Note: this is the fourth article in a series about heartburn and GERD. If you haven’t done so already, you’ll want to read Part I, Part II and Part III before reading this article.
Believe it or not, stomach acid isn’t there just to punish you for eating Indian food. Acid is in the stomach because it’s supposed to be there. It is found in all vertebrates. And while it isn’t necessary for life, it is certainly required for health.
Most people have no idea how many vital roles stomach acid plays in our bodies. Such misunderstanding is perpetuated by drug companies who continue to insist that stomach acid is not essential. Meanwhile, millions of people around the world are taking acid suppressing drugs that not only fail to address the underlying causes of heartburn and GERD, but put them at risk of serious (and even life-threatening) conditions.
There are four primary consequences of acid stopping drugs:
- Increased bacterial overgrowth
- Impaired nutrient absorption
- Decreased resistance to infection
- Increased risk of cancer and other diseases
I had originally intended to cover all four of these issues in this article, but as I started to write I realized it would be far too long. So I will cover increased bacterial overgrowth and impaired nutrient absorption in this article, and decreased resistance to infection and increased risk of cancer and other diseases in the next article.
A stomach full of germs
We’re not going to spend much time on this here since the connection between low stomach acid and bacterial overgrowth was the focus of Part II and Part III.
To review, low stomach acid causes bacterial overgrowth in the stomach and other parts of the intestine. Bacterial overgrowth causes maldigestion of carbohydrates, which in turn produces gas. This gas increases the pressure in the stomach, causing the lower esophageal sphincter (LES) to malfunction. The malfunction of the LES allows acid from the stomach to enter the esophagus, thus producing the symptoms of heartburn and GERD.
Bacterial overgrowth has a number of other undesirable effects, including reducing nutrient absorption, increasing inflammation, and raising the risk of stomach cancer. Studies have confirmed that proton-pump inhibitors (PPIs) can profoundly alter the gastrointestinal bacterial population by suppressing stomach acid. Researchers in Italy detected small bowel bacterial overgrowth (SIBO) in 50% of patients using PPIs, compared to only 6% of healthy control subjects. The prevalence of SIBO increased after one year of treatment with PPIs.
Well-fed but undernourished
Stomach acid is a prerequisite to healthy digestion. The breakdown and absorption of nutrients occurs at an optimum rate only within a narrow range of acidity in the stomach. If there isn’t enough acid, the normal chemical reactions required to absorb nutrients is impaired. Over time this can lead to diseases such as anemia, osteoporosis, cardiovascular disease, depression, and more.
Macronutrients
Stomach acid plays a key role in the digestion of protein, carbohydrates and fat. When food is eaten, the secretion of stomach acid (HCL) triggers the production of pepsin. Pepsin is the enzyme required to digest protein. If HCL levels are depressed, so are pepsin levels. As a result, proteins don’t get broken down into their component amino acids and peptides. This can lead to a deficiency of essential amino acids, which in turn may lead to chronic depression, anxiety and insomnia.
At the same time, proteins that escape digestion by pepsin may end up in the bloodstream. Since this is not supposed to happen, the body reacts to these proteins as if they were foreign invaders, causing allergic and autoimmune responses. I’ll discuss this more below.
Micronutrients
We can eat the most nutritious diet imaginable, packed with vitamins, minerals and other essential nutrients, but if we aren’t absorbing those nutrients we won’t benefit from them.
As acid declines and the pH of the stomach increases, absorption of nutrients becomes impaired. Decades of research have confirmed that low stomach acid – whether it occurs on its own or as a result of using antacid drugs – reduces absorption of several key nutrients such as iron, B12, folate, calcium and zinc.
IRON
Iron deficiency causes chronic anemia, which means that the body’s tissues are literally starving for oxygen.
In one study, 35 of 40 people (80 percent) with chronic iron-deficiency anemia were found to have below normal acid secretion. Iron-deficiency anemia is a well-known consequence of surgical procedures that remove the regions of the stomach where acid is produced.
Researchers have found that inhibition of acid secretion by Tagamet, a popular acid stopping drug, resulted in a significant reduction of iron. At the same time, studies have shown that adding acid has improved iron absorption in patients with achlorydia (no stomach acid production).
B12
Vitamin B12 (cobalamin) is needed for normal nerve activity and brain function. B12 enters the body bound to animal-derived proteins. In order for use to absorb it, the vitamin molecules must first be separated from these proteins with the help of – you guessed it – stomach acid.
If stomach acid is low, B12 can’t be separated from its carrier proteins and thus won’t be absorbed. In one study of 359 people aged 69-79 years with serious atrophic gastritis, a disease characterized by low stomach acid, more than 50 percent had low vitamin B12 levels.
A number of studies have examined the negative effect of PPI therapy on B12 absorption. In a study on healthy subjects treated with 20 mg and 40 mg of Prilosec per day for two weeks, B12 absorption was reduced by 72% and 88% respectively.
FOLATE
Among other things, folate (folic acid) is vital for keeping the cardiovascular system healthy and for preventing certain birth defects. Low stomach acid levels can interfere with folate absorption by raising the pH in the small intestine. At the same time, when folate is given to achlorydric patients (with no stomach acid) along with an HCL supplement, absorption of the vitamin increases by 54 percent.
Both Tagamet and Zantac reduced folate absorption in another study, though the reduction in the Zantac group was not statistically significant. The overall reduction of folate absorption was sixteen percent. This modest reduction is probably not enough to harm a healthy person consuming adequate levels of folate, but it may cause problems in those with folate deficiency (relatively common) or other health problems.
CALCIUM
Calcium makes our bones and teeth strong and is responsible for hundreds, if not thousands, of other functions in our body. The importance of stomach acid in the absorption of calcium has been known since the 1960s, when one group of researchers noted that some ulcer patients were barely absorbing any calcium at all (just 2 percent). When they investigated they found that these subjects had a high gastric pH (6.5) and very little stomach acid. However, when the researchers gave them HCL supplements, lowering the pH to 1, calcium absorption rose five-fold.
ZINC
Zinc takes part in several metabolic processes related to keeping cell membranes stable, forming new bone, immune defense, night vision, and tissue growth. In one controlled trial, Tagamet treatment reduced zinc absorption by about 50 percent. Another study found that Pepcid, which raises intragastric pH to over 5, had the same effect.
Although there is little systemic research on the absorption of other nutrients, there is good reason to believe that low acid levels may also effect levels of vitamin A, vitamin E, thiamine (vitamin B1), riboflavin (vitamin B2), and niacin (vitamin B3). Theoretically, the absorption of any nutrient that is bound to protein will be inhibited (PDF).
In Part B of this article I will explain how acid stopping drugs decrease our resistance to infection and increase our risk of stomach cancer and other diseases.
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{ 43 comments… read them below or add one }
I have been off Aciphex for almost two weeks now. Other than a mild twinge of burn, I’m fine.
Fantastic!
I’ve been following this series with keen interest; thanks! As a result of reading the first couple of installments, I rashly (boldly?) went off my Prilosec OTC regimen of 18 months’ duration, and after a couple of slightly difficult days, have had no significant heartburn.
Both on the PPI and still occasionally off it, however, I do have stomach pains (which sometimes translate into scary “chest pains” in the middle of the night) that are helped by antigas meds (like dimethicone). Do you suppose the story is as simple as “Ingest anything that creates IAP, and you will need to tamp down abdominal gas to keep the LES closed”?
(By the way, in my comment on Part 1, I mentioned planning to get an upper endoscopy. I’m now thinking of scrapping that part of the plan.
Eve,
Congratulations! It certainly sounds like your pain and heartburn are being caused by gas. As I mentioned in the previous articles, that is probably caused by maldigestion of carbohydrate. What is your carb intake like at present? I’ll be writing more about how to treat GERD naturally soon, but in the meantime I’d recommend a period of strict carbohydrate restriction, HCL w/pepsin and a high quality probiotic (foods are best, sauerkraut, kombucha, kefir, etc.). Smaller meals can also be helpful as you make the adjustment.
On an average day my carb intake is probably below 50 grams, often well below. I haven’t seen a consistent pattern, to be honest. Some of the worst pain was during a week when I was trying out some intermittent fasting and sticking to eating small amounts of high-quality fats. But then, as admitted in the earlier thread, I do like the occasional drink! It sounds like I’m going to have to eliminate the gin martinis and scotches, or at least track them carefully to see how they contribute, and experiment with probiotics and HCL/pepsin supplementation if the improvement doesn’t continue. Thanks again.
Any idea how water consumption affects stomach acidity? Maybe we shouldn’t be drinking with meals?
Consuming liquid during meals dilutes the concentration of stomach acid, impairing digestion. It’s best not to drink liquid during meals for that reason – especially water. A few sips of wine probably won’t hurt.
This is a fantastic series of articles. I’d like to print them out and give them to my father, if you don’t mind. He’s type 1 diabetic and has been on PPI’s for years now.
My own experiences with GERD (or, as I called it “chronic heartburn” since I never went to get diagnosed) fall in-line exactly with what you have described in this series. Most notably, the food causes of my heartburn as I found through my own experiments of eliminating certain foods: sugars, starches, and grains. Wheat and sugar being the two biggest culprits for me.
A few months ago I embarked on a paleo-esque plan à la Mark Sisson’s “Primal Blueprint”. Within 72 hours of eliminating grains and sugars from my diet, my heartburn that kept me up 3-4 hours per night was gone. Completely.
Now, I’ve heard of not drinking during meals to improve digestion. How long is it recommended to wait after the meal before drinking? Also, I have a habit of mixing a bit of apple cider vinegar in a glass of water and drinking it. Not necessarily at meal time, but just throughout the day. I actually like the taste and find it quite refreshing. What impact would this have on my stomach acid production?
Hi Todd,
Please feel free to print the articles and give them to your father. That’s what this blog is all about! Thank you for asking, though.
I wouldn’t drink much liquid for 1-2 hours after eating, to give the stomach a chance to empty. The exception would be hot herbal teas that promote digestion, like fennel and peppermint.
Apple cider vinegar is an old home remedy for indigestion. I’m planning on mentioning it in the upcoming treatment article. I think a small amount before meals, mixed with some warm or room temperature water, can be helpful.
I am new to this information. My recent research suggests peppermint is a trigger for GERD so we should avoid it. Ginger might be a better choice?
Hi folks,
The continuation of this article (Part B) is now up.
Can you comment on the rebound of acid after stopping ppi’s. If we assume that long term ppi use may result in bacterial overgrowth, does the excess of rebound kill the bacteria or should we take antibiotic to do so? Also, how to protect the lower esophagus while recovering from ppi influences?
Another question or two. When you stop ppi’s after several years of treatment, does the les actually recover and start to function properly again? If so, how long might it take to transition back to normal? How risky is the acid reflux experience during this transition for Barretts cells?
Final article in the series is up.
Also, the entire series as well as recommendations for books and offsite articles can be found here.
I may have missed it, but I did not see something else worth mentioning about GERD.
In some (many) people, the valve between the esophagus and stomach does not close properly or quickly enough. This causes stomach acids to enter the esophagus and cause the burning discomfort.
This problem can be dealt with by some yogic practices, by paying attention to that area, and also by not going to be or lying down with food in the stomach.
If you get a bad case of GERD in the middle of the night, often it is due to food in the stomach not being able to drain out. Just sit up for a while and it will leave the stomach and the GERD incident will be over.
Tom,
The entire series is about why the LES malfunctions: because of excess carbohydrates and low stomach acid.
Chris:
I did not make my point clearly, sorry.
What I am saying is that yoga and the other techniques mentioned can help with this problem in the way that resting, elevating, and using ice on a sprained toe can help with that problem.
Yoga may not be the bottom line on GERD, but it can help alleviate an instance of the problem and the awareness can make people better understand what is triggering the problem.
Also, thanks for this series and your blog in general. They are very good.
Chris, I am beside myself and don’t know what to do. My 89 year old uncle is ailing and I believe it is due to Prilosec. He was complaining of occasional heartburn several months ago so his doctor put him on Prilosec 40mg. in a.m. and Pepcid in p.m. Over the last few weeks he has been having severe stomach pains, ie. burning to the point that he has gone to the ER. What do they do…endoscopy…which showed nothing. Hence, more prilosec, carafate, and dilaudid. He has lost weight over the this time because he can barely eat without being in pain. He drinks a lot of milk (whole milk) thinking that it miight help, but, of course, it doesn’t and his arthritis, whether rheumatoid or osteo seems to be much worse. He lies down most of the time because he is so weak and his joints hurt so bad when he’s up. Prior to all of this, he could outwalk me at the grocery store. I have always been skeptical of long term antacids. I’m also aware that as we age, we tend to produce less stomach acid anyway. So now that acid production in my uncle is virtually stopped, it’s no wonder he’s getting very sick. But how do I convince him (you know, old people believe everything their doctor’s say without question and I question everything)and his doctor that he’s killing him albeit unintentionally? I’m having a real hard time just standing by watching this happen to an otherwise relatively healthy man. HELP, PLEASE!
Donna: I empathize with your plight, but unfortunately I don’t have an easy answer. The best we can do is educate and inform, but from there people have to make their own choices. You could try getting him a copy of Dr. Wright’s book called Why Stomach Acid is Good For You. He’s an M.D., so perhaps your uncle would take it more seriously.
What about supplementing with Betaine HCl and see if that works by increasing stomach acid?
I am a 60 year old female that has suffered with restless legs syndrome and upper airways resistance syndrome for decades. Even though I have never told them that I have heartburn, doctors insist that I have GERD. Recently, I gave in and stated taking Protonix. I have unintentional weight loss (due to early satiety) at a rate of one pound a week and have lost over 10% of my body weight. Since starting taking proton inhibitor I feel as if my body isn’t receiving any nutrition. (I have been checked for cancer). Thanks for the article on proton inhibitors because I now have a reason to review the effects of this prescription with my doctors.
Hi, I was referred to you by my boss, a Dept Chair. who is a total vegan etc. Have had GI problems for years, including a GI bleed in the 80″s. I understand your reasoning for limiting the PPI’s but especially among the elderly on blood thinners,etc, there is a problem with bleeds.. My main question concerns abnormal “giant” cells in the small intestine, with a hx of IBS, GI bleed,diabetes, et al. The area referenced has caused discomfort for two months now. That is with and without PPI, tagamet, pain med, etc. Thyroid is low normal, on metformin. Have asked for B12, internist sees no need. I understand there is now a correlation of brain to bowel, and would a hx of inc. fluids, cord compression, and s/p surg for same contribute to this ongoing bowel irritation?? I realize there is alot in here but it is the correlation of brain, bowel I am most interested in. Thanks for any insight. PElden
If acid is helpful to the stomach, and low stomach acid is the cause of GERD, why do acidic foods tend to make hearburn/GERD worse?
Not sure if you’re still monitoring this post from 2010, but I was hoping you could give me your opinion on a related issue. I have been diagnosed with cholinergic urticaria (heat induced hives), and have been taking Zantac and Zyrtec daily to control that condition for between 6-7 years. This article has caused me some concern, because for the last 6 months I have been dealing with serious dry mouth issues, dermatitis, and an overgrowth of facial and scalp yeast. My dermatologist gave me both oral and cream-based ketoconazole, which helps, but the problem comes right back once I stop taking the keto. Based on your article, it seems like the problem may be related to the fact that I’ve taken Zantac for so many years. The problem, obviously, is that if I stop taking Zantac, the heat-induced hives come right back. Any thoughts/comments would be appreciated.
Is it correct that if I take methylcobalimin in place of cyanocobalimin that my body will not need to separate the cyanide from the good stuff. If this is correct then why bother to take the poisonous cyanide type B12 and why aren’t you promoting that change??
Is it proven that mastic gum kills h pylori?
I’ve found sprinkling citric acid on my meals seems to prevent some excessive gas and nausea after eating breakfast. Chris – is adding HCl much better than adding citric acid? Thanks Candice
am wondering if taking a product called carbgest would help, as this product is designed to help digest carbohydrates
Hi Chris I have had a gastric bypass and I have been told I have to take vitamins iron and calcim twice aday is there anything I can take without taking 3 different pills
What alternative to surgery is there for someone who has no LES at all, which was confirmed years ago by an upper GI? When I’m not taking my Nexium, I’m miserable with frequent gastric issues, regardless the food I eat.
“In one study, 35 of 40 people (80 percent)”
Er… that would be 87.5%, I believe.
Reading my way through this series of posts, but it seems helpful so far. I’m hoping to avoid taking Prilosec for the rest of my life – I’m sure there’s a better solution.
What about magnesium and the absorption of other mineral salts being suppressed? I got terrible headaches when I took Nexium and other PPIs for gastritis a few years ago (a biopsy supposedly ruled out H Pylori), the doc switched me to Zantac and the headaches came back. He said that two different meds couldn’t cause the same symptoms. I stopped the meds and healed my gastritis through diet, and no-alcohol (wine and champagne seemed to really irritate my stomach). And no more headaches.
Then when I was pregnant a year or so later I started getting headaches again, a midwife suggested I start getting more mineral salts from soup broths and this naturally salty bottled spring water you get in France. Well I needed 4 bottles of this water a day to keep the headaches at bay, I eventually found a chelated mineral supplement that worked instead. And once I stopped breast-feeding I was able to stop the supplements. This mineral salts cure for headaches led me to suspect a link with the antacid drugs.
I’m now on the Gaps diet that I initially started to heal chronic urinary and kidney infections and hopefully food allergies, namely gluten. On hot days I still find I need an electrolyte drink for headaches. I now dilute himalayan crystal salts in water with some lemon (I hope I’m not taking too much salt).
I wonder if there are other bacteria or yeasts that cause gastritis and GERD symptoms? Like Candida for example? I find its the candida type diet in combination with GAPS that helps settle my acid stomach symptoms the quickest. For example, if I’ve cheated on GAPS with a little bit of starch (some rice crackers or a tiny bit of sugar) and had wine with dinner a few days in a row my stomach can get a bit acidy again. Lots of homemade chicken broth and some raw vegetables really sorts me out quickly. I had acid stomach issues on the GAPS intro diet when I was eating a lot of boiled meat and cooked vegetables and found that I needed some raw alkaline veggies to feel better.
Finn,
How did you solve your gastritis through diet. What exactly you avoided and what you included in your diet? Will Bone-broth, Gelatin supplements help? I was diagnosed with antral gastritis few months ago and was prescribed a month-long Nexium course. Even after completing it, am still experiencing issues on and off.
Hi Chris –
I’ve been following your website for a quite while now and recommend your heartburn/gerd section to anyone who even mentions that they have it to me…family members, customers, co-workers, friends, you name it! Now I have a question and I hope you might be willing to answer it. I agree with the logic that acid production reduces as you become older. So the question is, my newborn obviously has some issues with sleeping flat on his back after being the hospital for a week and a half after delivery with a feeding tube down him. I thought that he was adjusting to home life but now it seems to be pretty persistent to me. As of today I am putting a wedge under him so he is elevated like I would be in the bed for acid reflux…it seems to let him sleep a little more calmly? I keep reading on baby forums that he might have acid reflux and the doctors put the baby on medicine. Obviously I am skeptical of acid reducers and was wondering if you had an opinion on what the culprit might be and how to fix for the long term or if you know what medicine it is the doctors would prescribe him in advance. I appreciate any input you may have.
Thanks,
Michelle
Of course we are breastfeeding and I have to supplement with Neosure for preemies because he is a ferocious eater since they sent him home. thanks.
In infants reflux is most often due to sensitivity to something mom is eating. Try removing dairy and gluten first; if that doesn’t help, soy, citrus, nightshades, onions, garlic and beans are other common culprits.
I appreciate your timely response! I love dairy so great place to start. Thanks!
Hi Chris, I have found these articles of great importance to me. I have been taking Prevacid for almost 25 years when I was diagnosed with a hiatus hernia. I would love to stop taking Previcid. I eat a primal. diet exclusively for almost 4 months and have lost 30 lbs and 9 inches of belly fat and feel great and for me there is no other way to eat now. I have tried to stop taking Previcid for a day or two but heartburn comes on very quickly and I have to take it again for relief. Is there anything I can do to stop taking the Previcid? I know there is surgery to do the repair but it sounds like even if I get the surgery the symptoms could return from taking the drug for so long?
I feared antacids long before reading your articles because it just seemed common-sense to me: restricting stomach acids=poor absorption of nutrients.
I’ve been reading further into this to know the exact mechanisms because I wanted to be able to defend my positions against scrutiny, and unfortunately I’ve found just the opposite:
http://www.ncbi.nlm.nih.gov/pubmed/8568113 (Hypochlorhydria from short-term omeprazole treatment does not inhibit intestinal absorption of calcium, phosphorus, magnesium or zinc from food in humans.)
http://www.ncbi.nlm.nih.gov/pubmed/1852094 (Calcium absorption in elderly subjects on high- and low-fiber diets: effect of gastric acidity. – “We conclude that, in humans, the reduction in calcium absorption with high fiber intake is unaffected by gastric pH.”)
http://www.ncbi.nlm.nih.gov/pubmed/6707197 (An evaluation of the importance of gastric acid secretion in the absorption of dietary calcium.- ” A large dose of cimetidine, which markedly reduced gastric acid secretion, had no effect on calcium absorption in normal subjects, and an achlorhydric patient with pernicious anemia absorbed calcium normally.”)
I’m not sure why these results are the way they are, but maybe anemia is the cause of mal-absorption, not low stomach acid? What do you think?
I just read all of your articles last night. I’ve had problems with ibs in the past and was diagnosed with GERD in November. I still cant get it under control. I had an upper endoscopy and they didn’t find anything. I’m taking dexilant, another ppi. My stomach is still a mess. My doctor had me try nexium and Prilosec and they did nothing. I have more nausea and bloating where the esophagus and stomach meet up than I do the heartburn. They first diagnosed me when i would wake up in the middle of the night and cough up a small piece of food. After a couple nights of this I found it odd and called my dr. It is now March and I’m still struggling. I know that stress and anxiety can worsen GERD symptoms and I’m having a lot of that now. Do you have any suggestions? Foods to avoid? Foods I should eat often? I’m really at a loss.
Dear Shelly – while my problems have not been as great as yours, I’ve had a lot of success alleviating both IBS and low acid stomach issues (similar symptooms to you) by adding lemon juice/citric acid to my food and eating yogurt and home made kim chee. I believe there are better solutions than citric acid, but that is all that I could get my hands on. Also, limiting consumption of food in the evening and cutting out carbohydrates and dried fruit as well as working out which other food irritate my bowel and not eating them. .
I suggest you read other articles on this site as much of the advice seems to interact to provide a more wholistic solution. I subscribe to the newsletter and find that very good.
Good luck!
C
Hi! I’m just getting off of acifex and starting Hcl tabs. My question is ” how long does the average person have to continue taking these tabs. I have been on Acifex for about two years.
Your take on this issue has been incredibly eye-opening – thank you. I had been on various PPIs for upwards of ten years after being one of the early diagnosed cases of eosinophilic esophagitis. I could tell my body wasn’t getting nutrients, despite the large amounts of natural vitamins I was taking and eating extremely healthy. After reading your revolutionary articles, which made perfect sense to me, I went off my PPI, started taking 1-2 pepsin + HCL tablets with heavy meals, and added a licorice supplement. My reflux was bad for a little while, but better after a few weeks. However, my stomach must still be very damaged because every time I eat green leafy vegetables or more than a small portion of food, I am violently sick within about 10-15 minutes. Afterward I feel ok. When that happens, I notice I haven’t digested meals from as much as a day prior and my acid levels are next to nothing. Do you have any suggestions? Should I be taking more than one-two HCL pills? Is this intolerance to raw veggies normal? Thank you!!