Gastroesophageal reflux disease (GERD) is an extremely common ailment with studies indicating that 10-20% of the western population suffers from it’s symptoms. The basic pathophysiology of GERD involves the acidic contents of the stomach making their way back up into the esophagus. The stomach has mechanistic properties that protect it from the caustic nature of stomach acids whereas the rest of the GI tract does not. This includes the esophageal tract (1).
I find it fascinating and sometimes quite frustrating to see medicine and medical research heading off down one particular road with very little awareness that there could be other factors at play.
A prime example of this is conventional medicine’s approach to dealing with GERD. Quickly after diagnosing the condition an acid suppressing pharmaceutical will be prescribed and off goes the patient thinking that their problem has been sorted.
Many times, as we’ll explore later, this is not the case.
Another View of GERD
Dr. Wright argues very convincingly in his seminal book ‘Why Stomach Acid Is Good For You’ that we are dealing with an epidemic of people suffering from low stomach acid (medical speak = hypochlorhydria.) In this light he speaks on acid refluxing into the esophagus as being the symptom and not the actual root cause of the problem at hand. Unfortunately for most cases the use of acid suppressing drugs including proton pump inhibitors (PPI’s) and even over the counter options simply masks the symptoms.
To contrast this point we can look to an interview published in Gastroenterology and Hepatology where a lead doctor continues to explore the same angle that they have been investigating for decades.
‘Over the last few years, due to the effectiveness of controlling the acid component of reflux, we have become aware that up to half of these reflux patients continue to have symptoms (most commonly, regurgitation and chronic cough) and will reflux even though there is minimal acid left in the stomach, due to the relaxation (ie, opening) of the sphincter. This reflux is considered nonacid reflux or weakly acidic reflux (ie, reflux of a pH greater than 4). It is very important at this point to stress that acid is not the cause of all reflux nor the only component of reflux that causes symptoms. Therefore, proton pump inhibitors do not completely eliminate reflux in all patients’
Let’s see if we can pick out the important points of difference in this approach
- Even after treatment with powerful acid suppressing drugs up to half of patients continue to experience the symptoms common with GERD.
- The acid suppressing drugs are working as there is ‘minimal acid left in the stomach.’ Understanding that stomach acid is crucial for proper digestion and assimilation of nutrients this comment is highly concerning.
- ‘Acid is not the cause of all reflux.’ If this is known medical knowledge then why are we treating the symptoms instead of addressing the root cause?
Digging Deeper into the Causes of GERD
Although GERD and heartburn in general are both characterised by stomach acid in the wrong place we know that this is simply a symptom. The mechanism that allows this to occur involves an involuntary relaxation of the lower esophageal sphincter (the LES.) Properly functioning the LES allows food and drink to pass into the stomach while keeping the stomach’s contents from refluxing back into the esophagus. Transient lower esophageal sphincter relaxation (TLESR) occurs even in healthy individuals but when it happens too frequently and for longer periods it can lead to the symptoms of GERD and damaging of the esophageal lining (4, 5).
What Causes TLESR?
This is the 9.5 billion dollar question! (combined sales of PPI drugs in 2012)
Instead of treating the reflux by reducing stomach acid to near nothing and looking for pharmaceuticals to treat the LES relaxation let’s instead look into what actually causes this malfunction.
There are a number of different ideas to explore here. The body is complex and the root cause of GERD can be different depending on the situation and the individual.
#1. The first option to explore is impaired digestion.
Eliminating all refined foods and exploring a paleo/ancestral template is an excellent start.
With anyone suffering from GERD or heartburn the 30 Day Elimination Diet is a great place to start.
A lower carb version during the elimination challenge may be beneficial. Large scale trials are lacking for this approach but there are a number of smaller trials and a very interesting case study of 5 patients that all eliminated their GERD symptoms as well as a cohort study of 8 individuals who had improved symptoms by adopting a low carb diet (8, 9, 10).
#2. Stomach Acid Production
Contrary to popular belief stomach acid is essential for proper digestion. Unfortunately stomach acid production is impaired in many people and declines as we age. Improving stomach acid production can be an approach to dealing with GERD and heartburn closer to the root cause.
Safe supplementation with betaine HCL, digestive enzymes, digestive bitters (herbs), apple cider vinegar or lemon juice in water before meals can all help to stimulate acid production and improve digestion.
Cleaning up the diet by removing refined carbohydrates (bread, pasta etc) reducing sugar and supplementing with HCL has been a tried and true way for many people suffering from reflux.
Further Exploration into GERD
There are cases where further intervention needs to be explored.
Obesity, metabolic syndrome, smoking and a number of different foods including coffee, alcohol, chocolate, citrus and carbonated drinks have all been explored in the literature with varying results as to their influence on GERD. The one thing that has been demonstrated is that all of these factors do decrease the LES pressure leading to the classic symptom of GERD, reflux (10, 11).
Other possible factors at play.
If a low carb diet combined with adequate stomach acid helps to relieve GERD symptoms it seems possible that dysbiosis could be the root cause of GERD. Poor digestive function combined with bacterial fermentation (bloating!) causes intra-abdominal pressure and results with reflux into the esophagus.
If the previous steps have been taken and there is still no relief then exploring your microbiome and screening for bacterial imbalance (dysbiosis), SIBO and parasitic infections is essential.
For information on this approach see this article – Recommended GI testing – CDSA + PCR
What have been your experiences with GERD and heartburn? Share your thoughts below.
References and Resources
- Diagnosis and treatment of gastroesophageal reflux disease
- Why Stomach Acid Is Good For You
- interview published in Gastroenterology and Hepatology
- Gastroesophageal reflux disease: From pathophysiology to treatment
- combined sales of PPI drugs in 2012
- 30 Day Elimination Diet
- IMPROVEMENT OF GASTROESOPHAGEAL REFLUX DISEASE AFTER INITIATION OF A LOW-CARBOHYDRATE DIET: FIVE BRIEF CASE REPORTS
- A Very Low-Carbohydrate Diet Improves Gastroesophageal Reflux and Its Symptoms
- Gastroesophageal reflux disease (GERD): a review of conventional and alternative treatments.
- The role of diet and lifestyle measures in the pathogenesis and treatment of gastroesophageal reflux disease
- Recommended GI testing – CDSA + PCR