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Acid Reflux: Too Much or Not Enough Stomach Acid?

Acid reflux occurs when the contents of the stomach come in contact with the esophagus causing a burning feeling in the chest and throat. Unlike the stomach, the esophagus does not have a layer to protect against acid. Chronic acid reflux is also called gastroesophageal reflux disease (GERD). Often these terms are used interchangeably, however heartburn is a symptom of acid reflux, and GERD is a form of chronic, severe acid reflux. Symptoms of GERD include indigestion, nausea, bloating, sore throat, a feeling of something stuck in the throat and epigastric pain.1

 Why Do We Get Heartburn?

Potential causes or contributing factors to heartburn include things like: 

  • Relaxation of lower esophageal sphincter1
  • Increased intra-abdominal pressure (IAP)
  • Obesity1,2
  • Overeating3
  • Lying down after eating3
  • Delayed gastric emptying 2
  • Stress*
  • Hiatal hernia1

*Stress affects gut motility, decreases blood flow, and changes the composition of the gut microbiome. It has been shown that stress aggravates reflux symptoms by blocking the lower esophageal sphincter and increasing sensitivity to acid.4

Too Much or Not Enough Stomach Acid?

Too much stomach acid is usually to blame for heartburn but oftentimes, the opposite is true. Medications used to manage symptoms target this action by reducing stomach acid yet do not address why acid is reaching the esophagus.3 Stomach acid is very important for the digestive system to function properly. It kills opportunistic pathogens and aids in proper digestion and absorption of nutrients. Without enough acid your body cannot digest carbohydrates properly, leaving them to be fermented by bacteria which releases gas and increases pressure.3 

Why Stomach Acid is Good for You

Stomach acid is necessary to digest protein and food, to activate digestive enzymes in your small intestine and to help you absorb important nutrients. Nutrients such as iron, copper, zinc, calcium, folate and vitamin B12 all rely on adequate stomach acid in order to be absorbed into the bloodstream and be used by the body.5 When nutrient absorption is compromised by a high pH this can lead to a host of problems including osteoporosis, autoimmune disease, anemia, depression, and much more. Prevention of bacterial overgrowth is another important role of stomach acid. Stomach acid keeps bacteria from growing in places where it should not be, such as the small intestine. Overgrowth can lead to Small Intestinal Bacterial Overgrowth (SIBO) with symptoms that include GI discomfort after eating, diarrhea, abdominal pain and nausea. 

Drug Therapy

Proton pump inhibitors (PPIs) work by suppressing gastric acid secretion in the parietal cells of the stomach. This lowers the stomach acid content drastically. While this makes you feel better in the short term, these medications actually worsen the underlying problem.3 As your stomach acid decreases so does the overgrowth of bacteria. When these medications first came to market, they were approved for use for a maximum of 6-8 weeks, but now are among the most commonly used drugs worldwide.6 PPIs have been linked to serious conditions like increased risk of bone fractures7, chronic kidney disease8, and pneumonia7, among others.

Histamine H2 receptor antagonists (H2RA) block the histamine in your parietal cells. While they are less effective at blocking stomach acid than PPIs, H2 blockers like cimetidine and famotidine still lower stomach acid and can contribute to some of the same issues as PPIs. Other medications such as antacids also work to suppress symptoms but do not address the root cause of heartburn symptoms.

Nutrition

Our diet has a profound effect on acid reflux. Foods that have been associated with increased acid reflux include things like spicy foods, citrus, tomato-based products and alliums (ex: onions and garlic).4 Additionally, certain foods lower esophageal sphincter tone including chocolate, peppermint, coffee, carbonated drinks and alcohol.4 It may be best to avoid these foods while working to address any underlying causes. Other helpful lifestyle practices include avoiding tobacco and alcohol, not eating close to bedtime or late at night, and having your last meal 2-3 hours prior to lying down. 9,10

Nutraceuticals and Herbal Therapies

There are many nutraceuticals and herbal therapies that can be beneficial to those dealing with acid reflux. Not only can they help with symptoms but many of them soothe and repair the lining of the gut.

  • Alginate, pectin and carbenoxolone products create a barrier that protects the esophagus4
  • DGL (deglycyrrhizinated licorice) *caution in those with high blood pressure
  • Chamomile
  • Digestive bitters
  • Slippery Elm
  • Marshmallow root
  • Betaine (not recommended until healing/soothing of esophagus lining has occured)

Bottom Line

Heartburn is a problematic symptom that if left untreated, can be very uncomfortable and even painful. Using diet and lifestyle choices, it’s possible to be free from reflux.

Our Pharmacists at PharmToTable are a great resource for helping you achieve remission in your heartburn symptoms. By looking at your full history, medication history, dietary habits and other lifestyle stressors, we can get a better idea of why you may be having these troublesome symptoms and guide you to relief.  Book an appointment or schedule a free 15-minute discovery call today!

*If you are taking medications for heartburn or GERD, do not stop without first talking to your healthcare provider.   

Written by Dr. Katie Johnstone, PharmD, CHC

References

  1. Young A, Kumar MA, Thota P. GERD: A practical approach. Cleveland Clinic Journal of Medicine. 2020;87(4):223-230
  2. Lee Y, McColl. Disruption of the gastroesophageal junction by central obesity and waist belt: role of raised intra-abdominal pressure. Diseases of the Esophagus. 2015;28(4):318-325
  3. Kresser, Chris. How to Cure GERD without Medication. 2018. https://chriskresser.com/how-to-cure-gerd-without-medication/. Accessed on 05/08/2021.
  4. Konturek P, Brzozowski T, Konturek S. Stress and the gut: pathophysiology, clinical consequences, diagnostic approach and treatment options. Journal of Physiology and Pharmacology. 2011;62(6):591-599.
  5. Wright J, Lenard L. Why Stomach Acid is Good For You. M. Evans. 2001.
  6. Sukhovershin RA, Cooke JP. How May Proton Pump Inhibitors Impair Cardiovascular Health? Am J Cardiovasc Drugs. 2016;16(3):153-161
  7. Takagi T, Naito Y, Inoue R, et al. The influence of long-term use of proton pump inhibitors on the gut microbiota: an age-sex-matched case-control study. J Clin Biochem Nutr. 2018;62(1):100-105.
  8. Li T, Xie Y, Al-Aly Z. The association of proton pump inhibitors and chronic kidney disease: cause or confounding? Curr Opin Nephrol Hypertens. 2018;27(3):182-187. 
  9. Alzubaidi M, Gabbard S. GERD: diagnosing and treating the burn. Cleve Clin J Med. 2015;82(10):685-692.
  10.  Surdea-Blaga T, Negrutiu DE, Palage M, Dumitrascu DL. Food and gastroesophageal reflux disease. Curr Med Chem. 2019;26(19):3497-3511
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