A few months ago my training was nearly derailed by a period of severe acid reflux. It took me a while to figure out what it was, since the main symptom was chest pain during my runs. Of course I first became totally paranoid and took myself off to the GP to have my heart checked out.
An ECG and several blood tests later it was confirmed that my ticker was strong and healthy, but I still did not have any answers for the pain that was steadily growing stronger during my runs – especially my hard running sessions.
It was only after a weekend of red wine and fatty foods, when the more classic symptoms of heartburn and trouble sleeping in any position other than on my left side joined in, that the penny dropped. Since then, I have done lots of research and experimenting and have finally found a recipe for treating acid reflux that works for me.
In this article:
- What is acid reflux?
- Symptoms associated with reflux
- What causes acid reflux during running?
- Dietary factors that can cause reflux
- Other factors contributing to reflux
- Treatment for acid reflux in runners
What is acid reflux?
Acid reflux is when the contents of the stomach (acid + food etc.) moves up from the stomach into the oesophagus. This happens in all healthy people. It is only considered as a disease or problem when exposure of the oesophagus to gastric acids exceeds normal limits, occurs at night and is not related to meals.
Symptoms associated with reflux
I always thought that reflux had to be associated with heartburn (and old men!), but that’s not the case for everyone and certainly wasn’t for me.
Some of the symptoms include:
- A burning sensation radiating up from the sternum, commonly referred to as heartburn.
- A dry cough (I’ve had this for a couple of years now and hadn’t realised what it was.)
- Erosion of your teeth
- Irritation of the oesophagus, causing it to spasm (which may explain the chest pain that I’d experienced while running)
- Irregular heartbeat during sport – this is likely due to irritation of a nerve that runs very close to the oesophagus.(8)
- Increased asthma symptoms, due to the acid irritating the upper airways.
What causes acid reflux during running?
Most reflux symptoms during exercise occur during hard or very long sessions. The research suggests that you are a lot less likely to suffer reflux during mild or moderate exercise.
Decreased blood flow to the gut and stomach: Exercise can cause up to an 80% decrease in blood flow to your digestive system. This is mostly due to the brain shunting the blood to the exercising muscles, but may also be worsened by dehydration. This means that digestion will slow down dramatically and food will linger for longer in the stomach. (1,5)
Intra-abdominal pressure: The lower oesophageal sphincter works as a valve between the oesophagus and the stomach. It lies at the level of the diaphragm. While the pressure in your chest cavity is higher than the pressure in your abdominal cavity, it stops food from coming back up into the oesophagus. Exercise can increase your intra-abdominal pressure which can lead to the valve failing and reflux to occur. (4,5)
Research has also shown that the oesophagus’ contractions becomes weaker and thus less effective in moving food down towards the stomach during exercise. The valve between the oesophagus and the stomach also tends to relax more often and for longer periods during exercise.(1,5)
Dietary factors that can cause reflux
Some of the foods or eating habits that may contribute to increased acid reflux include:
- Eating within 60 minutes before exercise.
- Eating large meals in general or eating late at night.
- Eating solid food, protein or fat before exercise.
- Fatty foods in general: Some studies have indicated high fat foods to cause reflux symptoms while others have found it to have no effect. I find that it only affects me if I eat very fatty food at night (like lamb chops). I seem to be OK if I have it during the day.
- Eating spicy foods, chocolate, mint or tomatoes.
- Drinking orange juice, coffee and carbohydrate/sugary drinks.
- All types of alcohol has been found to increase reflux symptoms, but white wine is apparently worse than red wine or beer.(6)
- Eating fibre-rich food during physical activity can increase reflux (stomach takes longer to empty) while having a diet generally high in fibre may decrease the symptoms.
- Exercising after a carbohydrate drink makes reflux episodes last longer than after water ingestion.
- Dehydration also increases reflux, so make sure that you are well hydrated before you start training.
Other factors contributing to reflux
- Using NSAIDS or anti-inflammatory drugs has been associated with a threefold increase in upper gastro-intestinal complaints in athletes.
- Being overweight or obese
- Sleeping on your right side.
Treatment for acid reflux in runners
There are 3 steps that I would suggest you follow to treat your reflux.
Step 1: Confirm your diagnosis
Make sure it truly is reflux and nothing more serious. Book an appointment with your GP and make a detailed list of all your symptoms before you see them. This will also give you the opportunity to discuss what medications you can take for the condition as you will likely have to use something during the acute stages.
Step 2: Acute management
If, like me, you took a while to figure out what was going on, you’ll likely have a very sensitive and irritated digestive system by the time you start treatment. The biggest mistake that I made at the beginning was to not stick to a strict diet for a long enough period. I would take some medication for about 3 days while eating and drinking all the right things, feel better, revert back to bad eating habits and then everything would flare up again despite using the medication.
After this happened for the third time, I finally realised that I was being stupid. What I was doing was the equivalent of trying to run on an injured leg after just giving it a few days of rest. Most sports injuries takes about 6 weeks before you can get back to your pre-injury training and I decided to apply this method to treat my reflux. I had to give the cells in my oesophagus enough time to heal before I reintroduced potentially aggravating foods.
Please check with your GP before you use any medication.
So for 6 weeks I committed to a strict regime:
- I used PPI (proton pump inhibitor) medication for roughly 10 days while restricting my diet to low fat, bland foods. I stayed away from any refined carbs and sugar as well as coffee (this was difficult) and alcohol.
- Fruit used to be my snack of choice, but I’ve realised that I can only have it if I combine it with other food. It really plays havoc if I have it on an empty stomach.
- I had a habit of chewing gum during the day. I’m not sure why, but this is something that I still find can flare up my symptoms especially if I do it on an empty stomach.
- A big swig of Gaviscon about 15 minutes before a run kept symptoms at bay. I did not find the Gaviscon tablets as effective as the fluid.
- I would have a very small bowl of porridge about 1 hour before a run, as running on an empty stomach seemed to aggravate my reflux as much as running on a full one.
- One of my main problems was that, because I sometimes work until late at night, I would have a big meal around 22:00. I made a point of taking enough food to work with me so that I could have several small meals throughout the day and restricted the size of my late meal.
- I had to either sleep on my left side or elevated on a few pillows. The GP gave me a strange look when I said this to him, but I’ve recently found a research paper that actually shows I’m not crazy! The researchers found that the valve between the oesophagus and stomach relaxes for longer if you lie on your right side and thus increases reflux.(6) Research suggest that you should lift the head of the bed between 6 and 8 inches, but I was too lazy to do this and instead opted to live with a stiff neck for 6 weeks from being propped up on pillows. Gaviscon before bedtime also worked well for me.
Step 3: Switch to a long term management strategy
After 6 weeks of following the regime above, I found that I could introduce a relatively normal diet again. It’s amazing how quickly I now notice what foods or habits are contributing to my reflux.
I no longer need any medication unless I overdo things. I intermittently use Gaviscon before a run or sleeping, but stay away from PPI’s as these have been found to cause bone loss if you use them for a long period.(7)
The most important factor for me seems to be what I eat or drink at night. As long as I keep my evening meals small and stay away from wine, I have very few problems.
I still suffer if I have spicy meals and wine is pretty much out of the question. Full fat dairy and meat isn’t a problem, except for lamb. I can eat chocolate (massive smile) in moderation. Refined carbs like bread and pasta affect me badly, but rice appears to be OK. I found that my stomach is happy with milky coffee, especially if I combine it with a meal. Fruit has to be very ripe and preferably combined with yogurt.
My main concern now is that I am due to start marathon training in January, which means that I will have to eat or drink some form of carbohydrates during exercise. Research has, however, found that you can “train” your digestive system to tolerate food and drink during exercise so I’ll make sure to experiment from the start.(1)
- De Oliveira EP, Burini RC, Jeukendrup A. Gastrointestinal Complaints During Exercise: Prevalence, Etiology, and Nutritional Recommendations. Sports Med 2014;44(1):79-85. doi: 10.1007/s40279-014-0153-2
- Djärv T, Wikman A, Nordenstedt H, et al. Physical activity, obesity and gastroesophageal reflux disease in the general population. World Journal of Gastroenterology : WJG 2012;18(28):3710-14. doi: 10.3748/wjg.v18.i28.3710
- Festi D, Scaioli E, Baldi F, et al. Body weight, lifestyle, dietary habits and gastroesophageal reflux disease. World Journal of Gastroenterology : WJG 2009;15(14):1690-701. doi: 10.3748/wjg.15.1690
- Herregods TVK, van Hoeij FB, Oors JM, et al. Effect of Running on Gastroesophageal Reflux and Reflux Mechanisms. Am J Gastroenterol 2016;111(7):940-46. doi: 10.1038/ajg.2016.122
- Jozkow P, Wasko-Czopnik D, Medras M, et al. Gastroesophageal Reflux Disease and Physical Activity. Sports Med 2006;36(5):385-91. doi: 10.2165/00007256-200636050-00002
- Martinucci I, de Bortoli N, Savarino E, et al. Optimal treatment of laryngopharyngeal reflux disease. Therapeutic Advances in Chronic Disease 2013 doi: 10.1177/2040622313503485
- Ozdil K, Kahraman R, Sahin A, et al. Bone density in proton pump inhibitors users: a prospective study. Rheumatology International 2013;33(9):2255-60. doi: 10.1007/s00296-013-2709-0
- Swanson DR. Running, esophageal acid reflux, and atrial fibrillation: a chain of events linked by evidence from separate medical literatures. Medical hypotheses 2008;71(2):178-85. doi: 10.1016/j.mehy.2008.02.017
Maryke is an expert sports physiotherapist who provides online physio consultations using Skype. She is registered with the Chartered Society of Physiotherapy as well as the Health and Care Professions Council.