Exam Room Nutrition: Nutrition Education for Health Professionals

21 | Beyond Antacids: Nutrition Strategies to Manage Heartburn

November 21, 2023 Colleen Sloan, PA-C, RDN Episode 21
Exam Room Nutrition: Nutrition Education for Health Professionals
21 | Beyond Antacids: Nutrition Strategies to Manage Heartburn
Exam Room Nutrition Podcast
If you love the show, help me make it better. 🙌🏻
Starting at $3/month
Support
Show Notes Transcript

Join Colleen Sloan and Registered Dietitian Patricia Skolnik, as we unravel the mysteries of reflux, its triggers, and effective strategies to manage it. It is no longer appropriate to give your patient a list of 10-15 different foods they must avoid to manage their reflux. So how can we offer relief to our patients?

In today's episode, you'll not only have a clear understanding of general foods that MIGHT trigger or relieve reflux, but we also discuss the importance of using a symptom tracker, because not everyone needs to avoid the same foods.  And I think you're really going to enjoy some surprising lifestyle changes that you can suggest your patients implement. And you are really in for a treat today because we'll teach you a powerful exercise for stress relief that only takes 16 seconds. We'll also debunk some old wives tales regarding milk and its use in the treatment of reflux. You'll learn some red flags that should alert you to think of alternate diagnoses that you cannot miss. And make sure you stick around to the end for my Nutrition Notes segment, because I'm teaching you three strategies to prevent you from jumping to the diagnosis.

So, get comfy, listen in, and let's make our patients healthier, one exam room at a time.

Connect with us on Instagram! ============================= 

Exam Room Nutrition IG: ➡︎examroomnutrition

Patricia IG: ➡︎ @patriciaskolniknutrition
https://www.patriciaskolniknutrition.com/


Support the show

Connect with Colleen on Instagram! ======================

Exam Room Nutrition IG: ➡︎@examroomnutrition


*** Stay up-to-date on nutrition hot topics ***

Sign up for the Nutrition Wrap-Up Newsletter

Nutrition hot-topics and professional growth strategies delivered to your inbox each week.

This no-fluff blog simplifies nutrition for busy medical professionals.

Support the show!
If you love the show and want to help me make it even better, buy me a coffee to help me keep going! ☕️

Just as helpful is sharing the show with someone who'd love it and leaving us a 5 star rating. Thanks for your support!

Colleen:

Welcome back to the exam room nutrition podcast where each week, I'm answering common nutrition questions so that you can become a more competent, confident clinician. I'm your host, colleen Sloan. I'm a registered dietitian and pediatric PA. Ger is most commonly referred to as heartburn or reflux, and it's one of the most commonly diagnosed digestive disorders in the US, with a prevalence of about 20%. These typically manifests with symptoms of heartburn and regurgitation, but it can also present in an atypical fashion with extra esophageal symptoms such as chest pain, dental erosions, chronic cough, laryngitis or asthma. If you're treating patients who suffer with reflux, they may ask you what foods should I avoid? In today's episode, you'll not only have a clear understanding of reflux management, but we also discuss the importance of using a symptom tracker, because not everyone needs to avoid the same foods. We'll also discuss different foods that can help relieve the symptoms of reflux, and I think you're really going to enjoy some surprising lifestyle changes that you can suggest your patients implement. And you are really in for a treat today, because we'll teach you a powerful exercise for stress relief that only takes 16 seconds. We'll also debunk some old wives' tales regarding milk and its use in the treatment of reflux. You'll learn some red flags that should alert you to think of alternate diagnoses that you cannot miss. And make sure you stick around to the end for my nutrition notes segment, because I'm teaching you three strategies to prevent you from jumping to the diagnosis. So, to help me unpack all this and so much more, I am super excited to welcome back to the show Patricia Skolnick. Patricia is a registered dietitian of nearly 20 years and she's currently specializing in digestive health and disorders of the GI tract. You can find her on Instagram at patriciuskolnicknutrition. Patricia, I'm super happy to have you back. Welcome to the show.

Patricia:

Thank you so much for having me back. I'm very excited to be here.

Colleen:

I always love when you're here because you always bring the science and the facts and you clarify so many things for us. And reflux really is a very common complaint that patients will come to the office for. So I'm super excited to get into the nutrition with this, because I know a lot of patients will be asking my listeners hey, what foods help, what foods worsen it? So let's get into that. Are there certain foods that actually cause reflux or worsen reflux?

Patricia:

That's a great question. So there are some very common potentially triggering foods that people are often told to avoid when they have acid reflux. And this is going to be your typical like one page handout that you're going to get from your clinic that is going to have this list of foods. It's going to be the coffee, alcohol, chocolate, peppermint, carbonated beverages, spicy food and high fat meals. Those are the things that you're typically going to see on a list of foods that cause reflux and I actually would prefer to phrase it like they might trigger your reflux. And it might do so in a variety of ways, most of them in multiple ways actually, including weakening the lower esophageal sphincter, that sort of gateway, that doorway between the lower part of your esophagus and the stomach. They could increase stomach acid production, they could actually slow down the motility of the stomach, moving the food from the stomach to the small intestine. It could lower the intra-esophageal pH and or it could increase the abdominal thoracic pressure gradient, which is just a fancy way of saying that pressure from the stomach or the abdomen area, sort of like pushing up upwards into the esophagus. So, unfortunately, typical American diet consists of a lot of restaurant food, fast food and convenience food which are ripe for having high fat content, and so some people report acid reflux after eating citrus also, or onions and garlic and tomato-based foods, and so you might see those foods lumped into a list of foods to avoid if you have acid reflux. And I feel like it's important to point out that everybody has different food triggers for acid reflux, and avoiding any particular food should be based on symptoms. For example, if citrus foods do not cause or trigger acid reflux in somebody, then they do not necessarily need to be avoided.

Colleen:

I love that you pointed that out, because if you tell your clinician, hey, I feel like I have reflux and it's so easy to go, we're like, okay, here's a handout, here's all these foods that you shouldn't eat, but that's not true, and then you're just unnecessarily avoiding so many nutritious foods. So I love that you said what foods might trigger those reflux symptoms, because it's like you said, it's different for everybody. So do you think it's important for clinicians to specifically ask the patients which foods seem to worsen your symptoms, or maybe track their foods?

Patricia:

Absolutely. A symptom journal really goes a long way, I think, for some people to track their foods and their symptoms. They might start to put the pieces together just by simply writing it down and paying attention to it. They might see a pattern themselves, and even if they don't, their specialist clinician might, and so I really do think that documenting food intake and symptoms when there seems to be an issue can be very helpful to the team, and but I think it's also important to point out that for some people, like documenting food intake, can be a slippery slope into becoming obsessive, for lack of a better way to put it, and so for most people, I like to suggest just a very bare bones like what you ate, the time that you ate it and then, when you have symptoms, what those symptoms are and when they happened. I don't necessarily want people to focus too much on like amounts of foods or anything like that. If that is needed, then down the road, that is a decision to be made between the clinician and the patient.

Colleen:

Really helpful and I think that's the best and first place that all clinicians should start, before assuming that the patients need to avoid this list of 15 foods, is let's track your symptoms and come back to me. When do you think a good follow-up would be to review that list of foods and the symptom tracker?

Patricia:

I think most people might start to see patterns or such after like three to four weeks. Some people might notice that sooner, but I think to give yourself a solid month of what you're eating and what your symptoms are like and then coming back with, you know, a full month worth of data for lack of a better way to put it. For you as the clinician and your patient to review is a good place to start.

Colleen:

Love that Super, super helpful Right off the start. That's why I love having you here, Patricia. So let's talk about what foods are helpful now. Now we've kind of laid the foundation. Maybe we have our symptom tracker. We've known some foods that we're gonna try to avoid, just to see if there is an improvement in symptoms. Now are there certain foods that can help reflux symptoms and heal the esophagus and the stomach.

Patricia:

There are a couple, and the first thing I do want to mention is ginger, and for myself as a GI dietitian, ginger is great for a lot of different GI conditions, but I love to let people know about ginger chews, like Chewies, candies and also hard candies. They're an easy way to just grab a few and keep them with you, whether it's like in a bag, in a purse, even in your car. Ginger tea would work well also, as well as simply eating a small piece like a one inch by one inch piece of crystallized ginger. A lot of people might have that in their cabinet for like cooking and baking. Ginger helps to speed up gastric emptying a little, helping to reduce the volume of contents in your stomach and reducing that upward pressure that you might be feeling from a very full stomach and a full abdomen pushing up towards the esophagus. That might be contributing to acid reflux. And I do want to point out that when I say that ginger speeds up gastric emptying a little, I do mean a little. Please don't be afraid that you're going to experience this like dumping syndrome type of effect if you drink ginger tea or have a ginger candy and then otherwise generally the use of chewing gum or lozenges to help stimulate saliva production can help with acid reflux, and so the saliva that you produce will help to neutralize the acid that has already sort of refluxed up into the esophagus, which is the issue, right? The acid that refluxes up into the esophagus is what causes the irritation and the damage to the lining of that lower esophagus, and that is essentially what you're feeling with that sensation of heartburn, right? Other than that, there aren't any specific foods to help reflux. I think it is more important to identify the foods that might be triggering symptoms and then working to expand the diet as best you can, with you and your patient, to have that wide variety of foods, to have that sort of adequate fiber intake and balance of carbs, protein and fats and fruits and vegetables and that sort of thing. That would be the goal. There seems to be a connection between eating adequate fiber in your diet and having a lower incidence of acid reflux. At this point, it seems like more of a coincidence rather than there being an actual relationship between having an adequate or high fiber diet and having a lower incidence of reflux. Now, don't get me wrong. It is my goal for everybody to eat enough fiber, right, and I would love if everybody with acid reflux had it magically go away. But you might see recommendations for eating high fiber foods. I might caution against that, considering what symptoms your client might be having, because eating those high fiber foods that take longer to digest they might sit in the stomach longer and actually unfortunately might trigger acid reflux symptoms instead of helping them go away.

Colleen:

Very, very good point, and I know that you are the fiber queen. You came on a couple of weeks ago when we talked about constipation and fiber is king there. So I think this is an interesting caveat and I'm really glad that you brought that up, and we keep coming back to going over the symptom and food tracker with your patient. So that is definitely the first place that you guys need to be starting with is making sure your patients are tracking their symptoms and tracking the foods that might be triggering that. After that, let's just say, maybe citrus and tomatoes seem to make their reflux symptoms the worst, so at follow-up they're gonna come back, we realize this and then we tell them okay, let's avoid those foods. How long do we trial that elimination diet for to see if there's an improvement?

Patricia:

That's a really great question. I think there again, giving the body maybe six to eight weeks to sort of heal after reducing or eliminating those foods might be a good place to start and that might feel like a long time, especially if your patient really likes those foods. But I think it is important to recognize how long nutrition therapy can take. Unfortunately it takes a while to sort of heal from the inside out and also put in place some of the non-nutrition and lifestyle type things and creating new habits or breaking old habits, kind of like, at the same time. So if you have more than one thing that you're working on with your patient, you might wanna give them a solid six weeks to work on those things and really be good with avoiding those foods while also working on those other non-nutrition strategies.

Colleen:

Yeah, let's jump into that. That's a really nice segue into what other things that we could be doing that's outside of food avoidance that might help with their symptoms. So let's hear what those kind of lifestyle factors would be.

Patricia:

Thank you for asking, because how a person eats is just as important as what they eat. This is true not only for acid reflux and the sensation of heartburn, but a whole lot of GI conditions. The first couple of things might seem a little bit obvious, but I'm going to say them anyway because we might need to hear them. Sitting upright while you're eating, as opposed to being slouched or hunched over. If you are slouched on the couch, squishing your abdomen while you're eating, those things can be helpful. As well as taking time to not rush while you're eating. It is important for the mind-body connection to slow down and take your time, but then also give your body the time that it needs to adequately respond for all of those digestive triggers, from the brain to the mouth, to the stomach, to all of your intestinal organs, to go through their triggers to release their digestive juices appropriately. If you're just rushing through your meal in five minutes or less, then you're stressing out your GI and not giving adequate time to let it do what it's supposed to. Taking the use of straws to reduce the accidental swallowing of air that could fill the stomach and contribute to abdominal pressure. This is especially useful if regurgitation or bloating after the meal are symptoms that happen as well, as if somebody is known to have a hiatal hernia and that might be an underlying reason for the reflux. Then there is the suggestion to avoid eating a large meal two to three hours before bed. And that is just so that gravity is not working against us. If we fill our tummies and then we lay down flat, we are more likely to have the contents of our stomach sort of reflux back up towards the esophagus. Also, having a solid stress management plan in place will help to reduce the disruption of the gut-brain axis. One thing I like to share with pretty much anybody who will listen is the use of box breathing as a stress management tool. This is especially useful for GI patients when used before eating. It can also be used as part of a bedtime routine and pretty much at any time when acute stress is happening. For those of you who don't know, I'm just going to review it very quickly. Box breathing is simply breathing in for four counts, holding it for four counts, breathing out for four counts and then holding your lungs empty for the last four counts. I would suggest trying to do this for about a minute, especially if you are busy, busy, busy, like so much of us. You have a minute, trust me, you have a minute, but if you have five minutes that would be better, right? This helps to stimulate your vagus nerve and put your body into that rest and digest mode. Intentional movement, like taking a walk within 30 minutes after your meal, can also help to reduce GI symptoms of acid reflux. This helps, similar to ginger. It helps to speed up the gastric emptying just a little bit and move those stomach contents into the small intestine. Now for people with acid reflux symptoms at nighttime, there are a couple of things that you can try also, including sleeping on your left side to help reduce acid reflux. Here we are using gravity to our benefit because of the way the shape of the stomach is. If you sleep on your left side, it will help keep those stomach contents down into the pouch of the stomach facing the ground. Basically, if you sleep on your right side, there is more of a chance for it to be able to reflux back up into your esophagus. Then also, elevating the head of the bed about six inches can be helpful. Using blocks under the bed posts at the top of the bed is a little bit more effective than using wedge pillows. Then the last couple of things I want to mention is wearing clothes that fit well or might have some stretch to them. Tight fitting clothing can put a little bit extra pressure on the abdomen and can contribute to symptoms of acid reflux. Then, last but certainly not least, if you are a tobacco user or a smoker, smoking sensation can be very helpful in reducing acid reflux symptoms related to saliva production. Like I said, saliva production can help to neutralize acid that has already come up into the lower esophagus. Smoking reduces saliva production. You're blunting a natural way that you have to reduce your symptoms of acid reflux by smoking. It also lowers the pressure of the lower esophageal sphincter. It makes it a little bit weaker, enabling those stomach contents to come back up a little bit easier. Smoking also promotes coughing, which can also encourage acid reflux, just from what happens physically when you cough.

Colleen:

So powerful. Patricia, wow, I knew some of those, but some of those were new to me. Thank you for that. Because, reflux, you have to take a whole body approach to it. People forget that digestion actually starts in the mouth, so I love all of those suggestions. And, right, I want everyone to pause and we're actually going to do a box breathing exercise. We're going to make one box and everybody could benefit from just pausing where you are and breathing with us. So can you just lead us in one of the four breath holds so we can all practice.

Patricia:

I would be thrilled. Thank you so much for this idea. This is wonderful. Okay, so everybody settle down, settle in and just take a breath to sort of get that baseline All right. And we're going to breathe in on a count of four One, two, three, four. Hold two, three, four, breathe out two, three, four and hold two, three, four.

Colleen:

I loved it. So I know you recommended to do it for like a minute, five minutes, whatever works for you guys, but even just that 16 seconds of breathing and being intentional, it calmed my soul. So thank you so much for that. I'm going to be utilizing that all the time, and I hope you guys will as well, and that's a simple tip for your patients as well, too. It's not only stress management, but we're now helping them breathe better, pay attention to their bodies, and this can help with reflux too. So simple things like that can really really impact your patients. So thank you so much, patricia. That was awesome, all right. So I wanted to end this segment with a few questions that might come up from patients, especially if they've Googled reflux and nutrition, or what foods can I eat with reflux, and one of them is does milk help with heartburn? So how do we answer our patients when they ask us that question?

Patricia:

Right. So I think this is something that comes up quite a bit. It feels a little bit like an old widescale and it's theorized that it neutralizes high stomach acid and can soothe the stomach, and I think some people might have that feeling of it settling down. But actually, you know and I checked a couple of different gastro associations and their recommendations and their practice guidelines I didn't really come up with anything that really mentioned milk at all. To be honest, the only thing that I was able to find is that drinking full fat milk with that sort of high fat content might trigger acid reflux symptoms, which is the opposite of what we want, right? Because that high fat content is going to take a longer time to digest in the stomach and it's going to sit in there, and that is how high fat foods and high fat meals contribute to acid reflux they just take longer to empty out of the stomach. So the answer is there's not really much there to say. Yes, it's a little bit of, like I said, an old widescale that some people might feel like it helps, but there's nothing to really say that this is something that people should be doing and, in fact, if you drink full fat milk, it might make your symptoms worse.

Colleen:

So when there isn't any evidence based literature to support a recommendation, guys, make sure you're not the one that's saying, hey well, why don't you drink milk? It might help your symptoms. There's not literature to support that. However, if you have a patient who's drinking milk and that's not a trigger food, let them continue to be drinking milk. So I think, again, going back to that symptom and food tracker is super, super important, but it's not appropriate and it's not supported in literature to be eliminating milk or to be recommending milk as a treatment for reflux. So super helpful. Thank you for digging for us regarding that. I love that you did the research for us. Lastly would be does cooking methods matter? So frying chicken versus grilling it, broiling it? Give us some suggestions on how we can be recommending our patients be preparing their foods.

Patricia:

So there again that is going to come down to whether or not high fat foods are trigger for somebody's acid reflux symptoms. So cooking methods like baking, broiling, even steaming, boiling, grilling, sauteing, you know, those are all lower fat cooking methods that you might see recommended on a GERD nutritional handout education sheet. And to avoid fried foods, including deep fat frying and pan frying. And the reason for this is because high fat foods and high fat meals are common trigger for people's acid reflux symptoms. So it might be helpful for some people who react to high fat foods and high fat meals to avoid fried foods. But there again this is going to be like, based on what your patients symptoms are like and what triggers them.

Colleen:

You know, nutrition is very personalized, right. That's why we've got registered dieticians to help us do this. But I really hope that you guys have learned a few things about reflux with Patricia and learned how to specifically address the patient that's sitting in front of you and not be giving blanket recommendations, because that's not going to work for everybody. You really need to tailor your guidelines and your recommendations to your patient. So I wanted to close the segment out with discussing some red flags that clinicians really should be aware of. This might be a refresher or reminder for some of us, but this is really important because I know it's really easy when someone comes in oh, I've got a heartburn, what can I do? And you're thinking like oh yes, this is going to be like a five minute visit. I'm going to catch up and not be running an hour behind. Now. Take an antacid and here's a list of foods you should eat. See you in a few months. Not the best way to do that, right? Because of all those other reasons, because they might not need to be avoiding all those foods. Second of all, you might be missing something that's not just reflux. So pause and consider some red flag symptoms that might point you to a different diagnosis. So, Patricia, let us know some of these red flags that should make our clinician alarms be going off.

Patricia:

Absolutely so. The first red flag I want to mention is unintentional weight loss, and for myself, coming from the clinical setting, for so so long that was like the number one thing that we screened people in the hospital for was if they were losing weight without trying. And so I think this is especially important for people with GI symptoms, because they could be losing weight without trying because they keep removing foods and eating less and eating less to try and get their GI symptoms Under control, or to just go away or just like feel better for half a day, but then they end up not meeting their basic calorie requirements so much over time that they are losing weight without trying. So if somebody is coming to you with a little bit of weight loss, it is crucial, in my opinion, to ask the question are you trying to lose weight or not? And I feel like a lot of people will say, well, no, but it's not so bad. Right, because we live in such a weight centric world and body size centric world. But no matter what the body sizes of your patient, if they are losing weight without trying, that is a red flag. And so really trying to suss out if it is from avoiding foods or food restriction or having smaller and smaller portion sizes. This can help you to understand the underlying reason for why they might be losing weight, such as high atl hernia, for example, might be one of the reasons, or gastroparesis would be another reason. I also want to mention if your patient is having any changes in their bowel habits along with their acid reflux symptoms. This could indicate something like constipation, for example. Constipation can make acid reflux symptoms worse and it might seem a little bit out of this world, because constipation happens at the very end of the GI tract, right, and we're talking about acid reflux which is pretty high up in the GI. But if somebody is constipated, especially chronically or for a long time, they just can't get it cleared out. That increased pressure, that backup, really can make its way all the way up to the stomach and the lower esophagus and contribute to acid reflux symptoms. A couple of other things I do want to mention is that GI patients, including those with acid reflux, are at higher risk for having a disordered eating or food fear, and I think it's important to try and determine the rationale for any sort of food avoidance so that can be addressed. And similarly, if somebody has like a history of an eating disorder or if you might start to feel like they might have an eating disorder. An elimination diet or even giving somebody a list of foods to avoid would not be recommended for your patient with acid reflux. That's going to feed into that eating disorder and that's not what we want either.

Colleen:

Thank you so much for that review because, again, like I said, it's really easy in clinics to be like, oh, reflux, here's your treatment plan, see you later. But it's so critical to pause and make sure that you're not missing something that is more harmful, more dangerous. So, patricia, I always love having you on here. This conversation has been so, so helpful. If you have any clients that you would like to refer to, work with Patricia. She sees patients virtually. You can find her on Instagram, at patriciuskolnicknutritionorg, or online, and I will link up to both of those down below in the show notes. Patricia, thank you so much for being with us. I'm so grateful that you spent this time with me. Thank you so much for having me back. It's always a pleasure. All right, guys. Now it's time for my nutrition notes. In this section, I will leave you with a nutrition tip and encouraging quote or an interesting case that I think might add value to your day. So today, I'm going to be leaving you with three things that you can do to prevent yourself from jumping to conclusions, or from jumping to assuming you automatically know what the diagnosis is If you've been practicing medicine for any amount of time. Of course, the longer you've been practicing, the easier it is to kind of spot those triads of symptoms and to quickly be able to diagnose and come up with a treatment plan based on patient symptoms. But I want you guys to practice slowing down and not just jumping to your diagnosis immediately and although you're probably going to be right 95% of the time, those five or that 2% or even that one patient where you jump to the diagnosis too quickly and there were catastrophic effects or missed diagnosis for years, and now you've had to have a patient be struggling with symptoms that could have been managed had the diagnosis been made properly. So here are three things that you can do to ensure that you are not jumping to your diagnosis. Number one Pause and look at your patient. We'll use the example of reflux for today's exercise. So sometimes it seems very black and white. Your patient comes in I've got heartburn, they point to the upper abdomen and it feels like a burning in my chest. And it's worse when I eat fast food. Right, and you're thinking, oh sweet, this is an easy diagnosis it's reflux. Try an antacid, track your diet or stop eating greasy foods. Come back to me let's see how it goes. But I want you to pause and actually look at your patient. Are they in any distress? Is the pain out of proportion to what it should be on physical exam? Are they losing weight unintentionally or are they in any significant distress? Because reflux really doesn't cause life-altering pain or distress, whereas other GI disorders or we might be in a totally different body system and this symptom is just in the stomach and the patient is thinking that they have reflux. But it's something else. It might be cardiac, it might be respiratory, it might be something going on in the skin and they're not aware of. So look at your patient. Number two ask really good questions. So again, don't allow the patient to lead you to a diagnosis. You know, sometimes they paint the picture beautifully of what they think it is, because maybe they've Googled their symptoms and it meets their criteria exactly. But you should be the one leading the discussion, doing the investigating and asking the right questions. So, regarding reflux, you do wanna be asking them. Well, what foods are you typically eating? Do you notice if there's certain foods that make these symptoms worse than others? Are you eliminating certain foods already? Just like Patricia had said, maybe these patients are only consuming five foods because these are the only five foods that they can even swallow or that they can even handle. And then you need to be asking questions about other body systems to rule out other things. Are you having any difficulty swelling? Is the food getting stuck in your throat? Are you having any hard poop? Are you having any watery poop? Are you having blood in your soles? Are you vomiting? Are you excessively fatigued? Are you getting headaches? Asking great questions beyond the GI system is going to open up your thinking to other things that it might be. And number three provide specific recommendations and close follow-up. Please do not provide a handout on reflux with a list of 10 to 15 different foods that the patient should be avoiding, because now you've got 10 to 15 different extremely nutritious and healthful foods that the patient is gonna be avoiding unnecessarily. It's gonna cause burden on them and they're not gonna enjoy it For the more. They might not need to be eliminating all of those foods. So specific recommendations. So if your patient automatically comes in and says, yes, I feel like every time I eat an orange, I get this sensation in my stomach. So your recommendation should be well, let's cut out all citrus foods for the next three to four weeks and then come back and see me and let's see how it was going. If you wanna cut it to shorter and do two weeks, that's fine. If your patient has no idea and they think like, oh well, all foods are causing these symptoms or I can't pinpoint what's going on, then that's when you wanna recommend that they create a food log and a symptom tracker and have them come back within two to four weeks so that you can review that with them. A safe and excellent thing that you can recommend for all patients to do are those lifestyle changes, because it's not revolving around food, because, as you notice from our conversation with Patricia, the food triggers are gonna be very specific from patient to patient, so you can't just give general guidelines regarding which foods to avoid and which foods to consume more of, but the lifestyle modifications can be general guidelines. So that's one thing that you can implement, change in with your patients immediately. So those few things that Patricia had mentioned chewing foods thoroughly, eating more slowly, eating more upright, lose fitting clothes not laying down immediately, moving your body and walking more often, maybe avoiding straws for some people those few things are very important and so that's something that you can implement now and might have substantial impact on their symptoms. Thanks so much for joining me today, guys. I'm so grateful that you spend this time with me. I'd love to connect with you on Instagram. You can find me at Exam Room Nutrition. You can also watch this video on YouTube and, if you're watching, leave me a like below or send me a comment and let me know what are your practical tips that you provide your patients to help with their reflux symptoms. Well, that's it for today, guys. So let's continue to make our patients healthier, one exam room at a time. I'll see you next time.