Hi everyone. I'm Dr. Pracha Eamranond, chief medical officer at Doctorpedia.
And today I have the pleasure of presenting Dr. Jonathan Aviv.
He is clinical director of the Voice and Swallowing Center with ENT and
Allergy Associates. He's also clinical professor of otolaryngology
at the Icahn Mount Mount Sinai School of Medicine. Welcome John.
Great to be here. Thank you for the opportunity.
So it was lovely actually having dinner with you,
and I learned so much talking to you, there's so much to cover. But,
just to give our audience some background,
can you tell us a little bit about yourself?
Sure. I'm a board certified ear, nose and throat doctor.
I did specialized training in something called microvascular head and neck
reconstruction.
What that means is if someone is unfortunate to have head and neck cancer,
I would take out the cancer and then reconstruct the
patient's jaw or throat or tongue using tissues from other parts
of the body.
So I would fashion a forearm to make a new tongue.
I would take part of the iliac crest, the hip bone, to make a new jaw.
And that's how I got started in the entire field of
ENT.
But one of the amazing things about this was that one of the biggest problems
people had after these big reconstructive procedures was being
able to swallow normally. And what we found is,
almost all of these people had severe acid reflux disease that was
swelling the tissues in their throat,
and that contributed to their swallowing problem.
Right. Right. So thank you for that. Reconstructive surgery,
I'm sure for a lot of our audience members, is somewhat scary and ominous,
what you just described. I will say I did a ear, nose,
throat rotation when I was in medical school and I wanted to be an ENT surgeon,
but the cards didn't have it in for me. Now, as a primary care doc,
I'm referring my patients with reflux and other problems obviously,
to folks like yourself, but the whole, the flap surgeries are so amazing,
what you do.
And even more amazing is actually the authorship skills that
Dr Aviv has and looking at the books that you've published,
and thank you very much for giving me those books. So --
My pleasure.
So John has
written The Acid Watcher Diet, which is very popular and has its own,
a sizable Facebook following.
And he recently came out with The Acid Watcher Cookbook.
So John, can you just tell us how this even came to be?
What got you interested in all this in the first place?
So as we just talked about reconstruction in the head and neck,
I was director of head and neck surgery at Columbia University in the nineties.
And long time ago, however, in the middle of the night, one night,
probably one of the nights after I finally got home,
I woke up in the middle of the night, suddenly choking. No air.
And when that happens, you think that's it. Life's over.
But we also know, we're trained, that when the airway closes,
if you do something called a closed lip sniff, you close your lips,
sniffing through your nose, and it actually tells the brain to open the airway.
So I figured that out. Well, I was very frightened.
How did this happen? And for almost ten years,
I went to my doctors and they said, "Oh, it's allergies.
Take some antihistamines." And this literally went on for years and years,
only to discover that this was all from acid reflux disease.
So that got me interested, it was a very personal thing, happened to me.
And when people come in and I say, "How can I help you?" And they say,
"I woke up choking." Now we call it a jump-up,
cause in the middle of the night you're literally jumping up.
So I can relate to that devastating symptom.
And it sort of inspired me to look at solutions other than
medications. Food based solutions, really,
to try and figure out something that affects 75 million
Americans and 1 billion people worldwide.
Okay. So definitely big topic. Now,
in reading your book, there's so many things to tell our audience.
And we like to think of reflux, some of us anyway,
as an important problem,
yet it doesn't get at that much play in the media sometimes,
just that term. But you have another term, influx. Can you tell us about that?
Yeah, so we're obsessed with acid reflux. That's the idea of --
the stomach is literally right here. If you take your pinky and thumb,
put your thumb right in the middle of your collarbone and drop your pinky down,
that's essentially where the esophagus ends. And if you make a fist,
that's where your stomach begins. So it's not down here, it's up here. Okay.
So it's not a big distance.
So heartburn is when acid in the stomach comes up and you can sometimes feel
symptoms. The way ear, nose and throat doctors got involved, really,
is that the acid, as you can see, short distance, comes up and can, say,
literally burn the throat. So what happens when the throat is burned?
You're hoarse, you cough, you have nasal drip.
And the question is, why, why, why, why, why?
And I'm just gonna give your audience 35 seconds
of science and it'll explain everything and it'll explain the acid influx
concept.
Yeah. But before you start, I'm so excited.
Because I was seeing a patient today virtually with reflux and you've really
reformatted how I even conceive reflux. So thank you for that. Go for it.
Great. And most of this is readily applicable to the patients we see,
whether it's physicians, audience members, lay people at home,
virtually working now or soon hopefully actually working in their offices.
And what is it? There's an enzyme in the stomach called pepsin, PEPSIN.
And what pepsin does is it breaks down food once it's in the stomach.
It gets activated, below pH four.
If you remember from high school chemistry, pH seven is neutral.
The smaller the number, the greater the acidity, the higher the number,
the greater its alkalinity. So pepsin, which breaks down food,
gets activated below pH four. The stomach is pH two.
It's very acidic. But about 10 years ago,
researchers in the UK found that pepsin can float.
It can climb right up into the chest and it could sit in the vocal cords,
in the sinuses, in the teeth, in the middle ear spaces.
And when you eat or drink something less than pH four,
what you eat starts eating you, meaning causing swelling.
So what does that mean?
That means that if you're eating or drinking the handful of foods,
it's only six, less than pH four,
you're gonna activate pepsin and have symptoms.
What happens if you have pepsin in the nose? You'll feel nasal congestion.
You have it in the sinuses? Sinus pressure and drip. In the throat. Again,
you're gonna sound like this. And occasionally you will have chest symptoms,
chest pain, chest burning. So,
we can talk about these six foods, which I call the dirty half dozen.
[Pracha laughs] And it then impacts,
and you begin to see very quickly without having tremendous experience in
science or chemistry,
how certain things we're eating and drinking can really cause huge numbers of
symptoms.
Thank you for that, John.
Now I'm particularly excited because we've spent the last
several months actually working with our colleagues across the Atlantic,
in the UK, and talking about mental health,
but now I look forward to looking at this webcast and learning, relearning,
about the dirty half dozen and pepsin to see how I can actually
educate my patients, and this is exciting, not just to talk amongst doctors,
but how do we convey this to patients so that they understand it too? So,
along those lines,
can you break down for us the myths about reflux that you've written about so
extensively?
Yes.
What we see when people come and ask us to help them,
a lot of the patients that come to see ear,
nose and throat doctors don't have heartburn. In fact, it's less than 10%.
So what do they come in with? Cough, throat clearing,
you'll be in an audience, you're about to start your next interview,
start your next lecture. And in the days before Zoom,
when the mute was off, what did you hear?
Everyone's going [Jonathan clears throat] The first thought is, oh my God,
your sinuses are acting up, the allergies are, it was 20 degrees last night,
it's 80 degrees today, you're gonna have a problem. Well,
actually that's not what's happening.
We produce one to two liters a day of mucus from our nose and sinus.
If you're swollen in the bottom of your throat,
it's sitting there like backed up plumbing, you're gonna clear that.
And most of the time that's coming from either acid in this way or up this way,
swelling this tiny little area.
And so that's how the myths began.
And I'll start with a simple thing. People, I say to people,
"You have acid reflux." They say "Oh, I know, I know, I read. No coffee." Why?
Coffee, they say, "Well, coffee's very acidic." Coffee's not acidic.
I've tested the pH of coffee. It's six. All right.
And we just talked about pepsin in four.
So coffee and chocolate have a compound in there called methylxanthine.
Methylxanthine loosens the lower esophageal muscle and
increases acid production by the stomach. It's not acidic.
So if heartburn is not your symptom and you're coming in with what I call,
I don't even know how to spell this, the haching, the hach, right?
You come in with the hach, no coffee, why no coffee?
If you don't have heartburn, and if we know, say,
what it looks like down here from an endoscopy or previous exam,
have your coffee. I'd say cut yourself off around noon,
because it can loosen the lower esophageal muscle for hours and hours.
So that the... I love the concept of a post dinner
cappuccino or espresso, but really you're gonna be up for hours,
cause this is just gonna be sitting there loose. So
that's one of the big myths. Coffee, chocolate, they're not acidic.
So this idea of low acid coffee, I'm a little confused what they mean.
It's pH six, how much lower are we gonna go? So I don't get that.
Another big one, and people get very, very passionate about this,
as if I'm not passionate about it, and that is vinegar.
Apple cider vinegar. You have heartburn, drink apple cider vinegar.
You have throat burn, drink apple cider vinegar.
And just this morning I saw someone. [Whispers] They were like this.
It was the Don Corleone whisper. Right?
And, "Do you have heartburn?" "No heartburn,
no heartburn." "What do you eat or drink?" And this is an important question.
What do you eat or drink? You've been a patient, I've been a patient,
you've been a patient... Is anyone ever asking you what you eat or drink?
Do you ever even tell your doctors what you eat or drink?
If that's the one take home message I can give to an audience is,
tell your doctors what you eat or drink. And as physicians,
please ask your patients what they eat and drink. So let's get to it.
I say, "Well, how do you start your day?" "Every morning,
I have a glass of apple cider vinegar." I said, "Keep talking,
what else you got?" "Some orange juice." Okay. What else you got?
"Vinegar on my salads." Okay. So I took a look,
and the vocal cords, instead of being thin violin strings,
looked like sausages right off the barbecue. So when it's swollen,
they can't vibrate. So when they're stiff, you get this rough voice.
I'm not gonna continue cause I won't be able to carry on,
but that's one of the great myths. Vinegar,
pH two to three, releases tissue bound pepsin,
causes a massive inflammatory response. And what we know,
it causes a body wide inflammatory response, not just a local response.
So the treatment options actually not only help the local issue,
but you get a reduction in inflammation throughout the body.
So our patients with irritable bowel, our patients with Crohn's,
when they shift to a low acid, high fiber diet,
if they're allowed a high fiber piece, inflammation gets reduced everywhere.
Alrighty. That was a lot to take in, so many pearls there. I want --
we're running out of time, so I wanted to just ask a final question from you,
which we haven't really talked about.
So Dr. Aviv has taught us so many things about our health.
What have you learned throughout your journey? I mean,
you've had so many experiences writing books,
educating, even
being on Dr. Oz and giving your input to the whole world.
What have you learned throughout all of these journeys that you've had?
Often, it's
the simplest things that give us the clue, how to help people.
Very often people come in so anxious, years and years of symptoms,
you know that from all your clinical experience,
and what we try and get people to do is, tell me what's bothering you.
Say I have a hiatal hernia. That means part of my stomach's above the diaphragm.
Okay, but what's hurting you? If you can tell us what's hurting you,
what's bothering you, that's step one. And step two is,
as we just alluded to, tell me what you're eating and drinking.
And to the physicians out there, I know it sounds extremely simple,
but in answer to your question,
ask them what they're eating and drinking.
If we can get that two way street going,
I think we'll be able to help even more people.
So John, you've told us so
much about your passion for acid reflux.
Can you tell us a personal story of how this impacted you?
Yes.
When my current healthy 18 year old
daughter was seven or eight days old,
she had a massive reflux event.
I didn't know what it was at the time, but she had a respiratory arrest.
Oh my goodness.
She turned blue. They called 911.
They rushed her to the pediatric emergency room at Weill Cornell.
Yeah. That's gotta be scary.
And I was out for a run at the time because it was seven, eight days,
I figured I could leave for a little bit and I get this,
the only time in my life I got a 911 page at the time, and I rushed over.
And by that time they did not need to intubate her. She was okay.
She coughed up whatever she aspirated.
And for the next almost year, while she was quietly breathing,
she sounded like a Harley Davidson.
Multiple courses of antibiotics, a chest x-ray for presumed bronchiolitis.
Right around that time, Dana Thompson,
who was director of pediatric otolaryngology at the Mayo Clinic in Minnesota,
in Rochester, Minnesota,
invited me to be visiting professor for two or three days to talk about acid
reflux, and our take on it. It was a great two days,
incredible department. And as I was leaving to go back home,
I said, "Dana, my daughter Nikki sounds like a Harley. What
could be going on?" And she looks at me like I had either 10
heads or zero heads. [Pracha laughs] And said,
"You've been talking to us for two days about reflux.
Your own daughter has reflux and you can't even see it?" I was like,
"Oh my." So she writes down a prescription for me, how much does she weigh,
she did the calculation. So when I got back to New York,
I spoke to our pediatrician and I said,
"Can we try ranitidine?" Now they've taken ranitidine off the market, but then,
okay. [Pracha laughs] It was the H2 blocker of choice. She said,
"Let me run it by the director of Peds GI at Columbia." She said,
"I'm willing to learn something new."
This is 18 years ago, 2003.
The director of Peds GI said, "Great, try it," within four weeks,
that Harley Davidson sound was gone.
And of course, my daughter says, "Oh, I remember that." [Pracha laughs] Okay.
But
it just shows that, as clinicians, when
it hits home, our objectivity may not quite be there.
Some of the emotional parts, which is so necessary,
is how we manage these potential catastrophes,
gets lost.
And to come back to what we know and what we would
instantly address today,
maybe as all these symptoms were starting years ago,
before it became common knowledge,
was something that was really disturbing.
And I couldn't figure out.
Right. Thanks, John, for sharing that with us. So much to learn from this guy.
I have to say,
this afternoon I'm teaching at Harvard and what I love about talking to doctors
like Dr. Aviv and working with students is that there's so much to learn.
And I'm hopeful that this forum will allow us to actually educate others,
educate ourselves, and thank you for that.
Thank you.