Medicalization is defined as the process through which medical perspectives and treatment become increasingly influential and common in a society. The United States underwent intense medicalization in the latter half of the twentieth century and the process is continuing to gain momentum.

Many examples can be given. Shyness, which formerly required those possessing the characteristic to step out of their comfort zones and expand their horizons, is now known as "Social Anxiety Disorder” with "FDA approved” medical treatments.

A child or adult who daydreams or has difficulty sitting still for long periods of time is no longer encouraged to pursue those dreams or engage in activities that do not require periods of silent inactivity. Those individuals are said to have attention deficit disorder or attention deficit hyperactivity disorder and treated with the indicated medications.

Nearly every aspect of life and death in the United States has become medicalized. For example, one in every four babies is now born by Caesarian section. (The actual percentage in 2002, the last year for which statistics are available, was 26.1 %.)  Update:  By 2010 the U.S. Caesarian Section rate had reached 32.8 %.  At this point 1 out of 3 babies in the United States is delivered by Caesarian Section! 

It is extremely rare to find a child over two years of age that has not has not received a prescription for an antibiotic. The percentage of girls placed on medication for attention deficit disorder tripled during the 1990s and the percentage of boys on medication for the condition doubled.

More than three in four persons age forty-five and over report that they take prescription medications on a regular basis, and, on average, these people take 4 prescription medications per day.

The process of dying is highly medicalized. According to the 1992-1996 Medicare Current Beneficiary Survey, medical expenses during the last-year-of-life account for one fourth of all medical spending in the United States. Average medical expenditures during the last year of life are over five times those in prior years.

One of the most dramatic examples of medicalization is the emergence of the entity called gastroesophageal reflux disease, commonly abbreviated GERD. Over six billion dollars is spent on prescription medications to treat this condition. That does not include the cost of over-the-counter medications.

GERD did not exist prior to 1985. Prior to that time people experienced indigestion, heartburn, and reflux (stomach contents coming back up into the esophagus), but they were not said to have a disease. It was the conferring of disease status to those symptoms that brought them to the forefront of American medicine and led to a proliferation of drugs to treat the condition.

Most people do not realize that gastroesophageal reflux is a normal phenomenon. This is particularly apparent in infancy. Every mother knows the wisdom of placing a towel over her shoulder when burping her baby. Almost everyone has had the experience of food starting to come back up, particularly if they have overindulged in food and drink.

Heartburn and indigestion, on the other hand are not normal. They are warning signs that something is wrong with the digestive process. They are not, as is commonly assumed, indicators of excessive stomach acid production.

GERD is defined as the condition in which an abnormal amount of gastric juice refluxes into the esophagus. While there are instances in which an abnormal amount of acid is present in the stomach, these are relatively rare. Situations in which the amount of stomach acid and digestive enzymes present is inadequate to initiate proper digestion are far more common. Unfortunately, nearly everyone who experiences indigestion, heartburn, or reflux today is advised to take an acid blocking or acid neutralizing drug.

The use of stomach acid neutralizers is not new. An entire generation of American children grew up believing that relief was spelled R O L A I D S. Neither is indigestion. Many of us remember "Speedy Alka-Seltzer” and his jingle, "Plop, plop, fizz, fizz. Oh, what a relief it is!”

What is new is the emergence of potent agents called proton pump inhibitors. These agents are capable of completely blocking the body’s ability to produce stomach acid. The number of individuals using these drugs is astounding. It is also alarming, given what is known about achlorhydria, the medical term used to describe the body’s inability to manufacture adequate amounts of stomach acid.

Because animal studies had shown a significant increase in the incidence of certain cancers the drugs were introduced with great caution. They were to be used only as a last resort when all other possible means to correct a problem had been exhausted. It was even suggested that the ability to prescribe them should be limited to specialists in stomach and intestinal diseases.

I shall never forget a pharmaceutical representative advising me that the concerns were overstated and that proton pump inhibitors would be the treatment of choice for peptic ulcers and heartburn within five years. If anything, his prediction has been exceeded, for Prilosec is now available over-the-counter without a prescription. Despite warnings that the drugs should generally be discontinued after two to four weeks and should not be continued for longer than eight weeks under any circumstances, many people take them indefinitely. It is commonly said that these drugs have few side effects and are well tolerated in long-term use.

Evidence supporting the claim that proton pump inhibitors are safe when used over a period of years is lacking. Logic suggests that the ongoing use of these drugs will ultimately prove to be associated with a number of serious consequences, since achlorhydria, the condition in which the body is unable to produce stomach acid, and hypochlorhydria, low stomach acid, are known risk factors for many disease states.

There is no reasonable basis for assuming that the result of drug-induced achlorhydria or hypochlorhydria will differ substantially from that due to other causes. Anyone who chooses to use drugs such as Prilosec, Prevacid, Aciphex, and Nexium for extended periods should be aware of the potential long term risks. A review of the published medical literature reveals that a number of complications of long-term use have been noted. Unfortunately, the reports tend to be found in foreign or obscure journals and are not finding their way into mainstream United States publications.

The role of stomach acid in preparing minerals for optimum absorption and utilization has been recognized and accepted for many years. Proponents of the acid reducing drugs are now saying that stomach acid does not play a significant role in mineral absorption. A number of studies on acid blocking drugs suggest that mineral absorption is unaffected by their use.

Our historic understanding of the basic chemistry of mineral utilization may prove to be true, however. Iron deficiency is common in conditions of low stomach acid. This has been reported on drug-induced hypochlorhydria. A 1999 British article reported that the drugs increase osteoporosis risk. This may explain why a young woman I recently saw has severe osteoporosis. She had none of the usual risk factors for the condition, but she had been taking a proton pump inhibitor continuously for five years.

Since this article was originally published additional information on the risk of proton pump inhibitors and osteoporosis has emerged.  The risk is significant and increases over time.  After one year of continuous use individuals taking acid blocking drugs are 1.22 times more likely to experience a hip fracture.  The likelihood increases to 1.41 times after 2 years, 1.54 times after 3 years, and those who have been taking a drug for 4 years are 1.59 times more likely to have a hip fracture than non-users.

Animals given the drugs develop a type of cancer that is typically seen with achlorhydria but rarely seen in untreated animals. The fact that stomach biopsies in long-term drug users have shown a condition called atrophic gastritis is hardly reassuring. Atropic gastritis is a known risk factor for stomach and esophageal cancers. Since cancer typically appears decades after the onset of atrophic gastritis it is not surprising that a strong link to acid blocking drugs has not yet been proven.

Proof is emerging.  Since this article was written an "epidemic" of stomach polyps related to the use of acid blocking drugs has emerged.  While these were initially said to be universally benign (non-cancerous), pre-cancerous changes (dysplasia) are now being seen in some of the polyps.

Vitamin B-12 requires exposure to stomach acid for optimum absorption. It is well documented that long-term use of acid suppressing drugs leads to vitamin B-12 deficiencies. This can profoundly affect the production of red and white blood cells, the body’s ability to maintain safe levels of homocysteine, and inhibit the nervous system. In addition, lack of stomach acid impairs the digestion of protein and can lead to deficiencies in essential amino acids, the building blocks for growth and repair of cells and tissues throughout the body.

Stomach acid also plays an important role in protecting the body from invasion by disease causing organisms. Ongoing suppression of stomach acid has been shown to increase the risk of a wide variety of intestinal infections, especially for people over 65, immune compromised persons, sick patients with a reduced resistance and travelers to tropical areas. Pneumonia also occurs more commonly when stomach acid is suppressed.

Update - Complicatons of stomach acid suppression that have now been documented include:

• Development of B vitamin deficiencies
• Development of mineral deficiencies including calcium, magnesium, selenium, and iron
• Diminished protein digestion leading to hypoglycemic episodes and food allergies
• Diminished pancreatic function
• Overgrowth of bacteria and yeast in the body
• Reduced production of red and white blood cells
• Increased number of intestinal infections
• Increased incidence of pneumonia
• Appearance of atrophic gastritis

When confronted with the challenges of acid suppressive therapy the response of the medical community is that the benefits of providing heartburn relief clearly outweigh the potential risks of the pharmaceutical agents being used. If no alternative were available this might be true, but viable alternatives do exist for most people.

Reflux increases when the junction between the stomach and the esophagus fails to tighten properly. A muscle, called the lower esophageal sphincter, is designed to tighten reflexively in response to the presence of acid in the stomach. When the acid level is too low to trigger this reflex the small amount of acid that is in the stomach sloshes freely into the esophagus causing heartburn.

Ironically, it is a deficiency of stomach acid, not an excess, that causes the classical symptoms of what is called GERD. Using supplemental betaine, which the body uses to produce stomach acid, along with supplemental digestive enzymes will eliminate the symptoms and restore normal digestive function in most individuals. Betaine and digestive enzymes are combined in some products such as Primagest.

Other measures are also helpful in controlling GERD symptoms. Juicing one quarter lemon in water and drinking it 20 minutes before a meal will stimulate the production of digestive juices. Dietary considerations include eating small meals, increasing the percentage of raw or lightly steamed items in each meal, and eating the evening meal at least three hours before bedtime. Avoiding hot beverages and acidic foods that can burn the esophagus, salty foods, milk, alcohol, and chocolate is also helpful.

Do not forget that while the stomach is designed to contain acid the remainder of the body is designed to be slightly alkaline. Following the alkalinizing regimen detailed in the June 2003 issue will help maintain alkaline saliva, which is needed to protect and soothe the esophagus.

Normalization, not medicalization, should be the goal whenever symptoms appear. Correcting the root cause that is causing the symptom is always preferable to simply covering it up. GERD is an excellent example of this principle. Normalizing digestion will eliminate the symptom in the short term and promote long-term wellness. Medicalizing the symptom will bring immediate relief, but at the price of creating more serious health challenges in the future.