Acid Reflux, Chic Gastric Ailment, Replaces the Ulcer-Ask Gandolfini

The thing about the men in gray flannel suits, who came home

from World War II and got married and bought a house in Great Neck with its

very own fallout shelter, who lunched on Dagwoods and napped all weekend, who

feared only the boss and the communists: They all had ulcers.

Ah, the great American ulcer-“the little man living in my

stomach,” said Edward G. Robinson as the cigar-chomping insurance investigator

in Billy Wilder’s1944film, Double

Indemnity . Ulcers were all the rage among the high-powered neurotic set not

so long ago-the Marx Brothers made a cartoon promotional film for The Saturday Evening Post (premier

magazine of the ulcer sufferer) called Showdown

at Ulcer Gulch ; James Gleason played a stressed-out newspaper editor with a

hole in his stomach in Meet John Doe ;

Woody Allen’s character had an ulcer in Sleeper .

Then, in 1983, Barry Marshall made an amazing discovery. Contrary to medical

opinion of the time, ulcers are caused not by stress, not by hoagies, not even

by the Russians; they’re caused by bacteria called Helicobacter pylori . Suddenly, they were curable with simple

antibiotics. Just as suddenly, they became passé. Who gets ulcers anymore? In a

recent article in the Annals of Internal

Medicine , Dr. Martin Blaser, chairman of the department of medicine at New

York University, writes: “The discovery of H.

pylori and its relationship with peptic ulcer disease has led to a new

era.” The ulcer went the way of afternoon highballs, newsreels, Sputnik and

fin-tailed convertibles.

But now, the children of the ulcer age are claiming a

digestive grievance of their own. Acid reflux, an ailment caused by the back-up

of stomach acids in the throat, is becoming the ulcer of the New Age. And just

as the mere mention of ulcers conjures images from the mid–20th century,

someday acid reflux will do the same for the early 21st: The stressed-out

dot-commer, the harassed defender of the Clinton family, the edgy day

trader-all of them reaching for brand-name capsules to relieve the sour, verklempt feeling in the throat.

Heartburn and acid reflux are the digestive epidemics of the early 21st century.  Heartburn affects one in five Americans.

Twenty-one million Americans get acid reflux, a heartburn-related disorder that

wasn’t part of the lay person’s lexicon even a decade ago. Americans spend

billions a year on treatment-$4.2 billion on the brand-name drug Prilosec,

which treats acid reflux. Sales of Prilosec are up 34 percent from two years

ago. Now the makers of Prilosec are “developing data for use of Prilosec in

kids,” according to Jim Coyne, a spokesman for AstraZeneca, makers of Prilosec.

And AstraZeneca just got F.D.A. approval for a new drug called Nexium, an

isomer of Prilosec that it hopes will do even better.

In a way, this frenzy is nothing new. Urbane observers of

the human condition generally are always in the throes of some gastric malady

or other. The fin-de-siècle

existentialists-Dostoyevsky, Kierkegaard, Nietzsche-started calling that

not-so-fresh feeling you get when you stare into the void and realize all

existence is absurd “nausea.” Sartre later named a novel after it. Nausea is full of pithy little episodes

like the following: A waitress in a café asks the narrator, “‘What will you

have, Monsieur Antoine?’

“Then the Nausea seized me, I dropped to a seat, I no longer

knew where I was … I wanted to vomit.”

You think that’s bad, nausea boy? Try watching your stock

options turn into toilet paper. You can feel the acid creeping up your throat,

making it tighter and tighter until you think you’ve swallowed a golf ball.

Your well-modulated baritone suddenly bears a distinct resemblance to Jack

Kemp’s scratchy rasp.

Yes, this latest fin

de siècle has its own special nausea: “I think a lot of what was termed

‘ulcer disease’ in the past really is now recognized to be reflux,” said Dr.

David Peura, a physician on the board of the National Heartburn Alliance. “It’s

definitely going up.”

Acid reflux begins when

the valve that lets food into your stomach and keeps acid from washing back

into your throat-the lower esophageal sphincter, or L.E.S.-relaxes too much.

Food and acid refluxes, scalding the esophageal lining. Over time, this causes

a condition called Barrett’s esophagus, an abnormal lining in the throat.

Anything that involves swallowing air, reclining too much or

putting too much pressure on the chest contributes to L.E.S. dysfunction-eating

too much, eating too fast, eating too late at night, not exercising, working

sweatshop hours, wearing tight clothes, being overweight or pregnant. And foods

that contain acid, or take a lot of acid to digest, can be brutal: chocolate,

garlic, orange juice, hot peppers, coffee, beer, aspirin. “Reflux makes more

sense than ulcer disease,” Dr. Peura said. “Since ulcers are caused by the

bacteria, not just by stress, the habits we have when we’re stressed promote

reflux more than ulcers. For instance, people who smoke increase their acid

production. Plus they swallow air. And fatty foods-it’s a double whammy. They

relax the sphincter muscle, but also delay the emptying of the stomach.”

In laymen’s terms, what the doctors are saying is that if

you are a hard-working urban professional in New York in 2001, just about

everything you do is liable to give you acid reflux. Dr. Bruce Yaffe, a

gastroenterologist based on the Upper East Side, calls it “the great New York

City digestive-tract conspiracy.” Dr. Yaffe was talking about his conspiracy

theory over breakfast in a restaurant near Gramercy Park. His meal included

orange juice and coffee, beverages with enough acid to take the paint off cars.

Isn’t that, like, poison? “Moderation is the key,” the doctor said with a grin.

More easily said than done, at least in this city. Take

portly porn king and general man-about-town Al Goldstein, publisher of Screw magazine. Mr. Goldstein rates

every restaurant in the city by the number of Tums it takes him to digest the

food. (Tums is an old-school way to relieve traditional heartburn. Acid-reflux

sufferers generally rely on prescription drugs.) “Katz’s is a three-Tum

heartburn,” he said. “And Il Mulino, that’s a great place. They got a spicy

pasta that is death-defying. One time I complained that they didn’t make it

spicy enough. They put so much pepper on it, I was destroyed for hours.” Talk

of acid reflux makes Mr. Goldstein philosophical: “I deserve heartburn,” he

said. “I’m an overeating fat pig. It’s God’s way of telling me I’m going to

die.”

The Sopranos Angle

Mr. Goldstein is not alone in his suffering. At the premiere

party for The Sopranos in late

February, a gaggle of boldface names admitted to being acid-reflux

victims.  “Oh, yeah, I get it,” said

Aida Turturro, who plays Janice Soprano in the show. “When I eat too late at

night, it feels terrible.” Benicio Del Toro, who spent practically all of Traffic scowling the scowl of a man with

acid in his throat, averred, “I get it occasionally. But not so much now that I

have some money. I can eat a lot of shrimp now.” James Gandolfini, who as Tony

Soprano spent last season’s finale battling some serious indigestion, has some

real-life gastric difficulties, too. Not that he wants to talk about it. “Yeah.

I get it,” he said. “So?”

Well, perhaps Mr. Gandolfini should consider spending a

minute or two in quiet reflection. City Council Speaker Peter Vallone, a

Mayoral hopeful (and thus a candidate for the mother of all acid reflux), was

asked about his health during a tribute to Julia Roberts sponsored by the

American Museum of the Moving Image on March 4. “I wake up every morning and

pray,” he said. “That’s the secret.” He paused for a moment. “But at night ….”

He declined to elaborate. Later on, George Clooney told The Observer , “I heard Bob Balaban gets it really bad.” Mr.

Balaban-an actor and the director of the ill-fated NBC drama, Deadline -confirmed Mr. Clooney’s

diagnosis. (Hey, those years playing a doctor on TV really paid off!) “I used

to suffer terribly,” Mr. Balaban said. “But it’s not work. Work never makes me

anxious.”

Even fitness fanatic Regis Philbin occasionally refluxes. On

one occasion, he was dining at Babbo on what chef-owner Mario Batali described

as “the spicy lamb sausage ragout.

“The next day,” Mr. Batali said, “on national TV, he was

pounding his chest. ‘Oh, spicy,’ he said.” Mr. Philbin didn’t return a call

through his publicist.

Mr. Batali offered his own explanation for the rise in

reflux. “I think probably what gives a rise to heartburn is the change in the

administration [in Washington],” he said. 

For his own part, he said, “You know what gives me heartburn? No taxis.”

For the discriminating acid-reflux sufferer, Mr. Batali suggested a remedy:

“What works for me is bitters and soda. I don’t know what it is, but whatever’s

in them gives immediate relief.” It sounds like a remedy better suited to the

highball, double-feature generation, but hey, if it works, why not?

Rising awareness of acid reflux has changed the way people

diagnose themselves. “Fewer people are coming in and saying, ‘I have an

ulcer,'” Dr. Peura said. “The perception is, they’re less frequent.” Tamara

Sussman, a fine-art photographic printer from the Upper West Side, agreed. “All

I know is that in high school, you know, I was always kind of a tense person,”

she said. “A schvitzer , you might

say.” Ms. Sussman worried about her worrying. “I thought I was going to give

myself an ulcer. Now, though, I tell [my boyfriend] I have a tummy-ache and he

tells me it’s heartburn.” Stephen Weitz, director of sales at Mediabistro.com,

said: “I used to think I had an ulcer. But I cleaned up my lifestyle, and it

took care of itself.” Likewise, Josh Friedman, who writes and designs the Web

page RPlumms.com, said, “In college I saw a gastroenterologist because my

stomach was always hurting. I thought it might be an ulcer, but they said,

‘No-just chill out.'” Of course, that’s what they told the ulcer sufferers of

old, and it turned out that it was the bacteria, not the stress, that was

killing them.

As it happens, some scientists equate the rise in acid

reflux to the decline of ulcer-causing H.

Pylori bacteria. In his article, Dr. Blaser examines these trends: “As H. pylori has been disappearing, peptic

ulcer disease … [has] predictably been decreasing. However, maladies such as

gastroesophageal reflux disease … have been dramatically and progressively

increasing ….” This mystery bothered scientists for a long time. Why should

acid reflux-or GERD, as the professionals call it-increase while ulcers

decline?

Thanks for Nothing

Finally, Dr. Blaser came up with an answer: H. pylori . “Preliminary studies already

suggest that the presence of H. pylori

may protect against [GERD].” In other words, the same bacteria that caused

ulcers probably prevented acid reflux. It’s something like a vaccine-small

exposure to a pathogen can build up the body’s resistance to certain diseases.

At the dawn of human existence, H. pylori probably colonized every stomach, Dr. Blaser believes.

Like an arranged marriage, humans and bacteria developed common interests over

time. Since the stomach is too acidic for almost any other form of life, the

bacteria got a lot of good real estate to themselves. People, meanwhile, got

insurance against debilitating gastric problems like acid reflux.

But why didn’t the bacteria bore holes in Stone Age

stomachs? Curiously, ulcers didn’t develop until fairly recently. For

centuries, H. pylori and H. sapiens actually lived in peace.

Then, something happened. No one quite knows what, but Dr. Blaser has a theory:

Public health improved. The food and water that once made Nietzsche and his

friends nauseous got cleaned up. People started having smaller families;

conditions weren’t as cramped. The number of discrete strains of H. pylori in the American stomach

decreased from an average of around three to an average of one. “It could be

the change in that ecology has an effect of clinical consequences,” Dr. Blaser

said. As H. pylori decreased around

the beginning of the 20th century, people who did acquire it often got it at a

later age. That’s why the generation that fought in World War II was so

susceptible to ulcers in the postwar years. “It’s like chicken pox,” Dr. Blaser

explained. “When a young child gets it, it’s a mild infection. But if someone

gets chicken pox in their 20’s, it’s much more severe. With H. pylori , an infection could lead to an

ulcer when you’re 30, 40 or 50.”

Baby boomers don’t get ulcers as much-but they are more

susceptible to acid reflux. According to Dr. Yaffe, the fallout’s just

beginning. “What we’re really seeing is that the Baby Boom generation … is in

the 35 to 50 range, when different things are happening in the body,” he said.

The first generation born without much exposure to H. pylori is finally coming into its own dyspepsia. The L.E.S.

stops working as efficiently as it did in young adulthood. The stomach takes

longer to empty than before. “A 45-year-old who eats a hamburger late at night

knows that he’s going to wake up in the middle of the night with reflux,” Dr.

Yaffe said. “Whereas, when he was 25, he could get away with that.”

In the future, Dr. Blaser says, “It may be that doctors will

examine a baby and figure out what its genotype is, and then pull an H. pylori strain from the shelf and say,

‘That’s what we’re going to give you to maximize your chance of health for the

rest of your life.'”

What then? Dr. Peura believes that acid reflux is on its way

out. Public-health trends, like everything else in popular culture, just don’t

have staying power anymore. “With the medications and such, we can take care of

this,” he said. Brand-name drugs and newer treatments are getting the job done.

Could it be, then, that modern medicine will allow us to eat

whatever we want without suffering the consequences? Not a chance. “There is a

waste-basket term we call ‘non-ulcer dyspepsia,'” Dr. Peura said. “Some people

we’re seeing don’t have ulcers, we can’t document they have [acid reflux]-they

probably just have a sensitive stomach. Many of us think it’s sort of a variation

of an irritable bowel or intestine.”

Dr. Blaser, for his part, says, “Something else might come

along and adapt to the stomach. And it may not be as benign as H. pylori .”

Dr. Blaser’s playing it safe. “All I can say is, I haven’t

eaten a hamburger in 25 years,” he said.

-Additional reporting by Deborah Netburn

Acid Reflux, Chic Gastric Ailment, Replaces the Ulcer-Ask Gandolfini