Great post from a mentor in Chris Kresser. Enjoy this article.
Note: this is the sixth and final article in a series about heartburn and GERD. If you haven’t done so already, you’ll want to read Part I, Part II, Part III, and Part IVa, and Part IVb before reading this article.
In this final article of the series, we’re going to discuss three steps to treating heartburn and GERD without drugs. These same three steps will also prevent these conditions from developing in the first place, and keep them from returning once they’re gone.
To review, heartburn and GERD are not caused by too much stomach acid. They are caused by too little stomach acid and bacterial overgrowth in the stomach and intestines. Therefore successful treatment is based on restoring adequate stomach acid production and eliminating bacterial overgrowth.
This can be accomplished by following the “three Rs” of treating heartburn and GERD naturally:
- Reduce factors that promote bacterial overgrowth and low stomach acid.
- Replace stomach acid, enzymes and nutrients that aid digestion and are necessary for health.
- Restore beneficial bacteria and a healthy mucosal lining in the gut.
Reduce factors that promote bacterial overgrowth and low stomach acid
As we saw in Part II and Part III, a high carbohydrate diet promotes bacterial overgrowth. Bacterial overgrowth – in particular H. pylori – can suppress stomach acid. This creates a vicious cycle where bacterial overgrowth and low stomach acid reinforce each other in a continuous decline of digestive function.
It follows, then, that a low-carb (LC) diet would reduce bacterial overgrowth. To my knowledge there have only been two small studies done to test this hypothesis. The results in both studies were overwhelmingly positive.
The first study was performed by Professor Yancy and colleagues at Duke University. They enrolled five patients with severe GERD that also had a variety of other medical problems, such as diabetes. Each of these patients had failed several conventional GERD treatments before being enrolled in the study. In spite of the fact that some of these patients continued to drink, smoke and engage in other GERD-unfriendly habits, in every case the symptoms of GERD were completely eliminated within one week of adopting a very low carbohydrate (VLC) diet.
The second study (PDF) was performed by Yancy and colleagues a few years later. This time they examined the effects of a VLC diet on eight obese subjects with severe GERD. They measured the esophageal pH of the subjects at baseline before the study began using something called the Johnson-DeMeester score. This is a measurement of how much acid is getting back up into the esophagus, and thus an objective marker of how much reflux is occurring. They also used a self-administered questionnaire called the GSAS-ds to evaluate the frequency and severity of 15 GERD-related symptoms within the previous week.
At the beginning of the diet, five of eight subjects had abnormal Johnson-DeMeester scores. All five of these patients showed a substantial decrease in their Johnson-DeMeester score (meaning less acid in the esophagus). Most remarkably, the magnitude of the decrease in Johnson-DeMeester scores is similar to what is reported with PPI treatment. In other words, in these five subjects a very low carbohydrate diet was just as effective as powerful acid suppressing drugs in keeping acid out of the esophagus.
All eight individuals had evident improvement in their GSAS-ds scores. The GSAS-ds scores decreased from 1.28 prior to the diet to 0.72 after initiation of the diet. What these numbers mean is that the patients all reported significant improvement in their GERD related symptoms. Therefore, there was both objective (Johnson-DeMeester) and subjective (GSAS-ds) improvement in this study.
It’s important to note that obesity is an independent risk factor for GERD, because it increases intra-abdominal pressure and causes dysfunction of the lower esophageal sphincter (LES). The advantage to a low-carb diet as a treatment for GERD for those who are overweight is that LC diets are also very effective for promoting weight loss.
I don’t recommend VLC diets for extended periods of time, as they are unnecessary for most people. Once you have recovered your digestive function, a diet low to moderate in carbohydrates should be adequate to prevent a recurrence of symptoms.
An alternative to a VLC is something called a “specific carbohydrate diet” (SCD), or the GAPS diet. In these two approaches it is not the amount of carbohydrates that is important, but the type of carbohydrates. The theory is that the longer chain carbohydrates (disaccharides and polysacharides) are the ones that feed bad bacteria in our guts, while short chain carbohydrates (monosacharides) don’t pose a problem. In practice what this means is that all grains, legumes and starchy vegetables should be eliminated, but fruits and certain non-starchy root vegetables (winter squash, rutabaga, turnips, celery root) can be eaten. These are not “low-carb” diets, per se, but there is reason to believe that they may be just as effective in treating heartburn and GERD. See the resources section below for books and websites about these diets, which have been used with dramatic success to treat everything from autism spectrum disorder (ASD) to Crohn’s disease.
Another alternative to VLC that I increasingly use in my clinic is the Low FODMAP diet. FODMAPs are certain types of carbohydrates that are poorly absorbed by some people, particularly those with an overgrowth of bacteria in the small intestine (which, as you now know, tends to go hand-in-hand with heartburn). See this article and my book for more information.
Be careful to avoid the processed low-carb foods sold in supermarkets. Instead, I suggest what is known as a “paleolithic” or “primal” approach to nutrition.
Fructose and artificial sweeteners
As I pointed out in Part II, fructose and artificial sweeteners have been shown to increase bacterial overgrowth. Artificial sweeteners should be completely eliminated, and fructose (in processed form especially) should be reduced.
High fiber diets and bacterial overgrowth are a particularly dangerous mix. Remember, Almost all of the fiber and approximately 15-20% of the starch we consume escape absorption. Carbohydrates that escape digestion become food for intestinal bacteria.
Prebiotics, which can be helpful in re-establishing a healthy bacterial balance in some patients, should probably be avoided in patients with heartburn and GERD. Several studies show that fructo-oligosaccharides (prebiotics) increase the amount of gas produced in the gut.
The other problem with fiber is that it can bind with nutrients and remove them from the body before they have a chance to be absorbed. This is particularly problematic in GERD sufferers, who may already be deficient in key nutrients due to long term hypochlorydria (low stomach acid).
In Part III we looked at the possible relationship between H. pylori and GERD. While I think it’s a contributing factor in some cases, the question of whether and how to treat it is less clear. There is some evidence that H. pylori is a normal resident on the human digestive tract, and even plays some protective and health-promoting roles. If this is true, complete eradication of H. pylori may not be desirable. Instead, a LC or specific carbohydrate diet is probably a better choice as it will simply reduce the bacterial load and bring the gut flora back into a state of relative balance.
The exception to this may be in serious or long-standing cases of GERD that aren’t responding to a VLC or LC diet. In this situation, it may be worthwhile to get tested for H. pylori and treat it more aggressively.
Dr. Wright, author of Why Stomach Acid is Good For You, suggests using mastic (a resin from a Mediterranean and Middle Eastern variety of pistachio tree) to treat H. pylori. A 1998 in vitro study in the New England Journal of Medicine showed that mastic killed several strains of H. pylori, including some that were resistant to conventional antibiotics. Studies since then, including in vivo experiments, have shown mixed results. Mastic may be a good first-line therapy for H. pylori, with antibiotics as a second choice if the mastic treatment isn’t successful.
Replace stomach acid, enzymes and nutrients that aid digestion and are necessary for health
HCL with Pepsin
If you have an open-minded doctor, or one that is aware of the connection between low stomach acid and GERD, ask her to test your stomach acid levels. The test is quite simple. A device called a Heidelberg capsule, which consists of a tiny pH sensor and radio transmitter compressed into something resembling a vitamin capsule, is lowered into the stomach. When swallowed, the sensors in the capsule measure the pH of the stomach contents and relay the findings via radio signal to a receiver located outside the body.
In cases of mild to moderate heartburn, actual testing for stomach acid production at Dr. Wright’s Tahoma clinic shows that hypochlorydria occurs in over 90 percent of thousands tested since 1976. In these cases, replacing stomach acid with HCL supplements is almost always successful.
Although testing actual stomach acid levels is preferable, it is not strictly necessary. There is a reasonably reliable, “low-tech” method that can be performed at home to determine whether HCL supplementation will provide a benefit. To do this test, pick up some HCL capsules that contain pepsin or acid-stable protease. HCL should always be taken with pepsin or acid-stable protease because it is likely that if the stomach is not producing enough HCL, it is also not producing enough protein digesting enzymes.
Note: HCL should never be taken (and this test should not be performed) by anyone who is also using any kind of anti-inflammatory medication such as corticosteroids (e.g. predisone), aspirin, Indocin, ibuprofen (e.g. Motrin, Advil, etc.) or other NSAIDS. These drugs can damage the GI lining that supplementary HCL might aggravate, increasing the risk of gastric bleeding or ulcer.
To minimize side effects, start with one 650 mg capsule of HCL w/pepsin in the early part of each meal. If there are no problems after two or three days, increase the dose to two capsules at the beginning of meals. Then after another two days increase to three capsules. Increase the dose gradually in this stepwise fashion until you feel a mild burning sensation. At that point, reduce the dosage to the previous number of capsules you were taking before you experienced burning and stay at that dosage. Over time you may find that you can continue to reduce the dosage, or you may also find that you may need to increase the dosage.
In Dr. Wright’s clinic, most patients end up at a dose of 5-7 650 mg capsules. In my experience, this dose is too high for many people. In fact, some have trouble with even a single 650 mg capsule. I’ve also found that the addition of cholagogues (agents which promote bile flow from the gall bladder into the small intestine) and pancreatic enzymes can help tremendously, especially in the initial stages.
For these reasons, I created by own combination of HCL and enzymes called the AdaptaGest Duo. AdaptaGest Core contains acid-stable protease (to support protein digestion and complement HCL), cholagogues, and enzymes. AdaptaGest Flex contains HCL, but in a lower dose (200 mg per capsule) than is typical for standalone HCL products. This allows better fine-tuning of your HCL dosage. In my clinic, I prescribe AdaptaGest Duo for anyone str
uggling with heartburn and other digestive issues related to low stomach acid production. If you’d like to try it, you can order it here.
Another way to stimulate acid production in the stomach is by taking bitter herbs. “Bitters” have been used in traditional cultures for thousands of years to stimulate and improve digestion. More recently, studies have confirmed the ability of bitters to increase the flow of digestive juices, including HCL, bile, pepsin, gastrin and pancreatic enzymes. 1
Unsurprisingly, there aren’t many clinical studies evaluating the therapeutic potential of unpatentable and therefore unprofitable bitters. However, in one uncontrolled study in Germany, where a high percentage of doctors prescribe herbal medicine, gentian root capsules provided dramatic relief of GI symptoms in 205 patients.
The following is a list of bitter herbs commonly used in Western and Chinese herbology:
- Barberry bark
- Gentian root
- Globe artichoke
- Goldenseal root
- Milk thistle
- Yellow dock
Bitters are normally taken in very small doses – just enough to evoke a strong taste of bitterness. Kerry Bone, a respected Western herbalist, suggests 5 to 10 drops of a 1:5 tincture of the above herbs taken in 20 mL of water.
An even better option is to see a licensed herbalist who can prescribe a formula containing several of the herbs above as appropriate for your particular condition.
Apple cider vinegar, lemon juice, raw (unpasteurized) sauerkraut and pickles are other time-tested, traditional remedies that often relieve the symptoms of heartburn and GERD. However, although these remedies may resolve symptoms, they do not increase nutrient absorption and assimilation to the extent that HCL supplements do. This may be important for those who have been taking acid suppressing drugs for a long period.
It is also important to avoid consuming liquid during meals. Water is especially problematic, because it literally dilutes the concentration of stomach acid. A few sips of wine is probably fine, and may even be helpful.
Finally, for those who have been taking acid stopping drugs for several years, it may be necessary to replace the nutrients that are not absorbed without sufficient stomach acid. These include B12, folic acid, calcium, iron and zinc. It’s best to get your levels tested by a qualified medical practitioner, who can then help you replace them through nutritional changes and/or supplementation.
Restore beneficial bacteria and a healthy mucosal lining in the gut
Because bacterial overgrowth is a major factor in heartburn and GERD, restoring a healthy balance of intestinal bacteria is an important aspect of treatment. Along with performing several other functions essential to digestive health, beneficial bacteria (probiotics) protect against potential pathogens through “competitive inhibition” (i.e. competing for resources).
Researchers in Australia have shown that probiotics are effective in reducing bacterial overgrowth and altering fermentation patterns in the small bowel in patients with IBS. Probiotics have also been shown to be effective in treating Crohn’s disease, ulcerative colitis, and other digestive conditions.
Probiotics have also been shown to significantly increase cure rates of treatment for H. pylori. In my practice I always include a probiotic along with the anti-microbial treatment I do for H. pylori.
I am often asked what type of probiotics I recommend. First, whenever possible I think we should always attempt to get the nutrients we need from food. This is also true for probiotics. Fermented foods have been consumed for their probiotic effects for thousands of years. What’s more, contrary to popular belief and the marketing of commercial probiotic manufacturers, foods like yogurt and kefir generally have a much higher concentration of beneficial microorganisms than probiotic supplements do.
For example, even the most potent commercial probiotics claim to contain somewhere between one and five billion microorganisms per serving. (I say “claim” to contain because independent verification studies have shown that most commercial probiotics do not contain the amount of microorganisms they claim to.) Contrast that with a glass of homemade kefir, a fermented milk product, contains as many as 5 trillion beneficial microorganisms!
What’s more, fermented milk products like kefir and yogurt offer more benefits than beneficial bacteria alone, including minerals, vitamins, protein, amino acids, L-carnitine, fats, CLA, and antimicrobial agents. Studies have even shown that fermented milk products can improve the eradication rates of H. pylori by 5-15%.
The problem with fermented milk products in the treatment of heartburn and GERD, however, is that milk is relatively high in carbohydrates. This may present a problem for people with severe bacterial overgrowth. However, relatively small amounts of kefir and yogurt are therapeutic and may be well tolerated. It’s best to make kefir and yogurt at home, because the microorganism count will be much higher. Lucy’s Kitchen Shop sells a good home yogurt maker, and Dom’s Kefir site has exhaustive information on all things kefir. If you do buy the home yogurt maker, I suggest you also buy the glass jar that Lucy’s sells to make it in (rather than using the plastic jar it comes with).
If dairy doesn’t work for you, but you’d like to get the benefits of kefir, you can try making water kefir. Originating in Mexico, water kefir grains (also known as sugar kefir grains) allow for the fermentation of sugar water or juice to create a carbonated lacto-fermented beverage. You can buy water kefir grains from Cultures for Health.
Another option is to eat non-dairy (and thus lower-carb) unpasteurized (raw) sauerkraut and pickles and/or drink a beverage called kombucha. Raw sauerkraut can easily be made at home, or sometimes found at farmer’s markets. Bubbies brand raw pickles are sold at health food stores, as is kombucha, but both of these can also be made quite easily at home.
All of that said, probiotic supplements are sometimes necessary and can play a crucial role in treatment and recovery. But not all probiotics are created alike, and in the case of small intestinal bacterial overgrowth (or SIBO, which is commonly present with GERD), certain probiotics may make things worse. SIBO often involves an overgrowth of microorganisms that produce a substance called D-lactic acid. Unfortunately, many commercial probiotics contain strains (like Lactobacillus acidophilus) that also produce D-lactic acid. That makes most commercial probiotics a poor choice for people with SIBO.
Soil-based organisms do not produce significant amounts of D-lactic acid, and are a better choice for this reason. In my clinic, I use a product called Prescript Assist when treating SIBO and GERD. You can purchase it here. Other popular choices include Gut Pro from Organic 3 and D-Lactate Free Powder from Custom Probiotics. I used these in the past, but have much better success with Prescript Assist so I now use that exclusively.
Bone broth and DGL
Restoring a healthy gut lining is another important part of recovering from heartburn and GERD. Chronic stress, bacterial overgrowth, and certain medications such as steroids, NSAIDs and aspirin can damage the lining of the stomach. Since it is the mucosal lining of the stomach that protects it from its own acid, a damaged stomach lining can cause irritation, pain and ultimately, ulcers.
Homemade bone broth soups are effective in restoring a healthy mucosal lining in the stomach. Bone broth is rich in collagen and gelatin, which have been shown to benefit people with ulcers. It’s also high in proline, a non-essential amino acid that is an important precursor for the formation of collagen. Bone broth also contains glutamine, an important metabolic fuel for intestinal cells that has been shown to benefit the gut lining in animal studies. See this article and this one for more information about the healing power of bone broth, and how to make it.
Although I prefer obtaining nutrients from food whenever possible, , as I explained above, supplements are sometimes necessary – especially for short periods. Deglycyrrhizinated licorice (DGL) has been shown to be effective in treating gastric and duodenal ulcers, and works as well in this regard as Tagamet or Zantac, with far fewer side effects and no undesirable acid suppression. In animal studies, DGL has even been shown to protect the stomach lining against damage caused by aspirin and other NSAIDs.
DGL works by raising the concentration of compounds called prostaglandins, which promote mucous secretion, stabilize cell membranes, and stimulate new cell growth – all of which contributes to a healthy gut lining. Both chronic stress and use of NSAIDs suppress prostaglandin production, so it is vital for anyone dealing with any type of digestive problem (including GERD) to find ways to manage their stress and avoid the use of NSAIDs as much as possible.
When natural treatments may not be enough
There may be some cases when an entirely natural approach is not enough. When there is tissue damage in the esophagus, for example, a surgical procedure called “gastroplication” which repairs the LES valve may be necessary. These procedures don’t have the potential to create nutrient deficiencies and disease the way acid blockers do. It is advisable for anyone suffering from a severe case of GERD to consult with a knowledgeable physician.
The mainstream medical approach to treating heartburn and GERD involves taking acid stopping drugs for as long as these problems occur. Unfortunately, because these drugs not only don’t address the underlying cause of these problems but may make it worse, this means that people who start taking antacid drugs end up taking them for the rest of their lives.
This is a serious problem because acid stopping drugs promote bacterial overgrowth, weaken our resistance to infection, reduce absorption of essential nutrients, and increase the likelihood of developing IBS, other digestive disorders, and cancer. The manufacturers of these drugs have always been aware of these problems. When acid-stopping drugs were first introduced, it was recommended that they not be taken for more than six weeks. Clearly this prudent advice has been discarded, as it is not uncommon today to encounter people who have been on these drugs for decades – not weeks.
What is especially disturbing about this is that heartburn and GERD are easily prevented and cured by making simple dietary and lifestyle changes, as I have outlined in this final article.
Unfortunately, the corruption of our “disease-care” system by the financial interests of the pharmaceutical companies virtually guarantees that this crucial information will remain obscure. Drug companies make more than $7 billion a year selling acid suppressing medications. The last thing they want is for doctors and their patients to learn how to treat heartburn and GERD without these drugs. And since 2/3 of all medical research is sponsored by drug companies, it’s virtually guaranteed that we won’t see any large studies on the effects of a low-carb diet on acid reflux and GERD.
So once again it’s up to us to discover the truth and be our own advocates. I hope this series of articles has served you in that goal.
I have created a “myth busing report” page for heartburn and GERD which contains an index of these articles, as well links to books and other offsite resources. If anyone you know is suffering from heartburn and GERD, please direct them to http://chriskresser.com/heartburn.
- Wright, Jonathan M.D. Why Stomach Acid is Good For You. M Evans 2001. p.142 ↩