- Lindsey Dalton
- March 2, 2023
Heartburn: Root Causes and Natural Support
Heartburn is one of the most common digestive diseases. A 2013 systematic review reported that up to 27.8% of the North American population had experienced gastroesophageal Reflux Disease (GERD) symptoms.1 While anyone can get heartburn, advanced age and obesity are associated with higher risk. Symptoms are often tolerable and short-lived; however, for those with GERD, it is the reality of daily life. Before digging into what we can do, we must understand heartburn and its causes.
What causes heartburn?
Heartburn, the primary symptom of GERD, occurs when the digestive acid in the stomach splashes up into the esophagus. This acid can cause a burning sensation in the chest that may radiate up into the neck, throat, and even the back.2 This list of symptoms is not all-inclusive; each case may be different.
You may be wondering, how does the acid get into the esophagus, doesn’t the body have a way to keep it contained? Yes. In the digestive tract, there is a muscle, the lower esophageal sphincter (LES), that wraps around the entrance to the stomach. Picture an elastic band or a drawstring. The LES is always tightly closed, except when you swallow food, to keep the contents of your stomach inside. When pressure builds up in the stomach, or the muscle doesn’t stay completely closed, acid can escape up into the esophagus causing pain.
Finding the right solution for your own cause of heartburn can be challenging if you are not well-informed about your own gut health. Increased intra-abdominal pressure is a major cause of heartburn and can result from maldigestion, overgrowth of bacteria in the gut, food intolerances, and obesity.3
Maldigestion
In a healthy adult, the pH of stomach acid is around 1 and rises to about 5-6 after eating. While your food is being digested, your stomach acid will re-acidify. This process can take at least 4 hours in older adults compared to one hour in younger adults.3 The acidic stomach environment is necessary for proper digestion and absorption of proteins, vitamins, and minerals. It can also reduce the level of bacteria in your stomach preventing “bad” bacteria from over accumulating. While there is no guideline to define “healthy” parameters, the importance of the acidity of the stomach is clear for proper digestion to take place.
Chronic stress is a key contributor when looking at maldigestion. Stress slows down motility, reduces digestive acid secretion and blood flow, and can change the microbiome in the gut.4 When the “fight or flight” response in the body is always active, the “rest and digest” process is put on hold.
Maldigestion may also simply be caused by a lack of digestive enzymes. PEI, or pancreatic enzyme insufficiency, reduces the body’s ability to absorb fats leading to gastrointestinal (GI) effects like diarrhea and deficiencies in fat-soluble vitamins. PEI can be difficult to diagnose. Certain pancreatic enzymes can be measured to determine pancreatic function, specifically fecal elastase-1 (FE-1).5 The results of a stool test can help reveal a diagnosis of PEI but may also produce falsely negative results.5 For example, an FE-1 result of <200µg/g is the cutoff for PEI, but the average FE-1 level in a group of adults aged 20-28 is around 450µg/g or higher.5 The difference between 200 and 450 is pretty significant and if you fall into that range, you may not be producing enough pancreatic enzymes to digest your food properly. One study correlated increased age with decreased FE-1, with 1 in 5 adults over the age of 60 having results consistent with PEI.5 None of the participants had a history of diabetes or any GI disease.
When the body is unable to regulate stomach pH or fully digest food, the microbiome in the gut can become imbalanced.
The Gut Microbiome
As discussed in many of our prior posts, there is a strong connection between gut microbiota and your overall health. Heartburn, of course, is no exception. Having too much or the wrong bacteria in the GI system can contribute to poor digestion and the release of gasses within the digestive tract. Small intestinal bacterial overgrowth (SIBO) is a great example of this. Gasses in the stomach and small intestine increase intra-abdominal pressure.3 Increased pressure will make it harder for the muscle keeping the stomach’s contents contained to stay tightly closed. This will, of course, allow stomach acid up into the esophagus causing a burning sensation (heartburn).
Food Intolerances and Allergies
The digestive tract is protected by a single layer of cells sometimes referred to as the mucosal lining. Consuming foods the body is sensitive to can result in activation of the immune system in the digestive tract causing damage to this protective layer. Continued exposure to these foods may lead to increased inflammation, damage to the mucosal lining, and potentially more complicated immune conditions including irritable bowel syndrome (IBS), celiac disease, and inflammatory bowel disease.6 A damaged, leaky gut allows particles through that can further activate the immune system.7 Too many immune cells, specifically eosinophils, in the tissues around the esophagus can result in relaxation of LES.8
Treatment and Prevention:
Lifestyle Changes
What you eat and how you eat can be one of the most impactful pieces of the heartburn puzzle.3 Fermented foods (kimchee, sauerkraut, kombucha, etc.) contain natural probiotics which can help balance the gut microbiome (so eat up).3 Some foods, like spicy and fatty foods, can affect stomach acid and worsen symptoms (try to avoid these).9 Overeating and eating too quickly puts additional pressure on the LES (eat less and slow down).9 Obesity and excess weight can also increase the amount of abdominal pressure.3 Body posture during and after meals can even affect heartburn symptoms.3 The LES does not fully close and seal immediately after eating. Bending over and lying down after eating gives the gastric juices an opportunity to leak out of the stomach. Spending just 10-15 minutes upright after eating can reduce this risk.
If a food allergy or intolerance is suspected, doing an elimination diet may help find the culprit.9 An elimination diet typically consists of removing foods believed to be a potential cause of symptoms. Some foods commonly known to be linked to intolerances are gluten, dairy, corn, soy, peanuts, alcohol, caffeine, and sugar. After 2-3 weeks of avoiding these foods, each can be added back into the diet one at a time 2-3 days apart while monitoring for the return of symptoms. There are also functional lab tests that can check for food sensitivities.
If diet and lifestyle changes are not enough to control symptoms, there are a variety of options outside the typical prescription medications.
Supplements and Medications:
- Betaine
- Chamomile
- Digestive enzyme supplementation3
- Digestive bitters
- DGL (deglycyrrhizinated licorice)
- HCl supplementation3
- Marshmallow root
- Probiotics3
- Slippery Elm
If you are interested in knowing more about these supplements, we did a whole blog post on them here.
As you can see, heartburn is a complex topic. A condition that seems so common and simple has many different root causes and solutions. That’s why it’s so important to work with a practitioner and get on a treatment plan that is tailored to you. If you are still wanting more heartburn information, check out this other blog post we did.
As always, if you want to find a practitioner near you, you can find one here.
Written by, Zachariah Bevins PharmD Student
Edited by Lindsey Dalton, PharmD
Resources
- El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal reflux disease: A systematic review. Gut. 2014;63(6):871-880. doi: 10.1136/gutjnl-2012-304269.
- Richter JE, Rubenstein JH. Presentation and epidemiology of gastroesophageal reflux disease. Gastroenterology. 2018;154(2):267-276. doi: 10.1053/j.gastro.2017.07.045.
- ND KF. Episode 23: Functional strategies for the management of gastrointestinal. 2017.
- Konturek PC, Brzozowski T, Konturek SJ. Stress and the gut: Pathophysiology, clinical consequences, diagnostic approach and treatment options. J Physiol Pharmacol. 2011;62(6):591-599.
- Vanga RR, Tansel A, Sidiq S, El-Serag HB, Othman MO. Diagnostic performance of measurement of fecal elastase-1 in detection of exocrine pancreatic insufficiency: Systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2018;16(8):1220-1228.e4. doi: 10.1016/j.cgh.2018.01.027.
- Mayo Clinic. Food sensitivities may affect gut barrier function. . 2016. https://www.mayoclinic.org/medical-professionals/digestive-diseases/news/food-sensitivities-may-affect-gut-barrier-function/mac-20429973. Accessed Feb 23, 2023.
- Rosa R, Ornella R, Maria GC, et al. The role of diet in the prevention and treatment of inflammatory bowel diseases. Acta Bio Medica : Atenei Parmensis. 2018;89(Suppl 9):60. https://www-ncbi-nlm-nih-gov.cedarville.ohionet.org/pmc/articles/PMC6502201/. Accessed Feb 23, 2023. doi: 10.23750/abm.v89i9-S.7952.
- Cloyd DJ. A functional medicine GERD protocol. Rupa Health Web site. https://www.rupahealth.com/post/a-functional-medicine-gerd-protocol. Updated 2023. Accessed Feb 23, 2023.
- ND KF. Episode 71: Cornerstone interventions for GERD with victoria albina. . 2019. https://www.drkarafitzgerald.com/2019/10/02/cornerstone-interventions-gerd-victoria-albina/. Accessed Feb 23, 2023.
Dr. Dalton’s areas of focus include disease state management, medication therapy management, and health/wellness coaching. She is a Whole30 Certified Coach, and is passionate about helping people improve their lives through lifestyle modifications. She has seen first hand how changing food alone can vastly improve your health.
