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Acid Reflux Truths and Myths

In the center of your chest, there is a small, muscular tunnel that separates the end of your esophagus from your stomach. Think of it like a fist that can be closed tightly or loosely. It’s called your lower esophageal sphincter (LES). When you’re eating, the fist should be open and loose, so food can travel to your stomach. But at all other times (unless you need to vomit), the sphincter should be tightly closed. This prevents all food and digestive fluids from traveling upward. Acid reflux is just having a loose sphincter when it should be tight.  It does not mean that there is too much acid.

Your stomach produces a few different digestive juices. A primary dominant one is hydrochloric acid (HCl). One of nature’s strongest acids, HCl is designed to make light work of breaking down proteins, like the tough meat in that burger you just ate.  It’s also key for killing pathogens that might otherwise move in and set up shop in your intestines.  If you put HCl directly on your hand, it would quickly burn you – badly. Another key “digestive juice” component is pepsin, a digestive enzyme that breaks down protein.  HCl activates pepsin and starts the protein digestion.

If digestive juices are in the wrong place, it hurts!  Likely because of the acidity and because the pepsin is beginning to digest your tissue instead of your lunch!  Animal research also shows that pepsin in the esophagus triggers an inflammatory cascade which might be the largest driver of reflux pain.  The cells of your stomach lining are coated with mucus to protect them from digestive juices. The lining of your esophagus is not nearly as well coated. So when the LES is loose and these juices bubble upward, it hurts.  Acid reflux is not evidence of excessive stomach acid; it’s evidence of stomach acid in the wrong place.

There are many reasons why your clients might have acid reflux. I’m going to share some of my top tricks for making acid reflux go away.  Not because your clients have to pop a TUMS or use a PPI drug, but because you can help them to get rid of the true root cause(s). And their long-term health depends on it!

Slow Down, Sit Down, and Chew, Chew, Chew.  This is what we call Eating Hygiene.  The average American chews each bite of food only a few times before swallowing it down hard. Often with several gulps of water as a chaser. Many of us eat so quickly that meals feel like a race – an annoying must-do to put hunger at bay.  I like to teach my clients that meal time can be a meditation – a very real form of self-care and healthcare.  Try to chew your food until it’s mostly liquid. This significantly reduces the work of your stomach. I know this seems simple. But you would be stunned to know the number of clients I’ve seen cure their reflux this way.  Just by chewing their food 20-30 times per bite and not drinking too much liquid with meals (below).

Avoid the Big Gulp. Certainly it’s fine to have some water along with your meals, but many people use meal time as an opportunity to tank up and hydrate.  Too much liquid during meals can dilute your stomach acid and make it less potent, leading to belching and bloating. Food can hang around in your stomach longer than it should and ferment. Gas builds up and blows open your LES – causing reflux.  I recommend my clients – especially those with GERD and indigestion – focus on steady hydration in between meals and have only a small glass handy during meals to help clear the palate (e.g. 8 oz).

Eat more often and less at once. Sometimes our LES gets blown open by the sheer volume of food we try to cram into our bellies. This is especially true when we eat at restaurants. Yes, the stomach will stretch. But only so far. Research shows better digestion for people who eat smaller meals.  Note this is not the same as “grazing”. Your body needs a break from digestion, so eating here-and-there all the time is often counterproductive (the GI tract’s cleansing waves (MMC) don’t happen while we’re digesting food).  Small meals every 3-4 hours may help those with GERD greatly.  Then stop eating when you are 80% full. You have to leave (literal) room for digestion to take place.

Wear loose clothing around your midsection. If you wear a tight belt or waistband, you put tremendous pressure on your digestive organs. This can push food and digestive fluids physically upward and beyond your LES. Muffin-Tops and Belted Beer Bellies, take particular note of this one!

Address a need for magnesium.  This is a widespread issue in the US.  The USDA estimates that the majority of Americans don’t get optimal intake of magnesium.   Low magnesium can cause your muscles to be too tight or to spasm erratically.  This includes the LES.  I often recommend the glycinate form of magnesium because it’s easy to find and well tolerated and absorbed.  If you also struggle with any regular constipation, consider magnesium citrate instead.

Stop eating foods that cause your LES to spasm. Ok, here’s the big one. Unfortunately Americans love some of the foods which are most irritating to the LES. If your clients struggle with daily GERD, encourage them you to consider giving their body a break from these foods. Yes, it will take some coaxing because they love these foods!  But continuing to eat them and just pop a pill to ignore the pain is likely to turn into a serious illness or disease  some day. These are the most powerful triggers: cooked tomato sauce, citrus juices, coffee, black tea, soda, alcohol, peppery or spicy foods, fried food, chocolate, and things with mint in them (e.g. gum, mints, toothpaste, tea).

Don’t eat or drink anything for 2-3 hours before bedtime. Reflux can often be worst at night. This is when all of our muscles relax at least a little bit, including our LES, and then we go horizontal.  If your client puts food in their stomach and then goes to bed before it’s fully digested, reflux is much more likely. If this is your patient’s struggle, you might encourage them to eat throughout the day such that they go to bed with an empty stomach – but not hungry.  Avoiding food for a full 2-3 hours before bed is also an excellent way for many to improve the quality of their sleep (don’t get me started about Ambien).

Fight-or-Flight as a way of Life.  The culture that encourages you to Go-go-go also promotes chronic mental/emotional stress.  When we are in a “fight or flight” (sympathetic) nervous system mode, it is quite normal body functioning for digestive secretions and peristalsis to be reduced in order to support other body function that promotes survival (e.g. running for your life).  We are intended to live primarily with our parasympathetic nervous system mode active (akak “rest and digest”).  Helping your client to understand the direct connection between her stress and her chronic GERD is a powerful tool of empowerment.  This is especially true at meal time and why a few calming breaths and a conscious effort to sit and relax the body prior to and after eating can help alleviate acid reflux.

Be aware of common medication triggers.  These include a rich variety or oral drugs such as nitrates, anticholinergics, benzodiazepines (common for anxiety or insomnia), calcium channel blockers (common for hypertension), and theophylline.

Food sensitivities.  In many cases, people know that certain foods trigger their reflux (beyond the LES irritants above).  In over 50% of my clients, dairy foods (e.g. milk, cheese, cream, ice cream) are a major trigger, and dairy elimination from the diet brings tremendous relief.  Other food sensitivities might be at play too (e.g. gluten, soy).  While food sensitivity testing is available, no single test assesses all possible pathways via which the immune system can react negatively to a food.  In most cases for GERD in particular, a simple elimination experiment works very well (e.g. ~10 days before reintroduction – one food category at a time per three days).

If all the above fails, rule out other physiological drivers of chronic reflux.  Encourage them to work with their doctor to find out if  they have a hiatal hernia (a simple x-ray) or an H Pylori bacterial overgrowth (this is a bacteria that commonly causes ulcers but can also cause chronic GERD – diagnosed with a simple breath or blood test) or insufficient stomach acid (actually very common as we age and in those with thyroid, adrenal, and/or chronic stress issues – and a strong likelihood if these individuals struggle with belching all the time). I have successfully supported many clients in working through all of these – including how to approach doctors about testing.  If this dis-ease is a common issue in your clients (or if your target market includes many who wrestle with acid reflux), you will get great clinical pearls and knowledge from our Disease Begins in the Gut 101 course.

Long-term use of PPI medications can be dangerous.  These drugs were actually originally developed to help those with gastritis or ulcers to heal and were prescribed for a few weeks at most.  PPIs can impair absorption of critical protein and minerals that, over years, can be the true root cause of ailments such as osteoporosis, arthritis, depression, heart disease, and diabetes.   In particular, don’t let your patients just suddenly stop cold-turkey taking these meds; that can actually do more harm than good.  And GERD root causes for a unique individual should be addressed before weaning off of acid-suppressing drugs.  A progressive titration downward (typically over 4-6 weeks) allows the body to adjust, and during the weaning, targeted supplements can help to fortify and soothe the protective mucosal lining in the stomach.  If this is a key interest area in your practice, note that our GI classes cover issues (and opportunities!) like this in detail.

 

21 Questions for “Acid Reflux Truths and Myths”

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  1. 9
    Lisa Mair says:

    Some people attempt to replace their low stomach acid with once daily straight apple cider vinegar shots. Is it possible for this practice to harm the esophagus due to exposure to the strong acid (which it looks like is similar pH to stomach acid)? I wouldn’t have thought so because it’s just a brief exposure, but I wanted to see what you thought. Would ACV shots be contraindicated for someone with Barrett’s esophagus? Thank you!

    • 9.1
      SAFM Team says:

      Yes, plain apple cider vinegar is not something I would recommend given its low pH; it can also aggravate GERD in some sensitive individuals. I would dilute 1:1 at a minimum with water. And yes, I do consider them to be contraindicated for someone with Barrett’s esophagus.

  2. 8
    Janeen Wood says:

    If a patient has Barrett’s Esophagus, are there any additional precautions we should take if recommending HCl and pepsin as the patient is weaned off of PPI?

  3. 7
    Eileen Ramos says:

    For low stomach acid, we recommend using HCL with pepsin, the strongest acid. When do we recommend digestive enzymes? I know there are different enzymes for different foods such as lipase for milk products and if we know there is a specific food that is not being broken down then a specific digestive enzyme would be appropriate. But I would like to better understand when HCL is better to recommend over digestive enzymes and vice versa. TIA!

    • 7.1
      SAFM Team says:

      Insufficient stomach acid often leads to increased belching/burping, early satiety during a meal, fatigue very soon after eating (though this can be poor eating hygiene too) bloating up the upper GI area (up by the rib cage where the gastric cavity lies), acid reflux, suboptimal levels of B12, minerals, and/or protein (as seen in Albumin and Total Protein labwork). Insufficient digestive enzymes is a state common in those with Type 2 diabetes, and common symptoms include lower belly bloating, distention, flatulence, feelings of fatigue 1-3 hours after eating (though this can be food sensitivities too). Both of these can be measured overtly with a comprehensive stool test (e.g. Genova’s GI Effects). You can’t always tell from the outside looking in! And sometimes people need support with both. But there are some themes. If in doubt, support with a combination formula that includes a full-spectrum digestive enzyme and a mild amount of HCL support (e.g. Thorne’s B.P.P.) and see if this brings relief. Otherwise, an HCl challenge test can be helpful too.

  4. 6
    Claudia Reshetiloff says:

    I have a prospect who wrote the following on an intake form: “my GERD triggers the vagus nerve which causes bp and pulse to drop then go into fight or flight and become tachycardic.” Can you explain the connection between GERD and the vagus nerve?

    • 6.1
      SAFM Team says:

      Sure, this is a fun one! There is definitely evidence that acid reflux and arrhythmia/tachycardia are connected. The vagus nerve is the center of the parasympathetic nervous system (aka “rest and digest” mode) and affects dozens of functions in the human body including all digestive activity in the GI tract; it connects the gut to the central nervous system, a key part of keeping the brain informed of the status of your world down in the gut. When one is in a sympathetic nervous system mode (aka fight-of-flight) the vagus nerve activity is highly reduced. Acid reflux and indigestion are two of many symptoms that can occur when one tries to perform a parasympathetic nervous system action (food digestion and nutrient absorption) while the nervous system is focused on other priorities/stress/action. All digestive secretions and GI motility are dramatically reduced when in a sympathetic nervous system mode (and vagus nerve is less active). This is why the “eating hygiene” we teach is so critical for helping patients to reduce/eliminating GI symptoms (and the resulting poor nutrient absorption). When we relax, breathe deeply and slowly, chew slowly and thoroughly, focus on our food and allow our vagus nerve to be strongly stimulated, we digest well. We are much less likely to have acid reflux. Pulse and blood pressure normalize to a lower level. When one has food sensitivities, especially strong ones, the sympathetic nervous system might be triggered by the immune system’s alarm at sensing the food. This causes a release of stress hormones which can promote acid reflux, tachycardia, reddening of the face, and a sense of anxiety and unease; I have experienced this myself repeatedly and have had several clients report the same. This is one mode of explanation. Another is that acid reflux itself into the esophagus triggers inflammatory cytokines in that part of the anatomy which are (literally) a tiny distance from the heart, and the inflammation can trigger arrhythmia in the heart simply as a bystander effect of what the acid reflux caused (keeping in mind that poor eating hygiene and/or food sensitivities are common causes of acid reflux). Another is that the acid in the esophagus affects receptors and causes an overstimulation of the vagus nerve which causes an excessive drop in BP and heart rate (which may progress to fainting as in vaso-vagal syncope) which the body may try to recover from with a compensatory sympathetic surge (this seems closes to your client’s self-assessment). There is great debate in the FM/integrative medicine world as to which of these is the most “valid explanation”; however, I think the particulars likely, simply vary by individual. The bottom line for wellness, however, comes back to the importance of creating nervous system balance, mindful eating hygiene, avoiding food sensitivities, and addressing other true root causes of acid reflux (e.g. high intake of stimulatory foods, poor esophageal sphincter tone, insufficient magnesium, insufficient stomach acid, hypothyroid, hiatal hernia). I hope this is a helpful summary, and I believe this detail will be of interest to you: http://www.medscape.com/viewarticle/759995_1 .

  5. 5
    Heather Conley says:

    What can someone with a hiatal hernia do to fix it?

    • 5.1
      SAFM says:

      Well, for most people, the cause of a hiatal hernia is obesity (perhaps exacerbated by stress), so getting rid of excess abdominal weight can increase the likelihood of resolution. Surgery is an option for chronic, severe cases; in a fundoplication, the wayward part of the stomach is pulled back into the abdomen, wrapped around the esophagus, and stitched down to prevent it from “wandering” up into the chest again. I have had a few clients over the years be able to fully resolve hiatal hernia with targeted chiropractic support, especially if the cause was pregnancy or prior weight gain. In terms of lifestyle, the key is to minimize pressure in the gastric cavity….ensuring optimal stomach acid, good eating hygiene, not eating too soon before bed. Also related might be straining to pass a bowel movement (so address constipation overtly). If there is a lot of coughing (e.g. asthma), that may also be a driver.

  6. 4
    Kasia Hrecka says:

    Is there a connection between GERD and menstrual cycle hormone fluctuation? A client is noticing that her GERD symptoms get much worse during the few days before her period. I know that hormones can affect many systems, including the digestive one, but I’m curious about how it works – what is the actual connection? Thank you

    • 4.1
      SAFM says:

      Interesting! Certainly there can be many dynamics at play! When women have rough PMS, they tend to eat different foods and perhaps register more stressful thoughts and feelings, both of which can trigger GERD. They may sleep less well or have poor eating hygiene or consume more coffee or alcohol or chocolate in order to feel better during a trying time. Biochemically, assuming there is some estrogen dominance, I can think of two likely connections. 1. Higher levels of estrogen can impair thyroid hormone function which, as you know, can have a direct effect on the GI tract motility and contractions. 2. Higher levels of estrogen can also increase copper in the body and contribute to higher levels of stimulatory neurotransmitters, a known contributor to GERD (in the same way that stress promotes it). But I think the larger issue at hand is that of prostaglandins, inflammatory mediators. These are secreted in response to the rapidly changing hormones in the run up to the start of the menstrual cycle, and they might create GERD in the same way that they can promote cramping and spasm elsewhere. This will be of interest: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.575.7563&rep=rep1&type=pdf .

  7. 3

    I wish I had known about this 18 years ago when I was put on PPI’s. I’m 47 and had to have both of my hips replaced last year due to early arthritis. Thankfully, I’ve now been off the PPI for a year or so. I’m so happy to be in this course to finally be able to get to my personal root cause and be able to help others!

  8. 2
    Celeste says:

    I have recently heard of two infants (6 and 9 months) having acid reflux. The 9 moth old was put on PPI. She is a very large baby. They are eating baby food but nothing listed under the triggers you mentioned like spicy food, coffee, chocolate, etc. The 6 month old (2 weeks preemie) has always had hiccups-is that part of acid reflux? She was fed breast milk for the first 4 months then supplemented with formula. Now exclusively formula and baby food. Could formula be to blame?
    Any research out there for babies and what to do? This one is dear to me, since the 6 month old is my granddaughter! Thanks! Celeste

    • 2.1
      SAFM says:

      Oh my! Definitely it’s important to get to the root cause and to eliminate the drug as soon as possible, especially at such a critical young age for nutrition and growth. First of all, it’s important to realize that reflux is very common and normal in babies. Also, just as with older children and adults, stress promotes reflux. This needs to be considered carefully in the home environment as a very real driver. But if this appears to be more intense, then indeed, the formula could definitely be to blame! We know that immune system reactions to foods can trigger reflux; I have seen this in dozens of clients, and dairy is the most common culprit. There are many chemicals in typical formula. And in addition, both dairy an/or soy can be major drivers. The spasm in the diaphragm that causes a hiccup can be due to eating too much at once…and certainly an inflammatory allergen or sensitivity reaction could contribute to that dynamic. I would recommend age-appropriate probiotics and doing a trial ~10 days in a row with no diary and no soy at all (100%). Alas, I believe it would be ideal for breastfeeding to continue longer. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3166669/

      • Celeste says:

        Luckily, my granddaughter is not the one on the drug. I will share this with my friend also who has a granddaughter on the PPI.

        Is it ok to use epsom salts in the babies bath water. I was thinking only 1/2 cup in the baby tub. The other thing I will have them check out is mold!!! That is on my radar this month. Yes, probiotics. I have to approach this gently. Even though we have a great relationship, I am the mother-in-law, hahahah

        Thanks again, so much, Celeste

        • SAFM says:

          Alas, I am not a pediatrician. But I know of no reason to discourage small amounts of epsom salts in bath water for babies. Of course, it’s critical that they always be supervised, so they don’t ingest the water. In fact, there have been some clinical studies looking at the potential benefits of using magnesium sulfate to counter some perinatal concerns e.g. hypoxia, cerebral palsy, and other potential neurotoxicity.

  9. 1
    Lisa Sanderson says:

    Do you produce less HCI if you eat less meat? That is would eating a mainly plant based diet help with GERD?

    • 1.1
      SAFM says:

      In principle, I haven’t seen less stomach acid production as a result of dietary choices. Ultimately we need strong stomach acid for reasons that have nothing to do with digestion of specific foods such as killing off pathogenic microbes before they can enter the intestines. I do believe, however, that our production of digestive enzymes can become skewed over time as the body adapts to what we consume. Thus it can take some time to make a major change in the diet and allow the body to readjust; hence the wisdom of going slowly and gradually vs. a sudden, drastic change. I have also had a few clients in the past realize in retrospect that they had chosen vegetarian diets earlier in their lives *due* to low stomach acid – because they inherently felt more uncomfortable consuming animal protein.

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