This article is part of an ongoing series comparing prescription medication with a Paleo diet as a means of treating common diseases and health problems. Click here to read the other articles in the series.
Gastroesophageal Reflux Disease (GERD), a more serious form of acid reflux, is the most common digestive disorder in the United States. Sixty percent of the adult population will experience some type of GERD within a 12-month period, and 20 to 30 percent will have weekly symptoms. The diagnosis of GERD increased by an unprecedented 216 percent between 1998 and 2005.
Drugs for heartburn and GERD are cash cows for the pharmaceutical companies. More than 60 million prescriptions for GERD were filled in 2004. Americans spent $13 billion on acid stopping medications in 2006. Nexium, the most popular, brought in $5.1 billion alone – making it the second highest selling drug behind Lipitor.
Got heartburn? Find out why acid-stopping drugs are a bad idea, and what to do instead.
As sobering as those statistics are, it’s likely that the prevalence of GERD is underestimated because of the availability of antacids over-the-counter. This permits patients to self-medicate without reporting their condition to a doctor.
What Really Causes GERD and Heartburn? (Hint: It’s Not Too Much Stomach Acid.)
If you ask the average Joe on the street what causes heartburn, he’ll tell you “too much stomach acid.” That’s what most of the ads seem to suggest too.
However, anyone familiar with the scientific literature could tell you that heartburn and GERD are not considered to be diseases of excess stomach acid. Instead, the prevailing scientific theory is that GERD is caused by a dysfunction of the muscular valve (sphincter) that separates the lower end of the esophagus and the stomach. This is known as the lower esophageal valve, or LES.
In GERD, the LES malfunctions because of an increase in intra-abdominal pressure. This pressure causes distention (i.e. bloating) in the stomach, which pushes the stomach contents—including acid—through the LES into the esophagus.
But what causes the increase in abdominal pressure in the first place? Ironically, one of the main causes may be too little stomach acid, which in turn contributes to an overgrowth of bacteria in the small intestine. This idea is supported by studies on mice that have been genetically altered so that they are incapable of producing stomach acid. They develop bacterial overgrowth in their intestines—as well as inflammation, damage, and precancerous polyps. (1)
The understanding that not enough—rather than too much—stomach acid may be to blame for heartburn and GERD has important implications when it comes to determining what the safest, most-effective, and longest lasting treatment would be. With this in mind, let’s see how conventional treatment of heartburn and GERD measures up.
Conventional Treatment of Heartburn and GERD
Conventional treatment of heartburn and GERD involves the use of drugs that suppress the production of acid in the stomach. There’s no doubt that these drugs can be effective in reducing the symptoms of GERD. After all, if there’s no acid in the stomach, then no acid will escape into the esophagus.
But is suppressing stomach acid production really the best approach—especially if low stomach acid is one of the potential underlying causes of GERD in the first place?
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, including:
- Reduced absorption of essential nutrients (including B12, magnesium, calcium, iron, folate, and zinc)
- Increased risk of bone fractures (likely a consequence of impaired nutrient absorption)
- Increased bacterial overgrowth in the intestines
- Decreased resistance to infections (including life-threatening ones like pneumonia and clostridium difficile)
- Increased risk of cancer and other diseases, such as irritable bowel syndrome (IBS), Crohn’s disease, depression, anxiety, autoimmune disease, and asthma.
It’s worth noting that proton-pump inhibitors (PPIs), the most commonly used class of acid-suppressing drugs, were only approved by the FDA for 8 weeks of use. They were never intended to be prescribed for years or even decades, as is often done today.
Perhaps this is why the FDA has issued a series of reports cautioning against the prolonged use of PPIs, citing increased risk of infection, bone fractures, and life-threatening infection (clostridium difficile) as the primary concerns. (2, 3, 4)
So if acid-suppressing drugs aren’t the answer, then what is?
A (Relatively Low-Carb) Paleo Diet for Heartburn and GERD
If GERD is caused—or at least contributed to—by low stomach acid and bacterial overgrowth in the intestines, it follows that the best way to treat it is to improve stomach acid production and reduce bacterial overgrowth. This strategy actually addresses the underlying causes of the problem, whereas the conventional approach (acid-stopping drugs) merely suppresses the symptoms.
In his excellent book, Heartburn Cured, microbiologist Dr. Norm Robillard argues that carbohydrate malabsorption leads to bacterial overgrowth, resulting in the increase in intra-abdominal pressure that drives reflux. When stomach acid is sufficient and carbohydrates are consumed in moderation, they are properly broken down into glucose and rapidly absorbed in the small intestine before they can be fermented by microbes. However, if stomach acid is insufficient and/or carbohydrates are consumed in excess, some of the carbs will escape absorption and become available for intestinal microbes to ferment.
The standard American diet is high in carbohydrates—particularly refined carbohydrates like flour and sugar that feed bacteria in the small intestine. It shouldn’t come as a surprise, then, to find that low-carbohydrate diets have been shown to be effective in managing the symptoms of GERD.
For example, in one study at Duke University, patients who had failed conventional GERD treatment (i.e. acid-stopping drugs) experienced a complete resolution of their symptoms within one week of adopting a low-carbohydrate diet. This was true in spite of the fact that some of the patients continued to drink alcohol, smoke, and engage in other “GERD-unfriendly” lifestyle habits. (5)
In another study, also at Duke, a low-carbohydrate diet was just as effective as PPIs in a group of obese patients with GERD. (6)
There are many ways to do a low-carbohydrate diet. I suggest a low-carb version of the Paleo diet for my patients with GERD, since it restricts gluten and other foods that may be problematic, in addition to reducing carbohydrate intake. (For more tips on how to treat GERD naturally, see this article.)
In most cases, once you’ve addressed the GERD and improved your digestive function, a Paleo diet that includes a moderate amount of “real-food” carbohydrates like fruit and starchy plants such as sweet potatoes should be adequate to prevent a recurrence of symptoms. A very low-carbohydrate diet is not only unnecessary for most people over the long-term, it may cause problems of its own.
I’ve found Paleo to be remarkably effective for reversing GERD in my work with patients, and I’ve also heard success stories from literally hundreds of readers, like this one from Laura L.:
I found the paleo/ancestral community initially by reading Dr. Loren Cordain’s book; my further research lead me to Chris Kresser. At the time I was readying myself for a surgical procedure for my unremitting GERD. I was taking 80mg of Nexium per day and two extra-strength Tagamet pills prior to going to bed. Under the care of one of the leading Gastroenterologists from Columbia Presbyterian in NYC; I was given no alternative but to go through a drastic procedure which had a 40% sucess rate. Not the best odds, for sure. My other alternative would be to stay on PPIs the rest of my life (I had already taken them for 3 years); destroying my bones; and leaving me open to infections, etc. that occur when you reduce necessary stomach acid over long periods of time. From time to time I would try to stop taking my meds but the rebound reflux was unbearable.
After reading as many Paleo books as I could get my hands on and following more blogs than I can count; I started the Paleo diet removing all sources of grains, dairy, and industrial seed oils from my diet. In the meantime I gradually reduced the Nexium, etc.. As the weeks went on I could feel myself getting better and better. It took me a year to get off those nasty drugs and I could not have done it without the diet. I’ve been Paleo since 2008 and I’ve never looked back. I’ve been able to add safe starches to my diet but never anything containing gluten (activates my reflux within hours).
So what will it be for you? Pills, or Paleo?
If your answer is Paleo, make sure to check out my book (just published in paperback with a new name: The Paleo Cure) for a detailed explanation of how to use the Paleo diet and lifestyle to prevent and reverse disease and feel better than you have in years.
As always, check with your doctor before starting or stopping any new treatment plan—including what I’ve suggested in this article. This is not intended to be medical advice, and is not a substitute for being under the care of a physician.