Transitioning from the Induction Reflux Diet to Maintenance
In the few months since the publication of Dropping Acid: The Reflux Diet Cookbook & Cure, we have received hundreds of notes, inquiries, and questions about specifics. In my own medical practice, patients usually return to see me following the 2-3 week Reflux Induction Diet with big smiles, saying that they feel much better … asking, “now what?” Some patients think that you can go from the Reflux Induction Diet back to eating anything they want, anytime, but nothing can be further from the truth. Once you start down the road of self-monitoring and dietary self-maintenance for reflux disease, you will have to always be responsible for what, how much, and when you eat.
In reality, after a few months of thoughtful and planned analytic eating, it becomes second nature. For example, I always order sauces and dressings on the side; I always ask, “Is this baked, grilled, or steamed, but not fried?” It is marvelous that one can eat out without problems. In its most elemental form, the Reflux Maintenance Diet is a low-fat, low-acid (not no-fat, no-acid) diet, with an emphasis on using fats as flavorings and on pH balancing foods and beverages.
Remember to pH-Balance
Sometimes people are surprised that there are ingredients such as orange juice in some of our recipes. Let me assure that a few ounces of orange juice does not cause reflux, and that orange juice used as a flavoring in a recipe is not a problem. In other words, as an ingredient in a pH-balanced recipe, orange juice is just fine. Here is another example of pH balancing: I used to snack on raisins all the time. I would eat two or three little boxes of raisins at a sitting, but by themselves raisins are acidic and not good for someone who has acid reflux, particularly LPR. There is, however, no problem eating raisins in Raisin Bran cereal with milk (preferably low-fat milk) or in oatmeal. Why? Because of pH balancing … the milk will buffer the acidity of the raisins as will oatmeal.
So how do you go from Induction to Maintenance? Without question at the beginning of the transition, the worst-for-reflux foods still have to be completely avoided, including carbonated and other acidified beverages, all citrus, chocolate, and fried food. You may want to look again at the chapter “Notoriously Bad Reflux Foods” on pages 55-64 of the book. And for sure, late-night eating remains strictly off-limits.
Use Tasty Fats as Flavorings and Avoid Your Trigger Foods
What about a sautéed dish? How about grilled fish with a lemon-butter-caper sauce? What about a glass of wine or a cocktail? The answer to these questions is in moderation and with some vigilance. But the moderation is crucial. Have the fish dried on a paper towel, and the sauce served on the side. Put one tablespoon of acidic sauce on the fish max. For alcohol, it’s one beer, one glass of wine, or one cocktail, and not every day or not late in the evening. One glass of orange juice with Sunday morning brunch. One teaspoon of butter or cheese. Each of these things are permissible, particularly within the context of a generally low-acid, low-fat dish or meal. But all the while, you must self monitor. If every time you have wine, your throat burns, beware!
Here’s the thing – there is no hard and fast one-size-fits-all formula. Our book gives guidance, but your trigger (“idiosyncratic”) foods have to be identified by you. I have patient for whom even a small amount of tomato or wine causes problems. Unfortunately, a doctor alone can not identify your idiosyncratic foods for you. It takes a good deal of trial and error.
Another example of smart maintenance eating: I love eggs. I buy Jumbo eggs, because the yolk (the fat in eggs) is the same size in the different sized eggs. That’s why I get the Jumbo eggs, much more egg white. I make myself omelets with one whole egg and two eggs with the yolks discarded. My omelets taste as good to me as regular three-egg omelets.
Is Barrett’s Esophagus Curable?
About two years ago, a medical colleague called, “Jamie, I have Barrett’s Esophagus; what should I do?” That was before the book had been published, and he lived far away so I could not monitor his progress via examinations here in New York. For many people, the throat, which can be examined by an otolaryngologist, is an excellent barometer for reflux disease, and it can easily be examined in the office.
Barrett’s Esophagus is a pre-cursor to esophageal cancer, and is thought to be irreversible, but I have seen Barrett’s go away on our low-acid, low-fat diet. Make no mistake about, I encouraged him to take his PPIs (e.g., Nexium, Prilosec, Prevacid, Protonix, Zegerid, Aciphex) twice a day (30-60 minutes before breakfast and dinner) with a third pill, an H2-antagonist like Zantac or Pepcid just before bed with a sip of water. And here’s what I told him about his diet:
“My friend for one year this is it: No Carbonated beverages. No fruit except for melons and bananas. No alcohol, chocolate, or fried food, and nothing out of a bottle or can, except water. ‘Eat close to the ground.’ Grains, cereals, fish, poultry, and vegetables should be the mainstay of your diet.”
A year later, I saw my colleague at a medical convention. He eagerly took me aside and with a big smile announced, “Guess who’s Barrett’s is gone? …MINE!”
So, how do you go from Induction to Maintenance? Slowly. Take a look at the recipes in the book. Look at some of the things we substitute for bad reflux foods. Prosciutto, for example, is a great substitute for bacon and other high-fat meat products. I often get a single slice of prosciutto (less than a ¼” thick), trim the fat, and cube it fine to add to soups, salads, and sauces. Lemon zest is a great substitute for lemon. It has the entire flavor and none of the acidity. Ginger, capers, olives, sesame seeds, rosemary, cilantro, basil, and parmesan cheese are some of my favorite flavorings. These are used as flavorings.
Here are a few more reminders and tips. Don’t exercise after eating; exercise on an empty stomach or have some antacids like Gaviscon before, if exercising makes you reflux. Beef is okay once a week, but not every day, and lean cuts are preferred. Try not to combine fatty foods at the same meal. When eating something acidic think about pH balancing. Orange juice is not quite as acidic when consumed with oatmeal, pancakes, egg whites, etc. (all non-acidic foods). Generally, low-fat products should be selected when it comes to dairy products, e.g. milk, ice cream, yogurts, and snack foods as well. Remember, The Reflux Maintenance Diet is less concerned about sugar and salt as some other diets. Obviously, if you have diabetes or hypertension you may have to restrict sugar and salt.
Here are other examples of my personal “good reflux practices.” For breakfast, the three best choices are cereals, oatmeal, and whole-grain low-fat bakery products. And remembering the concept of pH balancing, it’s okay to have fruit in your muffins or with your cereal. Try to have a similar lunch everyday. I like a salad with chicken, turkey, shrimp, mushrooms, and other vegetables. For dinner, the best choices are fish, poultry, vegetables, grains, rice, and tubers … with sauces on the side. Limit the amount of bad fat – Remember fats are flavorings! Last night, for example, I ordered endive salad with blue cheese and asked for the blue cheese on the side. The piece of blue cheese that came with the salad looked like 4 ounces of cheese. I took one spoonful and sent the rest back to the kitchen, enjoying my endive salad very much. For many people, learning trigger foods, fat moderation, and dietary restraint takes time. But over the long haul, low-fat and low-acid eating is the potential cure for your reflux disease. If you already have our book, the ball is in your court.
Bon Appétit! Dr. Jamie Koufman