Is it something we ate?
During the last four years, American consumption of heartburn remedies has almost doubled. Business analysts describe what is now a $1.4-billion-a-year industry as a "phenomenon."
When asked about the boom, Dr. Roy Wong, chief of gastroenterology at Walter Reed Army Medical Center in Washington, D.C., and spokesman for the American College of Gastroenterology, exclaims, "It's huge! It's enormous!"
Huge? Enormous? Phenomenon? Doubled? Did we all come down with heartburn overnight?
Surely dyspepsia is as old as eating. Knotty roots and gristly bits of behemoth must have set the gastric juices of at least one hunter-gatherer aboil. Today, as the latest Tums ad has it, it is more a case of too many hot dogs eaten too fast.
However we manage it, the American College of Gastroenterology estimates that 60 million people--or one in four Americans--suffer at least once a month from heartburn.
Although heartburn pain strikes in the chest, the term is a misnomer: Heartburn has nothing to do with the heart. Rather, it is digestive insurrection striking the alimentary, or gastrointestinal, tract.
One of the first glimpses of how food behaves in this tube came in 1906, when a certain Walter Cannon of Boston used early X-ray technology to photograph movement in the alimentary canal of a cat. What with the great battery of scopes and peeping devices available today, we now know that, in heartburn, gastric juices designed to digest food in toughly lined stomachs slosh up onto our altogether more tender esophagi.
"Gastric acid is pretty powerful stuff," says Wong. "It's not unlike battery acid. If you put it on your skin, it burns." Chronic heartburn, Wong warns, can leave the esophagus with scar tissue and even change the type of cells that line it. These altered cells may be more likely, he warns, to develop cancer.
A minority develop it for anatomical reasons, but heartburn's prime cause is our talent for excess. The trade magazine Chemist & Druggist took this faintly lip-smacking approach to the problem in a November 1997 issue: "As always, Christmas is expected to boost the indigestion remedies market.
"Stress-inducing lifestyles, irregular and over-indulgent eating habits and the popularity of fatty and spicy food should keep the market buoyant."
But what, exactly, causes heartburn? According to Wong, being overweight is a common culprit. As in pregnancy, girth presses on the stomach. Lying down too soon after eating and tilting the contents of the stomach toward the throat can also bring on heartburn.
It is not simply a question of how much and when we eat, but what. Carol Koprowski, a PhD in preventive medicine and a research fellow at USC School of Medicine, says some people are simply sensitive to certain types of food, drinks, sweets and spices. "Orange juice can cause a lot of problems," she says.
For many of us, though, it is fatty foods. Wong explains with an unlikely but vivid scenario. "Let's say that I had you drink a quart of water, then a quart of oil. Same volume. Your stomach would clear the water much faster than the oil. So that fat stays in your stomach longer and you get more acid production."
Because of this, he advises his patients: "Stay away from fatty foods. Don't eat large meals. Don't eat before you go to bed." Carol Koprowski gives the same sort of advice. So do thousands of pharmacists, dozens of Web sites and every hander-down of medical wisdom going.
Everyone except, that is, Madison Avenue. For the last four years, stomach remedies have been among the most advertised products on television. The New York-based firm Competitive Media Reporting calculates that between 1995 and 1998 they have commanded $300 million to $400 million a year in advertising. Much of this has been devoted to a relatively new class of heartburn medicines called H2 histamine receptor antagonists or, more casually, H2 blockers. They turn off the acid-producing cells before heartburn starts.
These were discovered in Britain in the 1970s by Sir James Black, who in 1988 shared a Nobel Prize for medicine. The original H2 blocker, cimetidine, sold in the U.S. under the name Tagamet, was so successful that even before it went over-the-counter in 1995, it had become the first prescription drug to pass the $1-billion mark in sales. Other best-selling blockers, such as Pepcid AC and Zantac 75, are based on chemical analogues of cimetidine.
Wong underscores their positive impact, stressing that he sees "fewer and fewer" of once-common complications from severe heartburn.
But is good news for those under a doctor's care bad news for the rest of us? After the Food and Drug Administration approved them for over-the-counter sale, advertisers conjured up images of solar eclipses and streaking jets to connote the modernity of H2 blockers as compared to quaint calcium carbonate remedies such as Tums and Rolaids. The latter merely neutralize stomach acid already produced, using the same sort of chemical reaction as baking soda.
"They [H2 blockers] went from zero to huge in a year," says Nancy Loos, a management consultant from the Milwaukee-based firm D.P. Hamacher & Associates. It was this boom, Loos believes, combined with fairly resilient sales of the classic antacids, that accounted for the jump in heartburn remedy consumption.
So the numbers of us suffering heartburn did not necessarily double, just the range of products with which we could self-medicate and the ease with which we could buy them. This worries Jeff Goad, assistant professor of clinical pharmacy at USC, who believes that a doctor or chemist should be in the loop. "These drugs can now be sold at a 7-Eleven," he says.
Provided, that is, there is enough shelf space. The patents are now expiring for many of the H2 blockers, and generic and store-brand versions are already marking up yearly sales exceeding $163 million.
Brand leaders have fought back with novelty tastes and "delivery systems" of blockers and calcium carbonates: gel caps, chewables and flavors from mint to cherry and lemon-lime. "There's a zillion of them," says Loos. "It's a nightmare for retailers." Tums alone, she says, comes in "probably 30 different versions.
But do we really need this cornucopia? Or do we merely want it to underwrite our eating habits? Ads hint at the latter, with TV spots for Tums (SmithKline Beecham) and Pepcid AC (Johnson & Johnson-Merck) showing people chowing down with supposed impunity. Pecid AC even posts recipes for white chocolate banana cream coconut pie on its Web site.
However, Charles Ganley, FDA division director for over-the-counter drug products, bristles at the suggestion that they are being sold as licenses to binge. "I'm not sure that I would characterize it as something that would allow them [heartburn sufferers] to eat more junk food."
He says that anyone with complaints about ads should notify the Federal Trade Commission. Ironically, however, when it comes to finger-pointing, the antacid manufacturers themselves take the cake. Shortly after the 1995 launch, SmithKline Beecham (Tagamet) and Johnson & Johnson-Merck were in court, suing one another over ad claims having to do with fast action, doctors' preferences and side effects.
A trace of bile lingers. SmithKline Beecham is running ads showing how a busy couple riding in a car needn't stop for water if they take the calcium carbonate Tums, rather than Johnson & Johnson-Merck's H2 blocker, Pepcid AC.
For Goad, this is reckless. "I think the manufacturers are trying to make it so people can't differentiate between a true antacid or an H2 blocker," he says.
The distinction, he insists, is an important one. Calcium carbonates offer short-term relief, he says. However, if they are systematically abused, they can stimulate acid production, requiring more tablets, which induce more acid production and so on.
"It becomes a vicious circle," Goad says.
And the downside to H2 blockers? "People are probably going to gain more weight," Wong says, "and they're going to do things that they shouldn't do because of the new medications."