In the next few articles, I’ll be writing about the epidemic of gastroesophageal reflux disease (GERD) and its mismanagement by the medical establishment.
In this first article I will present evidence demonstrating that, contrary to popular belief, heartburn and GERD are caused by too little (not too much) stomach acid. In the second article I’ll explain exactly how low stomach acid causes heartburn, GERD and other digestive conditions. In the third article I’ll discuss the important roles stomach acid plays in maintaining health and preventing disease, and the danger long-term use of acid suppressing drugs presents. In the final article, I’ll present simple dietary and lifestyle changes that can eliminate heartburn and GERD once and for all.
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Heartburn and GERD Are No Joke
According to the National Institute of Diabetes and Kidney Digestive Diseases, sixty million people experience heartburn at least once a month and twenty five million experience symptoms daily.
Gastroesophageal Reflux Disease (GERD), a more serious form of acid reflux, is the most common digestive disorder in the United States. Studies show that 10-20% of individuals experience symptoms at least once a week, and prevalence of GERD is increasing steadily.
Drugs for acid reflux 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.
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.
Up until fairly recently heartburn wasn’t taken too seriously. It’s primarily been the butt of bad jokes about Grandma’s cooking. But we now know that heartburn and GERD can have serious and even life-threatening complications, including scarring, constriction, ulceration, and ultimately, cancer of the esophagus.
Problems with the Conventional Theory
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. I’m sure you’ve seen pictures like the one at the top of this post in ads for acid suppressing drugs on TV and in magazines.
But there’s a big problem with this theory: the incidence of heartburn and GERD increases with age, while stomach acid levels generally decline with age (Fig 1).
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. Another study found that 40% of women over the age of 80 produce no stomach acid at all. 1
Figure 1. Mean stomach acid secretion from the second to the eighth decade. (from Wright, 2001 p.20)
Just as studies show acid secretion declines with age, it is also well established in the scientific literature that the risk of GERD increases with age.
If heartburn were caused by too much stomach acid, we’d have a bunch of teenagers popping Rolaids instead of elderly folks. But of course that’s the opposite of what we see.
In fact, according to Jonathan Wright, MD of the Tahoma Clinic in Washington state, when stomach acid is measured in people suffering from heartburn and GERD it is almost always low, not high. In his book Why Stomach Acid is Good For You, Wright explains:
When we carefully test people over age forty who’re having heartburn, indigestion and gas, over 90 percent of the time we find inadequate acid production by the stomach.
In Wright’s 25 years of conducting these tests, he found very few people with excess stomach acid. Excess stomach acid is only found in a few rare conditions like Zollinger-Ellison syndrome), and GERD is hardly ever associated with too much stomach acid.
What’s more, Wright and other clinicians have found that giving hydrochloric acid supplements to patients with heartburn and GERD often cures their problem:
In 24 years of nutritionally oriented practice, I’ve worked with thousands of individuals who’ve found the cause of their heartburn and indigestion to be low stomach acidity. In nearly all these folks, symptoms have been relieved and digestion improved when they’ve taken supplemental hydrochloric acid and pepsin capsules.
My own clinical experience confirms this. So far every patient I’ve had with heartburn or GERD has responded well to hydrochloric acid supplementation. We’d expect just the opposite to be true if these conditions were caused by too much stomach acid.
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A Symptom Is Not a Cause
When I explain to patients that GERD is caused by not enough stomach acid, rather than too much, they are initially doubtful. “If that’s true”, they say, “then why do my antacid drugs provide relief?”
I’m not denying that the symptoms of heartburn and GERD are caused by stomach acid refluxing into the esophagus. Nor am I arguing that reducing or eliminating stomach acid with drugs doesn’t relieve those symptoms.
What’s crucial to understand is that any amount of acid in the esophagus is going to cause problems. That’s because its delicate lining isn’t protected against acid like the stomach lining is. You don’t have to have excess acid in your stomach to have heartburn.
The misguidedness of this approach is clearly demonstrated by the use of acid inhibiting drugs to treat heartburn and GERD – problems which are caused by not enough stomach acid!
The Consequences of Ignoring the Cause
As I wrote above, Americans spend more than $13 billion on acid stopping drugs each year. This expense might be justified if antacid drugs were actually curing heartburn and GERD. But just the opposite is true. Not only do these drugs fail to treat GERD, they will make the underlying condition (not enough stomach acid) worse. This virtually necessitates the lifelong use of these medications for anyone who takes them.
While this is a nifty sales strategy for the drug companies, it’s a bitter pill to swallow (yes, pun intended) for those suffering from heartburn and GERD.
Curing a disease means eliminating its cause. When a disease is cured, the symptoms don’t return once the treatment is removed. This of course is not the case with drugs for heartburn and GERD. As soon as the patient stops taking them, the symptoms return. And often they’re worse than they were before the patient started the drug.
Unfortunately, pharmaceutical companies aren’t interested in cures because they aren’t profitable. It’s much more lucrative to sell drugs that people have to take for the rest of their lives than it is to promote dietary or lifestyle changes that would cure the problem.
Therefore, although the drug companies are well aware that GERD isn’t caused by too much stomach acid and that low stomach acid causes serious health problems and complications, they continue to sell billions of dollars worth of antacids to an unsuspecting public. Even worse, these powerful drugs are now available over-the-counter with no warnings about the dangers they present.
Note: if you think this sounds strangely like the situation with the #1 selling drug, Lipitor, you’re correct. Lipitor arbitrarily lowers cholesterol across the board, even though evidence clearly indicates that high LDL cholesterol is not the cause of heart disease. What’s more, low cholesterol is associated with greater risk of death in the elderly population. Something is definitely wrong with our “healthcare” system when the #1 and #2 medications are actually contributing to the conditions they’re supposed to treat. But I guess if you’re looking at it from the standpoint of the drug companies, who are in business to make a profit, it’s the perfect business model.
In the Part II I explain exactly how low stomach acid causes heartburn, GERD and other digestive conditions. We’ll also look at the primary causes of low stomach acid, and how you can prevent this condition from occurring. Read on!
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- Sharp GS, Fister HW. The diagnosis and treatment of achlorhydria: ten-year study. J Amer Ger Soc 1967;15:786-791. ↩
Thanks SOOOO much for having this info available!! can I ask a few questions… I KNOW that I have a gut imbalance and I am trying to move myself to the GAPS diet. I noticed that it get bad when I don’t get enough calories??? not sure what this means. Also, it started with major bloating for awhile and then went to chest pain (seriously felt like a heart attack) and then heart burn/cooling in the throat and and chest pain. (right in the center of chest and back) I am not worried about my heart as I have had it checked and all is well in that department! thank goodness! I am only 27!
I have been downing homemade chicken stock, cutting out grains and adding good fats. I will check out the HCL for sure.
I would like to know what HCL/pepin is?
Does sleeping on the left side of the body help with acid reflux more than sleeping on the right side? I had read somewhere that since the stomach pit (for the lack of better word) is towards the left side of the body, it will keep the acid from getting into the oesophagus linings?
Btw… I just stumbled upon your website when I was googling about my fasting sugar levels and I love the content… Thank you.
Some people do seem to find this is true, but it’s individual.
I recently saw an ENT and was diagnosed with “silent reflux”. I have persistent post-nasal drip and frequent throat clearing. She scoped me and saw redness on part of my nasal cavity just above my throat and redness around my larynx.
I’ve recently read Dropping Acid: The Reflux Diet Cookbook & Cure by Dr. Jamie Koufman, which recommends reducing high pH level foods. I don’t have much of a problem with GERD in the common sense… heartburn, indigestion, etc.
I’ve read all 4 of your articles and am not sure what connection low stomach acid may have with “silent reflux”. What are your thoughts?
Thanks!
I had frequent throat clearing and constant post nasal drip, plus frequent sinus infections and headaches and a feeling of a lump in my throat for several years. Since eliminating wheat and most grains, most dairy from my diet (paleo/primal) the sinus headaches/infections, allergies, and post nasal drip are gone along with most of my reflux which was found to be causing the “lump in the throat” feeling. I’m reading Chris K’s articles to find keys to the remaining issues, but Chris, from my experience, I would try eliminating grains, dairy, and sugar for a month and see how you feel.
I have been suffering with excessive phlegm in my throat for a few months, had heartburn approx. twice/week for about a month, then it went away, initially I was told that I have allergies, then had testing and the allergy results were negative, then an ENT did a barium swallow and showed that I had moderate gerd. I’ve been on PPI’s for a month now, have completely changed my diet, cut out pop, caffeine, alcohol, etc., the phlegm has lessened, but it is still there, doctors are now telling me that I may have to remain on the PPI’s indefinitely. I’m now afraid to go off the pills for fear that the phlegm will come back fast and furious. Not sure what to do, any suggestions?
I have been burping a lot for the past six months. I have tried all kinds of antacids to treat the problem, and they don’t seem to help. Do you think that low acid could be causing the problem? I’m still taking Ranitidine 75, but am afraid to stop. I burp the most after dinner, but even during the day, with little in my stomach, when I move around I burp.
Yes. Follow the strategies I outlined in the series.
I also burped continually on this medication.. It became so normal that I even forgot I was doing it..Horrendous! I stopped the med and after about a month it gradually stopped.. I re-introduced Lemon Juice, Ginger Pickles and digestive enzymes with my food.
I just want to confirm this articles true. I believe I am one perfect test subject considering that I have never had GERD or even occasional heartburn until recently when I was given steroids to treat my rashes. While the rashes gone off after 2 weeks of taking it, the steroids brought side effects like GERD which is now a headache I am facing. I have tried antacid and it is only temporary relieve and then, it will come back feeling even worst such as esophageal spasm so much my jaw can hurt. When I have visited the doctors, they all prescribed me acid blockers which again works only short time, but problem is each time when I popped one if those inside me, my stomach gets bloated up and my stomach starts to growl.
Now I am only believe drugs should be avoided at all cost and natural remedy from mother nature is still best. While writing this, I am still having this drug-inflicted GERD and if anyone of you has a great solution, please let me know. Thanks.
Just had an upper endoscopy yesterday and was changed from omeprazole to pantoprazole for my GERD. (40yo otherwise healthy male.) Looks like I have some reading to do. Any suggestions on how best to approach my ENT doc with this information?
Hand him/her there articles and see what happens…
Hello Chris – Thank you.
I have been paying hard earned money to ruin my health but I plan to turn things around. I was treating for IBS and wide-ranging food allergies. Essentially I was producing IgE in my GI tract for almost every plant-based food. I was not having asthma or anaphylaxis; simply awful abdominal pain and sinusitis. While trying to rule out EE, I was found to have GERD and put on acid reducers. In the course of several years of modifying my diet to suit my allergies I found less and less reprieve, going backwards with even more stomach and abdominal pain, frequent loose stool production, fatigue and poor ability to fend off infection. I thought my decline was due to a poor diet from avoiding so many fresh fruits, nuts, grains and vegetables. On a recent colonoscopy I was diagnosed with inflammatory bowel disease / Ulcerative Proctitis (UP) and put on Canasa and Apriso with a recommendation for VSL#3. Maybe it was the sheer quantity of pills I was about to start gulping down, but something clicked. I have asked my GI MD to weigh the needs for me to be on Ranitidine and Omeprazole. With everything I am rapidly learning, I want to dose up on VSL # 3, reduce complex carb intake, let stomach acid rebuild and hopefully heal my GI tract. Who knows – my allergy response might be partly due to the toxic environment inside of me. Wishful and uneducated thinking perhaps, but maybe I could reduce the auto-response to food proteins if my GI immune system can heal and re-educate itself. Dear God, I can only hope so.
Again – thank you for what you do.
John.
Chris,
When I was 8 weeks old I was diagnosed with GERD. From then until I was about 8 or 9 I was put on virtually every prescription drug to reduce acid production. I came off the medications for a few years and then around ages 12-15 I was on Nexium. At age 15 I had a Nissen Fundoplication to physically prevent acid from going into my esophagus, but (fortunately) the wrap undid itself and a barium swallow test indicated that there is no sign of the wrap at all. In 2009, when I was 19, I started working on an organic farm and was introduced to Sally Fallon and the Weston A. Price Foundation, and since then I have been trying, to the best of my ability, to follow her dietary guidelines. While I can say that I rarely have heartburn anymore, I have experienced on and off pain of what I think is a hiatal hernia, pain of the ileocecal valve, joint pain, I passed kidney stones in January, and I have a rapid heart beat. So I’m wondering if I’m still not properly digesting and assimilating the food I’m eating. Do you think that a paleo diet would be a better fit for me, and if so would it be viable, economically and in terms of time, for a college student?
Thank you for any suggestions,
Joe
So you didn’t mention anything about what foods to eat. You always hear people complain about how they can’t eat spicy food because they have heartburn. Is this true? Should they not be eating spicy food? Or is this another myth?
It depends on the person. Correcting the underlying cause is the goal.
I don’t have heartburn but do have Laryngopharyngeal Reflux (LPR) which caused some distress but also caused me to become so hoarse I couldn’t speak. After drugs, five doctors, diet and lifestyle changes without result, I dug up some old research and found alginic acid compound (AAC) to be very effective. The research clearly indicates that PPIs do not have any measurable effect on LPR. I’ve quit the PPIs and Xantac and can speak again. The mixture does contain an antacid that I would rather not take but since it is the only thing I have found that has any effect, I take it.
I seriously doubt that acid is my problem but suspect digestive enzymes such as pepsin were causing the irritation.
If anyone cares to read my entire blog about it, you should read the oldest posts first which means you should start at the bottom of the page.
My husband was just diagnosed with LPR. Is there a link to your blog?
Dan,
Do you get hoarse if you sleep in a recliner? Can you breath out of your nose? After being told I have LPR and suffering from “croak voice” for several years, I found out I have a deviated septum and could not breath out of my nose and was breathing out of my mouth. This was drying out my throat and causing me to lose my voice.
I just got over H.Pylori about a year ago and I FINALLY feel normal. BUT sometimes when I get hungry or wake up some morning my stomach has a gnawing pain for about 5 minutes. My symptoms slowly went away once I got off all the PPI’s (I was only on them for about a year on and off them… maybe a total of 3 months) and my acid reflux/gurd went away then the burning and nauseous.. now I just have one minor symptom and that is the gnawing every blue moon. I’m thinking this is because I have overgrowth bacterial in my gut from your article. Could this be the case? Also, what would you suggest I do? Or is this something that is just going to work its self out over time like my other symptoms? Thanks.
You make some interesting points. However, to maintain credibility, it’s critical that you support what you say with scientific data. For example, you need to provide a reference for a research article is you make the assertion that lowering cholesterol is detrimental in older people.
Tori,
When people have a bad reaction to ACV or HCl, it’s often because in addition to GERD they’re dealing with gastritis as well. So yes, even a little acv or hcl will exacerbate the already inflamed tissues. When this happens with people I see, I know I have to go slower and heal that stomach lining before introducing HCl. Things like deglycyrrhizzinated licorice (DGL), aloe vera juice and fish oil may help. Many companies formulate supplements with a combination of known gut healing nutrients as well.
I have a friend who is over 65 and has GERD that makes her too thin as she has trouble digesting and causes her distress. She takes Prilosec daily. I have suggested she take ACV instead but she says she has a very bad reaction to even a little vinegar. How can someone like that take Betaine?
She won’t listen to any alternative medicine approaches and insists she has too much stomach acid. I sent her the New York Times article about how doctors are finding that taking Prilosec and those types of drugs can lead to c.difficile and other infections and that made her cut down on the Prilosec. The article though did not talk much about GERD.
Her GERD is largely stress -elated she says, so that’s one thing that she could work on. Basically my question is, if people with GERD have a bad reaction to vinegar (I’m assuming that would extend to Betaine) what can they do?
if people with GERD have a bad reaction to vinegar (I’m assuming that would extend to Betaine) what can they do?
It won’t necessarily be the same response. She can still try everything else I mentioned in my article on treatment.
I have heard of exactly what you are saying. I had a friend who actually thought she was having heart problems because of acid reflux type pain. When her doctor advised her to take a hydrochloric acid supplement this pain went away. It wasn’t too much stomach acid, but too little that was the problem.
By the way, could you fill out my Drug Adverse Reaction Survey? http://PrescriptionDrugProblems.com
I have doubts about the argument that as we age our acid is lower, and therefore we shouldn’t have GERD. We should take into consideration accumulative effect – if we weakened our LES during earlier decades of high acid, it’s possible that we pay for it at a certain age, in combination with other factors, such as increased weight. I am obviously not a medical doctor, and English obviously isn’t my native tongue.
The fact that stomach acid declines in elderly people is well-established in the scientific literature. The decline is primarily caused by an increase in rates of H. pylori infection as people age. As I’ve explained in this article, GERD is caused by low – not high – stomach acid for most people, so it makes perfect sense that elderly people (who have low stomach acid) have GERD.
anna, why then do elderly people who take extra acid in supplements (HCL) no longer have a weakened LES? The acid keeps the LES closed. If the acid is low, the LES opens. Make sense?
Great! I am a physical therapist and make a habit about going over GI issue with all my patients; I specialize in Visceral Therapy. It is crazy how many of them take these drugs for years……and never bother to ask the doctor about getting off of them, and the funny thing is that many of my patients read the warnings that say you are not to exceed 6 weeks, but they continue to take them, Why? I plan on handing out your article in my clinic; Thanks
MK
Ever since I’ve been on a low carb diet (<10% carbs, >70% fat), I’ve only experienced heartburn once. My wife and I had a strawberry and whipped cream dessert and I ate about three times what I normally do on other occasions, and I was up half the night with a severe buring sensation.
It was a good reminder that exercising some discipline alleviates some many negative aspects of eating. It did take me about six months to reduce my carbs to under 80 g a day. That approach allowed me to make gradual changes without feeling deprived and listless.
I also exercise every day and my body has made the transition from burning carbs for energy to burning fat. I also rely a great deal on coconut products because they provide quick energy.
Thanks so much, Chris. Your articles have been so helpful! I’ve been a vegetarian and heavy carb eater for years. In recent years, I’ve also become very bloated, so your theory seems to make sense. I’ve reduced my carbs (not yet as low as you recommend) and added more potent probiotics. I’m amazed at how much better I’ve been feeling since doing just that! No bloating, heartburn or knawing stomach pain lately, even after spicy food! Keep spreading the word – I think you’re on to something!