really helpful, we always come back to practical ways to deal with stress because that's what we specialize in. Evidence is overwhelming that stress management and healthy lifestyle choices are at the root of almost all mental and physical afflictions. And if it's not the cause, then it definitely helps prevent mitigate or lessen, or even reverse some of the most common diseases that we have today. So today we're talking about a topic that hits really close to home, the impact of stress on our digestive systems. I mean, these days everyone seems to have issues with their digestive system, especially the younger generation. The stats are pretty intense. In particular, we're gonna talk about reflux today. I've been dealing with it for a while. And 1 out of 3 adults have reflux in their lives and probably more who are misdiagnosed. Children also suffer with reflux and along with increase in obesity, which is a risk factor for reflux. I had a visit with my ENT specialist, ear, nose, and throat, who is a world-renowned expert in reflux disease. He also told me something alarming that recently when they look inside the esophagus of younger people under the age of 30, they're seeing more and more of Barrett's esophagus. And Barrett's esophagus is something that, uh, the name for something that's precancerous. And surprisingly, esophageal cancer is now the number 6 cancer. Reflux is a huge problem here and all over the world with all the processed foods that we eat. We're gonna talk about that a little more in depth today, and then we're gonna talk about how we can manage our stress and walk through a few things that you can take away.

It's gonna be such an important conversation because as doctor moms, we really know firsthand that the The challenges of juggling stress and keeping our bodies healthy. And that really is so true, especially for our gut-brain access, because bloating, heartburn, uncomfortable irregularity, stress really makes everything worse.

Right? So they call it the gut-brain axis because our nervous system is connected. So now they call this the little brain, the enteric nervous system, ENS for short, but it's not really little according to John Hopkins. Uh, medicine, the enteric nervous system has two thin layers, but it's composed of 100 million nerve cells from the esophagus, which starts around here all the way down to our anus.

It's really amazing. You mentioned the enteric nervous system. That's one of the parts of the autonomic nervous system. And we talk a lot about the stress response is the sympathetic nervous system and the parasympathetic nervous system is part of the relaxation response. And those two make up the autonomic nervous system, plus the enteric. So it's all connected, Juna, just as, as you point out. And it's important to know how stress affects the gastrointestinal system. Where in the stress response our body really shuts down activity to the gastrointestinal system and sends it elsewhere, like our heart and our lungs. And our big muscles, right? And our, and our big muscles if we need to run away. But it's important because that slows down and changes the gastrointestinal motility, actually slows down gastric emptying, the stomach stomach emptying, which can lead to that gastroesophageal reflux, that extra acid in our stomach, but it also can move along the colon, you know, and speed up some parts. So things just get a little extra out of whack when we're in the stress response. And that stress adds to so many gastrointestinal problems, like the reflux you mentioned. It can be inflammatory bowel disease, irritable bowel disease. Unfortunately, the list goes on and on. It can lead to so many different types of gastrointestinal problems. And the one that we're gonna talk about today is the dreaded gastroesophageal reflux or GERD.

Yeah. And what you were talking about, I had a friend who used to get so anxious in medical school when he, we had exams, he would literally go and throw up. And I, I do know performers who throw up before they go on stage and things like that. And that, again, it's that stress response, right? You're just emptying your stomach so that you can run or fight or whatever you need to do to survive. And of course the stage or an exam is not a life-threatening event. However, our brain kind of, you know, perceives it that way. So it can happen the other way too. You were so scared, you bleeped in your pants. Those sayings really have truth and our nervous system does shunt away the blood like you said, and that is what's causing those like butterflies in your stomach when you're feeling nervous, right?

Yes. Well, and not to mention the effect that it has on the neurotransmitter, because when we are in the stress response, the cortisol is released and that affects the whole inflammatory cascade.

We love to talk about stress. It's not about getting rid of the stress, but it's about controlling stress and not being in the stress response when we don't need to be, right? Because the stress response is really important for us, but we don't always need to be in it. We tend to do that. So we wanna dial down those times. Where we don't need it because it could really lead to chronic issues. So for example, with reflux, I've had this chronically since medical school. I think that was the first time when I experienced it. At the time I was occasionally having cigarettes, which is terrible for you.

Oh gosh. Yes.

I confess I used to smoke sometimes. And then, so I quit that. I remember in med school, so I had that, that heartburn. Kind of thing. That's what everybody thinks of when they think of reflux. However, I wanna talk more about LPR, that it's called laryngopharyngeal reflux, and that's silent reflux cuz most people don't know that it's even happening. It might be something like clearing of your throat all the time, feeling like you have a lump in your throat, having some issues swallowing, but it could also disguise itself as, as allergies. So actually that's what doctors thought that I had. I did actually have allergies to dust mite and dog, but it turns out that most of my symptoms are coming from LPR, which is the silent type of reflux. And the most frightening part of it, and the reason why I went to go see a doctor, was one night I woke up and I thought I was having a panic attack. And I've never really had a panic attack in my life, so I thought it was really weird. But you know, things happen, right? So I jumped up out of bed. I felt like I wasn't getting enough air, put on a pulse ox. I was, you know, feeling like I couldn't get, catch my breath. So it turns out my doctor, Jonathan Aviv, he is a world expert on LPR, silent reflux, and as well as all different other kinds of reflux. He is the go-to guy for all the, um, singers in, in New York City. And, uh, he's even written a book. Here's his book, Acid Watcher Diet. It's awesome. And his, uh, cookbook, the Acid Washer Cookbook. That's new. Anyway, that's what happened to him as well. Dr. Aviv, when he was a surgeon in his 30s, he also woke up with that sort of, um, panic in the middle of the night. He calls it the jump, the jumping out of bed. And this is like something that happens to people who have reflux. So the misdiagnosis then is you're thinking it's allergies. They give you antihistamines and you think it's working. You know, maybe it clears you up a little bit. But it's really this reflux that's going on silently for years. Danger of it is that once it's going on chronically, you lose pain receptors, so you don't even know that it's happening. And then eventually, uh, sadly into like precancerous lesions or scarring, you can have all kinds of complications like strictures, which means narrowing of the tube. So it's really important that you see your doctor, that they take a look, give you the, the right meds, which, um, usually proton pump inhibitor. And those have gotten some bad press recently, but it's really important to use those in the beginning, especially if your doctor recommends it. And other H2 blockers and things like that, that everybody's familiar with now. It's on, you know, it's in pharmacy where you could get it over the counter. Anyway, so the point is that this could be easily misdiagnosed. So if you ever feel like you can't, you feel like something's caught in your throat, or if you have a lump in your throat, or if you're constantly clearing your, your, you have mucus back there. Or you're coughing every time you eat, things like that. These are all signs and symptoms that you should really go see your doctor, uh, get it evaluated. And if you do have swelling like I did, what you need to do is then, well, even if you didn't have swelling, you should still see a, a gastrointestinal specialist doctor. And, um, depending on your symptoms, they will scope you, like endoscopy through your mouth, uh, down to look at your stomach and your esophagus and take little samples and make sure that you don't have anything bad going on. Again, this is something that's so common and I don't think most people know that. And it's one of the biggest causes for sleep apnea as well. So he was one of the first physicians that prescribed to me food when I saw him about 12 years ago. And that was surprising, right? At that time. And these recipes, like you're, you want to eat high pH foods for about 2 weeks or more, depending on what he, the doctor tells you to do. But, um, this is a watermelon and cucumber smoothie, and it's one of the best, and it's in his cookbook. What's happening is that when, when that reflux is coming up, it's coming all the way up into your larynx where your vocal cords are, and it's even coming up into your nasal passages, like I mentioned, even in your ears. Like I thought I had something. In my ear, like little something. And my ENT looked in there, she's like, it's clean as a whistle. There's nothing in there. It's like a little tickle in my ear. So all of these things were related to the reflux. And that is happening because when the reflux comes up, there's pepsin, this little enzyme called pepsin from our stomach. And it's, and it reacts to acid and basically is like eating you from the inside out. That's what Dr. Aviv calls it. So these pepsin enzymes are stuck. All over your throat, larynx, nose, everywhere that I mentioned in your head and neck. And then when you eat something acidic, they become activated. And so that's why all the mucosa swelling and you feel stuffed up and all that stuff, the postnasal drip, everything. The idea is not to activate the pepsin, which is stuck there in your tissues. So when you drink something like soda, even canned foods, all of these foods have acid in it. If you look, it's a citric acid, even though it's a natural element, a, a natural ingredient, it still makes things acidic, right? So the whole thing is if you make things acidic, all these foods will have a longer shelf life. That's the whole point of it, right? So anything in cans, and he mentions iced tea drinks in particular in bottles and coffee. Wine all day. So I quit coffee and amazingly my blood pressure is also lower than ever before. I've never had such low blood pressure. I mean, it's good. It's a good pressure cuz all my doctors used to be like, oh, you're borderline hyper— hypertension. You need to maybe start meds. But it's really a lot of the caffeine issue. So eating high pH foods for a while is really healing. So that's what I'm doing now. And that's the strawberry cucumber drink that I'm having. I'm also drinking a lot of alkaline water. Which I just discovered and love, which I did. So, um, although I don't love that they're in plastic bottles.

I know it's so hard to, to find things that are environmentally friendly, but also good for us as well. One of the things you mentioned, cuz I think many of us don't think of those carbonated beverages, we think of them bad for many reasons, but not this reason. So thank you for pointing this out and I think most people often think, you know, when they think of reflux or making acid worse, they think of like tomatoes or tomato sauce and avoiding Italian meals late at night or something like that. Right. But thank you for telling us all about those common ones that we might not know.

And actually it's not tomatoes, it's only tomato sauce. So it's all in his book. Yeah. It's really— oh, and there, you know, there's so much misinformation out there and I really highly recommend his books cuz he's done tens of thousands of scopes. He's treated so many people. I saw this misinformation out there the other day. A dietitian was criticizing his books because he's an MD, not a dietitian. God. And, and she said that there was no omega-3s in kale. And I looked up a few scientific papers and there are omega-3s in kale. So again, I'll fact-check. There's a lot of misinformation out there. I do believe His books are very accurate. He has, you know, decades of experience treating this one thing. He's truly an expert.

Okay.

You know, I would highly recommend these and, and the links will be in the show notes.

Well, and I, and again, the impact you've already said you've had from these beverages, you know, just going off the coffee and adding these things into your life is really sounds like improving things.

Yeah. And it's interesting because the carbonated drinks, it's just like flavored water. So you wouldn't, you know, you think it's healthy, right? So I didn't, I stopped drinking soda, for example, and I was drinking carbonated flavored water, which has no calories, just a little infusion. But for some reason that infusion of flavor creates the acidity.

Yes. Mm-hmm.

And I was drinking a probiotic drink, which wreaked havoc on me cuz it became very addictive, but it was like bubbly. It had an awesome flavor and I was going, they say you can drink it 2 times a day, but it was like literally put me over. Into disease states once again.

Wow.

But I am absolutely hitting it hard with all the lifestyle changes right now. And I do wanna stress one thing here though, uh, which is not eating before bedtime. And dietitians, doctors will tell you to not eat 3 hours before you go to bed. I think really it's about 5 to 6 hours before bed. And if you want to eat something or you're hungry, try to drink a smoothie or something cuz liquids will empty about 60 to 90 minutes. Solids, it takes much longer. That YouTuber Brian Greene, he's an entrepreneur. He wants to stay young forever. He's very extreme. And now I know why he stops eating at 11:00 AM because you're literally, your colon and everything, it takes 8 to 24 hours to completely empty. So 11:00 AM is pretty extreme. I'm shooting waiting for around 3:00 to 4:00 PM to eat my last big meal. And every meal should be around 70 to 80% full. You shouldn't be stuffing yourself, of course. But anyway, all of these are, are habit that we work on. And April, you were gonna talk about some stress management tips, which are really at the root of behavioral change.

Exactly. I mean, you mentioned some important tips and I think that hopefully people when they hear that, you know, some of the science about why not to eat so late at night, they'll be more likely to do it. It's not just for weight management or something like that, but it really does help this gastroesophageal reflux or the acid levels to go down and it enhances our digestion. It helps our sleep. There are several ways to help lower our stress hormones and lower our stress levels and engage our parasympathetic nervous system, which will help with our relaxation and rest and digest. That's the other part we learned in med school. So, and I think when people learn that and remember that, it really is helpful. I wanted to talk about the first one, eliciting the relaxation response through breathing or mindfulness exercises. So there are several ways in which to do that. We can do the deep breathing, the mindful breathing, and focus on that breath. There are so many apps. There are guided meditations. You do a number of guided meditations on Insight Timer, which is awesome, including some courses. You know, people can access these types of meditations to focus on breath and relaxation through other apps. Calm has an app. There's also Headspace, which I love their tagline. I think they still use it, gym membership for the mind. There's a number of great apps. You don't have to have a formal app to follow, but just focus on controlling and taking deep, full breaths.

So, April, since you mentioned relaxation response, which is the opposite antidote to the stress response and it dials up our parasympathetic nervous system. Can you lead us through a little mini that people could do throughout the day to just tap into their parasympathetic nervous system?

Oh, sure. One of the things that I always do is my go-to, and it's, it's one of the first ones we do in the stress management course is the, the one, just this.

Mm, I love that.

And I always do that one because I think sometimes when we ask people, even though I just suggested to focus on your breath, it's a little bit too much because then you start thinking like, am I breathing the right way?

Or— I had a client just tell me that she's a bad breather recently.

But it's, it's hard to have that sort of primary focus. So I always like, cuz as Dr. Benson said, you know, it's nice to have a word or a phrase, a repetitive focus. That's a key element of eliciting the relaxation response. And so I choose to recommend just this. So, so you have a focus on the word just as you're breathing in, and you have a focus on the word this on your breathing out. So we'll just take a few moments to do that. So if you want to close your eyes, you can, Juna Bobby MD. So what I'll invite you to do is if you choose to close your eyes, that's great, or maintain a downward focus. And what you can do is focus on the word just on the in-breath and this on the out-breath. Just. And this. Just on the in-breath, and this on the out. If other thoughts come into your mind, return to your intended focus. Just on the in-breath, and this on the out. Just take another couple breaths here. Just this. So that wasn't even 30 seconds. It was about 30 seconds.

I love that pause.

It's a brief pause.

I love that one. Almost all my students tell me that that's their favorite one. So just inhaling and saying just silently to yourself and exhaling and saying this. And you can do that throughout the day, right? So Dr. Benson, for those of you who don't know who, who's listening, the physician who we trained with at Harvard Medical School. He's a cardiologist. Sadly, he passed away a few years ago, but he coined the relaxation response, right? And he discovered this response that was opposite of the stress response in a laboratory experiment he was doing at Harvard Medical School. And it was actually the exact same laboratory where Walter Buchanan discovered the stress response. So, um, he also studied blood pressure and The relaxation response, and that's how I was introduced to it. I, my doctor is a Harvard graduate and she told me about Dr. Benson and she actually wrote his book on a prescription pad when she thought I had borderline high blood pressure, which was, now we know, due to caffeine and New York City.

It's so full circle. Yeah.

New York City traffic. So thank you for leading us through that very short relaxation response. And again, people can do it all day long and you should do that when you're eating, right?

I was just gonna say that, Juna, it's a nice practice. And I think so many of us are in such a busy, harried lifestyle that we just kind of hurry up and eat, or we're eating while we're doing something else. I mean, God forbid, but driving kids to sporting events or something, but taking a mindful moment or even a couple of full deep breaths before we eat to kind of slow down. And to be mindfully in that moment, it's going to encourage us to not just enjoy our food more, but just take a moment to ourselves and activate that and elicit the relaxation response before we get to eating. It slows us down in so many different ways. It calls attention to the food that we're eating, but also can slow our digestion and actually improve the amount of chewing we're doing. That also aids the digestion. It also decreases the risk of overeating, as you mentioned. You know, a lot of us tend to eat until we feel 100% full, and really the goal should be about, you know, 75 to 80% full. And that's really hard to do unless you're being mindful in eating. But there are other ways to elicit the relaxation response and lower your body's stress levels and your cortisol levels. And that's by taking time for yourself. And doing things you enjoy. And for many of us, that does involve movement. And there's just the added benefit of moving after meals. You mentioned, you know, maybe not eating as late, but another great habit to get into and add into your life rather than taking everything away is adding a little walk-in or physical movement after eating because that aids our digestion. It helps move things along. But it also helps us regulate our blood sugar levels as well as help our weight management because of the calorie burning. But it includes and enhances lowering our stress levels, but also lowering those insulin levels, which keep our blood sugar more even. So, so many benefits, not to mention the fact that, you know, moving more helps our mental health and lowers our stress level from a mental and emotional level because of the improvements there.

Yeah. So walking might actually be one of the most incredibly beneficial things, which all are, um, hearing about, right? It sounds so silly.

Yes.

It's so basic, but it's one of the most important things we can do for our health. And it does lower blood sugar. They said even maybe 2 to 5 minutes of walking right after you eat. But I like to walk 10 to 20 minutes just to get. Things moving downstream in my GI system.

Yeah. And the thing is, you don't have to get outside and go for a walk. And some people aren't able to ambulate as readily as others, but, you know, having some movement after meals is really important. And what's really important is not to lay down or be sitting down. You don't wanna be having— that's why we don't recommend people eating right before bed. You know, you wanna have as many hours, as you point out, as possible. But doing something for yourself movement-wise. And then I just, I'd be remiss if I didn't encourage people to do other fun things for themselves, which help lower their stress levels and improve and aid digestion. Because doing things for yourself, like taking a bath or watching a funny show. I mean, we can do a, we should do a whole other podcast on the importance of humor and ways in which enjoying something funny can also lower stress levels. So take some time for yourself. You don't have to always take things away, like restricting.

Yeah, exactly. Instead of restricting, replacing with something that you enjoy. And yeah, I've picked up sketching and I love sketching and doodling. It's so relaxing. Um, and I also wanna mention that there is this thing, it's a Japanese tradition, it's called hara hachi bu. I think a lot of people have heard of it. It's basically stopping when you're 80% full. But you know, you don't know if you're 80% full, but you get, you get the idea. You, you shouldn't be uncomfortable when you're full cuz that doesn't reach your brain for like 15 to 20 minutes.

Exactly. That satiety, you know, signal doesn't. And that's why the slowing down is really important. But I think many of us eat just as fast as possible to move on to the next thing.

Yeah. Slow until you wake up in the middle of the night and you feel like you can't breathe. You say things and you're like, oh my God, I'll do anything. To never have that.

Wow.

It's really a frightening experience.

So it's a real wake-up call, as they would say. Oh yeah.

It's a jump-off call, as Dr. Aviv would put it. And I'm not getting anything for these books. I'm, and I'm just saying, I'm just sharing this information because I think it's so important and amazing. The recipes in there are really good. So, and it doesn't feel restrictive in any way. And it's really important to teach our kids early too. All these habits, like just always take a little walk after eating, et cetera.

And one of the things, I don't know if you were gonna mention this, Juna, but another great thing to do is add, you mentioned some beverages, but hydrating in general, because adding water to our daily regimen is really important to our overall digestion. And I think some people really don't drink enough water.

Yeah. And I think drinking clean water, and that is definitely an episode we're gonna do because there's so much confusion about what kind of filters are good. And then now that I've been drinking the high pH waters, you probably shouldn't be drinking it all the time, especially if you're not having problems, but maybe some of the time, you know, because low acid can also cause issues, which is too much to talk about right now.

But that's an important thing to mention is that everybody has their own unique dietary needs and their own physiology. That's important. So one of the things that is important to do is if you are having trouble, of course, talk to your physician or medical professional, but also tracking and writing down things that you are noting that bother your digestive system, you know, taking a daily record of your eating or nutritional log or some way in which to keep track of these things and see which foods kind of bother you.

Yes.

Because everybody's an individual.

Yes. pH levels are not individual, but yes, you are absolutely right. So, you know, following that pH guideline and then seeing which foods trigger you. 'Cause some foods trigger other people and others do not have any problems with it. Thank you for being here again, April. I love these conversations with you. And to all those who are listening, even as a lifestyle physician, I specialize in stress management and, you know, people say to me, what, you're stressed? You teach stress. And that's always to me, I'm like, I'm the most stressed out person. That's why I went into this field to help myself. So, and to help those around me. We all know what we need to do. We all know we should get restful sleep. We all know we should relax. We should have loving relationships. We all know we should avoid toxins and exercise, but knowing is not doing. And that's why we are here for you to remind you of all these important things. And we're here for you with a variety of classes that you can take so that you can be together and to remind yourself these are not things that we can do without reminders, right, April?

Absolutely. I was smiling when you were saying that because every time I give a talk on the importance of stress management, I always lose a little sleep and feel a little hypocritical talking about the importance of sleep. But it's so important and it's one of the first things to go. Sleep, diet, you know, we try to do the best that we can, all of us humans, but we do need help sometimes and certainly reminders all the time.

And, you know, you might feel guilty, but because we're in this field, I know for myself, if I didn't have all this knowledge that I would be much worse off. And it really is averaging out what, you know, healthy versus unhealthy throughout your lifespan. That's your allostatic load of stress versus destressing. And, uh, you can think of it like, you know, aging versus reversing aging or whatever way you wanna think about it. But it's a balance over a lifetime of those choices. And, um, you know, you can't do things correctly 100% of the time, especially in the environment that we live in, right? So, but everything adds up. Every time I go onto a whole food diet, those times add up over my life. So try to cut those times I'm eating poorly or when I'm stressed.

Well, each day is a new day, and so we can only make the choices that we've made going forward. We have that ability to choose differently and try not to be too stressed out about the past because that's only gonna disturb the sleep, which will lead us to maybe not the best eating decisions, but it's important to take each day and You know, try the best that we can to make these choices because you're right, it's only going to improve our overall well-being.

Yeah. Like all the things that we talked about today, I could beat myself up about not having done that over the last 10 years. And now I find myself having this issue again. But on the other hand, I had so many times where I did do healthy things and that's going to help me get through this little bump.

Exactly. Well, thanks so much for having me here today, Juna Bobby MD. It's always a pleasure to talk with you about these important important topics.

Thank you, April. See you next month. And everybody out there, don't forget to send us your questions.