A Natural Approach To Treating Acid Reflux, Heartburn, & GERD
I became pretty interested in acid reflux and GERD because my husband has suffered with it for years. Understanding the underlying mechanisms behind these common ailments and more importantly, how to address and alleviate them, has been a recent interest of mine.
Gastroesophageal reflux disorder (aka GERD) usually presents as heartburn (burning pain in your chest, just behind your breastbone), a regurge of food up in the throat, or a sour taste in the mouth. Sometimes GERD is asymptomatic or produces non-digestive symptoms like a chronic cough or post-nasal drip.
It’s often made synonymous with acid reflux, but the terms don't necessarily mean the same thing.
Acid reflux is the backward flow of stomach acid into the esophagus.
Occasional acid reflux ( occurring perhaps after a specific food or during times of stress) is just called acid reflux, but if it occurs frequently or is chronic then it is considered to have progressed to GERD (gastroesophageal reflux disease) which is the more severe ongoing form of reflux.
Acid reflux and heartburn occurring more than two times a week usually indicates GERD.
There is a significant amount of evidence suggesting that GERD results from inappropriate relaxation, or a malfunction or weakening of the lower esophageal sphincter (LES), a muscular ring that acts as a door to the stomach.
When you swallow food, it makes its way down the esophagus and into the stomach, where the LES closes to keep the food in. But sometimes the LES is weak or doesn’t properly close, allowing stomach acid to back up, which irritates the lining of the esophagus and results in acid reflux, or heartburn.
If this happens occasionally, typically no major harm is done. But when it happens daily, multiple times a day, for months and years, it can become a serious problem.
Stomach acid has a pH in the same vicinity of concentrated sulfuric acid, lemon juice and vinegar and your esophagus is nothing more then a thin tube of unprotected mucous membranes and soft tissue. So you can imagine what happens if the harsh stomach acid gets up into the esophagus. Not only does it hurt, it creates damage. If it happens over and over again, your body doesn’t have a chance to heal the irritation and it can become a serious problem.
In this blog I wanted to share some non pharmaceutical interventions to address acid reflux, GERD and a weak LES. I will discuss dietary strategy as well as which foods to examine as potential triggers, lifestyle strategies for symptom management, and how you can utilize herbs and supplements for additional support.
But first, I wanted to discuss common medications and OTC treatments for acid reflux and GERD, and explain how these treatments add to the root problem rather then relieving it.
WHY CAN'T I JUST TAKE A PPI? OR POP A TUMS?
The market for anti acids is over 10 billion worldwide. An antacid is a medication that neutralizes or suppresses stomach acid.
However, most of the time, reflux, heartburn and GERD are not the result of too much stomach acid at all. It’s usually either too much acid in the wrong place OR too little stomach acid altogether.
Yes, these conventional products give short term relief, but not without ramification. Prolonged reliance on conventional solutions, over the counter medications and prescriptions can really damage the esophagus, the entire digestive system, and consequently, the body.
Antacids can basically be broken down into two categories:
Acid neutralizers- these temporarily neutralize the stomach acid currently present in the GI tract. This is why they work when taken but don’t have a lasting effect.
Acid neutralizers include calcium, sodium, aluminum and magnesium salts. Popular acid neutralizers are Tums, Mylanta, Milk of Magnesia, and Alka Seltzer. Occasional use won’t hurt but if taken too frequently over time they can cause there to be too much calcium in the blood. And buffering stomach acid can cause other problems, while still not addressing the root of the problem.
Acid blockers- these were developed in the 1970s and include H2 blockers (histamine receptor antagonists) and PPIS (proton pump inhibitors).
H2 blockers prevent the action of histamine by blocking their receptor sites in the stomach. This is problematic because histamine helps stimulate the production of stomach acid. Normally gastric stimulates these histamine producing cells in the stomach to produce HCL. When this process is blocked with an H2 blocker stomach acid production is halted. While this provides short term relief from acid reflux and GERD, by the time you're done reading this blog you'll understand that long term suppression of stomach acid is dangerous.
PPIs were released in the 1990s and were touted as the saving grace for heartburn and acid reflux. Proton pumps are the parts of the cell that secrete and produce stomach acid. As the name implies, proton pump inhibitors disable this process. PPIs are potent. They can reduce stomach acid by as much as 95%.
Why is low stomach acid so bad?
Low levels of hydrochloric acid can have a profound impact on the body's ability to properly digest and absorb nutrients.
Stomach acid breaks down food for digestion. In order to do that job, the pH level (or level of acidity) must be within a certain range. The pH levels also signal the opening of the valves at both ends of the stomach. When pH levels are normal, digestion occurs as it should, and food moves from the esophagus to the stomach to the small intestine.
When acid levels are low. pH levels in turn, rise too high, and food does not break down as it should which can cause an overgrowth of bacteria as in SIBO. In fact, one often overlooked cause of GERD, is SIBO.
When food stays in the stomach for too long, it can ferment and excess gas accumulates. Now the stomach is filled with gas, but the pH levels are too low to signal the valve to open to the small intestine. So the body only has one way to relieve the pressure – it opens the LES valve and releases the gas and acid back up into the esophagus.
In addition, a specific bacteria in the stomach, helicobacter pylori (or H. pylori), can reach high levels when stomach acid is too low. This causes inflammation in the lining of the stomach, also known as gastritis. The symptoms of gastritis are very similar to and often confused with those of acid reflux and GERD. Something else you should know about H. pylori is that it actually reduces the secretion of stomach acids, which sets off a very nasty cycle.
H.pylori is also difficult to eradicate from the stomach because it is capable of developing resistance to commonly used antibiotics (antibiotic-resistant H. pylori). Symptoms of H.pylori include poor appetite, bloating, burping, nausea and unintended weight loss.
Left untreated, hypochlorhydria can cause damage to the gastrointestinal system, infections, and a number of chronic health issues including more then doubling your risk of stomach cancer.
When you don’t have enough acid, the chemical reactions that are necessary to absorb vitamins, minerals and other nutrients into your bloodstream are impaired. Research confirms that low stomach acid reduces absorption of iron, B12, folic acid, calcium and zinc.
Another issue with low stomach acid is the increased susceptibility to infections. One of the most important roles of stomach acid is to kill harmful bacteria. When you reduce the amount of acid in your stomach, you are increasing your risk of infections. Research has linked acid reducing drugs to increased risk of pneumonia, tuberculosis, typhoid, and disentary. Other studies found evidence of contracting salmonella, campylobacter, chorea, listeria, giardia, and c.difficlie. Here and here.
Decreased levels of stomach acid can also lead to atrophic gastritis which is associated with an array of serious health concerns including: stomach cancer, allergies, ulcers, asthma, depression, anxiety, auto immune diseases (e.g. RA and Graves disease), Irritable Bowel Syndrome (IBS), Crohn’s disease, ulcerative colitis, and many more.
This is a great link with loads more science on the dangers of low HCL: HERE
Yet ANOTHER problem is that undigested food left in the gut acts as an irritant. As a result, intolerances and inflammation can develop and someone who (for example) has chronically used PPIs for years, and suppressed HCL production, may inevitably find themselves battling a barrage of food sensitivities and negative digestive symptoms that they never had before.
This is because stomach acid is vital for your body to break down food. So if you take acid-suppressing drugs, the food you eat isn't broken down into small enough pieces. Intact allergens are sent to the intestine, where they can cause an allergic reaction and inflammation. Here and here.
It’s also worth noting that part of the problem is that these drugs are widely abused. In factg it's estimated that 70% of PPI use is outside of FDA guidelines.
According to their dosage instructions, Prilosec OTC can taken for 14 days up to 3 times a year; Nexium and Prevacid can be taken up to 8 weeks; and Pepcid and Zantac are intended to be taken for 14 days.
Yet, it’s not uncommon to talk to people who have been taking these drugs daily, for years, sometimes even on the advice of their doctor!
The best approach, is to manage symptoms by making the necessary lifestyle and dietary adjustments, using herbs and supplements for support, and addressing the underlying root cause of the reflux.
ALTERNATIVE OPTIONS FOR ADDRESSING ACID REFLUX & GERD
1.IDENTIFY FOOD TRIGGERS
GERD is horribly uncomfortable and it’s almost always made worse by dietary choices. One way to alleviate symptoms is by identifying your trigger foods.
Foods may trigger GERD via several mechanisms and a food will often become a trigger based on what is causing the GERD in the first place.
For example spicy foods relax the LES.
IgG food sensitivities or high fat foods may cause inflammation and delay the emptying of the stomach. The longer the stomach takes to empty the more likely it is that digestive juices and acid will come back up.
People with a histamine intolerance may develop GERD after consuming histamine-rich foods.
Every person with GERD has a unique set of food triggers which is why there is no definitive list of foods to avoid. However I have put together a list of common food triggers from various research studies below. By no means is this all inclusive, nor does it mean these foods will be triggers for you, but you can use this list to begin pinpointing your own triggers. You can try removing one of these foods at a time, or you can remove them all at once then reintroduce them one at a time to assess your tolerance.
High-fat meals (Fried food)
Tomato and tomato sauces
Yeast (Wine, Beer, Bread)
Soda or carbonated beverages
The key to approaching your diet if you have reflux or GERD is to remember that no two people will respond the same way to the same foods. Your trigger foods may or may not be someone else’s.
However, two dietary approaches that have been shown to provide healing benefits for reflux and GERD in some individuals include:
• Low-carbohydrate diet: By decreasing the amount of simple carbohydrates in the diet, you can reduce the amount of unabsorbed carbohydrates (such as refined sugars and grains) that can be left behind to ferment in the stomach. When carbohydrates are not broken down properly and ferment in the stomach, gas pressure can build. That high pressure can then push the stomach contents upward. A lower-carb diet can also help with weight management, which lowers the risk for heartburn, acid reflux, and GERD.
The amount and types of carbohydrates to be consumed on this diet will vary based on bio-individuality and should be approached with professional guidance.
• Low-fermentation potential diet: This therapeutic diet also called the Fast Track Diet was pioneered by Dr. Norman Robillard of the Digestive Health Institute. It restricts certain fibers and prebiotics that can increase the production of gas.
I am going to emphasize that you should not be on any restrictI’ve elimination diet for more then about 3 months. It increases the risk of nutritional deficiencies. it is also important that any elimination diet be overseen by a dietician or by somebody who’s experienced with it because you have to reintroduce foods with time. If you don’t it increases the chances that you will reduce diversity in the microbiome, which may be harmful in the long run.
That being said, removing trigger foods or following a specific protocol can be helpful while the root cause of the issue is pinpointed.
2.EXPERIMENT WITH LIFESTYLE MODIFICATIONS
Research supports the following lifestyle changes to reduce GERD:
Eat to 80% stomach capacity. Overeating stretches the stomach and increases pressure in the stomach and makes the LES work harder. Also, it delays emptying of the stomach. It’s best to eat until you’re comfortably full, not stuffed.
Eat small meals. Smaller meals limits the pressure on the abdomen. When excess weight pushes against the stomach it lessens the pressure on the LES which increases the likelihood that food contents and digestive juices will come back up. Smaller meals reduce the risk of reflux.
Maintain proper posture when eating. The angle of the body while digesting is important. It helps to sit upright, not slouch forward which places more pressure on the abdomen. You also want to avoid lying down afterwards for at least an hour or two. In fact one simple strategy I encourage clients to do is to stand after eating or walk around for a bit if they can to help lessen reflux and heartburn symptoms.
Eat at regular meal times. Our bodies crave routine so they can optimize processes. Predictable meal times helps prime the digestive tract for food and reduce GERD.
Eat early and no bedtime snack. Eating dinner several hours before bedtime has been shown to reduce the risk of night-time GERD. This is especially true if your GERD is attributed to a weak LES, as lying horizontally makes it harder for your body to contend with gravity.
Raise the head of the bed. Another tip to prevent night time reflux is to sleep with your head elevated, about 6”.
Minimize mealtime stress. Stress around meals isn’t healthy for anyone, but if you are battling reflux or GERD it can be particularly problematic. Stress disables the body’s parasympathetic nervous system function (rest and digest) and enables your body’s sympathetic nervous system (fight or flight).
If you’re “fighting and flighting” you’re not “resting and digesting.”
Long term stress has been shown to decrease mucus production. It can also weaken the LES and cause reflux regardless of your stomach acid levels. This can contribute to functional heartburn. Sitting down for meals, eating without distractions, chewing food thoroughly and completely (consistency of applesauce), and taking time to eat (aim for at least 20 minutes a meal) are great ways to minimize mealtime stress.
3.SUPPLEMENTS & HERBS FOR DIGESTIVE SUPPORT
Demulcent herbs relieve heartburn because they insulate the esophagus from corrosive acid. DGL, Slippery Elm, and Marshmallow Root are three that have been researched and shown to be effective.
Deglycyrrhizinated Licorice (DGL) helps heal ulcers. It also stimulates mucous protection to protect the esophagus and the gastrointestinal tract. According to a 2012 study, DGL was shown to promote mucus activity. This extra mucus may act as a barrier to acid in the stomach and esophagus. This barrier can allow the damaged tissue to heal and prevent future occurrences of acid reflux.
A 2018 study found that DGL was more effective than acid-suppressive drugs. This supported earlier research.
DGL is a form of licorice that has been processed for safer consumption. They remove a substantial amount of a substance called glycyrrhizin. This makes DGL safer for long-term use and has less interactions with medical conditions or medications than regular licorice extract.
Marshmallow root and slippery elm both contain mucilage that forms a slimy, viscous liquid when added to water. Mucilage coats the esophagus to shield it from acid and relieve heartburn.
Slippery elm is a traditional Native American remedy. It’s an herb that comes from the inner bark of a deciduous tree native to eastern Canada and the eastern and central parts of the United States. Slippery elm is dried and produced in the form of capsules, teas, and tinctures and can be used to protect, soothe, and heal irritated mucous membrane tissue in the esophagus, stomach, and intestinal membranes.
Marshmallow is demulcent, emollient, and anti-inflammatory. It’s made up of 10-30% mucilage and that mucilage coats the esophagus and the stomach. This coating effectively protects the LES and esophagus from stomach acid, so if acid gets up into your esophagus it won’t cause any further irritation. This also enables existing irritation to heal.
Magnesium has also demonstrated a positive impact in some cases. It helps relax the LES. This means that food can pass through more easily. And when the exit door of the esophagus is blocked the stomach contents have nowhere to go. It may try to make its way back up, resulting in reflux.
People with GERD frequently have issues digesting their food, and in most cases, stimulating digestion with digestive bitters can work. Bitter herbs stimulate the release of saliva, stomach acid, pancreatic enzymes, and bile.
Bitter herbs also work to increase the lower esophageal sphincter tone to help keep the stomach contents from flowing up. They also increase mucous production as well.
I find 5-30 drops of Yellow Gentian sipped 10 mins or so before meals can help prevent most cases of reflux. Bitters needs to be sipped and tasted in the mouth so it’s important to not down them in a tincture then eat immediately. The bitter taste is what secretes enzymes, so mix bitters in water and sip 10 minutes or so prior to meals.
Caution: In rare cases, bitter herbs can aggravate heartburn caused by other factors like SIBO, H. pylori, certain drugs, hiatal hernia, erosive esophagitis, and anatomical issues. If you take hitters and heartburn worsens, stop immediately.
If someone doesn’t want to use bitter herbs or they prove un-helpful, I sometimes recommend zinc or apple cider vinegar which are supplements that can help the body produce sufficient HCL.
Zinc is one of the co-factors necessary for several different enzymes to perform different reactions including the production of HCL or stomach acid. This activates the chief cells in the stomach, telling them to get ready to secrete pepsin which is the main enzyme responsible for the digestion of protein. If the stomach is not acidic (insufficient HCL) then pepsin is not released. This can result in reflux from undigested food particles lingering in the stomach. Zinc can help the stomach’s natural production of HCL.
Raw apple cider vinegar is a fermented liquid made from crushed apples, bacteria, and yeast. It’s rich in protein and enzymes that can help break down bacteria in food. Raw apple cider vinegar can increase stomach acid levels because its acidic properties introduce more acid into the digestive tract.
Other than increasing stomach acid levels, raw apple cider vinegar has also been associated with reducing symptoms from acid reflux, diabetes, and high blood sugar.
To use apple cider vinegar, dilute 1 TBSP in 2 TBSP of water and drink it before your meal. Without water or another solvent, apple cider vinegar can damage the enamel on your teeth.
In the event these supplements do not work you can try digestive enzymes, betaine HCl with pepsin, or even ox bile. These support digestion, particularly of proteins and fats, and accelerate gastric emptying to reduce GERD.
Caution: Digestive enzymes and betaine HCL can sometimes irritate inflamed mucosa like esophagitis and ulcers. So again, if consumption worsens symptoms, stop taking immediately.
Interestingly enough melatonin is another helpful supplement. The intestinal tract makes 500x more melatonin than then pineal gland. This “sleep hormone” plays a vital role in digestive function. Significant research supports the use of melatonin for GERD. Melatonin works by numerous mechanisms including increasing mucous production, decreasing stomach acid and increasing LES tone.
Supplementing with melatonin is particularly useful if you consistently suffer from night-time reflux.
THE BOTTOM LINE: These diet, lifestyle, and supplement suggestions offer some rational, natural and alternative approaches to reflux and GERD management. If you have mild occasional reflux you will likely only need to identify and remove your food triggers and make some simple lifestyle adjustments.
If your GERD symptoms are ongoing and accompany digestive issues you may also benefit from digestive support like bitter herbs, apple cider vinegar, or enzyme supplements. I would also encourage you to work one-on-one with a professional to pinpoint and address the underlying root cause of the reflux and GERD.