If you missed Part 1 of this series, you can find it here.
Digestive distress is the most common problem I see in people switching to a Paleo diet. This can range from mild gas and bloating, to changes in stool frequency and consistency (i.e. constipation, diarrhea or alternating between the two), to severe heartburn or abdominal pain. There are three primary reasons people experience these symptoms when they transition to a Paleo diet:
- Low stomach acid.
- Decreased enzyme production.
- Intestinal inflammation.
I’ll cover each of these in more detail below. Before I do that, it’s worth pointing out that in the vast majority of cases, people who have digestive issues on Paleo also had them before. They may have consciously or unconsciously compensated for them by limiting animal proteins (if they have low stomach acid), eating more simple carbohydrates (decreased enzyme production) or limiting intake of fibrous vegetables and fruits (intestinal inflammation). This doesn’t mean the diet they were on before was necessarily more gut-friendly; the symptoms were being managed, but the underlying problems weren’t addressed.
Don’t let digestive problems sabotage your Paleo diet.
Low stomach acid
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.
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. These undigested proteins putrefy in the gut, and may cause gas, bloating, heartburn and other digestive issues.
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.
Low stomach acid also impairs carbohydrate digestion. Stomach acid (HCL) supports the breakdown and absorption of carbohydrates by stimulating the release of pancreatic enzymes into the small intestine. If the pH of the stomach is too high (due to insufficient stomach acid), the pancreatic enzymes will not be secreted and the carbohydrates will not be broken down properly. As Dr. Norm Robillard explained in his book Heartburn Cured, undigested carbohydrates provoke an overgrowth of bacteria in the small intestine (a.k.a. “SIBO”) which in turn leads to increased gas production and acid reflux. (I’ve written an entire series on low stomach acid and GERD, so check that out if you haven’t already.)
There are numerous causes of low stomach acid. The most common are:
- H. pylori infection. This is extremely common; studies suggest that 1 in 2 people are infected globally. (1) H. pylori suppresses stomach acid production as a survival strategy.
- Stress. Chronic stress has been shown to decrease stomach acid production.
- Acid suppressing drugs. Long-term use of Prilosec, one of the most potent acid suppressing drugs, reduces the secretion of hydrochloric acid (HCL) in the stomach to near zero. (2)
- Low animal protein (i.e. vegetarian/vegan) diet. I haven’t seen studies on this, but my clinical and personal experience suggest that eating a diet low in animal protein decreases stomach acid secretion over time.
- Age. Numerous studies have shown that stomach acid secretion declines with age. In one study researchers found that over 30 percent of men and women past the age of 60 suffer from atrophic gastritis, a condition marked by little to no acid secretion. (3) Another study found that 40% of women over the age of 80 produce no stomach acid at all. (4)
Imagine this scenario: you’ve been on a vegetarian diet for a few years and under a lot of stress at work. You switch (literally overnight) to a Paleo diet where you are now eating meat at least once and often twice a day. Is it any surprise that your digestive system may not respond well to this? The combination of a vegetarian diet, chronic stress and possibly an H. pylori infection would significantly reduce your stomach acid, and thus ability to digest animal protein.
Decreased enzyme production
Digestive enzymes break down larger molecules in the food we eat into smaller molecules that can be absorbed across gut lumen into our bloodstream. They’re found primarily in the mouth (saliva), stomach and small intestine, and are categorized according to the food substrate they break down:
- Proteases and peptidases break down proteins into peptides and amino acids.
- Lipases break fats into fatty acids and a glycerol molecule.
- Carbohydrases break carbohydrates into simple sugars (i.e. glucose/fructose).
- Nucleases break nucleic acids into nucleotides.
If your enzyme production is insufficient, you can’t break down or absorb protein, fat or carbohydrates properly. It’s not hard to imagine that this could lead to digestive issues, is it?
The primary causes of poor enzyme production are:
- Low stomach acid. The pH (acidity) of the chyme (partially digested food in the stomach) must be in a particular range in order to stimulate enzyme production when it enters the small intestine. If the pH is too high due to low stomach acid, enzyme production will be inhibited.
- Stress. Once again, chronic stress rears its ugly head.
- Micronutrient deficiency. Enzymes don’t work alone; they require other nutrients (vitamins and minerals) which act as “co-enzymes”. If your diet is low in certain micronutrients (i.e. B12, iron & zinc for vegetarians/vegans, or magnesium, selenium, vitamin C for those on a standard American diet), or you’re not absorbing them properly due to low stomach acid, your enzyme production will be impaired.
- Western diet. Highly processed, refined and cooked foods contain no enzymes at all. Raw fruits and vegetables are rich in enzymes.
- Age. Some evidence suggests that enzyme production also declines with age.
Decreased enzyme production almost always occurs together with low stomach acid, which creates a digestive double-whammy.
Inflammation
Inflammation is part of the body’s response to harmful stimuli such as pathogens, irritants or damaged cells. It is a crucial aspect of our body’s protective system, and we wouldn’t live very long without it. It is only when inflammation becomes chronic that it becomes a problem. Chronic inflammation in the gut can lead to constipation or diarrhea, gas, bloating and abdominal pain, as well as extra-intestinal symptoms like skin rashes, muscle and joint pain and even depression.
One of the little known manifestations of gut inflammation that may be one reason people struggle when adopting a Paleo diet is a sensitivity to insoluble fiber found in certain fruits, vegetables and nuts and seeds. As I discussed in this article, there are two primary types of dietary fiber: soluble, and insoluble. While soluble fiber can be soothing for the gut, consuming large amounts of insoluble fiber when your gut is inflamed is a little bit like rubbing a wire brush against an open wound. Ouch.
Like low stomach acid and decreased enzyme production, gut inflammation has numerous causes. The most common include:
- Gut infections. Parasites, pathogenic and opportunistic bacteria, and fungi can all cause a low-grade, chronic inflammatory condition.
- Autoimmune disease. Inflammatory bowel disease, including ulcerative colitis and Crohn’s disease, are conditions where the immune system mounts an inappropriate attack against intestinal tissue.
- Western diet. Gluten, sugar, refined flour and other highly processed and refined foods can inflame the gut.
- Environmental toxins. Pesticides and other chemicals like BPA have been shown to disturb inflammatory cytokine production.
- Intestinal dysbiosis. An imbalance of good and bad bacteria, including SIBO (small intestine bacterial overgrowth), can create an inflammatory state.
Note that only two of these causes are exclusively related to diet: environmental toxins and western foods. The others are potentially modifiable by diet, but diet is not the primary cause. If you continue to experience digestive issues after a 30-day trial of the Paleo diet, chances are you have some gut inflammation and one or more of these causes is present. There are some dietary tweaks that can help (which I’ll discuss below), but ultimately the most important thing is to address the underlying cause, and that will probably require additional support (i.e. supplements or medications) above and beyond dietary changes.
First steps in fixing your gut
A discussion of how to fix the gut could fill an entire book. (Indeed, I plan to write that book after my first book.) While I obviously can’t go into that kind of detail here, I can give you some “first steps” that have proven to work well in my practice.
Restore stomach acid production
The first step in restoring stomach acid production is addressing any factors that are inhibiting it. This means getting tested for H. pylori if you suspect it, taking steps to manage chronic stress and avoiding acid-suppressing drugs.
The next step is to take hydrochloric acid (HCL). I describe the rationale and protocol for this in detail in my article called Get Rid of Heartburn in Three Simple Steps, but the short version is this: taking HCL can often help kick start the body’s own acid production. Most patients I’ve treated only need to take HCL for somewhere between 3-6 months, and are then able to gradually titrate off it. A minority of patients, such as elderly people with atrophic gastritis or people that have been on PPIs for many years, may need to remain on HCL indefinitely. That is a much better option than the alternative, which is to suffer from digestive problems as well as the potentially serious consequences of low stomach acid (such as decreased nutrient absorption, bacterial overgrowth, increased susceptibility to infection and even a higher risk of gastric cancer).
Be aware that HCL should always be taken with pepsin — or, better yet, acid-stable protease — because it is likely that if the stomach is not producing enough HCL, it is also not producing enough protein digesting enzymes.
Another way to stimulate acid production in the stomach is by taking bitter herbs. “Bitters” have been used in traditional cultures for thousands of years to stimulate and improve digestion. More recently, studies have confirmed the ability of bitters to increase the flow of digestive juices, including HCL, bile, pepsin, gastrin and pancreatic enzymes. (5) The following is a list of bitter herbs commonly used in Western and Chinese herbology:
- Dandelion
- Fennel
- Gentian root
- Ginger
- Beet root
- Goldenseal root
- Milk thistle
- Peppermint
- Wormwood
- Yellow dock
Bitters are normally taken in very small doses – just enough to evoke a strong taste of bitterness. Kerry Bone, a respected Western herbalist, suggests 5 to 10 drops of a 1:5 tincture of the above herbs taken in 20 mL of water.
Replace digestive enzymes
As I mentioned above, the single most important step in increasing digestive enzyme production is by restoring stomach acid production. This will give the chyme entering the small intestine the proper pH level (acidity), which is what stimulates the pancreas to produce enzymes. Managing chronic stress and ensuring adequate micronutrient (co-enzyme) intake are also important. Raw, fermented foods like sauerkraut, kim chi, kefir or beet kvaas are rich in enzymes and should be consumed regularly if tolerated.
Supplemental nutrients can be helpful for immediate relief. These include:
- Ox bile. While not technically an enzyme, ox bile is one of the most effective supplements for improving fat absorption.
- Acid stable protease. Improves protein digestion; acid-stable protease is able to survive the low pH of gastric juices to further aid in protein assimilation.
- Pancreatin. A mixture of enzymes produced by the pancreas, including lipase (fat digesting), protease (protein digesting) and amylase (carbohydrate digesting).
- Bromelain. An enzyme found in pineapple that helps with protein digestion, and may have systemic anti-inflammatory effects.
- Ginger. A time-tested digestive remedy.
As with HCL, in most cases you will only need to take these nutrients temporarily, until you are able to address the underlying issues. But they can be incredibly helpful in the meantime.
Reduce inflammation
This one is a little harder to give a quick overview of, because there are so many potential causes, and some of those causes require a fairly complex approach. What I can do is give you a few general tips that are helpful in most circumstances, regardless of the cause.
The first step would be trying some tweaks to your existing Paleo or “real food” diet. (You are on a Paleo or “real food” diet, aren’t you? If not, that is the first step.) There are three tweaks I’ve found to be helpful, and they’re listed in the order I suggest you try them:
- Take it easy on the veggies. Some vegetables (and fruits) are quite high in insoluble fiber, which as I mentioned above, can be very irritating to an inflamed gut. One of the easiest ways to address this is to simply reduce the quantity and variety of vegetables you eat. I know this will sound like heresy to some of you, but keep in mind that while vegetables are nutrient-dense foods, a little goes a long way, and there are other more nutrient-dense foods like organ meat and meat. Read this article if you need more info and a pep talk.
- Try a low-FODMAP diet. FODMAPs are specific types of carbohydrate that are poorly digested by certain people, particularly those with dysbiosis and SIBO. Read my article on FODMAPs for more info on how to do this.
- GAPS diet. The GAPS diet is a comprehensive, anti-inflammatory, gut-healing diet. It’s especially helpful with SIBO, dysbiosis, and inflammatory bowel disease (IBD). Check out this article for a primer.
Putting it all together
There’s no question that healing digestive issues can be a confusing and time-consuming process. In my experience it usually takes a good 3-6 months to unravel a chronic digestive issue — and sometimes longer. This may not be the news you were looking for, but setting realistic expectations will help you to stick with a therapeutic approach long enough for it to work.
The changes I suggested in this article should give you a good head start. I’d also recommend checking out a new line of supplements that Robb Wolf and I created specifically to address the challenges we’ve seen people experience as they adopt a Paleo diet — including digestive problems. One of my biggest frustrations as a clinician has been finding supplements that contain exactly the ingredients I want and don’t contain the ingredients I don’t want. For example, in the case of a digestive supplement, I wanted something that had HCL, acid-stable protease, carbohydrate and fat digesting enzymes, cholagogues to stimulate bile production, and bitters to stimulate acid secretion — with the right doses and forms of each — but that product didn’t exist. So I decided to create it myself. You can learn more about it here, and it will be available for purchase (along with the other products in the “Paleo Transition” pack) next week.
Now I’d like to hear from you. Have you experienced digestive issues on a Paleo diet? What have you found to be helpful?
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{ 89 comments… read them below or add one }
Adding HCL and digestive enzymes has helped me tremendously. I had previously tried an autoimmune paleo protocol in which my digestion got much worse. This helped me to see it was my stomach acid. It’s been wonderful to be able to slowly add back in some of my favorite veggies and sauerkraut. I am enjoying the added freedom of not being so gassy. Thank you for your work and sharing it through this blog.
For years, my mom had what the doctors called “a sort of IBS,” but they didn’t have anything that could help her or even a concrete diagnosis. Just this last summer, she also started taking HCL and digestive enzymes before meals, and her stomach issues have decreased dramatically. Plus, due to having more stomach acid, she is also extracting more nutrients from her food, and she says she is feeling better than ever. Just by looking at her, you can tell she is healthier. It is a wonder the sorts of miracles that HCL and digestive enzymes can work!
Mindy- your post has turned on a light bulb for me!! I have been on a strict autoimmune protocol and have had painful constipation and more problems than ever! I am ordering HCL today to add to my digestive enzymes. Thank you!
Chris
Have you read An Epidemic of Absence?
http://www.amazon.com/Epidemic-Absence-Understanding-Allergies-Autoimmune/dp/1439199388
This is a quote from the book:
” “We truly believe that Helicobacter pylori has advantage, that it’s not a pathogen,” says
Kienesberger, referring to the bacterium’s talent for surviving where little else can. She’s
arguing that its dominance of the gastric niche suggests that it belongs there—that we, the hosts,
need it there…………Martin Blaser thought that humans had probably incorporated this bacterial regulation of stomach acid into our own day-to-day operations. Now we depended on H. pylori to maintain optimal acidity…………………For his part, Blaser thinks that in the future, pediatricians will deliberately introduce H. pylori into young stomachs, strains designed to fit the genotype in question. The bacterium will help prevent asthma, allergies, and maybe other inflammatory and autoimmune diseases.”
This book is amazing!!
Could you maybe give us a review on this book?
In a nutshell the author discusses how our modern cleanliness removed much of our gut flora and parasites such as hookworm.
I have read it, and I agree that it’s a fantastic book. The talk I proposed at AHS13 is “Parasites are Paleo: The Hidden Costs of Modern Hygiene”. So yes, I’ll be covering these topics a lot this year. I’ve tried to contact Manoff to be a guest on RHR, but so far he hasn’t responded.
That’s good news. That will make for a great RHR show.
And I’m seriously considering infecting myself with hook-worm.
Hopefully we’ll find them in the paleologix.com store someday.
Ha! That would be the day.
I’m confused. Do we want H pyloria
In our gut or not? I had H pyloria treated with antibiotic when I was 16 yrs old after yrs of reflux and ulcers. This made my symptoms go away for good. Should it have been left alone or treated differently?
Seriously confused as well on H. Pylori, to have or not, or is it a problem with absence and also a problem in overgrowth?
Not that I’m a scientist, but from all this it would sound like the problem is overgrowth. If it’s that important, I would suspect that like candida it’d be all but impossible to completely kill off, so you just want to beat it back into homeostasis.
Our symbiosis with our bacterial overlords is a fascinating story, honestly.
Another quote.
Hopefully it will convince you to read the book.
“….And the Stanford University scientists Sharon Perry and Julie Parsonnet stumbled on a plausible answer. They were tabulating the results from a survey of tuberculosis prevalence among immigrants living in south San Francisco when they noted that while people with H. pylori were just as likely to carry tuberculosis, they were far less likely to develop active tubercular disease. Did H. pylori somehow protect from active tuberculosis?
The scientists confirmed that harboring H. pylori protected against active TB in the Gambia
and Pakistan. Then they tested the idea experimentally. They exposed macaque monkeys that
naturally carried H. pylori to M. tuberculosis. These monkeys were, they found, one-third as
likely to develop disease six months later compared with noninfected counterparts. How did it
work? By activating antimicrobial aspects of the immune system—especially interferon gamma,
which was also, incidentally, so important in protection against allergy—H. pylori helped its
host manage the tuberculosis infection. One bacterium helped control a second. (And another
infection—worms—may have helped limit damage caused by the first.)
The finding “raises the intriguing possibility that our microbiota can be manipulated to
modulate disease risk from M. tuberculosis, as well as other common human pathogens,” wrote
Perry and Parsonnet in 2010. Indeed, German schoolchildren harboring the bacterium were
nearly one-third as likely to suffer from diarrhea compared with their helicobacter-free peers.
And Israeli soldiers hosting H. pylori were less susceptible to diarrheal disease than those
without. In the future, before you travel to a region where tuberculosis is endemic, or
dysentery common, physicians may colonize you with a specially tailored helicobacter strain.”
By acid stable protease, you mean bromelain and papain right? The bacterial produced proteases are not stable in acid, which leaves the fruit proteases.
I’ve struggled with IBS before and after switching to a paleo diet. What a great summary of all of the things I’ve learned. I unsuccessfully tried the GAPS diet and SCD diet (for various reasons I believe, probably mostly not addressing stress and dropping calories much too low but I have learned along the way). I’ve read about all I can on GAPS, SCD, SIBO, IBS, etc. I’m now working with a paleo dietitian. I’ve learned to avoid a lot of high FODMAP foods through trial and error but it’s a difficult landscape to navigate (who’s right, how might this apply to me, what exactly is the cause, and finally figuring out the role that stress plays into the entire thing).
As always, thank you for the information you share through the blog.
I have experienced digestive issues on a Paleo diet that I didn’t on the SAD diet. And I haven’t as yet, found anything that helps. I know that my problems are compounded by the fact that I have PCOS and that I have had surgery for uterine prolapse. Both of which are probably creating an environment of severe inflammation.(At least going by the level of pain that I am experiencing)
I wonder in reading this, if there is any help for people who have had some sort of abdominal surgery or who have cysts on their ovaries? WIll you ever really be healed by following the above protocol if you still have a problematic environment – in that you always(potentially)have inflammation present?
I am wondering if, as in the case of PCOS, how much fixing the hormone problems would help with any of this.
I have PCOS also. I think I’ve read that it is quite common to also have IBS. I’ve been primal for over two years and it definitely addressed the blood sugar and weight issues. I’ve only just begun to address the gut issues with digestive enzymes and HCl. There is hope and you’re on the right track. It does take so much time. I know I need to get a stool test to see what exactly is going on, but will stick with the enzymes until I can afford it.
Stephani Ruper of http://www.paleoforwomen.com/ covers PCOS and just released a book on it. If you’ve got two x’s, you’ll really appreciate her blog.
I’ve been eating paleo for about 6 months now but I’m still suffering from the digestive issues I had pre-paleo, although they have slightly reduced.
I was never a vegan or a vegetarian but I did eat a lot of grains (cereals, pasta, couscous, bread etc), which I’ve of course cut out since starting on paleo, the only thing I still eat on occasion (maybe 1-2 times a month is white rice, culturally this is a BIG part of our food and it doesn’t cause me distress)
I also did the whole low-fat, lite dairy thing until I quit sugar over a year ago, which is when I switched to full-fat dairy but again since going paleo I’ve stopped dairy all together.
I’ve had numerous tests done, food allergy tests, colonoscopies, endoscopies, other allergy testing and nothing has shown up. I’ve been told over and over gain that I have IBS-D and that I need to treat it (the conventional way) by eating plenty of whole-grains etc etc.
There’s a few things that seem to help like making sure I eat slowly and chew well, not having liquids with my meals but either an hour before or after, not eating large portions of food in one sitting. Like I said these things have helped reduce the symptoms slightly but they’re still there.
The problem I have is I don’t know where to start with treating it, I eat fermented foods with my meals, I drink kombucha, I make and have bone broth regularly but still the symptoms are there.
And then there’s the supplements, which one do I take? how many do I take? I don’t know it’s all a bit confusing!
This sounds like me. The digestive enzymes have helped ( I use NOW Super Enzymes) I eat with every meal. For the last couple weeks I’ve added NOW HCl with Pepsin. It’s the first time I’ve seen real improvement since going Primal over 2 years ago. I had digestive issues before Primal.
Thanks Mindy, I will give the NOW super Enzymes and the HCL to see if I have any improvement!
Have you checked your gut flora?
I had NO gut issues prior to getting a routine colonoscopy for the 1st time-the osmotic bowel clean preparation didn’t work,as my bowel is resistant to osmosis,thus causing the salt solution to dry out my bowel,leaving me badly constipated instead of the bowel emptying effect most people experience.
Well,my salt filled bowel suffered bacterial die-off as one would expect(salt kills bacteria) and I subsequently have suffered gut ache ever since.
Stool tests show my gut flora are damaged and I’m currently looking at getting a feacal transplant,as all dietary attempts to rectify normal gut flora have proved ineffective.
What you need to do is ingest minerals and amino acids and essential fatty acids in large amounts. Look up a company called youngevity. I wish I had time to write out what their products did for me but I do not. Just trust me though. Dr Joel Wallach is correct and you cannot be healthy without supplementation. “Listen to Dead Doctors Dont Lie”
The article says the steps to take are to reduce veggies, reduce FODMAPS, GAPS diet. Where is this sequence would one do the personal paleo code program?
I do cover the FODMAP diet in the Personal Paleo Code, and there will soon be a “low FODMAP” option in the Meal Plan Generator.
Follow the link in the article for more information about eating fewer veggies.
I have not covered the GAPS diet in depth because there are so many books, websites, resources, etc. that already have. I did do a podcast a while back on when you would choose GAPS vs. Paleo vs. FODMAPs.
Grammar correction: In the following line, “it’s” should be “its”.
Stress. Once again, chronic stress rears it’s ugly head.
Should be:
Stress. Once again, chronic stress rears its ugly head.
Thanks Ingrid! I appreciate my loyal proofreaders.
Really? H’es giving us all this help and you’re worried about his grammar…
Afaik it is a B-12 deficiency issue with vegetarians, which makes them unable to produce enough HCL…
I overcame severe Ulcerative Colitis on a Paleo/SCD diet and I used principles of food combining to plan my meals. I tried not to eat fruit and carbs with fat and protein because it made sense to me that the rate of movement through the stomach and small intestine were different. Seems that our ancestors GI tract may have evolved more to eat one thing at a time,but who really knows? Holding up sugar may allow fermentation from anaerobic pathogenic microorganisms IMO. Anyways, I was wondering if you ever suggest proper food combining to your patients or what your overall opinion of it is and if you think it is worth considering?
Great article Chris, thanks!!!
This article has helped synthesize all the information I have been absorbing in a very practical and actionable way. I first started the Low FODMAP diet about 7 months ago. I got 40 % relief. I then combined it with the Paleo diet 3 months ago and am now 60% relief. I have not been able to tolerate HCL so far but am getting ready to try again. My main symptoms are gas, bloating, gut pain, sore throat, abdominal muscle spasms. Do you think a stool test like the Gut effects DNA test could unlock more clues? I’m skeptical of those tests as they are high out of pocket expenses and the skeptic in me does not trust them. Are they legit? Thank you.
OMG, I have all of those! I was running out of things to eat. Luckily I am back on the HCL (I tried it last year when I wound up with a B12 deficiency even though I was taking supplements). I don’t remember why I stopped. Now I’m mostly Paleo and going to try the SCD or GAPS diet to get over some digestive problems. But the HCL has made a huge difference. Thanks for all the great info.
Hi Chris,
This misinformation regarding betaine hcl has been pretty widespread and I was hoping you could either revise your recommendations or debunk a statement made by Dr. Art Ayers in regards to betaine hcl increasing stomach acid. This is a response of his to my question about betaine hcl
“Psychic24,
The confusion comes from the fact that betaine has two ionizable groups, like amino acids in water. The N, bonded to four carbons has a positive charge and the carboxylic acid loses its proton to have a negative charge. When HCl is added, the H+ reprotonates the carboxyl group and the Cl- forms an ionic bond with the positively charged quaternary amine to yield a salt.
There is no HCl in NaCl and no HCl in ammonium chloride and no HCl in betaine-HCl. All of those are salts.
Betaine-HCl cannot be claimed to increase stomach acid in over the counter medications, because there is no evidence to support the claim.
Thanks for the questions.”
I’m aware of what Art says about this, but my clinical experience conflicts with his position. The vast majority of patients with signs of low stomach acid improve with HCL, and are able to reduce their dose and stop taking it eventually, which suggests their endogenous production has improved.
Chris, these are the most informative articles I’ve read lately and address right the issues I was worried about after adopting the Paleo lifestyle. I Wonder if you would deliver your supplements to Brazil (?)
They’re working on it. International (and frustratingly Canada still counts) shipping and customs clearance is tricky. I know, I harassed them about it already.
That’s right — thanks JHM!
If you’d like to be notified when international shipping becomes available, you can sign up here: http://www.paleologix.com/international-orders.php
Hi Marco: you can sign up here: http://www.paleologix.com/international-orders.php to be notified when international shipping becomes available. I’m glad you’re enjoying the series.
Tks. I’ve signed up. I’ll be wating.
As a naturopath that uses Paleolithic eating plans regularly as part of my treatment strategies, I’ve had to do quite a bit of research into SIBO & fructose intolerance syndromes as this seems more commonly the cause in those individuals with gut problems on Paleo, especially when they’ve had a long history of poor food choices. It’s remarkable how big a role intestinal flora dysbiosis plays in gut issues such as IBS, and while a tweaked Paleo/FODMAPS diet starts improvement, specific supplements which address SIBO directly are absolutely necessary for long term changes. I use Metagenics for this. Great article, a lot of us Paleo converts don’t address this downside sufficiently, thanks for supplying further insight.
I would DEARLY love to get off of the PPIs after having been on them continuously for well over 10 years, but I have had no real success on any of the multiple times I have tried. The rebound heartburn – which is well-documented side effect after long-term PPI use – is truly horrendous and it doesn’t seem to matter whether I go cold turkey or attempt to reduce the drugs slowly. And, yes, I was carefully following your suggestions for using the HCL and digestive enzymes.
In fact, I find the standard advice to increase the amount of HCL at meals “until you feel a slight warmth” kind of funny/sad. Considering the volcano I am already experiencing, how on earth am I supposed to identify a “slight warmth”? Some suggest just “staying the course” and suffering the heartburn pain with the hope that it will gradually get better, but since I already have Barrett’s, I’m a little leery of doing even more damage. Any suggestions for those of us whose issues are more serious?
Hi Chris: sorry to hear about your difficulty. Are you working with someone on this? People in your situation need to be under the care of someone who is experienced with this transition. Increasing melatonin and GABA levels is another interesting therapeutic approach for people who don’t do well on HCL.
See this study: http://www.biomedcentral.com/1471-230X/10/7
Thanks, Chris.
About 6 months ago I had read another similar melatonin study (that I can’t find the reference for right now) and tried their protocol of 3mg nightly for 40 days since I was having a period of bouts of heartburn even with the PPI. Based on a quick reading of the study you referenced, it looks like the tightening effect of the melatonin on the LES may have been what did the trick for me. I am leery however of continuing supplementation long-term because of several other references reporting various autoimmune and/or thyroid issues w/high doses of melatonin but I may add lower amounts to my next “trial”.
And I agree with you that I need some guidance going forward. My (traditional) gastroenterologist wasn’t averse to my “tinkering”, but he also wasn’t very interested, supportive or informed. But … I have a new GP who is strongly paleo-oriented (!) and he has recommended I also see a local naturopath/Chinese medicine specialist for what we have determined are some pretty serious adrenal insufficiency issues. So I will see if both he and the new guy are willing to add this GERD/PPI thing to the mix and monitor how it goes.
Just wondering if you have tried drinking aloe vera juice? I know it seems so simple in the face of what you’re dealing with but for many it can be immediately palliative for heartburn, without side effects, and can also help longer term. I don’t mean to suggest it will cure, but that it may help here and there. And I do hope you add Naturopathic care to your wellness regime; their support as a partner in health is amazing.
i have found the aloe vera gel is even better
I have been living low-carb since 2000, gradually easing into a more primal/paleo lifestyle. Unfortunately my stomach kept troubling me, mainly with constipation, but also with occasional bouts of diarrhea. The problem seemed to increase over the years and I could never find out any specific cause – except stress and lack of sleep made things worse.
September 2012 I had a dental root amputation. For the first time in 13 years, I had to take antibiotics – two different kinds and quite strong stuff. I was truly dreading what this would mean for my poor stomach, so I made sure to take lactobacillus and bifidobacterium along with the antibiotics. Surprisingly, after all this my stomach started working perfectly.
I wonder if my stomach problems were caused in some way by dental infection, which probably have been simmering slowly for years and years since a root canal way back. Or could it be that the antibiotics killed off some unwanted bacteria while I was refilling with the good stuff? I am happy either way, is has been three and a half months since my dental surgery and my stomach is still doing great!
Chris B. – I took acid reducers for over two years because of Barrette’s and felt terrible the whole time. I finally just quit the drugs and switched to HCL, digestive enzymes and probiotics. I was particularly helped by Probiotic CD (American Health). I went to a naturopath and had a lot of tests, including one for food allergies. I eliminated all wheat, most grains, dairy and other foods. At night I still take a simple anti-acid like Tums or Milk of Magnesia tablets and also DGL and I sleep on my left side. I also took a mixture of slippery bark powder and marshmallow root powder (one teaspoon of each) mixed in water. You can eat it raw or heat it up – I sometimes add a little coconut milk and stevia to make it taste better. Take it at night. My last endoscopy showed no evidence of Barrette’s. I can eat spicy food but not too much grain or especially fruit or baked goods. I suggest taking the simple anti-acids to get through the initial heartburn phase when you give up the PPIs (in addition to taking them before bed). It took me about three years to get rid of the Barrette’s and begin to heal from taking those drugs for only two years. Be patient and find a good naturopath who can guide you.
Laurie,
Thanks for all the info. As I said in my comment to Chris above, I am getting ready to see a naturopath for some other issues so I was going to see if we could work on this too. I have already basically off all grains except white rice for over 3 years now so I’m ahead of the game there. And I will definitely discuss your other recommendations with him.
Chris B
Chris, how do you recomend getting rid of H. Pylori?
I use some combination of anti-microbial botanicals, monolaurin, biofilm disruptors (apolactoferrin, NAC, Interfase Plus, etc.) and probiotics.
I have been eating Paleo for about a year and have eliminated gas but do still struggle with constipation from time to time. I have tried digestive enzymes but find they cause incredible nausea and I can’t tolerate them.
I wonder what the nausea points to and if it is a temporary reaction? Does this mean I should stop taking them?
Have you tried magnesium glycinate at 400-800 mg per day for the constipation? You may tolerate enzymes better once the constipation resolves.
Ageless Hydro C is another option if magnesium glycinate doesn’t do the trick.
Ultimately, though, chronic constipation is almost always caused by dysbiosis (not enough good gut bacteria), so restoring a healthy gut microbiota is paramount.
i also have been experiancing nusea when taking enzymes, is this a temp reaction or am i taking too many enzymes at one time (i currently take 2 tablets)
Reading this makes me hope for my future health. I have suffered with gut problems forever. They have gotten better since going paleo but definitely not great. About a year in to my paleo diet my stomach issues began to get worse and then I got salmonella poisoning. Suffering from chronic upper respiratory issues that seem interconnected. Also suffered with depression for awhile when my stomach was horrible prior to paleo. This is an amazingly great article. I am working hard at getting better. Thank you for all your information Chris.
Celiac, dairy-allergic, and fructose intolerant here, so although I don’t follow any one belief system (be it spiritual or dietary!) I’m pretty much Paleo by default, by way of originally learning to deal with my food intolerances through Atkins. Long story short, I was a very very sick vegetarian and now I’m not.
Paleo-style eating has solved my digestive issues by maybe 85-90%, but I still have random digestive attacks even when I don’t do anything to bring it on. I have to limit vegetables to small portions; if I overdose on, say, kale (I LOVE kale) or cauliflower (I LOVE cauliflower) I’ll pay for it later. I take digestive enzymes, which definitely contribute to the 90% success rate, but clearly there is still a missing piece to the puzzle. My next experiment will be to try eliminating groups of foods that trigger inflammation in some – e.g. eggs, nuts, nightshades, to see if one of those could be the culprit.
Hi Janeray, both cauliflower and kale are high FODMAP foods. Try eliminating FODMAPS for a while and see if you feel better. It was a huge help for me
Hi Nicole, thanks for the reply. I do watch FODMAPS and have tried following a couple of the low-FODMAP plans out there but my results have been pretty inconsistent. Many of the supposedly low FODMAP foods really set me off – zucchini and tomatoes, for example, which I now avoid like the plague – while I can eat other higher-FODMAP foods to my heart’s content (such as avocado and yam). I tend to think my issues have to do with long-term undiagnosed celiac/casein intolerance and the damage that those things have done… and am remaining hopeful that as time passes, this will all heal
If tomatoes bother you, then definitely try avoiding all nightshades, tomatoes, peppers, eggplant, potatoes (not sweet potatoes). I had a severe allergic reaction to a raw tomato when I was about 3 years old, so consequently I never had raw tomato in my life (I could eat cooked tomato sauce). I tried one awhile ago and had the same reaction, swelling and sores all over my mouth. Now I’m off all Nightshades. I love eggplant, but it would turn my mouth numb when eating it. Also raw peppers. Potatoes never really bothered me, but I’d rather have sweet potatoes now. Handling tomato or pepper plants can make my hands or face break out if I don’t wear gloves. Which is a shame because I like to grow tomatoes for my husband, he loves them.
Thanks Bet, seeing your list really is making some alarms go off here. While I avoid tomatoes diligently, peppers and eggplant seem to be hit or miss so I think I should add those to the list. As for potatoes – I tend to think they don’t bother me when I eat them, but I do eat them fairly often so maybe I’m getting a delayed reaction or something… won’t hurt to cut them out for a while and see how it goes. I’d rather have sweet potatoes as well – happy to know that they are not in the nightshade family, I wasn’t sure but now I’ve done my research
I started giving my 80-year-old step-father Betaine HCL. At that time he had eaten little apart from cakes and sweet biscuits for over 10 years and his vigour is declining a lot. I increased the dose 300ml at a time. He experienced no heat in his stomach but belched more than usual. We got to 900ml and he still was getting no hot feeling in his stomach but suddenly one night (about 8 – 12 hours after taking the HCL) he experienced a great deal of nausea. I suspect this was due to SIBO die-off. He stayed off HCL for a few days then started again on a lower dose and got the nausea again that night. He now absolutely refuses to touch HCL again. Neither he nor I have the money to start paying a functional doctor and getting tests done even if I could locate a good one in my area of the UK, which I very much doubt. Could your new product help this problem? Does anyone have suggestions to offer?
He probably needs a lower dose, and it sounds like the most important change you can make with him is his diet. No supplements in the world will solve his gut issues if he’s eating nothing but sweet cakes and biscuits.
Changing the diet is always the first step. If he continues to have problems after that, yes, the digestive supplements I mention in this article could help.
As someone who suffers from a multitude of food intolerances (gluten, soy, lactose, nightshades, mushrooms) switching to a paleo diet has dramatically improved my digestion.
Hi Chris,
Thank you for your recommendations on gut health. After a long and difficult episode of bronchitis, I started experiencing acid reflux to the point that I can’t sleep unless I am in a sitting position. The acid reflux moves up the esophagus and causes bronchial spasms, during which I can’t breathe. I am cutting back on eating, losing weight, and cutting back on glutens that are causing phlegm production. I’m also taking antacids like prilosec and tums. Any recommendations? Thank you
Cat Ridout, your combinations of symptoms , upper respitory and salmonella could indicate vitamin D deficiency. Further research on that subject would benefit you
I switched from a “fairly” healthy diet of whole grains, meat, veggies and good fats to Paleo one year after being diagnosed with Hashimotos. Endo said once I was “stablized” on thyroid hormone my problem with constipation would go away. It didn’t and neither did any of the 40lbs I gained almost overnight, so I went Paleo four months ago. Have to eat small amounts of sweet potato otherwise it’s too low carb…but the only change I’ve seen is that now my constipated BM’s are very smelly…didn’t have that problem when I was eating “clean” with oats and occasional whole grain pasta ( never ate bread) and full fat yogurt.
I added HCI with pepsin to one meal last week, no changes. Wondering if Kombucha would help?
Has anyone had any positive healing result from having a DNA stool test for GI effects? Thank you.
Dear Chris, congratulations on your article. You always produce valuable content.
I have a question..
Is it true that for low stomach acid, you can replace betaine with homemade sauerkrauts liquid or a spoon of apple cider vinegar 10 minutes before meals?
Thanks.
Yes, I’d be keen to know if it would help. I tried the cider vinegar (20 mls in a glasss of water) but it was really unpleasant and sauerkraut liquid sounds more appealing.
Hi Chris
My gut issues have gorton much worse since I’ve gone Paleo, but, yes, they were there before. Everytime I suffer a chemical exposure, acid rises up to my mouth. If I eat the wrong foods, or just plain overeat, I just about vomit in my own mouth. I’ve had my gut tested and found that 3 out of 4 of the good bacterias are missing, and i have a pathogen, which is Blastocystis hominid; I’m taking probiotics and Parace Forte for those. I also take the Ox Bile but find I can’t take it all the time, in fact when i have this acid problem, i can only take my vitamins sometimes.Oh, and I was given Mutalfor, which made me vomit. My diet is very restrictive, mostly apples, chicken pieces cooked whole in a pot for two hours and I have the broth too, pumpkin, zucchini, coconut oil, water and coffee. I can eat chocolate and totally crave it, but if I eat any of the wrong foods then I can’t have chocolate as it makes the acid worse also. The weird thing is this: apples, watermelon, lemon juice in water, these all sooth it so well. Apples are my best friend at the moment.
I’ve blogged about it here: http://the-labyrinth.com/2012/12/27/healing-the-gut/
Hello Chris, what are your suggestions for those who cannot take HCL or bitters, such as pregnant and breastfeeding mothers? I found that all of my stomach acid issues increased tenfold while pregnant and now breastfeeding. Also, what do you suggest for kids with the same issue? Thanks!
Ok I have a question re antibiotics. I know they are bad for your gut flora etc but I’ve gone and done a good one and given myself a burn on my lower stomach and upper right thigh… the thigh is the worst with an open wound which I’m taking care of now with dressing it etc etc. Anyway when I saw the doc he said I should take antibiotics for 10 days in case of an infection. I’m worried that if I don’t take the antibiotics something bad will happen and if I do take it then my whole gut flora/digestive system etc will be in distress (it already is) so what steps can I take to prevent this if I do decide to take the antibiotics?
Lots of kombucha and fermented foods?
I’m fairly new to the Paleo/Primal world so if anyone has any tips re this subject I’d love to hear (read) it!
I need advice. Im chronically constipated. Have been for a while now. I really dont know what to eat, theres many conflicting advice. From my observations, for some reason when I do Atkin’s style dieting Im constipated for weeks at a time, and take some laxative out of terror of all the junk in my intestines. Once I did a week long Fruit and Spinach fast, I think after the first two days I went to the bathroom daily, very easily.
I dont know If that will work again :S Right now Im not following any diet, because I got tired of stressing out about what I put in my mouth, but im regaining some kind of restraints. Coconut oil and butter give me extreme fatigue and I dont know why, specially the coconut oil. I dont have access to grass fed anything in my country, so I wonder if I can even do a Paleo diet here. What I COULD do is restrain my grains intake to only rice. I dont know if that could make a difference.
I already avoid wheat like the plague, gives me allergy reactions.
I would appreciate any advice
Thank you for the article, Chris.
Unfortunately, it’s been very hard to find the appropriate stock to prepare bone broth frequently. Is beef gelatin something worth ingesting instead?
Yes, if it comes from a good source.
I just found a paper “Dietary acetic acid reduces serum cholesterol and triacylglycerols in rats fed a cholesterol-rich diet”. http://www.ncbi.nlm.nih.gov/pubmed/16611381
Can low stomach acid be the reason of high cholesterol level in Hypo Thyroid patients?
Hi I was under the impression supplementing with enzymes and hcl will in fact down regulate the bodies own production, as it does if you take lactase? Could this not cause further issues and reliance upon these supplements?
Also wondering for some other advice, I’ve always had stomach issues. Was told it’s like ibs, but caused by being on codeine based pain killers for a long time. I go through a stage of slowly gettig constipated, never fully evacuating, then get incredible stomach cramps, and diarrhea, uncontrollable.
How ever it got much worse after getting really bad food poisoning, possible causes for that? I take probiotics everyday now, still have issues.
Does anyone have a scientific reference for the claim that raw fruits and veges contain digestive enzymes (other than bromelian and papain) that can work in the human gut, and are more effective than cooking as a way to break down these foods? I’ve found that cooked veges, weight for weight, are more digestible than raw, and don’t see any reason why veges should routinely supply enzymes that assist predators to destroy them.
Yes, there are a few oft-trotted out claims I’d be keen to see the evidence for e.g. the idea that anti-wheat agglutinin antibodies direct attack thyroid tissue as in Hashimoto’s disease. Not being cynical, I’d just like to be reassured that these lines are based on actual studies.
I’ve been on and off paleo eating for the past 2 years. But even when eating ultra strict on paleo, I wasn’t getting the same kind of results as some others get when on a paleo eating plan. Sure, I lost some weight, but when I look at myself in the mirror after after a month or two of paleo eating, I just look like a smaller version of my heavier self. Another huge problem I was having was that I was always feeling bloated after eating meat. I was burping a lot after meals.
I added NOW Super Enzymes and NOW Betaine HCL digestive supplements to my diet, and it helped, but I was still not quite feeling like the food I was eating was being absorbed properly. It still felt like it was sitting in my gut a lot longer than it should.
Things changed on January 1st when a Naturopath who volunteers at my local YMCA suggested I take a look at the concept of eating for my blood type, and give that a try. I spent that weekend Googling everything I could about the concept of eating for your specific blood type. Ended up buying the ebook Eat Right 4 Type off Amazon. I thought the concept was interesting at best, I was certainly skeptical, but the price of the kindle ebook wasn’t that much that it was going to kill me.
It’s now been nearly a month since I have been eating for my blood type so to speak. I found out there are certain blood types that do not respond well to paleo type diets, because they have naturally low levels of stomach acid, and eating meat is counter productive, as it does not get absorbed by the body properly. I’m one of those blood types (type AB) that meat – although I love it – clearly does not get digested well, even when I take supplementation such as HCL, Ox Bile, Pepsin, etc. According to the book, I needed to eliminate meat and poultry and consume fish as my main source of protein. Which is exactly what I did this past month, and the results have been extremely positive. Replacing meat and poultry with fish (for me, Tilapia and Salmon) has eliminated my bloating, burping, and I feel considerably more energetic. Basically, I’m eating mostly green veggies, fish, yogurt, tofu, and a handful of other healthy foods. For me, eating for my blood type worked. The foods which they stress the most on a paleo diet (meats) were the main items that had to go in order for me to get back into shape, eliminate the bloating, and the results I was expecting. Just thought I’d pass on my experiences.
Hi Chris,
I found the information about the diet I was looking for here! Thank you! Trish
I have been gluten free for over a two years now due to gluten intolerance. My gut has improved a ton over the last year. I have had gall bladder issues for about 10 years. I have been told to remove my gall bladder because of a very low injection fraction. et? I seem to have looser stools after a high fat meal. Example Breakfast: 2 eggs, whole avocado, banana and some coconut milk. Can gall bladder function return and what are the effects of a higher fat paleo diet?
Yes, i have chrons and my body decidedly does not like the paleo bread! Could it be the psylium? I suspect so …
Chris isn’t it amylase (salivary amylase to be exact) and not carbohydrase? Other than that, I love your articles!
I made the switch to a more paleo style of diet last summer. There was no medical stimulus. Of course afterwards I have no stomach burns anymore (and when I have them its after a day of non paleo restaurant or friends dinner). And I’m leaner then I ever was (even when I was cardioing like crazy in my racing days). I was doing fine on my grains and starches. Being an ex endurance athlete, carbloading was all there was.
I was looking to add some muscle mass. As that was hard on my diet at that time, I added some extra protein in. Still not the true gains I was looking for. Thats where the paleo diet came in. I started off by eating lots of fruit, lean meats and sweet patatos. Basically just switching my carb intake to more paleo products. This winter I made the switch to start having a more LC aproach. Thats when it really hit the fan. My stools were somewhat regular, but there was absolutely no consistancy and I had an upset stomach for the first hour after eating a meal (especially in the morning). I used olive oil and flaxseed oil to supplement my meals with some oils as I used lean meats. On my HC aproach I had some regularity in my stools, but there was too much variety to say that was the way to go. Not willing to give up the change to Paleo I tried tinkering the fiber balance (sol. vs insol in the favor of sol – i.e. zuchini, carrots, turnips, beets that I put in stews). This helped somewhat. But I still had a gut feeling that I wasn’t on to the real cause. The big difference came when I started to use lard instead of the olive oil. Killing the monster that was created by the last 30 yrs of mass media opinionating propaganda about saturated fats is the best thing I have ever done. After I ate a meal my stomach felt upset before. Now it’s all just fine and my stools are regular and with a good consitancy. Instead of the lean cuts, I stick to baking my veggies like asparagus or broccoli in lard I get out of bacon. Make bone broth from the spareribs I eat and fro the rest just adding some fattier cuts in with my leaner cuts. I’m still not sure about eggs though. Boiled they don’t seem to bother me. But when I bake them, there seems to be some upsetting effect.
Some practical tips about the topic:
- Don’t overdo on insoluble fibers and forget about the soluble ones.
- make sure you are properly hydrated BEFORE you eat your meals and don’t drink a lot of water with them or just after the meals, as this dilutes your stomach content (what you don’t want because this also dilutes the HCL concentration).
- Going LC, make this transition gradually instead of cold turkey. This gives yout gut time to adapt and change it’s enzyme production to the needed level.
- Don’t be affraid of saturated fats!
Hope this helps some of you that experience an upset gut with the paleo switch.
You didn’t mention anything about food sensitivity testing. Some believe this is a “beyond Paleo” step to resolve further gut issues (by removing the offending food that makes inflammation worse). What is your opinion?
What do you do when your gut is severely inflamed and you react to every food but are too inflamed to take hcl/enzymes?
Whatever else you do you could try grounding/earthing which appears to be very powerful against inflammation. I know it sounds pretty farcical but if you look around online you may end up believing it’s worth a try. You can listen to or read the seminal book on it at http://www.grounded.com/earthing-the-most-important-health-discovery-ever/earthing-book without paying for it and there’s stuff on Youtube as well as elsewhere online.
Earthing is at least as authentically Palaeolithic as any modern diet could be, not that that’s particularly important in itself.
I have sibo/candida/leaky gut/chronic gastritis, very low weight. im doing the gaps intro but just getting worse and worse.
Hi,
I think I’m suffering from low stomach acidity. I was a vegetarain for years and I am now on the paleo diet. I’m doing a very strict paleo diet and I still have a bit of bloating and burping after meals. Also, I do not break down well my food (undigested pieces in BM). I started suplementing on HCL a month ago and as soon as go take more then 600mg per meal, I start to feel heart burn and gastric reflux. So I stay on 600mg per meal, but I see no change in my symptoms. Is that normal?
thanks
Mélanie
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