Acid Reflux, GERD and Optimizing Stomach Acid

Optimal stomach acid and feeling well matters.

Acid reflux and Gastroesophageal reflux disease (GERD, or GORD in the UK) can be significant life disrupting issues for many people.  My own experience with these problems put me through the ringer.  I certainly don’t regret the work I did pinpointing my food and symptom triggers.  I regret the lengthy learning curve involved in changing my diet, lack of information and relying on short-term band-aid approaches long-term.  Through my own personal trials and helping clients as a Registered Holistic Nutritionist I can now say this: There is no need to struggle daily or weekly.  Getting to the non-struggling and possibly med-free part does require some sleuthing, dietary adjustment, and listening to your body…so be prepared.

If your body is reacting to foods, you need to pinpoint the problematic ones and stop putting them in there!  Sheesh!  While my own issues began pre-Internet, you have access to information, you’ve got a body that sends you a signal, and you’ve got me - a very reasonably priced, caring and experienced nutritionist!  I’ve lived through the discomfort of GERD and now experience its absence.  Hooray!  I’m very grateful to be on the other side of my digestive discomfort and I would be happy to guide you there too.

Antacids, OTC ranitidine, prescription Proton Pump Inhibitors

I began taking over-the-counter antacids at the age of 14 after consulting a doctor.  I moved on to an H2 blocker (histamine type 2 receptor blocker) in my 20s, and then got an ongoing prescription for a proton pump inhibitor (PPI) in my early 30s.  No one questioned the onset of my symptoms nor spoke to me about changing ANYTHING.  I had a constant feeling like something might come back up my throat (globus sensation), coupled with nagging fatigue.  I just chewed on my antacids and fixed that little fatigue problem with more coffee.  The pills and chewable tablets were presented to me as a solution with no further direction or discussion about causes.

Rebound Reflux (aka rebound acid hypersecretion)

I read Spontaneous Healing by Dr. Weil while living in Germany in 2010.  I had just graduated from University in Toronto and left my job in Canada.  It was a drastic change to transition from a jam-packed work and university schedule to a completely open one in a foreign country.  It was finally time for me to focus on my health.  I experienced terrible rebound reflux hypersecretion when I discontinued my proton pump inhibitor (PPI) after eight-months of regularly taking it. I had no intention of going back to these acid reducing medications, however.  Dose tapering was probably the way to go, but I didn’t know that discontinuing PPIs could feel worse than the original deal.  (Lodrup et al. 2013, Reimer et al. 2009).  I don’t recall how long it lasted, but it was so, so very uncomfortable.  I have a vivid memory of feeling fatigued, chilled, and having acid reflux to the extreme while taking the tram to work in Heidelberg.  The main advice I took away from the Dr. Weil’s book was:

1.      See an osteopath for visceral manipulation, and

2.      Take DGL (deglycyrrhizinated licorice) to aid my irritated stomach mucosal lining.

I did these things and they helped.  There was more work to be done, though, and there was a long road still ahead for me.

Einstein would say it was insanity

Everything up until that point was a pattern of eating the same things, seeking out temporary relief at the pharmacy, and hoping the next day would be better.  I thought I had solved a problem by taking the acid reducers and neutralizers, but days turned into weeks, months, years, and decades.  According to his adage, Einstein would define this pattern of behaviour as ’insanity’ - I’m sure of it.  These prescription medications are only meant to be taken for several weeks.  They are not meant to be a permanent solution in the case of chronic acid reflux.  (There are other digestive ailments and more serious issues that may need to be cared for differently with your doctor, of course).  I realized it was illogical not to investigate nor change my diet.  It was also illogical to think my body could break down food for absorption (and thereafter to repair and build of my body) with chronically reduced stomach acid.  It was worth trying to make some changes.  I had let it go too far.

Repercussions of long-term reduced stomach acid (Hypochlorhydria/Hyperacidity)

The downstream effect of consistently lowering stomach acid is a reduced capacity to break down and absorb food.  This especially applies to protein and minerals like calcium, magnesium, zinc, and iron.   Sufficient acidity is also responsible for tackling incoming bacteria, pathogens and parasites.  You may say, “But wait, I saw a doctor because my stomach acid was too high (hyperacidity) and I needed to lower it.”  This issue can be tricky.  Your stomach acidity is likely to decline with age as well so it may change over time.  For me, it’s hard to say if I started out with hyperacidity or with hypochlorhydria because no one investigated.  The assumption is usually that it is hyperacidity, but here’s the problem: both “hyper” and “hypo” acidity may present with the some of the same symptoms. 

Symptoms of acid reflux according to the Canadian Digestive Health Foundation:

• Heartburn, a burning sensation in the chest that is often associated with a sour taste in the back of the mouth (due to the regurgitation of stomach acid),

• Having a sore throat or hoarseness,

• A sensation of fullness or lump in the back of the throat,

• Coughing and wheezing, and

• Chronic nausea.

Based on the popular hyperacidity assumption it may seem counterintuitive that you actually need optimally HIGH stomach acid (low pH of between 1.5 and 3.5 = high acidity) to trigger the lower esophageal sphincter (LES) to function properly.  Acid Reflux occurs when the LES stays open/relaxed and digestive acid and pepsin is displaced from the stomach upwards where it can cause irritation and damage in the esophagus.  Acid has one safe place to be in the body.  Let’s keep it in there.  We want the LES to stay closed unless swallowing food..  It’s always best to check whether you have high or low acid and focus on its optimization.  

It’s possible to complete a simple baking soda or betaine challenge if there are no contraindications to determine if hydrochloric acid replenishment is needed.  My recommendation is to consult with a nutritionist (like me) after attaining a diagnosis from a doctor and ruling out other more serious problems, like active peptic ulcers, Barrett’s Esophagus, Eosinophilic Esophagitis or Helicobacter pylori.  If you want more in depth testing, go for it!  We spend a lot of time, effort and money buying and preparing the best food we can so we want to be mindful that your body is tolerating it well and actually absorbing it.

My Long-term Consequences

I arrived in Germany physically weak, anaemic, with gut dysbiosis, and reacting to every food after decades of lowering acid and eating the same way I always had.  My problems were likely compounded by small intestine damage later attributed to celiac disease. I’ll stick to improper diet and stomach acid issues here, but note, if you are experiencing GERD long-term you may want to rule out celiac disease.

Imagine the strain on the digestive system if one of the first steps requiring a strong acidic environment is not attained.  Food will be arriving at the next stop insufficiently prepared and in the wrong state to signal pancreatic enzymes and bile to be secreted for proper breakdown in the duodenum.  This will then affect fat absorption, which presents its own problems subsequently.

I went straight to an osteopath in Germany for visceral manipulation of my gut specifically for my reflux (nothing was working downstream at that point either).  While I saw him regularly he referred me to a German M.D. who ran a lot of tests.  These revealed that my deficiencies were severe and, furthermore, explained a lot of the weakness and fatigue.  My testing at the time showed pancreatic insufficiency, likely due to the chronically low and ineffective stomach acid (the orchestrator of the digestive system).  I was given a pancreatic enzyme supplement, but my stomach acid level was not explored.  So, once again I was ignoring one of the first important steps that would have sent my pancreas a little help and defended against Candida overgrowth.

My lab results showed that I was severely mineral deficient and imbalanced, deficient in a majority of amino acids and I was anaemic.  We weren’t checking fat soluble vitamins at that time, aside from vitamin D which was also deficient.  I’m fairly confident I was experiencing muscle wasting which was contributing to the weakness and fatigue.  My specialists and I focussed on some dysbiosis issues and attempted to bypass the digestive system by using IV mineral and iron infusions.  And no, eating a steak would not have helped my anaemia because I lacked the digestive capacity to break meat protein or iron down for absorption.  My labs showed I was not absorbing protein, minerals, including iron and…that’s how it felt.  What I know now is that these results should have pointed me directly to focussing on stomach acid.

Here are issues to consider with long-term low stomach acid:

• Microbial overgrowth/dysbiosis,

• Protein/amino acid deficiencies, and

• Poor overall digestion

Additionally, a journal article by Maideen 2023 reviews various studies on the consequences of taking PPIs long-term and lists them as follows:

• Renal disorders (acute interstitial nephritis (AIN), acute kidney injury (AKI), chronic kidney disease (CKD), and end-stage renal disease (ESRD)),

• Cardiovascular risks (major adverse cardiovascular events, myocardial infarction, stent thrombosis, and stroke),

• Fractures,

• Infections (Clostridium difficile infection, community-acquired pneumonia, and Coronavirus disease 2019),

• Micronutrient deficiencies (hypomagnesemia, anemia, vitamin B12 deficiency, hypocalcemia, hypokalemia),

• Hypergastrinemia,

• Cancers (gastric cancer, pancreatic cancer, colorectal cancer, hepatic cancer),

• Hepatic encephalopathy, and

• Dementia

My Food Triggers - Alterations are Worth it

My food triggers were coffee, gluten, orange juice, tomatoes, rancid and trans fats, drinking milk and poorly combining foods.  I recognized my intolerances to gluten, soy protein, casein, avenin, based on bodily symptoms and lab results (eg. high anti gliadin antibodies AGAs) and removed them from my diet permanently.  I have gone from daily acid reflux pretty much 100% of the time to chewing a couple of DGL tablets once or twice a year.

Those few times are usually because of poor food combining or being too full at bedtime.  I drink matcha instead of coffee now because I never reacted well to drip coffee.  I can eat organic nut butters, extra virgin olive oil (EVOO), ghee, dark chocolate and pretty much anything else I want in the healthy oils department as long as it’s unprocessed and good quality.  It’s possible to troubleshoot and find alternatives to foods you would rather not give up.  Or, simply prepare the food or drinks a different way to see if that helps.

Elimination Diet: What are your Triggers?

It may be necessary to embark on a comprehensive elimination diet rather than follow the simplified and more commonly known “anti-reflux diet” to experience relief.  It’s very hard to pinpoint trigger foods unless you track changes in a systemic way.  I know when I first started out it felt like I was reacting to every food.  For me, no amount of raising the head of the bed at night solved my problems.  Getting my stomach acid right is what supported my LES function.  I would gladly support you on an elimination diet.  Yes, it takes some work and it’s annoying, but you’ll appreciate knowing which foods your body tolerates when problems subside.  Noticing the absence of uncomfortable symptoms is better than experiencing the same symptoms daily and doing nothing to resolve them.  I found my intolerances over a span of years and planning a month or two to do it systematically is much more efficient.  I wish I had had some guidance.  No need to do it alone!

Aggravators and underlying problems

There are a few lifestyle factors that may also need to be addressed so that you can truly turn the corner on GERD:

• Smoking

• Alcohol

• Chronic Stress

• Extra weight/obesity (structural/mechanical)

• Pregnancy (structural/mechanical)

• Getting older (don’t we wish!)

Stress

Stomach acid production begins to decline with age, and chronic stress can exacerbate the problem further.  Keep this in mind if you are beginning to have acid reflux symptoms after age 40 and you’re stressed out (who isn’t?).

It’s best to eat in a relaxed state to allow your digestive juices to flow.  It’s important to note that chronic underlying stress also has a negative effect on digestion.  Psychological stress can not only reduce stomach acid and enzyme levels, but it can have a negative impact on gut bacteria as well.  Finding ways to manage and reduce your stress can go a long way when dealing with digestive distress.  It can be helpful to work with someone from a holistic perspective or you could miss important pieces of the puzzle.

Key Takeaways

1. Get a diagnosis from a doctor.   Rule out other digestive health issues and serious problems.

2. Be mindful not to use medications for longer than the instructions indicate for GERD.  Expect some Rebound Reflux if you decide to discontinue PPIs.

3. Do some sleuthing to find out if you have too much or too little stomach acid.

4. There can be health consequences to long-term hyperacidity and hypochlorhydria or to staying on acid reducing medications long-term.  Take charge of following up on your status regularly.

5. Pinpoint food triggers.  Remove them and find satisfying alternatives!

6. Smoking, alcohol, stress, weight, pregnancy, age and other medications can affect stomach acid and/or the LES negatively.

7. Consult with your doctor regarding safely discontinuing use of PPIs for GERD and mild esophagitis  (Farrell et al 2017).  Keep in mind that you may experience Rebound Acid Hypersecretion (RAHS) for up to 4-weeks after discontinuing PPIs.  (Lodrup et al 2013, Reimer et al. 2009).  I recommend working with a holistic nutritionist to guide you in examining and altering lifestyle and dietary factors that may help you avoid the need for PPIs in the future.

Conclusion

I’m passionate about helping you optimize stomach acid levels and find your food and lifestyle triggers.  I believe GERD should be taken more seriously at the outset than it is, given the potential downstream health consequences of long-term unresolved problems.   Use the short term fixes if necessary, but remember they should not be used as permanent solutions.  Acid reflux starts one day for a reason.  What is your reason?  You may require some individualized care to figure it out.  I would encourage you to work with a doctor and a holistic nutritionist to halt the discomfort, protect the oesophagus, and ensure optimized digestion.  A holistic nutritionist is an important addition to your health care team as “lifestyle changes remain first-line in management of GERD with a primary goal of symptom reduction and improvement in quality of life” (Clarett, Hachem 2018).  I will do a holistic analysis of your current diet, stress, and lifestyle and we will work together through regular meetings to implement long-lasting change. 

Clarrett DM, Hachem C. Gastroesophageal Reflux Disease (GERD). Mo Med. 2018 May-Jun;115(3):214-218. PMID: 30228725; PMCID: PMC6140167.

Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, Rojas-Fernandez C, Walsh K, Welch V, Moayyedi P. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician. 2017 May;63(5):354-364. PMID: 28500192; PMCID: PMC5429051.

Lødrup AB, Reimer C, Bytzer P. Systematic review: symptoms of rebound acid hypersecretion following proton pump inhibitor treatment. Scand J Gastroenterol. 2013;48(5):515–22. doi: 10.3109/00365521.2012.746395. Epub 2013 Jan 14.

Maideen NMP. Adverse Effects Associated with Long-Term Use of Proton Pump Inhibitors. Chonnam Med J. 2023 May;59(2):115-127. doi: 10.4068/cmj.2023.59.2.115. Epub 2023 May 25. PMID: 37303818; PMCID: PMC10248387.

Reimer C, Søndergaard B, Hilsted L, Bytzer P. Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology. 2009;137(1):80–7. 87.e1. doi: 10.1053/j.gastro.2009.03.058. Epub 2009 Apr 10.

*This content is not intended to diagnose or treat any diseases. Always consult your primary care physician or licensed healthcare provider for all diagnosis and treatment of any diseases or conditions, for medications or medical advice as well as before changing your health care regimen.