This is part 2 of a 2-part series that sheds light on the causes of GERD, Acid Reflux, & Heartburn, and provides new evidence-based solutions that can correct the root causes of these symptoms.
In part 1 of this article we reviewed how GERD is often treated in orthodox medicine, as well as how it is often treated in naturopathic practices, and some of the problems associated with those treatments. If you haven’t read part 1, go back and do that right now before going on. Here, I’ll discuss a new 9-step plan that address those primary causes.
The Primary Cause of GERD: Abdominal Pressure & Excess Gas
The evidence is overwhelming that acid reflux, in most common cases, is the result of excess intra-abdominal pressure (IAP) and gas pressing up against the lower esophageal sphincter (see right), causing it to open longer and more often, pushing stomach acid back up into esophagus.
If you want to beat GERD, then it starts with addressing that excess pressure and gas. The gastroenterology journals as well as functional medical doctors are starting to address this as well, and we are at a point now where we have some very effective interventions that could solve this issue for millions of people.
A Primary Source of the Excess Gas in GERD: Carbohydrate Mal-Absorption
There appear to be certain carbohydrates (sugars) that are not well absorbed or broken down by some people. So these sugars just sit in the digestive tract where they are eaten by bacteria, creating the gas that can cause acid reflux.
This theory explains why people who are given antibiotics get major relief from their acid reflux for a long time afterwards — because antibiotics kill off many of the bacteria that create all this gas.1http://www.ncbi.nlm.nih.gov/pubmed/9079271 It also explains why people who stop eating certain carbohydrates also get relief from acid reflux because they are removing the food these bacteria eat to create that gas as well.2Improvement of gastroesophageal reflux disease after initiation of a low-carbohydrate diet: five brief case reports. 2001. http://www.ncbi.nlm.nih.gov/pubmed/11712463 & A Very Low-Carbohydrate Diet Improves Gastroesophageal Reflux and Its Symptoms. 2006. http://link.springer.com/article/10.1007%2Fs10620-005-9027-7?LI=true
The New Nine Step Solution to GERD
Hopefully now you can see what is likely behind all that heartburn and acid reflux. Here’s the quick summary of the common causes of acid reflux:
- Excess gas and pressure in the abdomen…
- Caused by certain carbohydrates in the digestive tract…
- Being eaten (fermented) by an over-growth of bacteria in the small intestine.
That’s about as simple of a summary as I can do to help you understand what’s behind the GERD epidemic. Understanding this is critical in understanding why the next nine steps are what they are.
Nine steps might sound like a lot, and this is a very long article. But trust me, if I can do this, you can too. So finally, here it is.
Step 1. First, Get a Proper Diagnosis
I personally see too many people who have chronic GERD or Acid Reflux trying to self-treat for years with all sorts of remedies they’ve read about online. Some people are successful, but others make things worse — far worse — usually because they have an underlying mechanical issue that was never properly diagnosed. Here’s some things you will want to rule out before trying to treat GERD.
Hiatal Hernia: The first possible mechanical dysfunction is a hiatal hernia. Briefly, this is where a small portion of the stomach and lower esophageal spincter (LES) gets pushed up above the diaphragm. It is possible that up to 50% of people with GERD actually have a hiatal hernia.3Pathophysiology of GERD:
Lower Esophageal Sphincter Defects. 2004. http://www.practicalgastro.com/pdf/May04/MitreArticle.pdf and often surgery is highly effective, as long as there are not ongoing lifestyle factors that re-trigger the hernia or reflux.
Heart Conditions: Cardiovascular symptoms can also mimic symptoms of heartburn, GERD, and Acid Reflux. So if you are at risk of heart disease or have a known heart condition, heart complications should be ruled out. The good news is that very often, what people think are heart-related symptoms are actually from GERD, but it’s still important to rule that out.
Lower Esophageal Sphincter Dysfunction and Diverticula: There are other, less common, mechanical causes for reflux, including severe LES dysfunction, or diverticula. In all cases, an upper endoscopy or a barium swallow can be a critical part of assessing the cause of a patients’ GERD.
Severe Esophageal Damage (Barrett’s Esophagus): GERD can cause serious problem in the esophagus such as erosion, ulcers, and a constriction of the esophagus sometimes known as Barrett’s Esophagus. It’s important to have a medical evaluation ruling out these severe complications usually through an upper endoscopy or barium swallow.
Small-Intestinal Bacterial Overgrowth (SIBO): If you have true SIBO, diagnosed with a Lactulose Breath Test for Hydrogen and Methane, the following plan will likely give you some success, but it will be limited and temporary. I believe SIBO is a major cause of GERD because an over-growth of bacteria in the small intestine is a major source of the kind of excess gas that causes GERD. You cannot treat SIBO with diet alone — it requires some level of anti-biotic therapy, whether with pharmaceuticals or herbals, as well as a much more restricted diet.
Use of NSAIDs like Ibuprofen and Aspirin. The lining of your digestive tract requires something called “prostaglandin” to produce a thick mucous that protects you from digestive acids and enzymes. NSAID drugs work in part by reducing prostaglandin, and in many people, particularly those with certain genetic variants, these drugs can cause severe damage the mucosal barrier of the digestive tract. It is important that if you are taking these drugs and experiencing any symptoms of GERD or blood in your stool, that you see a licensed medical provider before trying to treat yourself for GERD.
Independent Risk Factors for GERD: Obesity, Over-eating, & Smoking: Just a little exception to the next steps is that if you are obese, chronically over-eat, or are a daily smoker, these are three independent risk factors for GERD, and doing the next steps may have limited effects until you address these factors.
By self-treating GERD before you have had a proper diagnosis or medical evaluation, you potentially run the risk of making things worse or at best wasting a lot of time and money.
So if you have anything more than very mild symptoms, or you have had this issue for many years, it will almost always help to have a professional who knows what they are doing evaluate you for any of these more serious problems, and can also show you how advanced your symptoms really are. Please see a medical professional that might include your primary care provider and/or a specialist like a Gastroenterologist, Pulmonologist, or an Otolaryngologist.
Step 2. Close the Kitchen at least 3 hours Before Bed
I am making a big deal out of this, because, well, one of the top physicians specializing in Acid Reflux, Dr. Jamie Kaufman, recommends this above all else. And I have seen this be the easiest and most effective step in my own experience too.
This is important for everyone with heartburn and acid reflux, but it’s particularly important for those who have night-time reflux and those with mostly respiratory symptoms (see part 1) and no heartburn. However, it’s really important for all people with acid reflux. If you’re the person with post-nasal drip, chronic “allergy” symptoms, asthma, chronic cough, sinus congestion, hoarse throat, hoarse voice, and similar symptoms, this is critical for you.
As I have mentioned earlier, your airways are extremely sensitive to stomach acid. While your esophagus might be able to withstand dozens of reflux episodes in a day, all it takes is one reflux to your airway to cause damage.
Apart from the 2 dietary changes below, this is the most important step you can take — simply do not eat 3 hours before bed.
You can achieve this by keeping your food intake in a regular 8-12 hour window each day (for example, eating breakfast at 8am, lunch around noon, and a smaller dinner around 6 or 7pm, and bed around 10pm). This not only can help reduce reflux, but it can also give your digestive tract the time it needs to rest and repair each day.
Step 3. Make Two Specific Changes to your Diet
In almost every case of GERD, it has been found that lowering the gas from carbohydrates in the digestive tract is the #1 factor in preventing GERD. Removing your intake of certain carbohydrates just might be the key for many people in at least reducing the incidence of acid reflux.
There have been at least two clinical studies on lower carbohydrate diets and GERD. Even though they were small studies, they were done on some very severe cases with striking results.4Improvement of gastroesophageal reflux disease after initiation of a low-carbohydrate diet: five brief case reports. 2001. http://www.ncbi.nlm.nih.gov/pubmed/11712463 & A Very Low-Carbohydrate Diet Improves Gastroesophageal Reflux and Its Symptoms. 2006. http://link.springer.com/article/10.1007%2Fs10620-005-9027-7?LI=true
What’s nice is that it’s often not necessary to remove all carbohydrates or even to severely restrict them. It turns out there are a few types of carbohydrates that are probably the biggest offenders. And the top one is lactose from dairy products.
First, Remove Dairy (Lactose) Completely. This is More Critical than You Might Think.
Double star this one, memorize it, imprint it on your brain if you have GERD, and think about it every time you drink milk or eat dairy.
Indigestion of lactose, the sugar found in dairy products, is the top culprit in all this excess gas pressure. Lactose is one of the most poorly absorbed carbohydrates we know of for many people, as most of us lack enough of the enzyme that breaks it down.
This means it spends a lot of time in your gut where bacteria can have a field day creating all kinds of gas that pushes back up into your stomach and esophagus.
In one study, patients were given 30 grams of lactose up their bums (yes, all in the name of science). This is the equivalent of about 2.5 cups of ice cream. The lactose created so much gas that it travelled all the way back up to the stomach and increased the time and frequency that their esophagus relaxed or opened, significantly increasing episodes of acid reflux in participants.
It also lowered the threshold by which the esophagus would open (allowing acid into the throat), meaning it took less pressure than normal to open it up.5Modulation by colonic fermentation of LES function in humans. Am J Physiol Gastrointest Liver Physiol 2000.
If you are serious about solving your reflux problem, entirely remove lactose for 3 weeks. If you do nothing else, try this, and let me know how you do. It’s probably not enough for everyone, but it may be the linchpin for many.
While removing dairy completely might be necessary for some, you might be able to get away with cheeses aged more than a month and other dairy products that are very low in lactose. (Hint: lattes are NOT low in lactose). I am also on the fence about raw dairy, since it contains the enzymes that break down lactose. While I do believe that some people can benefit greatly from raw milk, for others it may be part of what is exacerbating GERD.
Second, Lower Your Intake of Other Carbohydrates & Sugars known as “FODMAPs”
FODMAPs stands for 4 different types of carbohydrates that are known to cause the kind of excess gas in the digestive tract that can lead to GERD. The acronym stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols. Lactose from dairy is, in fact, one of these FODMAPs.
Here are the most common examples of these carbohydrates I see people eating that may be implicated in GERD and acid reflux. This is not an exhaustive list, just a place to start:
- Lactose from dairy products is the biggest offender here, as I just mentioned. Butter and cheeses aged more than a month are often ok, but some may not tolerate them very well. Ghee or clarified butter may be a better option as these are usually free from lactose.
- Oligosaccharides (“FOS” & “GOS”) — wheat, rye, barley, apples, peaches, watermelon, artichokes, onion, garlic, and certain legumes such as chickpeas, kidney, fava, navy, pinto and baked beans (although lentils and black beans appear to be ok in small amounts). Also avoid pre-biotic fiber supplements like inulin.
- High Fructose Foods — apples, honey, corn syrup, agave nectar
- Other Disaccharides & Monosaccharides — Table sugar, molasses, and beer are next in line.
- Polyols (Sugar Alcohols) — sorbitol, mannitol, xylitol, apples, watermelon, peaches, pears, blackberries, cauliflower, and more. Artificial sweeteners should be removed entirely.
It is almost impossible to give a general recommendation here as some of these will inevitably cause problems for some people and not for others. It’s important to get to know your body and what is affecting you.
In general, the foods listed above are known to be the biggest offenders when it comes to carbohydrates that are poorly absorbed and lead to excess gas. They are also highly implicated in IBS, so much so that the “Low FODMAP” diet is a leading dietary treatment for IBS in many university settings. I would like to see it also become a leading treatment for GERD and Acid Reflux as 67% of people with IBS also have GERD.6http://www.wjgnet.com/1007-9327/pdf/v16/i10/1232.pdf
Note: Restricting Too Many Carbs for Too Long Can Lead to More Problems: It can be important for some to highly restrict carbohydrates for a while, but as soon as it is possible and once digestive function has started to improve, I think it’s important to begin to add some good carbohydrates back in as they are tolerated. Restricting carbs or fiber too much for too long can cause some people to just feel bad and have pretty low energy or poor digestion. I recommend continuing to eat things like nuts, seeds, rice, potatoes, lentils and black beans in small amounts as tolerated if you are one of those folks who don’t do well on a very low carbohydrate diet.
Step 4. Beat the Bloat by Reducing Bacterial Overgrowth
The reason there tends to be excess gas pushing acid up the esophagus is due to a high level of little critters in the upper GI tract that shouldn’t be there. These bacteria feed on carbohydrates and make a lot of gas. Remember, that gas is a huge part of many reflux symptoms, and if you have any amount of bloating, or if you have fluctuating levels of bloating where youwake up ok and by the end of the day your belly is bloated, this might be a critical step for you.
This is where things can get very complex, very quickly, and well beyond the scope of this article. If you have something less severe than SIBO, anti-bacterial herbs like Barberry and other Berberine-containing herbs, Black Walnut Hull, Neem, and more can be useful. My go-to formula for this is first to try GI-MicrobX from Designs for Health. These should be used at the right doses and under supervision of a healthcare professional.
However, if this doesn’t help, you may have a more serious bacterial or fungal overgrowth, and I can only refer you out to a good medical provider who specializes in diagnosing and treating “SIBO” (Small Intestinal Bacterial Overgrowth) and other conditions of overgrowths in the upper GI tract. SIBO can be extremely hard to treat and keep at bay if that’s what you are dealing with. If you want further guidance, Dr. Allison Siebecker, ND, has developed some wonderful protocols on her site for you to learn more about testing for SIBO and reducing bacterial overgrowth and bloating from both a dietary, antibiotic, and herbal medicine perspectives here.
Probiotics, which are often used in GERD, are a double-edged sword here. In some cases they can cause more gas, and hence, more reflux. This is where things must be individualized.
If you want, getting a test for Small Intestinal Bacterial Overgrowth (aka “SIBO”) is becoming a common test run by many integrative and functional health practitioners — if your bloating is severe, this might be for you.
Step 5. Support and Heal the Esophageal Lining
If you’ve had GERD for some time, chances are your esophagus is already somewhat inflamed and irritated (esophagitis), and you may have erosion or an ulcer.
Since many people with GERD can actually benefit from more stomach acid, it’s important before they attempt to increase the acidity of the stomach that they ensure they first take steps to heal and protect the esophagus.
I’ve personally seen people who took betaine hydrochloride (a supplemental form of stomach acid) make esophageal problems worse since the lining of esophagus has little protection against stomach acid in the first place.
Here are the most effective ways I know to protect and heal the lining of the esophagus. I would recommend consulting with a clinical herbalist or a knowledgeable physician or nurse practitioner before using any of these methods.
Warning here: Some people who only have upper respiratory issues (sinusitis, allergies, asthma) may be told by a GI Specialist that it’s not from acid reflux because they see no damage to the esophagus. This is wrong. The esophagus can take a lot of refluxes in a single day without damage, but you only need one reflux a day into your throat, nasal passages, or lungs to create problems. This usually happens to people at night. If you have respiratory symptoms and you suspect “silent” reflux, the specialist who are best at diagnosing this, when there is no damage to the esophagus, are Otolaryngologists and Pulmonologists, not necessarily Gastroenterologists who sometimes mistakenly believe if there is no esophageal damage, there must not be any reflux.
Here’s 3 strategies for healing the esophagus if you have damage:
1. Demulscent (Coating) Herbs
These are plants that have been used for millennia for GI problems because when eaten they create a mucilage or mucous that coats and protects the lining of the GI tract. They can be very safe, easy, and inexpensive ways to support the healing of an inflamed esophagus.
Perhaps the most widely used among clinical herbalists are slippery elm and a kind of licorice root without the glycyrrizin, known as “DGL” or de-glycyrrhized licorice root. I personally like powdered Meadowsweet taken as a tea as well. These work best for the esophagus as teas, chews, or lozenges, not as capsules, because they need to make contact with the esophagus in order to coat it.
This is not a short-term thing. Most people need to use these often for a period of time for them to be ultimately helpful in healing. They work by coating and soothing the esophagus — so you need to keep it coated.
Generally, here’s my top methods to use before every meal when supporting the esophageal lining. Pick one:
- Chew either two DGL tablets (760 mg) or 1/2 teaspoon DGL powder (900 mg) in water. Take them 5-10 minutes before meals. My favorite is DGL Synergy from Designs for Health or Vital Nutrients DGL Powder. Some herbalists actually say they are best taken after meals, so you might try that.
- Drink 4 ounces of a tea made with Slippery Elm powder or Althaea (Marshmallow) powder. Mix just a small amount of them slowly into hot water while mixing. You do not want this too thick, and you will want to wait until it is well mixed and fully incorporated to drink (about 5 minutes).
- Drink 4 ounces of Meadowsweet tea, about 1/2 – 1 tsp of the dried herb steeped in hot water for 15-20 minutes 3x per day. You can even combine pre-made meadowsweet tea (which will keep in the fridge for up to 3 days) with some Slippery Elm or Marshmallow powder for an even better tea. Simply re-heat the Meadowsweet tea very gently, add your powders and you’re done.
2. Wound Healing (Vulnerary) & Anti-Inflammatory Herbs
The 2nd class of herbs used for healing an esophagus are the soothing and wound healing herbs. These would be added to a regimen specifically if there is known erosion or ulcers in the esophagus.
Meadowsweet (Filipendula ulmaria) has already been mentioned, but I’m repeating it because it is not only a wonderful coating herb, it is anti-inflammatory, analgesic, and tones and helps heal the esophagus and stomach. It’s often used for ulcers. A little trivia — this plant is where aspirin was discovered, but unlike aspirin, it doesn’t irritate the GI tract, but helps soothe and heal it. It’s great as a tea (1 tsp of dried herb steeped in 4 oz of water for 15 minutes) or as a tincture (30 drops in water, 2-3x per day).
Calendula flower (Calendula officinalis) is perhaps a favorite for soothing and healing an irritated esophagus. You can use the dried herb as a warm tea anytime. You could also put 20-30 drops of a tincture into your slippery elm or meadowsweet tea. Some people with ragweed allergies can have allergic reactions to this.
Goldenseal (Canadensis Hydrastis) is another wonderful esophagus healing herb. Goldenseal is a unique herb that contains Hydrazine, which promotes mucosal secretions and thickening of the lining of the GI tract so that ulcers and erosions can heal. It is also a natural “cholagogue” meaning it promotes bile and digestive enzyme secretions that can help you digest foods as well. It also happens to contain Berberine which is an anti-microbial that may support keeping levels of bacteria low. This was a very important part of my own treatment.
Goldenseal is very effective as a tincture, however due to it being an endangered species and that long-term use can be toxic, it should be used with great care and under the supervision of a clinical herbalist or medical professional. It’s not recommended for long-term use.
I recommend using it as a tincture, about 15 drops in a little water sipped 3-5 times a day for 2 weeks on and 5 days off, stopping use after 3 months unless guided otherwise by a healthcare professional.
Some other common herbs are Gotu Kola (for red or inflamed esophageal tissue) and Turmeric which is powerfully anti-inflammatory. Using these herbs it’s always best to check with a professional clinical herbalist.
3. Nutritional Support for the Esophagus
L-Glutamine – the most abundant amino acid in the digestive tract is critical for creating a strong mucosal protective barrier in your digestive tract, from mouth to anus. It is very hard to over-dose on it, and therapeutic doses range from 10-30 grams spread throughout the day. Anything less than 5-10 grams a day is probably useless, but don’t go over 30 grams.
Zinc Carnosine – this form of zinc specifically attaches itself to damaged parts of the digestive tract and helps promote tissue healing and reduces inflammation. It is a critical part of healing any damaged mucosal barriers in the body. Make sure it is Zinc Carnosine and not some other form of Zinc chelate.
In this case, I prefer it as a powder, rather than a capsule, so it can make contact with the esophagus itself. If you want capsules, Integrative Therapeutics makes a decent product as well as many other brands. 75mg twice daily (which provides 34mg of elemental zinc) and 30 days is enough time to know if it’s helping.
There are some combination products I have recommended and found useful that contain most or all of these things, including GI Revive from Designs for Health. This contains both L-Glutamine and Zinc Carnosine as well as other great anti-inflammatory and soothing herbs. It is my #1 go-to combination product for healing a damaged digestive tract in most cases, but I usually add a little extra L-Glutamine as there is only a small amount in it.
Melatonin – Up to 500x the amount of melatonin is made in the digestive tract than in the brain. Melatonin may work so well because it directly effects several complications of GERD: oxidative stress, inflammation, and gastric motility.
Several studies have shown it to be a rather powerful supplement for reducing symptoms of reflux. Most studies are on animals, but one human study used 6mg of melatonin, along with other nutrients against a group only taking PPIs. 90% of the melatonin group had relief in 1 week vs. 66% of the PPI group.7Regression of gastro- esophageal reflux disease symptoms using dietary supplementation with melatonin, vitamins and amino acids: comparison with omeprazole. 2006.
I personally recommend taking melatonin only in small amounts for short periods of time (1-3mg 2 hours before bed) as it is a powerful hormone your body produces on its own. I find it’s contra-indicated in those people who take it and wake up feeling too groggy.
However, you can raise your melatonin naturally by making your bedroom as dark as possible and blocking your eyes from all “blue” wave light in the evening after 7pm as blue light inhibits melatonin. Wearing “Blu Blocker” sunglasses, using programs like “F.lux” for computer screens or avoiding TV and other screens, and keeping lighting in the house in the evening to a bare minimum can all be useful to increase melatonin production.
Antioxidants — It’s been suggested that oxidation is a bigger factor in esophageal erosion than stomach acid, which is likely why studies on antioxidants for esophageal damage have had such positive results. Antioxidants such as turmeric/curcumin, mixed tocopherols, grape seed/skin extract, quercetin, and other antioxidants have been shown not only to protect but also help reduce inflammation and heal the esophageal lining 8http://www.altmedrev.com/publications/16/2/116.pdf One herb – artemisia asiatica — was more effective at preventing esophageal erosion and inflammation than Zantac, likely through its anti-oxidant effects.9Oxidative stress is more important than acid in the pathogenesis of reflux oesphagitis in rats. Gut 2001;49:364-371. I have no specific recommendations here other than to be sure that you include a modest amount of antioxidants from your diet as well as from some of the supplements suggested above.
Colostrum – I am a huge fan of high quality colostrum for healing the digestive tract from all sorts of inflammatory conditions. It is beyond the scope of this article to go into all the reasons why it is so helpful for gut healing, but it has been shown to heal leaky gut by repairing the intestinal lining.10http://www.ncbi.nlm.nih.gov/pubmed/21148400 I don’t know of any specific research for erosive esophagitis specifically, but I have found it to be very helpful for this condition. It does contain very low levels of lactose, but this is a case where the benefits may outweigh the risks unless someone is severely allergic to dairy or lactose. Of course, if it causes problems to worsen, there are other options.
The colostrum I use almost exclusively and have had the most success from is Immuno-G PRP from NuMedica. Typically 5-10 grams are needed per day in divided doses for 4-8 weeks.
Step 6. Support Stomach Acidity
We’ve already covered that we naturally lose stomach acid as we age. It’s common for people to lose 40% of their stomach acid production from their teens to their 30s and another 50% by the time they are 70,11Webinar with James Greenblatt, MD, 2014.
You could always have your stomach acid and stomach pH tested to know for sure, and I am almost always a fan of testing, not guessing. But based on the available evidence, it’s pretty clear that the majority of adults have low, not high, stomach acid production.
Raising stomach acid probably works because it actually addresses several problems underlying GERD all at once:
- Speeds up stomach emptying by creating a more acidic environment, which can lower abdominal pressure.
- Kills more bacteria in the stomach and small intestine that can cause excess gas, lowering abdominal pressure.
- Breaks down carbs faster before they can be fermented and create gas, lowering abdominal pressure.
- Breaks down proteins more fully, allowing you to absorb more important amino acids from your food.
- Likely supports the release of more bile and digestive enzymes, further supporting proper digestion of carbohydrates.
Here’s four ways I prefer to support stomach acidity:
First, Address Zinc deficiencies
Zinc influences carbonic anhydrase (CA), which is used to form acid salts in the stomach and CA deficiency leads to insufficient stomach acid. In other words, you need enough zinc to make stomach acid! Zinc is also critical in helping to heal the lining of the digestive tract.
Interestingly enough, PPIs and acid-blocking drugs deplete zinc. If you have been taking PPIs for a while, you likely will need to supplement with some zinc.
For this particular situation, I recommend a 75mg capsule of zinc carnosine (which contains 15mg elemental zinc) or GI Revive (see above) for a 2-3 months. After that 15mg a day from food sources is usually enough, though some people need more as lots of things are known to deplete zinc.
Second, Try a Good Digestive Bitter Tincture
If there is one thing that is a tonic to the entire digestive process, it is eating bitter foods.
It is the bitter taste of foods that really stimulates our entire digestive process from the release of saliva, to stomach acid, to digestive enzymes, and contractions of the digestive tract. A long time ago, a lot of our foods were bitter, but we have bred the tasted of bitter right out of pretty much all our foods, so it is no wonder to me that our digestive processes are weakened with the loss of bitter foods from our modern diets.
If you have a digestive problem, chances are that a good digestive bitter herb will support you. There is a reason it is common in India to eat fennel seeds after a meal — they are bitters!
Not all bitters promote gastric secretions — only non-alkaloidal bitters do that. For example, the bitter from coffee is alkaloidal, so it won’t help in this case.
The best digestive bitters are probably dandelion root, orange peel, and angelica root. Gentian root is phenomenal as well, but I recommend you avoid it because it is highly endangered and there are these great alternatives already mentioned. There are several bitter tinctures I love, including Urban Moonshine and Herbalist & Alchemist, but there are many formulas out there you can use, or you can visit a local clinical or registered herbalist to help guide you.
Note that in using a good digestive bitter, I do not recommend “Swedish Bitters” in this case, or almost ever, which can contain some habit-forming herbal laxatives such as Senna and Rhubarb Root. I have no idea how this is so popular in health food stores.
Digestive bitters are best used as tinctures, not as pills, as it is actually the taste that makes them work. It’s recommend to just use 5-10 drops on the tongue before every meal and holding them in the mouth and swallowing what’s left. Do that before every meal, after a meal if you want, and anytime in between for enhanced digestion. This works best over a long period of time, so keep at it for at least 3 months, and they are very safe for long-term use.
Third, Try Apple Cider Vinegar or Raw Kraut Juice
This is a popular remedy that some people swear by. It can be rather strong on the esophagus if you already have damage there, but if your symptoms are mild, or you are just trying to maintain your freedom from GERD, this is a great option for daily support.
I recommend Bragg’s Apple Cider Vinegar or Raw Juice from Sauerkraut, about 1 tbsp. in about 4 ounces of water, and you can drink it slowly over the day (after you have food on your stomach) or shoot it (diluted) just before or after a meal. If you have stomach inflammation, be very cautious here as this can make it worse — an inflamed stomach lining must be approached cautiously and you may want to work to heal that before increasing stomach acidity.
Adding a little whole himalayan (pink) salt also gives you some chloride (which helps in stomach acid production) and almost 100 other critical trace minerals that support your body.
Fourth, as a Last Resort, Supplemental Betaine HCl
My feelings are very mixed about simply taking large amounts of powdered stomach acid in a pill. I am appalled at the rampant recommendation of this supplement by naturopathic physicians and other natural health practitioners.
On the one hand, it can be very effective, and I mean so much so that I have seen people just jump for joy once they started Betaine HCl + Pepsin supplements. When it works, just about everything gets better, from their head to their toes, from their mood to their poop.
On the other hand, I have seen problems — serious problems. You are swallowing stomach acid, how could anything go wrong, right? Turns out, a lot. People prone to gastritis, who have ulcers, those who already have esophageal erosion, those who have a mechanical cause to their GERD (see step 1), and other factors can cause supplementation with Betaine HCl to be quite unpleasant, and perhaps even dangerous.
Also, maybe the biggest reason I’m not for long-term Betaine HCl supplementation is due to a process called “negative feedback” where taking too much could actually cause your body to react by creating less of its own stomach acid, so that when you stop the supplement, you may actually have less acid than when you started, leading to a kind of dependence on the supplement.
So, it’s important to be careful here with simply taking stomach acid supplements. There are other ways to try first to support your stomach acid production that are far safer and perhaps more sustainable in the long run.
However, if you go this route is to work with a healthcare practitioners. In general I recommend Hydrochloric Acid with Pepsin along with an Acid-Stable Protease, which is the enzyme that breaks down protein. If you really have low acid, you probably also have low digestive enzymes too.
Start with around 100-250mg of Betaine HCl with Pepsin & Enzymes after a few bites of your meal, not before or on an empty stomach. Then after a day or so, if there is no problem, increase to 500mg per meal. Then 750mg per meal, up to 1 gram per meal (1,000 mg). You should never feel a burning sensation — if you do, reduce the amount to a lower level where no burning sensation is felt. Also, your meal has no protein or low protein, you should skip the Betaine HCl with Pepsin for that meal. In general, I say to people if their meal has less than 15 grams of protein, skip the supplement.
Dr. Jonathan Wright, MD often has patients taking 3-4 grams per high protein meal, which is far too much in my opinion than I’ve seen people be able to handle. I feel that even 1 gram is quite a lot.
Last, I would avoid taking HCl with anti-inflammatory drugs like NSAIDs (Ibuprofen, aspirin, etc) or steroids like Prednisone. These drugs can damage the lining of the stomach and intestines and adding extra acid on there is no fun in most cases.
The Betaine HCL + Pepsin & Enzymes I use are varied, but I like Digestive Enzymes Ultra from Pure Encapsulations and Digestzymes from Designs for Health which have slightly lower and balanced levels of Betaine HCl.
Step 7. Support Stomach Emptying
Why Stomach Emptying is Important for Treating GERD: It is well established in medical research that delayed gastric emptying is a major contributor to symptoms of GERD12Delayed Gastric Emptying in Patients with Abnormal Gastroesophageal Reflux. 2001. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1422000/ and that up to 1/3 of people with GERD have a “slow stomach” that doesn’t empty normally, while up to 2/3 may actually have normal emptying, so this is not universal for everyone with GERD.13Gastroesophageal reflux and gastric emptying, revisited. 2005. http://www.ncbi.nlm.nih.gov/pubmed/15913477
When food sits in the stomach too long it can cause more gas pressure and stretching on the esophagus that may causee the esophageal sphincter to open allowing acid and food to come back up.
No one knows exactly why some people have a “slow stomach,” and it is likely there are many reasons. One reason is due to the dysfunction of the opening at the bottom of your stomach called the pyloric sphincter or pylorus (right) through which food is emptied into the small intestine. In some people, this sphincter just doesn’t open well, causing food to stay in the stomach for longer than it should, and this can lead to GERD.
If you have a “slow stomach” that doesn’t empty well, here are some known ways to support it.
- Promote Optimal Stomach Acidity: We’ve already addressed this in Step 4.
- Stay Well Hydrated: Chronic dehydration will cause the pyloric sphincter not to open as well. Drinking plenty of water will solve this, just don’t drink a lot within an hour or so of meals and not when you already feel too full.
- Address Magnesium Deficiencies: Almost 70% of people do not consume enough magnesium.14Dietary Magnesium and C-Reactive Protein Levels. 2005. http://www.ncbi.nlm.nih.gov/pubmed/15930481, and deficiency of this mineral is likely very high. Low magnesium will cause the pyloric sphincter not to open well, and magnesium insufficiency is very common in the United States. Interestingly, PPI drugs used for GERD deplete magnesium so much that the FDA has issued a warning about it to anyone taking these drugs.15http://www.fda.gov/Drugs/DrugSafety/ucm245011.htm
Your physician can test magnesium levels, and you should be at the upper end or even slightly above the standard lab ranges of serum magnesium. However, supplementing with magnesium is very safe, and I routinely recommend 400-800mg of Magnesium Glycinate or Magnesium Bis-Glycinate from Designs for Health a day for 8 weeks as a trial or taking epsom salt or “Ancient Mineral Flakes” baths.
- Try Acupuncture: One area I believe there is good data that acupuncture works is in increasing gastric peristalsis (contractions of the digestive tract) and accelerating stomach emptying.16“Electroacupuncture accelerates solid gastric emptying in patients with functional dyspepsia.” Gastroenterology 2004. & “The affects of acupuncture at sibai and neiting acupoints on gastric peristalsis.” Journal of Traditional Chinese Medicine 2001. Acupuncture also improves esophageal peristalsis, limits lower esophageal sphincter relaxation/opening, and reduces esophageal pain perception.17“Successful treatment of esophageal dysmotility and Raynaud’s phenomenon in systemic sclerosis and achalasia by transcutaneous nerve stimulation. Increase in plasma VIP concentration.” 1987 & Esophageal visceral pain sensitivity: effects of TENS and correlation with manometric findings. 1998.
- Address other medical conditions that can slow stomach emptying: Unmanaged blood glucose from diabetes, Parkinson’s Disease and other neurological disorders, surgical injuries to the vagus nerve, , 13% from surgical injury to the vagus nerve, 8% from Parkinson’s Disease or other neurological disorders.
- Try Meditation, Breathwork, and Relaxation exercises — We have two nervous system functions: “fight or flight” or “rest and digest.” When we’re stressed, our digestion shuts down. Deep breathing turns on our “rest and digest” process. If you haven’t tried it, my favorite is the 4-7-8 breathing method taught by Dr. Andrew Weil. Do this twice a day for 30 days before you judge if it works or not.
- Regular walking after meals — movement can be important in keeping the digestive tract moving optimally and supporting what’s called the “migrating motor complex” which is how the digestive tract keeps things moving through the gut.
- Use Pro-Kinetic Herbs — The go-to #1 formula here for speeding up stomach emptying is a 9-herb combination called Iberogast, which has several small but good clinical trials in its favor. It is also used by many naturopathic doctors around the world. Another plant that has been shown to be “pro-kinetic” or aid in emptying and moving food through the stomach is Atractylodes (Bai Zhu, in Chinese). However, consult a professional clinical herbalist before use, especially a Registered Herbalist found here.
A little side note here: beer actually greatly supports gastric emptying, but it also creates a lot of gas for people, so it’s a bit of a double-edged sword. Use with caution!
Step 8. Support Optimal Digestion with Probiotics and More
Once you have reached this point, this is the time when probiotic bacteria can be most helpful. If you take probiotics when you have slow stomach emptying, are eating a lot of sugars and lactose, have low stomach acid, and a lot of abdominal bloating, probiotics could potentially make problems worse by simply adding more bacteria that make gas in your stomach and small intestine.
However, once you feel like your digestive tract is moving well, as evidenced by reduced bloating and feelings of fullness and regular bowel movements, you might consider probiotics.
The evidence for probiotics is limited, but growing. The fact is, we know very little about which strains do what and which ones will benefit which people, and even how long they last in the gut. I have found most dosages are far too low to make an impact, so you want to look for quality, high dose, multi-strain brands like Garden of Life, Elixa, and more.
There is one exception to this, and that is the use of bacteriophages, which are actually self-limiting viruses that eat a lot of the over-grown “bad” bacteria in your gut that may be responsible for things like GERD, SIBO, and bloating. Even though they are rather safe, these should be used under supervision and there is only one product in the U.S. I’ve seen and it’s brand new from Designs for Health called ProBiophage, and it is targeted toward over-grown E Coli in the small intestines. The use of bacteriophages is very promising, and even though evidence is limited for their use in GERD, I believe they may be worth a trial in some cases.
If you don’t want to take probiotics, there are a few probiotic foods I would recommend. If you can tolerate it without bloating, raw sauerkraut or beet kvass and other raw fermented foods are great. If you cannot tolerate it, just drinking a tablespoon of the kraut or kvass juice or a tablespoon of Bragg’s Apple Cider Vinegar (diluted!) can be useful to start with (see Step 4 above for details). For those who are very sensitive to fermented foods, I have found water kefir to be one of the more gentle ferments, though it’s not as powerful.
Step 9. Maintain Your Progress & Avoid Relapse with Great Lifestyle Habits
The fact is, if you’ve had Acid Reflux in the past, you’re likely to be prone to it the rest of your life. That is, unless you maintain some great habits that, over-time, keep your body on the up-and-up.
Here is just a rapid-fire list of things that are a mix of things that have been researched as well as good old fashioned advice that people swear by for maintaining their freedom from GERD. I have ordered these roughly by level of importance.
- Avoid dairy (lactose) and other “FODMAPS” (see above)
- Stop eating 3-4 hours before bed and keep eating with an 10-14 hour window each day (again, see above).
- Don’t smoke (do I really need to say this in 2015?)
- Eat slowly, breathe deeply, and don’t eat distracted. Pay attention to your breathing and chewing while you eat.
- Relax and practice meditation or deep breathing techniques 2-3x per day.
- Address emotional stress, however you best do that. Anxiety and depression worsen symptoms of GERD, probably in part by impairing digestion.18Effects of Anxiety and Depression in Patients With Gastroesophageal Reflux Disease. 2014. http://www.ncbi.nlm.nih.gov/pubmed/25496817
- Eat Small! Avoid over-eating. Just one meal that is too big can really set some people back for weeks.
- Drink no more than a few ounces with meals. Avoid drinking much within 1 hour of eating.
- Sleep more on your left side.
- Try sleeping with your body slightly elevated. Either elevate the head of your bed or sleep on a wedged pillow. I prefer elevating the head of the bed about 6 inches. Do not just elevate your head by using more pillows.
- If you have “trigger” foods like coffee, peppermint, and tomatoes, consider avoiding them.
- Avoid sitting slumped forward. Sit up straight, get up every 15-20 minutes and walk around.
- Don’t suck in. Let it all hang out. Avoid clothing that is too tight around your waist.
- Avoid constant “grazing” on food.19GERD is becoming a challenge for the medical profession: is there any remedy? 2014. http://www.ncbi.nlm.nih.gov/pubmed/25513138
Fasting: One practice that I wish I wrote more about in this article is fasting. I think that once you’ve addressed underlying nutritional deficiencies, simply giving the GI tract time to rest is vital. If you are healthy enough, practice intermittent fasting — either short 16-20 hour fasts or slightly longer 1-3 days water fasts. However, simply restricting your food intake to an 8-12 hour period in the day is sometimes enough. Use pre-caution and consult with your healthcare provider first before beginning any fasting or nutritional program, of course.
As you can see, this is a huge topic, one I’ve tried to address as simply and as straightforward as possible for a general audience. I truly recommend working with a highly trained practitioner on this issue and getting a proper diagnosis before doing anything else.
Keep in mind that the human body is complex. As with any condition, there are usually unique sets of causes and conditions that bring about symptoms. It’s important that you address your symptoms with you in mind and with a treatment that’s been individualized to you, rather than following a general plan, as good as I believe this plan is. It’s also important to realize that no one is meant to use all of these strategies, or do them in this exact order — that would be overkill. Again, working with someone who can individualize a plan for you is the best road to take.
But I believe you are stronger than you have been led to believe, that your body is more resilient and more able to heal itself, given the right conditions, than you may know. Yet healing is almost never a straight road, it is often filled with twists and turns and good days and bad days. Take them all, use them all. If you can learn to use everything in life — both what you like and what you don’t like, rather than trying to configure a life where there is only what you want — then you will have really mastered the art of living and self-healing.
**If you enjoyed this article, let someone know! Share it and join my email list for exclusive content and to stay in-the-know with what I’m up to and my personal notes from my practice.
**An edited version of this article appeared in the Summer 2015 issue of The Price-Pottenger Nutrition Foundation Journal for Health & Healing.
References [ + ]
|2, 4.||↑||Improvement of gastroesophageal reflux disease after initiation of a low-carbohydrate diet: five brief case reports. 2001. http://www.ncbi.nlm.nih.gov/pubmed/11712463 & A Very Low-Carbohydrate Diet Improves Gastroesophageal Reflux and Its Symptoms. 2006. http://link.springer.com/article/10.1007%2Fs10620-005-9027-7?LI=true|
|3.||↑||Pathophysiology of GERD:|
Lower Esophageal Sphincter Defects. 2004. http://www.practicalgastro.com/pdf/May04/MitreArticle.pdf
|5.||↑||Modulation by colonic fermentation of LES function in humans. Am J Physiol Gastrointest Liver Physiol 2000.|
|7.||↑||Regression of gastro- esophageal reflux disease symptoms using dietary supplementation with melatonin, vitamins and amino acids: comparison with omeprazole. 2006.|
|9.||↑||Oxidative stress is more important than acid in the pathogenesis of reflux oesphagitis in rats. Gut 2001;49:364-371.|
|11.||↑||Webinar with James Greenblatt, MD, 2014|
|12.||↑||Delayed Gastric Emptying in Patients with Abnormal Gastroesophageal Reflux. 2001. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1422000/|
|13.||↑||Gastroesophageal reflux and gastric emptying, revisited. 2005. http://www.ncbi.nlm.nih.gov/pubmed/15913477|
|14.||↑||Dietary Magnesium and C-Reactive Protein Levels. 2005. http://www.ncbi.nlm.nih.gov/pubmed/15930481|
|16.||↑||“Electroacupuncture accelerates solid gastric emptying in patients with functional dyspepsia.” Gastroenterology 2004. & “The affects of acupuncture at sibai and neiting acupoints on gastric peristalsis.” Journal of Traditional Chinese Medicine 2001.|
|17.||↑||“Successful treatment of esophageal dysmotility and Raynaud’s phenomenon in systemic sclerosis and achalasia by transcutaneous nerve stimulation. Increase in plasma VIP concentration.” 1987 & Esophageal visceral pain sensitivity: effects of TENS and correlation with manometric findings. 1998|
|18.||↑||Effects of Anxiety and Depression in Patients With Gastroesophageal Reflux Disease. 2014. http://www.ncbi.nlm.nih.gov/pubmed/25496817|
|19.||↑||GERD is becoming a challenge for the medical profession: is there any remedy? 2014. http://www.ncbi.nlm.nih.gov/pubmed/25513138|