The lowest dose possible

Medication is sometimes necessary, sometimes not. It’s worth finding out if lifestyle changes can lessen your medication burden. Find out why with a specific example from the news this week (PPIs and dementia risk) below.

A foundational pillar of health, a principle regarding pharmaceutical medications, states it’s best to be on the lowest dose possible of your medicines for the least amount of time.

This is not a principle that is lost in mainstream medicine. On the contrary, it is deeply embedded in standard thinking. I would say doctors and pharmaceutical representatives would absolutely agree with this principle, it’s just not their priority to promote it most of the time. They often leave it up to the patient and their advocates to take the initiative with it.

This is such an important principle because drugs have undesirable effects, to put it mildly. From a PubMed review article from 2014: “Our prescription drugs are the third leading cause of death after heart disease and cancer in the United States and Europe. Around half of those who die have taken their drugs correctly; the other half die because of errors, such as too high a dose or use of a drug despite contraindications.”

Considering this, the aforementioned principle could be expanded to say, “It is best to be on the lowest dose possible of your medicines for the least amount of time.… and only as a last resort.”

Medical educators tell young physicians to use pharmaceutical agents only after self-care and lifestyle changes have been exhausted, of course. The problem is the entire curriculum is filled with describing the physiologic and pathological aspects of disease and the pharmaceutical options. We can again assume that the pre-prescription initiative to research and explore self-care efforts is left to the patient and their advocates.

The power of self-care

Let me advocate for lifestyle changes and self-care.

I. Self-care starts with realizing its great potential. Lifestyle changes are powerful, both for the strengthening of the body and in the ability to minimize drug exposure.

II. Self-care has unintended consequences just like medication does- the collateral benefit from proper diet, rest, and hydration goes well beyond what we often are identifying as the target.

III. There is a community of people that realize the body speaks to us, albeit in its own language, and they try to find the clues to decipher it.

IV. They look for the message in a symptom.

V. They would never say, “I take a pill so I can do whatever I want.” 

VI. Even if they’re on a medicine they still try to align with healthy habits that could have an impact.

Gastroesophageal Reflux (GERD)

We can develop this idea further by placing a spotlight on acid reflux or heartburn (Gerd): a common condition that is often greatly influenced by food choices. The drugs to treat it have an under-represented elevated level of toxicity, which has the latest installment in the news this week. I’m talking about the proton pump inhibitor class of medicines (PPIs)- omeprazole, pantoprazole, etc.

PPIs are effective at relieving chronic symptoms from Gerd and related disorders but their chronic use comes with risk. Continuous risk of PPIs increase the rates of certain illnesses:

  • pneumonia and C. Diff. colitis 
  • hip fractures
  • certain vitamin and mineral deficiencies
  • gastric cancer
  • kidney disease
  • and dementia. 

That last one has been debated for years but a new study in the news this week shows that the risk for developing dementia increases by 33% if a person has been on a PPI for more than four years. People are often on these medications for years. And dementia is far too common (1/3 of people over 85).

You can see why the principle I highlight above is more relevant than ever.

It’s important to say that people with certain medical conditions like severe esophagitis, eosinophilic esophagitis, Barrett’s esophagus, esophageal strictures, or idiopathic pulmonary fibrosis should not take the decision lightly to stop one of these medicines. This should be done with a doctor.

However, there is plenty of low-lying fruit here. PPIs are overused. Even with a serious condition, a lifestyle change may help reduce exposure by enabling a dose reduction. For people on long-term PPIs without a serious condition, it’s a no-brainer to review lifestyle changes because there is a good chance you can get off these medications altogether. I’ve seen it again and again. All you need is an appetite for self-care.

Lifestyle changes with GERD

Have a look at my patient lifestyle handout related to Gerd. Focus on my fourth point — foods that trigger and foods that alleviate Gerd.

  1. Eating habits: slow is best! Mouth closed while chewing; try to get to 20-30 bites, try taking it on as a Mindfulness practice. Chewing like this improves digestion. Please don’t underestimate this step. It’s a big one that we didn’t spend much time on today. It helps you eat less and improves digestion. Smaller portions by themselves decrease the likelihood of Gerd.
  2. Reflux or Gerd can become noticeable at night due to an increase in mechanical stress from lying down! Stop eating several hours before bedtime. Raising the head of the bed slightly if lying down triggers significant symptoms is worth a try.
  3. NSAIDS, and prednisone are two meds that can cause reflux. Certain antibiotics too.
  4. See the list of Gerd foods below. Gerd foods don’t need to be eliminated, just limited or not stacked with other foods that can cause Gerd.

Gerd foods to be aware of, limit, or in some cases avoid:

Any coffee even decaf, any caffeine, alcohol, tobacco, Onions/ garlic, spicy foods, Tomato-based sauces, Citrus fruits and juices, chocolate, Peppermint/ other mint, Carbonated beverages, Cheese/dairy, fatty meats, fried food, fast food, processed snacks, Chili powder and pepper (White, Black and Cayenne).

Foods can help diminish Gerd too! Look at this list of foods that calm Gerd:

Big two: almonds, apples (including a swig of apple cider vinegar every am); also bananas, melons, cauliflower, fennel, nuts, celery, cucumbers, lettuce, watermelon, broth-based soups, herbal tea, and high-fiber foods such as whole grains, oatmeal, brown rice, root vegetables, carrots, beets, green vegetables, broccoli, and green beans. Cooked veggies are best. If any of these don’t cause you trouble for any other reason you could try them.

For more information have a peek here:

It’s a great integrative Gerd handout from the university of Wisconsin family medicine department. It repeats and elaborates much of the above but has some other pointers, like supplements.

Take good care! In this case, as in care about what you feed you physical instrument. It matters!