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Announcer: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine, and how to improve your health today.
Dr Rupy: I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition, and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests where we discuss the multiple determinants of what allows you to lead your best life. If you've ever suffered heartburn, reflux, bloating, indigestion, stomach pain or nausea, then this is the episode for you. Today, I'm going to give you an integrative approach to help with gastritis. And this combines both pharmaceuticals with lifestyle and alternative tools that you may not have heard of from your regular GP. I'll be talking through the causes, symptoms and medications for gastritis, specifically when to see a doctor as well, if you have one of these red flag signs. You can read more about that on patient.info that I highly recommend you go check out as well. We'll also be talking about what specific lifestyle factors can influence gastritis, foods to eat and foods to avoid, as well as protective eating habits. So that's nothing to do with food, just about the way in which we eat food. I'll talk through herbal and alternative therapies that we have evidence for and what my personal gastritis routine would be and what I would do every single day if I had symptoms and I wanted to control them. I want to give a special thanks to our research team here at Doctor's Kitchen, our science writer, Sakina Akoko, and GP and CEO of Coloury Medicine UK, Dr. Sumi Bura, who helped out hugely with this episode over the preceding couple of weeks. My sincere thanks to them both for helping me review multiple sources of information, including patient information websites, NHS clinical summaries and academic papers reviewing lifestyle and herbal remedies. Remember, you can watch the podcast on YouTube and I highly recommend you do if you're interested in some of the graphics and tables that I've pulled together for this episode on gastritis. I will talk you through those diagrams and everything so you won't miss out if you are listening only, but if you are interested in some of those specific resources, I recommend you check it out on YouTube. And whilst you're there, subscribe, check out the other recipe videos we've got. I've done a whole Malaysia series where we went to Penang and we healthified some of the best local dishes that Penang and the vendors have to offer in that beautiful, diverse area of Malaysia. And download the Doctor's Kitchen app whilst you have a chance. Right now we have a smart meal planner, new health goals like menopause and gut health, and we have a ton of other resources that we're going to be adding to the Doctor's Kitchen app. You can download on iOS, Apple, Google, and even on the web and you can print recipes now as well, which is a highly sought after feature. For now, on to my podcast about gastritis.
Dr Rupy: If you've ever suffered from heartburn, reflux, bloating, indigestion, stomach pain, nausea, you've got to listen to this episode because I'm going to do a deep dive into gastritis, what it is, how we investigate it, diagnose it and treat it with both drugs, but also lifestyle measures as well. This is going to be a really important episode because 10 to 15% of people will suffer from gastritis at some point in their life. And actually in America, it's a lot higher than that as well. First off, what is gastritis? Well, it's a general term that we use for a group of conditions with one thing in common and that is inflammation of the lining of the stomach and it can manifest in many different forms, from mild and even asymptomatic cases to really severe chronic presentations. Now, the symptoms of gastritis may start suddenly and resolve very quickly. This is what we call acute gastritis. So comes on, you have it for a few hours and it goes away. Maybe you take some over the counter medications. In other cases, it can develop slowly and last for a long period of time, weeks, months, even longer than that. And this is something that we call chronic gastritis. And the symptoms can sometimes overlap as well. It can be stomach pain or discomfort, nausea and vomiting, loss of appetite, bloating is a very, very common one, belching, hiccups, this feeling of fullness after eating even small amounts and even blood in the vomit or in the stool as well. But for the purposes of this episode, we're going to focus on gastritis, but these could also be symptoms of many other conditions as well. Now you might have heard of the term gastritis or heartburn like I've just mentioned earlier, but there are lots of other terms that you're probably going to come across. One of them is dyspepsia or indigestion. This is actually derived from the Greek prefix dis, meaning faulty or impaired, and the verb pacein, which is to cook or to digest. So faulty digestion. It's also used to describe symptoms that are present for around four weeks or so that come from the upper part of the gut. The other term you've probably heard of is GORD, also known as gastroesophageal reflux disease. In America, you guys call it GERD because you incorrectly spell esophagus without the O at the start. And that's usually a chronic condition where there is reflux of the gastric contents from the stomach back into the esophagus, beginning with O, that causes the heartburn and the acid regurgitation with all those different symptoms as well. Now, there are lots of different causes of gastritis. I've just named one, GORD. But it can develop due to a variety of different issues as well. The one that has gained a lot of attention more recently because we only really began to understand that microbes can cause gastritis is Helicobacter pylori, also shortened to H. pylori. And that's something that we test for and it is a bacteria that lives in most of us actually, but when it comes to the symptoms of gastritis, there can be too much of this particular microbe that can cause symptoms. There are other causes like substances that irritate the stomach lining and this can be due to long-term use of anti-inflammatory medicines. This includes aspirin, ibuprofen, non-steroidal anti-inflammatories, and also excessive amounts of alcohol too. Other causes include autoimmune conditions where the body's immune cells actually attack healthy cells in the stomach lining. And there are other medications, other than the ones that I just mentioned, the non-steroidal anti-inflammatories, like calcium channel blockers, which is something that we use for blood pressure, anticholinergics. So these are a group of medications that block acetylcholine, which is actually used in many parts of your body and helps you stay alert, keep your steady heart rate, breathe, digest food, sweat and empty your bladder. So we use anticholinergics in lots of different ways, and these can also cause gastritis, as can theophylline, which is used in asthma, which is an allergic breathing disorder, benzodiazepines, nitrates. So lots of medications can inadvertently cause these gastritis symptoms, but also stressful events. So bad injury, critical illness, major surgery, these are physical stressful events. Psychological stressful events can also cause excess acid production that can lead to symptoms of gastritis as well. So lots of different reasons as to why someone might have gastritis. So what is the mechanism behind why you might be suffering from gastritis? Well, it really depends on the cause. So whether it's the result of H. pylori, whether it's an irritant, whether it is GORD, the reflux of acid materials. Generally, what we see going on is your stomach that normally produces acid to help with the digestion of food in your digestive tract and to kill bacteria. This is very, very corrosive. It's got a very, very low pH. And cells produce a natural mucus barrier to protect the lining of the stomach. So you need this balance between a lot of acidity in the centre of the stomach and you want that buffer on the outside so the normal cells don't get destroyed by those or irritated by those. You need a clear balance between the acid secretion and the mucus defense barrier. Now, if there's an alteration in this balance, the protective lining of the stomach can therefore become damaged and that's where you might get gastritis developing. You also have another reason specifically for GORD where you have a floppy sphincter at the top of the stomach and this can lead to refluxing of the normal materials that sit in the stomach going into the esophagus where again, it can irritate the lining as well, leading to symptoms. If you look at this first image, it just gives you a general idea of what I'm talking about here. So on the left hand side, you'll see a normal stomach. So at the top of the stomach, you have the esophagus, where you have the sphincter and that goes into the antrum of the stomach, the the major part of the stomach, which is split into three parts, but we don't need to go into those details. And at the bottom of the stomach, you have the small intestine as well. Where you have disruption of the normal lining of the cells with the mucus barrier that protects you from the acid in the middle of the stomach, that's where you get gastritis issues. That's where you get destruction of the cells and that's where you can get some symptoms as well. Now, despite gastritis being very common and usually mild and it can sometimes resolve without any treatment, I really do want you to think about some red flag symptoms. This is where you should see a doctor, a general practitioner, someone like myself, if you have severe or persistent symptoms of these. Stomach pain and discomfort that lasts for more than a week, frequent nausea or vomiting, loss of appetite or inability to keep food down, bloating or this feeling of fullness after eating just small amounts as well, blood in the vomit or your stool, which could indicate bleeding in the stomach or even somewhere lower down the digestive tract. You want to also look for specific types of stools that are abnormal to your normal stools as well, and any unexplained weight loss. Do not ignore any of those symptoms because if they are present, you need to make sure that you speak to your doctor about it because there could be suggestive of other things outside of gastritis. It could be tumours, growths, it could be different types of conditions that have their roots in the digestive tract as well. So you must make sure you get those investigated by your GP, particularly if these are new symptoms as well for which you have not had treatment in the past. Even if this is the result of gastritis, it is important to get an early diagnosis and treatment because you can prevent complications like stomach ulcers, which is at the sort of latter end of the spectrum of gastritis, and even things like nutrient deficiencies because if you do have gastritis, that lining of the stomach is impaired and so the absorption of the nutrients that you get from food can also be altered as well. I'm going to give you an example of a typical patient story that if there are any medics listening to this, have probably had one of these patients come in. Mrs. X, 45-year-old office worker who presents with a burning sensation in the upper part of her abdomen. They have bloating and occasional nausea. It's been happening for, let's say, two months on and off. Within the diet history, she might mention that the symptoms worsen after eating spicy or fatty foods. Perhaps she went to a friend's birthday party and had a couple of glasses of wine with her meal and then felt the symptoms that are there sometimes actually worsened, that triggered the appointment in the first place, you know, oh, I've got to get this sorted, you know, this has been happening for a long time now. It's worsened for when she's when she's under stress at work or at home and she's been taking over the counter antacids with minimal relief. As a GP, my initial thoughts are this is gastritis, but also I'm going to be making sure that I answer all the other questions. I ask the questions so I get the answers to them. So unexplained weight loss, any changes in the stool habits, any other symptoms that might be correlated with a menstrual cycle because we want to make sure that we're not missing anything that could be related to ovarian or uterine conditions. Making sure that we do a full history of any other medications or even supplements as well that could be leading to these symptoms, any change in diet. There are a whole bunch of other questions that I'd be asking as a GP. That is a typical sort of patient history that you might find in a general practice office. As a GP, most of us can make a diagnosis of gastritis by taking the history of the symptoms that very similar to the ones that I've just suggested there, and an examination of someone's abdomen and doing some basic tests. But if gastritis doesn't get better quickly or there are other things that I might be worried about, severe pain or any other symptoms, then we may arrange some extra tests. And these tests can be some of the following. So if this comes on quite quickly, the first thing that I might think of is a test for Helicobacter pylori, so the microbe that we mentioned earlier, and that's relatively easy done. It's a stool test or a breath test. I'd also check for non-steroidal anti-inflammatory use and any dietary factors as well. That's the probably the first thing that most GPs would do. In patients with a history of either alcohol abuse or high levels of alcohol intake, smoking, then you might also want to evaluate the impact of these risk factors and do something a little bit more aggressive in terms of further investigations with a gastroscopy. So that's where you put a telescope down the gullet and you look and you literally visualize what the gastric lining looks like to make sure you're not missing anything like an ulcer that could have developed pretty quickly or even something worse like a cancer as well. For chronic problems with gastritis, you'd also want to investigate things like autoimmune conditions with blood tests, pernicious anaemia, again, that's a blood test that's looking at a particular type of low iron and low haemoglobin level, and you'd want to rule out other causes like I mentioned earlier, gynaecological causes with an ultrasound and other specific blood tests as well. In older adults, we'd consider age-related factors like thinning of the stomach lining and increased autoimmune conditions as well. And with the gastroscopy, I've actually got an image here, you'll see what happens when the camera is passed down and the specific tests that we'll be looking for as well. You won't need to know any of the names of these specific tests, but it's just interesting to understand what we're looking for, how we take samples, how we visualize that in the lab and what kind of results we're looking for as well with a to diagnose the grade of gastritis. As I'm talking about tests here, I think it's important to distinguish between disorders and functional disorders. So you might have come across a term like functional dyspepsia or functional indigestion. This is where you have normal test results. So if I put a gastroscopy down someone, I did all the bloods and they all came back negative, i.e. they were all normal, but a patient still had symptoms, that's suggestive that there's still something going on here, but we just don't have the investigations to prove exactly what it is. A disorder is where you have abnormal tests that are suggestive or diagnostic of a disorder, something like gastritis. So it can be quite frustrating for people who have these symptoms who feel that there is something that surely there's something physical to see there, but all the tests are normal. That doesn't negate someone's diagnosis. It shouldn't suggest that there isn't something going on, but it just means it's harder to figure out exactly what might be triggering it as well and also provide the relevant and appropriate treatments. For anyone who feels that they haven't been asked the right questions, specifically, you want to make sure yourself that there are no drug interactions, you are doing a food diet history, and that, you know, is a food diary essentially. You're looking out for trigger symptoms. We're going to go into this in a bit more detail later. You are being conscious of periods of stress and you might not even realize that you're that stressed. A lot of people don't realize that checking social media or emails can lead to something called email apnea. So you literally do not breathe. You hold your breath and you hold yourself in this position, which is quite fixed and upright. That's a stressful position. Your body recognizes that even if you don't consciously recognize that stressful impact and that can lead to a whole host of symptoms including gastritis. You'd also want to look at whether eliminating certain foods may help. And the common things that I always ask people to think about are smoking, spice, sugar, and stress, the four S's. Smoking, spices, not all spices, but the chili spices, stress, sugar. These are things that you want to make sure that you are addressing even before thinking about drugs and other investigation and other treatments. Gastritis medication. There are lots of different types of drugs that we can use as treatments for gastritis, but it should be a short-term solution whilst you figure out what the underlying cause is and how you treat gastritis really depends on what you believe is causing it. So in the case of Helicobacter pylori, there is something called eradication therapy, which involves a host of antibiotics and other medications to to mitigate against the acid. That is something that we do on the basis of a positive investigation for H. pylori. So that's something very, very separate. A second big class of medications are antacids. And these have various salts like calcium, magnesium, or aluminium as their active ingredients. They're basic compounds that basically act by neutralizing the hydrochloric acid in your gastric secretions and they block the action of things like pepsin, which is a proteolytic enzyme. So these are the milieu of different acidic compounds that break down your food. And they're usually used, this is antacids, they're usually used to provide quick relief of symptoms, which is why you always see sort of like adverts of someone running around through life and, you know, they're eating on the go and they're running to work and they're catching the bus and they've got like, you know, family life and then they'll just pop a heartburn tablet to get these quick relief of symptoms. I find those adverts really irritating because it suggests that all you need to do is don't change your lifestyle and just pop this tablet. It's a really, really bad way of looking at things. And I I I hope they change that advertising strategy because it's probably pretty effective to educate people that this is all you need to do, but really what you do need to do is address the lifestyle stuff. Really figure out ways in which we'll talk about, figure out ways in which to mitigate the excess stress that is causing the acidity in the first place, so you don't need to become reliant on antacids that might have some side effects, particularly with long-term use as well. You know, for people who have occasional bouts of mild dyspepsia, mild heartburn, it's okay to use it every now and then, but it shouldn't be a long-term solution as any of these medications should be. The other thing, another big class are H2 blockers such as famotidine. These work by binding to receptors in the stomach cells, which lowers the amount of acid made in the stomach. We used to use ranitidine quite commonly, but that had a very severe side effect in that it raised the risk of cancer. That was taken off the market. There are other medications on the market that mimic what ranitidine was doing, but don't appear to have the same negative side effects. But this is why I'm always very cautious to minimize the amount of medications that we're relying on because we in a lot of cases don't have long-term data to suggest safety at this point anyway. Another class that you can now find over the counter are proton pump inhibitors. So these are also abbreviated to PPIs. These include lansoprazole or esomeprazole, omeprazole. They reduce stomach acid by targeting the enzymes in the stomach lining that produce that acid as well. Now, there are a lot of issues with all these different medications. PPIs in particular can bring temporary relief, so you just pop an omeprazole, gives you temporary relief, while your stomach is healing, but there might be a few issues. The first off is that they're masking the underlying problem. So it can help the stomach heal, but they're not treating the root cause of gastritis. And I think people have a warped idea about how these medications are working in that you take this for a short amount of time and that will lead your gastritis to be healed wherever it might be. That's not the case. It's just giving you a bit of time. So you can figure out what is actually the true trigger of the gastritis cause. So many people find themselves in a situation where they get relief after using a meprazole for a couple of weeks, they stop the medication and the symptoms come back straight away. It's because we haven't treated the underlying cause. The other issue that I have with PPIs is that there are other potential side effects. So they can cause problems like constipation, diarrhea, nausea, vomiting, a lot of very similar complaints that people are treating gastritis for. And the more serious issue that I have with them are long-term effects. So PPIs are generally considered safe for short-term use, but there is some emerging evidence that is showing the potential risk of using them in the long-term. And long-term is classed as over four years. There are a lot of unknowns. So the current advice to doctors is that the PPI class of medications, omeprazoles, lansoprazoles, etc, should be taken at the lowest dose for the shortest length of time and reviewed at regular intervals. So in 2021, there was an umbrella review of 42 meta-analyses that showed that the long-term use of PPIs was associated with a variety of conditions such as chronic kidney disease and enteric infection as well. A recent analysis of five prospective cohort studies published in Nature found that taking PPIs for over four years was actually correlated with an increased risk of 15 leading global diseases including ischemic heart disease, diabetes, respiratory infections, chronic kidney disease, Parkinson's disease, and depressive disorders. Now, the reasons why we don't really know. Based on lab studies, researchers suggest that by blocking production of acid, your PPIs can impair one of the body's natural defense mechanisms against ingested microorganisms, which is essentially, you know, why we have the acidity in the first place. The reason why you have essentially an acid bath is to yes, break down the products of your food, but also making sure that you're not getting any pathogenic bacteria that can make its way into the digestive tract and then cause inflammation, which is where your immune system lies, basically, mainly in your digestive tract. And so this could potentially disturb the balance of the microbial species in your gut as well. The additional issue is that with this diminished gastric acidity caused by the PPIs, it can lead to calcium and vitamin B12 malabsorption. And that can lower bone mineral density, which increases the risk of osteoporosis. So if you were to have a fall, you're more likely to break your hip or break a bone, which leads to sedentariness, which certainly in an older age group is correlated with a higher risk of all-cause mortality and morbidity as well. So a really, really serious potential side effect. Now, these studies that I've just talked about, even though they're published in Nature and a whole bunch of other good journals, they may show that there is a high risk of osteoporosis, but it is only an association. So you can't rule out the effect of confounders. So a regular PPI user, if I think about a regular PPI user, they generally tend to be in an older age group, they tend to be obese, they tend to be smokers, they're less physically active. So they have a higher rate of comorbidities and medication usage overall that could also be impacting a number of these different conditions or the likelihood of those conditions as well. So it's not proof, but there is an uneasy association that I'm willing to say is not problematic. I think we're something that we need to sort of be a bit cautious about. Now, if you're someone that's worried about this, now that you've heard about these associations, you might be tempted to stop your PPIs immediately. If you're taking PPIs, do not stop them all at once. Make sure you speak to your doctor and you work out a plan with them before making any rapid changes. The reason why is because stopping these drugs abruptly may also worsen symptoms. So if you think about it from a pragmatic point of view, if you're taking a medication that suppresses acidity in your stomach and you suddenly take that away, then you might get a rebound effect of the acidity and worsening of symptoms as well. Your lining of your stomach may not also be habituated to that condition having had such long use of the PPI in the first place. So every medical treatment has this risk-benefit balancing act to do. In the short term, they can be very helpful, but it's best not to get into the long-term use if you can avoid it. And someone listening to this might think, you know, I'm being a bit callous by talking about the overuse of PPIs. It's pretty oftenly prescribed and inappropriately prescribed as well. Up to 70% according to a recent study in 2024, do not need to be prescribed for the length of time that they are. PPIs are one of the top 10 most prescribed drugs worldwide with a global market evaluated, a global market share evaluated at 2.9 billion in 2020 and it's anticipated to grow year-on-year by about 7% as well. Yet there are a variety of ways in which to treat gastritis and acid reflux and different approaches will work for different people as well. So we definitely need to be exploring those before we rely on a medication that can potentially have some pretty drastic side effects. So, you know, I think it's often seen as something that's fairly innocuous, but with the size of the problem and the risk issues associated with them, the potential risk issues, it's definitely something that we need to be thinking about helping in other ways. And this is where we get to the Doctor's Kitchen toolkit of lifestyle and diet that can help with gastritis and mitigate against other causes like GORD as well. A lot of people see gastritis as something that is annoying and frustrating and whilst it is, I absolutely agree. I've had heartburn myself in the past. It is a message to you to pay attention to that something in your lifestyle is going awry. And it needs a solution. It needs a an upstream solution to the to the symptoms that you are suffering. And the other thing to recognize, in the same way, medications are not the single solution, a supplement or a lifestyle change on its own is not necessarily going to fix everything overnight or in the long term either. It's going to be a case of experimenting with a variety of blended approaches. And so the real challenge is actually working out what works for you. And so here is a step-by-step toolkit to help with gastritis from the most evidence-based to the least. Number one, you want to replace or limit irritants and triggers. The first one is non-steroidal anti-inflammatory drugs, NSAIDs, also known as ibuprofen and aspirin is another common one. They damage the stomach lining by reducing the secretion of protective bicarbonate mucus. So this is that barrier between the lining of your stomach and the centre of your stomach, which is where all the the acid is going to be housed. This increases the risk of gastritis and ulcers. So making sure you're only using them when needed and avoiding having them on an empty stomach. And there are also some alternatives, particularly if you are suffering from mild to moderate pain for which we usually just reach for whatever analgesic, any painkiller that we can get our hands on. So for menstrual pain, for which I know a lot of women will rely on ibuprofen regularly, like every month for a few days at a time, try heat pads, massage, teas like cinnamon and fennel. These can all help with menstrual pain. For chronic conditions like arthritis, explore alternative pain management options with your doctor as well. You could also try the very simple thing which is limiting the dosage and duration. So if you're using it for five days, use it for two or three instead and switch to other pain relievers like paracetamol, which is usually effective for mild pain and is easier on the stomach as well. There are some supplements like arnica, turmeric, ginger, these are all things that do have that analgesic, pain-killing effect, but might not be as perceived to be as effective. But actually, your belief in certain herbal remedies actually can have a significant impact on the analgesic properties itself. So how much you believe that this supplement or this herbal remedy is going to have in terms of the efficacy of it can actually lead to better results. So believe in the power of herbs and spices, honestly, it's pretty phenomenal what they can do and there is evidence for them too. The other thing is irritant foods. So this can be different for everyone, but some foods and drinks have been commonly linked to gastritis and reflux symptoms as well. The number one one is alcohol. This can cause direct damage to the stomach lining. If you are even a mild drinker of alcohol, try removing it completely because I mean, alcohol does have a lot of issues for people outside of the digestive tract. It's definitely something that can affect your microbial population as well. So if you were to able to remove it completely, that may have a significant effect on your gastritis symptoms. The other common one is spicy foods. So these can further irritate an already inflamed stomach lining as well. Fried, fatty, greasy foods. These are very hard to to digest. So if you think about it pragmatically from your digestive point of view, if you're if you're introducing something that's quite hard to break down, your body needs to throw more acid at it to digest it, to to to make sure you break it down to its component parts. So that can reasonably increase stomach acid production, which can lead to the issues that we've just been discussing as well. Another thing that is getting a lot of attention right now and rightly so is ultra-processed foods. Ultra-processed foods are high in sugar and salt and these can also increase stomach acid by altering the gut microbiota as well. And that can increase inflammation in the stomach lining. And observational studies have found that pro-inflammatory diets indicated by a high dietary inflammatory index score is associated with an increased amount of gastritis. So basically, the more processed foods you have in your diet, the more likely you are to suffer from gastritis problems. And you'd be really surprised at what counts as ultra-processed. So a lot of healthy cereals, healthy granolas, healthy bars, healthy meal replacements, healthy drinks, are all processed. So you really want to be stripping that out as much as possible, particularly if you have problematic symptoms as well. Another controversial one is coffee or caffeine, which is commonly found in coffee and tea and sodas. These can also stimulate acid secretion. We often advise patients to stop caffeine, but it remains controversial as to whether coffee worsens symptoms. Some researchers suggest that low-level coffee consumption does not seem to strongly influence the occurrence of reflux and gastritis, whereas higher levels of consumption might somewhat increase the risk. But depending on the type of coffee, the roasting method, decaffeinated, I don't have any idea around whether those would mitigate the gastritis symptoms. There is really limited evidence on that. But my general opinion is if you are suffering from gastritis, you would probably benefit from removing anything caffeinated for at least and monitoring symptoms to see if that improves it. But it can be an irritant to the gut lining for the reasons that I've just explained as well. I have my own patient story. So my wife had a very spicy ramen and ever since she had this spicy ramen, she would suffer from real debilitating gastritis symptoms after eating anything. And she really thought that, you know, she's never going to be able to have chili again and she's a big chili fan, like she loves spicy food. This is a particularly spicy broth. And it did last for a number of months. And I've had patients like this before in the past where they feel like anything they eat is just causing gastritis symptoms. But by doing a few simple things, removing any spicy foods for the short term, removing any other offending items that can lead to more gastritis, so things like coffee, things like processed foods, things like alcohol, allowing your gut to heal and then gradually introducing other foods whilst your resilience has been restored. Now, my wife and many other patients can have spicy food with no problem whatsoever. So I don't think this is a long-term restriction that you need to see this as, but it's certainly something that you want to truly commit to for at least for a few weeks if not months, and and and allow your your stomach lining to heal. This is assuming that we've ruled out all the other causes as well. Other irritants can be the way you eat food as well. So eating too quickly that I'll discuss a little bit later, irregular meal times or skipping meals, which can disrupt the normal digestive process. Now the first thing that might flag in people's minds are is fasting. Should I fast if I have gastritis symptoms? If I can't maintain a regular schedule, either because I'm trying a new diet or a new fasting regime, is this going to worsen my gastritis? Potentially, yes. So it really depends on how your unique body works. I know from my own personal experience that if I skip certain meals like breakfast in the morning, I'm more likely to have gastritis symptoms than if I was to skip an evening meal, for example. So it really depends on you and how your own unique body processes food. So I would be led by your symptoms, but if you are having issues with gastritis as a result of fasting, maybe that particular fasting method for you is just not the right fit. And that there are loads of ways in which you can fast if you choose to fast, whether that's a day fast or water fast, alternate day fasting, 5-2 fasting, or intermittent fasting, for which you can change that eating window from anywhere between 8 hours, 10 hours, 11 hours, you're still fasting. So just be cautious if you do have gastritis symptoms and you are a faster, for example, because it might be the fasting that's leading to the symptoms itself. Another common eating habit is eating late at night. And if you eat late at night and your body is still in the process of digesting food, it's released all this acid and you lie down, lying flat can lead to the reflux of the stomach contents, that acidity going into the esophagus and causing heartburn symptoms. So if you eat earlier in the evening, if you do choose to eat in the evening, that's something to to bear in mind. You want to try and eat as as far away from lying down, i.e. going to bed as possible. Another very interesting fact is wearing tight clothing, like trousers or underwear or very sort of tight-fitting active wear. So tight clothing can actually exert excessive and constant pressure on specific parts of your body that can have an effect on your internal organs like the gut as well. So I know like Spandex or Spanks or I think there's a whole bunch of like new products on the market that are all targeted to largely women to sort of hold everything in to look aesthetically more sleek. And look, no judgment whatsoever. If that's what you choose to do, that's great. But if you do have gastritis and you're wondering why this may be one of the issues as well because it is exerting that pressure that can have, it doesn't feel like it would do because it's so far away from your gut as in your the upper part of your gut and your stomach, but it can exert that pressure that can lead to reflux as well. So try wearing low-waisted items or looser clothing when you can, if you do need to wear whatever tight-fitting clothing during the day or for work, that's another thing, but where you can, try and wear looser fitting clothing and you'll be really surprised at the effects as well. So we've discussed irritants, certain triggers and irritant habits. What about protective eating habits? So even though I focus on food, I think the way you eat is also going to be very important when it comes to mitigating against a whole host of symptoms including gastritis. Like I've just mentioned, eating early dinners, more specifically, trying to eat three hours before bedtime and avoid lying down with a full stomach, which can increase the production of gastric acid and cause that reflux of the stomach contents. Typically, it can take up to four hours for 90% of a solid meal to move forward out of the stomach. So if you think about that, it's taking you four hours from the moment you put your fork down to 90% of the stomach. So there's still some food in there, but 90% of the stomach contents have moved out. So you're still going to have that acid whirling around your stomach after a couple of hours. And if you try and go to sleep then, it's no wonder you're going to get this reflux as well. So if you can, if you are suffering from gastritis, really try and push that window as long as possible. Three hours I think is a minimum, four hours would be ideal, depending on how severe your symptoms are and how disruptive your gastritis is as well. The other thing I would suggest is eating regular at regular times as well to support the normal digestive process. The irregularity and skipping meals can negatively impact your gut function like gut motility, which can affect the production of these digestive enzymes and cause an imbalance between the protective and harmful factors in the stomach as well. A third tip in terms of eating habits is a light digestive walk after eating. Now, I've heard of this term of a digestive walk, mainly from my parents, and I never really understood why you would need to go on a digestive walk. But there was a study in PLOS ONE that found that walking stimulates the gut and stimulates the intestines, and this can actually help move food along through the digestive system more rapidly. So if you're moving it through your digestive system more rapidly, you're getting less of the exposure to the acidity and you're having less reflux symptoms potentially as well. Now, there is a balance to be struck here. You don't want to be going for a run after your meal and you certainly don't want to be going at a pace that's going to put you out of breath. So again, making sure you are titrating this advice of a light walk after a meal to your capacity. I think it's really, really important. So if it's a slow walk, I'm a very slow walker. So a slow walk, particularly after a meal, is probably the best way to go. You don't want to go on a brisk walk because that can actually lead to more indigestion as well. I mentioned eating slowly to reduce stress and put your body into digest mode. Eating slowly is actually a thing. So research links eating speed with symptoms of gastritis. In cross-sectional studies, those who ate fast, which is defined as an eating speed of less than five minutes per meal, it's probably me, showed more symptoms of gastritis, so things like hiccups and belching and the symptoms of this acid reflux and a higher risk of endoscopic erosive gastritis, something that we term EEG, compared to those with a slower eating speed, which is defined as over 15 minutes per meal. So eating speed is something that we need to pay attention to. It's something that I probably didn't really respect myself. How does it potentially help? Well, number one, it lowers your stress levels. It puts your body into this parasympathetic mode, which improves digestion, something that we call rest and digest. The second thing is that chewing your food more before swallowing means that food spends less time in the stomach, you need less acidity to break it down, and so less gastric acid is required. And the third thing is, you're less likely to overeat because you're more exposed to these gustatory, olfactory, and visual stimuli that create that satiety signal. So in practice, where you can, give yourself enough time to eat, take deep breaths, put your fork down between mouthfuls, and avoid rushing after eating as well. If you think about a typical Mediterranean table, one that you conjure up in your mind, everyone's chatting, they're not just stuffing down their food, they're paying attention, there is the sort of like the visual cues, the the beautiful food. Like this is something that we want to try and mimic as often as we can during the week. So make time for your meals and avoid eating on the go. So wherever you can, find a quiet spot, put away distractions like your phone or your computer, don't eat al desko, try and eat al fresco, take a moment to slow down, enjoy the flavours and the textures of your meal and avoid rushing around straight after eating too. Take a couple of deep breaths before you actually start eating. That's something that I've been trying to do as well because I have a tendency to just scoff my food down because I'm usually in a rush before I need to go to the next meeting or jump on the next podcast and make sure you chew thoroughly as well. Take smaller bites, chew your food thoroughly before swallowing, it will help your digestion and reduce the burden on your stomach as well. Now, it wouldn't be the Doctor's Kitchen podcast without talking about eating more protective foods of gastritis. So if you pull up this image that you guys will be able to see on YouTube, if you're watching on YouTube, I'll explain it to everyone else. An anti-inflammatory diet is something that we know can have a protective effect on things like gastritis. Overall, we want to be moving towards a more anti-inflammatory diet. This includes fibre-rich foods, whole grains, vegetables, nuts, and seeds. Observational research has found that the intake of fibre was associated with a reduced risk of gastric disease and a reduced risk of H. pylori infection. So we can prevent the likelihood of H. pylori taking hold in its first place by having more fibre in our diet. In a small prospective study, adding fibre to people's diet, they basically gave them 15 grams of psyllium husk every single day, which is the equivalent to around 12 and a half grams of soluble dietary fibre, it actually reduced the risk of and the frequency of heartburn and gastroesophageal reflux disease as well. The reason why it could potentially help is because these dietary fibres, as we've discussed before, can help decrease gastric acidity, can shield the delicate lining of the stomach and increase gut motility, which may reduce the likelihood of uncomfortable symptoms as well. So my top tip is trying eating 30 grams of dietary fibre each day. And if you can tolerate something like psyllium husk as a supplement, then try and have that every day as well. You need to basically mix it in a ton of water because it can be quite viscous and then just basically have that in the morning. If you find the the fibre a bit too much, then separate it out into two smaller doses, either each end of the day or maybe once in the morning, once in the afternoon, if you can't tolerate the high amounts of fibre. And if you are new to fibre, then make sure you go slow, go go slow, slow. As well as fibre, probiotic-rich foods, sauerkraut, kefir, yogurt, they can help maintain a balanced gut microbiome and strengthen the intestinal barrier and improve digestion as well. Small trials have found that certain probiotic strains or fermented foods have actually improved markers of gastric inflammation and symptoms related to H. pylori such as abdominal pain and distension as well. So probiotics is something that I try and get into my diet most days. They improve the intestinal lining, they improve your tight junction function, they're adding new microbes to your gut microbiota, the population of all those different bugs. So probiotics are definitely one that I would recommend as well. Third type of food are flavonoid-rich foods. So apples, celery, berries, leafy vegetables, they show gastroprotective effects in lab studies by increasing the production of protective factors like the gastric mucus and the anti-inflammatory and antioxidant factors that can mitigate against gastritis, but we definitely need more human studies in that. And if you look at the scales on the YouTube here, you'll see the scales with peptic ulcer on one side and the protective factors on the other. And that basically summarizes the reason as to why flavonoids are so effective at reducing gastritis symptoms. Sulforaphane-rich foods. So sulforaphane is a particular type of phytochemical that you find in broccoli sprouts, cabbage, kale, that you find them in brassicas. There was a small trial in 48 patients with H. pylori that found that daily broccoli sprout extract consumption, 70 grams per day, which contains around 420 nanograms of sulforaphane precursors for eight weeks reduced the levels of urease measured by the urea breath test and H. pylori stool antigen, both biomarkers of H. pylori colonization. And so there does appear to be some effect of sulforaphane, this anti-inflammatory chemical in brassica vegetables that can mitigate against the colonization of certain microbes that can cause gastritis. It's also very much part of an anti-inflammatory eating pattern that we know is protective as well. So those are four things that I would definitely get into your diets. You want to get fibre, you want to get flavonoids, you want to get probiotics, and you want to try and get brassica vegetables as well. Gastritis and reflux problems can almost always be helped with approaches that reduce stress and relax the diaphragm. And we've seen some positive effects in trials looking at GORD patients. So there was a systematic review of seven studies, three RCTs and four cohort studies that concluded that breathing exercises can help with reflux disease and reduce the symptoms of reflux and improve their quality of life as well. There was a randomized control trial in patients with GORD that found that something called diaphragmatic breathing training improved symptom frequency, so lessened the frequency of symptoms and reduced the severity and improved their quality of life compared to the control groups. If you don't know what diaphragmatic breathing is, we'll put a link to it in the show notes, but it's where you're breathing into your abdomen and you're allowing the diaphragm that is usually domed at the bottom of your lungs to really push down. So you're taking a real important deep breath in and super aerating your lungs. And what this does, more so than just the aeration of your lungs, is that it signals to your brain and it signals to your gut to relax. And it's that parasympathetic mode that you can dive into that causes the reduction in stress and potentially the reduction in the acidity as well. The other hypothesis is that by pushing the diaphragm down, it creates a gentle massaging action that's actually felt by your internal organs like the intestines and the stomach, which can again reduce abdominal pain, urgency, bloating and constipation as well. So try 5 to 10 minutes of deep diaphragmatic breathing to your daily routine, especially before meals as well. And if you like the thought of your internal organs having a massage, it's actually one of the oldest forms of treatment and has been used to treat symptoms of various gastrointestinal disorders including constipation. There was a systematic review of six clinical trials that showed positive clinical effects with the use of manual techniques for the treatment of GORD. A typical massage is one where you start in the bottom right hand side of the abdomen, moving up towards your liver and then across the abdomen to your left hand side and then down towards the left lower part of your abdomen. It reduces muscle tension, it can increase blood circulation, it could stimulate again the parasympathetic activity and thus improve digestion as well. So try massaging first thing in the morning or even before going to bed to try and improve the sort of symptoms that you might be suffering with as well. There's lots of videos online to show you how to do abdominal massage and maybe even adding a little bit of oil to just keep the sort of fluidity of it. There are some sort of suggestions of castor oil helping and olive oil helping because of the anti-inflammatory action. We don't think it's due to the oil itself, it's more so the massage action. With regards to herbal and supplemental remedies, there are a few out there, but not many of them have solid evidence. We have seen small evidence for things like ginger, so we've done a whole episode on ginger. It's long been used for its benefits in reducing nausea and vomiting. And in healthy volunteers, ginger was found to enhance gastric and duodenal motility and accelerate gastric emptying and therefore improving things like burping without increasing reflux. So if you think about it, if you're increasing gastric emptying, you're moving food along the digestive tract, so it doesn't have to stick around and be sprayed with more and more acid. And if you're pushing food along, it therefore stands to reason that you're going to have less of the reflux symptoms as well, and less gastritis. A divided dose of 1500 milligrams of ginger was found to be beneficial in a number of different studies. Something else that you might have come across before is peppermint oil, but also peppermint oil and caraway oil in combination. These seem to improve symptoms of functional dyspepsia in clinical trials. The common dose of that was one capsule of peppermint oil of 90 milligrams and 50 milligrams of caraway oil twice daily. Turmeric, our old friend turmeric, potentially due to the curcumin, has also been shown in recent clinical trials to have comparable efficacy to omeprazole in treating functional dyspepsia. And we don't have the doses of that, but typically it is around one to two grams of the raw turmeric that we tend to suggest. Probiotics, like I've just suggested, there was one study but it was looking at H. pylori as part of combination therapy with the eradication therapy. They used something called L. reuteri or lactobacilli reuteri, which is something that you can find in supplemental form, but you can also get it in many different types of yogurts as well. So there is some scanty evidence for probiotics as well. And another one that I haven't personally used clinically is licorice. So a licorice extract called DGL or diglycerized licorice, I can't pronounce that, has been used for indigestion, GORD, ulcers. It's one of those old school herbal treatments and the active components are flavonoids and it's suggested that it might work by stimulating normal defense mechanisms and the healing of damaged mucus membranes rather than just blocking the release of acid. And plus there are other several flavonoid components of licorice that have significant activity against H. pylori in lab studies, but that's just in lab studies. We haven't found any human trial studies for those either. So licorice might be another one that you might come across. And another type of alginate, so something that kind of buffers the acidity are marine alginates. So these are extracted from seaweeds, sometimes added as an inactive ingredient to antacids like Gaviscon because they act as a protective barrier to gastric acid. And in clinical trials, these alginate-based therapies were superior to placebo and antacids for controlling reflux symptoms in adults as well. So there are lots online that you might come across like berberine or lemon balm, dandelion, fennel, even aloe vera juice, but we don't really have that much great evidence for those. Looking at the plethora of different treatments there are, those the ones that I just mentioned are probably the ones to go for. So if you did want to try any of them, peppermint, caraway tea, probiotics, ginger tea, turmeric, those are the ones that I think probably have the best efficacy for. I don't want to discount the emotional aspect of gastrointestinal disorders that we we can't overlook this. Multiple studies have found that psychologically based approaches lead to greater improvement in digestive symptoms compared with only conventional medical treatment. So if you can find a stress-relieving practice, talking therapies, even acupuncture, these might have some benefits in gastritis as well. So if I was to describe a 24-hour routine for gastritis in a perfect world, if you had all the time, this is what I would do today if I was experiencing symptoms. Now in reality, everyone's experience is unique, life happens, it's really hard to fit everything into a busy schedule, but any small change you can take from this whole episode, but maybe this 24-hour picture could be useful as well. So when I wake up, I would rehydrate, I would do 5 to 10 minutes of diaphragmatic breathing and movement to reduce stress and prepare my gut for the day. I would definitely wear loose, comfortable clothing to avoid putting any undue pressure on my abdomen that can cause gastritis symptoms. For breakfast, I would choose fibre-rich foods, something like a tofu scramble, hummus, beans, maybe even quality oats, berries, nuts. I would avoid caffeine. I would have a decaf if I wanted to maintain the sort of polyphenol consumption of my coffee, but I might experiment with something like a ginger or cinnamon tea, peppermint, hibiscus, lemon balm, cacao, something like that. I would always take the time to eat slowly. So if I work outside the house, I'd prep my breakfast before and eat it when I got to work so I don't need to rush through it. So I get to that over 15 minutes of eating window. And for lunch, I'd have something anti-inflammatory, something with a lean protein, some green veggies, maybe a legume soup. I would stay clear of spicy, overly fried or overly oily or greasy foods. I would take a light walk after my lunch to help with the digestive process. So, you know, you could even take a meeting on as a as a walk if you if you had to. I would have a probiotic-rich snack, so something like a yogurt or a small serving of kefir, keeping it small and early, so I'm maintaining my appetite for an early dinner. I would go come back home and have an early dinner around 6:00 p.m. I know it sounds early, but 6:00 p.m. with foods like leafy greens, celery, apples, broccoli, a light salad, maybe some watermelon with chicken and tahini. I would do light activity like a short walk again and light unwinding practices to aid digestion. I might even do myself a little gentle abdominal massage before I go to bed, some deep breathing again to relax and prepare for sleep, and I would record everything. I would make a food diary to see what my symptoms were like before and after eating and see how it affected my symptoms as well. So that's what I think a perfect day would look like. Now you might not be able to do everything, but if you could just slot in some diaphragmatic breathing or slot in a walk after a meal or slowing down your eating habits, these things could really make a big effect. So make sure you do a food diary, try some of those teas and light walking movements. These are things that would come back to if I had a flare up of symptoms as well. I really hope you found that useful. Like I said, there's a lot to unpack with gastritis and reflux and dyspepsia and indigestion, all these constellation of symptoms, making sure that you're going and step-wise fashion through all the different causes, doing appropriate investigations, speaking to your own personal doctor and personalizing your eating and lifestyle habits to meet your symptoms as well.
Dr Rupy: So much for listening to this episode of The Doctor's Kitchen podcast. Remember, you can support the pod by rating on Apple, follow along by hitting the subscribe button on Spotify, and you can catch all of our podcasts on YouTube if you enjoy seeing our smiley faces. Review show notes on thedoctorskitchen.com website and sign up to our free weekly newsletters where we do deep dives into ingredients, the latest nutrition news, and of course, lots of recipes by subscribing to the Eat, Listen, Read newsletter by going to thedoctorskitchen.com/newsletter. And if you're looking to take your health further, why not download the Doctor's Kitchen app for free from the App Store. I will see you here next time.
