What is GERD?
GERD stands for gastro-esophageal reflux disease. Many people experience the occasional acid reflux which is characterized by a burning sensation commonly referred to as heartburn, but GERD is diagnosed when acid reflux occurs more than twice weekly and becomes more of a chronic problem. GERD affects 10-30% of the population and is considered quite common. The strongest class of drugs that treat GERD, called proton pump inhibitors (PPIs), are included in the top 10 most prescribed drugs in the the world which provides some insight as to how many people suffer from this condition.
What causes GERD?
GERD occurs when the lower esophageal sphincter (LES) that connects your stomach to your esophagus relaxes, allowing stomach acid to travel into your esophagus and causing the classic symptoms of burning, discomfort and indigestion. Some people may also experience frequent sore throats, bad breath, coughing or hoarseness. The tissue in your esophagus does not contain the protective mucus lining that your stomach has, which is why you experience the burning sensation. If acid continues to travel into the esophagus, tissue damage occurs in the form of esophagitis, ulcers, strictures or more seriously, Barrett’s Esophagus (when esophageal tissue changes and can become pre-cancerous).
Known causes of GERD are obesity, smoking, hiatal hernia, wearing tight clothing or lying down immediately after eating. Additionally, low stomach acid or hypochlorhydria (caused by age, stress, H.Pylori infection or chronic medication use) can cause GERD due to pressure changes that allow the LES to relax.
Disparity in Conventional vs. Functional Treatment
Conventional treatment centers around suppressing acid production rather than identifying why the LES is relaxing in the first place. In fact, when we suppress the production of stomach acid through antacids we tend to have MORE digestive issues and continued issues with acid reflux due to increased intra-abdominal pressure. Mineral depletions are common in addition to medication induced hypochlorhydria (low stomach acid). Interestingly, the more stomach acid we have, the more tightly closed our LES tends to be. Treating acid reflux with supplemental stomach acid may seem counterintuitive, but it has been shown to reduce acid reflux symptoms in many. It’s reasonable to think that perhaps many cases of hypochlorhydria have been diagnosed as GERD and are being treated with acid suppressing medications. Of course, there are times when medications are needed: H. Pylori infection, gastric ulcers or gastritis are examples.
Bottom line: We should identify why the LES is relaxing in the first place, rely on PPI medications only as long as necessary but not long term if possible, and support overall digestion and stomach acid secretion.
Why do we need stomach acid?
Stomach acid, or hydrochloric acid, is vital for keeping pathogenic bacteria from traveling into the small intestine and residing there. It’s also important for protein digestion, and the utilization of Vitamin B12, Iron, Calcium, Zinc and Folate. Without stomach acid, we are more likely to get exposed to pathogenic bacteria that can cause infections or food borne illness. Long term use of PPIs is linked to increase risk of small intestinal bacterial overgrowth (SIBO) as well as an imbalance of pathogenic to beneficial strains of bacteria in the microbiome, known as dysbiosis and increased risk of hip fractures as well.
Long term use of PPIs may set us up to be in a vicious cycle: PPIs reduce stomach acid which promote bacterial overgrowth and poor digestion. This overgrowth in turn causes gas and fermentation, changing the pH of the stomach and relaxing the LES allowing what stomach acid is present to get into the esophagus.
Considerations for GERD
Low carbohydrate diet – Studies suggest that consuming a low (between 100 -150 g/CHO) or very low CHO (<20 grams daily) may reduce acid reflux, especially in obese individuals, while a high CHO diet exacerbates symptoms of acid reflux. One possible reason for this is that carbohydrates are readily fermented by bacteria. If food is not being digested well in the stomach (i.e – if someone has been on acid suppressing medication for a while), or if there is an overgrowth of bacteria in the small intestine (SIBO), carbohydrates may be fermented and gas produced. The more gas produced, the more the pressure changes in the stomach may cause the relaxation of the LES producing acid reflux.
Identify food sensitivities – Gluten, dairy and eggs have all been implicated as common sensitivities that may provoke acid reflux. Some people find that an elimination diet along with digestive support is the right course of action to determine the root cause of acid reflux. Click here to learn more about the MRT test that we offer for food sensitivities.
Avoid common dietary triggers – Chocolate, spicy foods, acidic foods like tomatoes, caffeine, alcohol, mint and high fat foods are well known triggers for acid reflux. They may cause the LES to relax, promoting more acid reflux symptoms.
Chew your food well – Digestion starts in the mouth! When we fail to chew our food well, we miss out on the protection that saliva offers to our mucosal tissue. If we are swallowing un-chewed food, we will need more acid to break it down.
Avoid eating large high fat/high CHO meals – High amounts of fat can stimulate the overproduction of stomach acid, increasing the likelihood of reflux.
Practice stress management – Stress makes digestion worse because it inhibits our parasympathetic or “rest and digest” nervous system. This can cause decreased digestive capacity and low stomach acid, which we now know can be a cause of acid reflux.
Natural Remedies for GERD
Licorice, Marshmallow Root, Slippery Elm, Meadowsweet – Demulcent herbs may help restore and repair the mucosal tissue in the esophagus and protect from the detrimental effects of acid exposure. Biotics Research HCL Ease is a nice combination product.
Apple cider vinegar or Swedish bitters– Anecdotal evidence points to relief from taking several teaspoons of ACV in warm water before a meal or Swedish bitters. It’s possible that the enzymes contained in them help with digestion and breakdown of proteins. It’s also possible that the acidity helps to balance the pH of the stomach and increase stomach acid, thereby allowing the LES to remain closed.
Digestive Enzymes/Betaine HCl – It’s postulated that supplementing with pancreatic digestive enzymes or HCl may help reduce acid reflux. It can be reasonably assumed that better digested food will require less stomach acid, therefore reducing symptoms. Those currently taking medication or those with active gastritis or esophagitis should not take supplemental stomach acid. However, doing a HCl challenge with a capsule of Betaine HCl (around 600 mg) and dosing up gradually to find the proper dosage is associated with reduced pressure changes in the stomach and less acid reflux.
Probiotics – While little hard evidence backs up the use of probiotics for GERD specifically, it’s likely that dysbiosis is present in many with this condition, especially if SIBO or IBS is present or they have been on a PPI for an extended period of time. If tolerated, spore based probiotics with bi-phasic life cycles appear to have the best change of arriving intact in the large intestine, rebalancing the microbiome and helping to heal the intestinal lining.
Calcium – Calcium improves muscle tone and neutralizes stomach acid when taken in carbonate form (i.e Tums or Rolaids). While not a long term fix for GERD, taking chewable antacids on occasion for symptom relief does not appear to have lasting ill effects like stronger prescription medications do.