Ever since I first went into clinical practice almost 29 years ago, I’ve been alarmed at the increasing number of people taking strong proton pump inhibitor drugs (PPIs) like omeprazole or lansoprazole for conditions that would probably respond very well to some dietary and lifestyle changes. My sense of alarm increases further when I see very young children being prescribed such drugs.
Too frequently, stomach acid tends to get bad press as it is considered to be the cause of many digestive symptoms; and consequently, medications such as the ones I’ve mentioned above that suppress its secretion are prescribed by the medical profession.
I am writing this particular post so that I can explain why we need stomach acid, why very often you may have too little rather than too much (especially if you are over 50), the very important roles it plays towards our health, and what you can do to support its levels.
What is stomach acid?
Stomach acid is composed of hydrochloric acid (HCL), potassium chloride, and sodium chloride. Stomach acid plays a key role in the digestion of proteins by activating digestive enzymes. The level of stomach acid needs to be correct so that we can digest our food, and it also offers protection against pathogenic bacteria, viruses including COVID-19 (see below for more the impact of low stomach acid and COVID-19) and parasites surviving past the stomach.
The implications of low stomach acid aren’t talked about as frequently as the problems associated with having too much acid in our stomach, causing heartburn and Gastro-oesophageal reflux disease (GORD), and this is why when people visit their GP with these symptoms, they are prescribed PPIs.
If stomach acid is too low (hypochlorhydria), it can also result in symptoms of acid reflux and this is difficult for some people to understand. People often believe that acid reflux is caused by high stomach acid (hyperchlorhydria), but this is not always the case, especially in people aged over 50. It’s more an issue of low stomach acid (hypochlorhydria) causing excess pressures in the stomach, weakening the valve at the top of the stomach and allowing the acid or acid-drenched food to regurgitate up into the oesophagus, burning it.
What is acid reflux?
Acid reflux, heartburn and non-cardiac chest pain, also called gastroesophageal reflux disease or GORD, is an uncomfortable and nowadays a surprisingly common condition. According to the NHS, there has been a 50% increase in people suffering from acid reflux over the last ten years, up to almost 20% of the population. In fact, acid reflux has become so common, it’s often regarded as a normal consequence of eating a rich meal and this should not be the case. It’s interesting to note how GORD has increased alongside levels of obesity. Is there a connection? Yes, I think so. We are just eating far too much, too quickly, too late in the evening; we are eating more than our digestive system and the secretions that help break down and digest our food can cope with.
Symptoms of acid reflux
- A warm, burning feeling at the top of the stomach, known as heartburn
- A persistent sore throat
- Acidic taste at the back of the mouth
- Chronic cough or asthma
- Recurring respiratory infections
- Bloated stomach
- Excess gas
- Burping or hiccupping
- Vitamin B12 deficiency
- Struggling to digest red meat
- Food intolerances
- Seeing food in your stools
- Random allergic reactions, especially if on PPIs as these drugs increase the amount of histamine in the body
- Erosion of tooth enamel
Red flags that need investigation by a GP immediately:
- Difficulty swallowing or the sensation of food being stuck in your throat
- The feeling of a constant lump in your throat
- Weight loss
- Vomiting blood
Why does acid reflux occur?
Many people believe reflux is simply triggered by eating the wrong kinds of food. Indeed, it’s often brought on by fried or spicy foods, acidic foods like citrus fruits, tomatoes, fizzy drinks, processed foods, coffee or alcohol.
It’s assumed the cause is an overproduction of stomach acid, which then escapes into the oesophagus and burns its delicate lining, but it’s not as simple as this. Our modern Western lifestyle appears to contribute to GORD; its prevalence in the developing world is much lower. Factors involved in an increased risk of developing GORD are:
- Excessive alcohol consumption
- High intake of fatty foods
- Low intake of vegetables and fruits
- Food allergies
- Chronic stress
- Hiatus hernia
- Some antibiotics
- Helicobacter pylori infection
(Note: Acid reflux in infants is usually due to cow’s milk allergy.)
Red flags: If you’ve had longstanding GORD symptoms that have not been investigated or treated, you need to be screened to rule out Barrett’s Oesophagus and/or oesophageal cancer.
How is acid reflux treated?
Conventional medicine treats acid reflux by prescribing acid neutralising or blocking drugs such as PPIs or H2 blockers like Ranitidine (now banned due to safety concerns). Such drugs treat the symptoms, not the cause, and PPIs, in particular, come with some nasty side effects such as:
- Osteoporosis and increased risk of bone fractures due to weakening of bones due to the drugs blocking the uptake of minerals, particularly calcium
- Fatigue, again due to the PPI blocking the absorption of iron
- Nutrient deficiencies
- SIBO (small intestinal bacterial overgrowth)
- Increase in dementia
- Increased risk of gastric cancer
- Kidney disease
- Increased risk of developing Clostridium difficile, a nasty and sometimes life-threatening bowel disorder
Note: there is a caveat with PPIs – if someone has been diagnosed with Barrett’s Oesophagus, a condition whereby the lining of the oesophagus can become pre-cancerous due to the constant regurgitation from the stomach of acid-drenched food ‘burning’ the oesophageal lining, then PPIs need to be taken to keep stomach acid low and reduce the risk of developing oesophageal cancer.
However, I would always recommend taking a probiotic capsule, such as my Live Bacteria ones, twice daily, before meals, to help mitigate the effects on the gut of the PPI.
How can you check stomach acid levels?
There is no definitive test for high levels of stomach acid, and there isn’t one for low stomach acid either, but there are a couple of things you could try:
The bicarbonate of soda test:
Dissolve a quarter teaspoon of bicarbonate of soda in a little water and drink this on an empty stomach. If you have adequate levels of stomach acid, the bicarbonate of soda is neutralised and converted into gas – this means you should experience belching within 3-5 minutes after drinking the solution. If no belching occurs, this suggests there may be insufficient acid present. While this test can give insight into stomach acid levels, it is not the most scientific method and, therefore, not one hundred percent accurate. To increase the accuracy of the test, it is advisable to take the test on 5 consecutive mornings and pull all the data together to get a better understanding of your stomach acid levels.
You could also try taking a natural, plant-based digestive enzyme tablet that contains some Betaine HCL (aka plant-based ‘stomach acid’) before meals. If you feel a warming sensation, then it’s an indication that you have sufficient stomach acid and are not deficient.
Low stomach acid and COVID-19
Among patients with confirmed COVID-19, research has shown that the current use of PPIs conferred a 79% greater risk of severe clinical outcomes of COVID-19, while the relationship with the past use of PPIs remained insignificant. Current PPI usage, starting within the previous 30 days, was associated with a 90% increased risk of severe clinical outcomes of COVID-19.
This suggests that patients taking PPIs are at increased risk for severe clinical outcomes of COVID-19 but not susceptible to SARS-CoV-2 infection. Physicians, therefore, need to assess benefit-risk assessments in the management of acid-related diseases amid the COVID-19 pandemic.
Effects of too little stomach acid
Stomach acid is there for a reason and serves an essential function. Reducing it can have adverse effects. For example, too little stomach acid can cause nutritional deficiencies of zinc and vitamin B12, which can lead to fatigue, poor immunity and even nerve damage.
Stomach acid is also needed to initiate protein digestion. If the stomach contents are not acidic enough, digestion in the small intestine won’t be as efficient, as it’s the acidity, which causes the digestive enzymes in the next stage of digestion to be released. This can cause poor digestion of carbohydrates and fats.
Stomach acid is our first line of immune defence. If stomach acid is low, it can’t kill off pathogens, including viruses, bacteria and parasites.
However, the cause of reflux is not as simple as overproduction of stomach acid. It’s unlikely so many of us would produce excessive stomach acid. In fact, reflux symptoms often increase with age, as the production of stomach acid actually decreases as we age, which is why I often recommend our natural Digestive Enzymes to anyone over the age of 50 who finds they get gassy and bloated, especially after food. Take one tablet before meals. Digestive Enzymes contain natural plant extracts that help to break down proteins, fats and carbohydrates, reducing excess gas in the digestive system.
The importance of abdominal pressure
Let’s have a look at the structure of the stomach. It has two main valves, called sphincters, one at the top (called the cardiac sphincter) and another at the bottom (called the pyloric sphincter or lower oesophageal sphincter), which control the entry and exit of food. If the sphincter at the top relaxes inappropriately, stomach acid can flow upwards into the oesophagus. Smoking can weaken these valves, so can pregnancies and hormonal changes associated with the menopause. Many menopausal women often get GORD.
The sphincters can relax when they shouldn’t and this often occurs because of an increase in intra-abdominal pressure (IAP) which is the pressure within the abdominal cavity.
It’s believed an increase in this pressure is connected with low levels of stomach acid rather than an excess. Low acid levels lead to incomplete digestion of carbohydrates. If carbs aren’t digested efficiently, they are fermented by bacteria. This causes excess gas, which can cause the 23ft or so of intestines to expand, stretch and bloat, creating IAP and this can push up into the diaphragm and stomach, creating pressure in the valve at the top of the stomach, allowing the acid to regurgitate up into the oesophagus.
If you’re taking antihistamines, painkillers, antispasmodics or bronchodilators, then have a chat with your GP as such medications may be relaxing the sphincter at the top of the stomach and allowing acid and acid-drenched food to be regurgitated.
Other causes of acid reflux
- Imbalance in the gut bacteria can lead to an increase in IAP. It can also be caused when bacteria migrate from the large intestine to the small intestine, a condition known as small intestinal bacterial overgrowth (SIBO). You can read more about SIBO in my blog post here.
- Bacteria called Helicobacter pylori are thought to be linked to the development of acid reflux, and stomach and duodenal ulcers
- Food sensitivities, especially to gluten and dairy
- A deficiency in magnesium may prevent the valve at the bottom of the stomach from relaxing and letting food out, causing a back-up of food and gases in the top of the stomach, thus pushing up and out the valve at the top of the stomach and regurgitating into the oesophagus
- If you’re experiencing ongoing stress, the body diverts energy away from the digestive system to help us deal with the stressor. It can also cause the valve at the top of the stomach to relax.
- Overeating, eating late in the evening, lying down or bending down after eating can also spark an attack
- As can being overweight, which causes an increase in IAP due to excess fat around the midriff and abdominal organs
Tips to reduce acid reflux
- Eat mindfully – sit down, take time to anticipate and appreciate your food, chew it thoroughly and breathe deeply during your meal. Don’t get up immediately after eating.
- Eat smaller meals
- Don’t eat more than your digestive system can cope with
- Don’t lie down immediately after eating. Wait at least 3 hours.
- Sleep on your left side. Due to gravity, the shape of the stomach, and the angle of the connection between it and the oesophagus, sleeping on your left side can greatly reduce reflux.
- Elevate the head of your bed by at least 2 metres
- Try not to strain for too long when having a bowel movement
- Avoid slumping and slouching, especially after meals
- Avoid wearing tight or ill-fitting clothing, including tight belts
- Try and identify things that may trigger regurgitation, the most common being milk, mints, coffee, tea, onions, acidic juices, alcohol and tomatoes. Be careful if taking anti-spasmodic type drugs, i.e., if you have IBS or suffer from uncomfortable bloating, as these may relax the stomach sphincters.
- Deal with stress – try yoga, meditation or deep breathing exercises
- Avoid drinking water during meals which dilutes stomach acid and will further hinder digestion
- Try taking a natural digestive enzyme tablet before meals to help with the breakdown of food, especially if you are over 50
- Take a good quality multi-vitamin/multi-mineral supplement that contains zinc and a full spectrum of B-vitamins and other anti-oxidants
- Include bitter foods to stimulate stomach acid production such as rocket, dandelion leaves, ginger, chicory
- Drink our Tummy Tea that contains ginger and other digestive herbs/spices
- Make sure you are not dehydrated as the right amount of fluid is needed for your body to produce stomach acid. However, if you have acid reflux, don’t drink water with your meals as the water may dilute stomach acid and other key digestive substances. Drink your water at least half an hour before and an hour after food.
- A colon hydrotherapy treatment can help ‘de-pressurise’ the intestines of excess gas and impacted stool, allowing the diaphragm to relax, taking the pressure off the stomach and its valves. To locate your nearest registered and regulated colon hydrotherapist, visit www.colonic-association.org
- Take a natural supplement such as marshmallow root or slippery elm, which helps to soothe and coat the lining of the membranes in the oesophagus. Your local medical herbalist should be able to make this up for you, fresh. To find a qualified herbalist in your area, contact the National Institute of Medical Herbalists
- Please always check with your nutritional therapist, naturopath or medical herbalist before taking new supplements if you are on medication or have a pre-existing health condition.
- Anything you’re not sure about, contact one of the Tummy Team here at firstname.lastname@example.org
- Get to the root cause. I often see SIBO infections as the root cause of reflux due to it increasing IAP
Nutritional therapy and acid reflux
Natural health practitioners will always seek to discover the root causes of health concerns. As well as identifying reflux triggers, your therapist will investigate what’s happening in your gut to cause your symptoms. They will assess your digestive health using a combination of a comprehensive case history concentrating on your diet, lifestyle and past and present symptoms, along with functional tests to detect food sensitivities and assess the bacterial balance in your microbiome.
For more support, join the active and helpful Tummy Talk Facebook group.