Heartburn might not mean heartbreak

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Few know that in the vast majority of cases, painful acid reflux and peptic ulcers are caused not by too much stomach acid, but by too little.  This may seem hard to believe for those who have been told that the burning they experience after meals is the result of overproduction of stomach acid.  Acid suppressant drugs, which include proton pump inhibitors (such as Prilosec) and H2 receptor antagonists (such as Tagamet and Zantac), are among the most prescribed drugs in the world.  In some countries these medications are available over the counter.  Additionally, over the counter acids including Tums, Rolaids, and Alka-Seltzer are very widely used.

Researchers have estimated that as many as forty percent of Americans experience heartburn at least once a month.  Remarkably, heartburn symptoms can result from too little acid, and while excess acid can indeed cause burning sensations in the GI tract, it is very rare for the body to product too much acid.  Insufficient stomach acid, on the other hand, is surprisingly common, especially in older people, as hydrochloric acid (HCl), or stomach acid, production often decreases with age.

In addition to heartburn and ulcers, a wide variety of symptoms and conditions are associated with low production of stomach acid, including but not limited to:  constipation and diarrhea; has and/or belching; bloating, sense of excess fullness, and/or sleepiness after meals; nausea from eating fatty foods; candida overgrowth and other guy flora imbalances, including parasites; fatigue; food allergies and sensitivities; frequent infections; nutrient deficiencies, especially B12, folate, iron, calcium, and zinc; general malnutrition and poor nutrient absorption; weak or brittle fingernails; liver toxicity; and depression and anxiety.

Proper Digestion:  A Brief Overview

How can los HCl cause all of the symptoms listed above?  When we eat a meal, the stomach produces gastric juice made up of HCl and the enzyme pepsinogen.  Pepsinogen is converted into its active form, pepsin, when it contacts HCl.  Together the HCl and pepsin begin the digestion of proteins in the stomach.  The normal resting pH of the stomach is between 1 and 3, which is very acidic.   A thick layer of mucus protects the stomach lining from this highly acidic environment.  It is normal and desirable for the stomach to be extremely acidic; the stomach is perfectly designed for such acidity.  Other tissues of the body, including the lining of the esophagus and small intestine, are unprotected from even the smallest amount of acid.

In the stomach, food is churned and mixed with the gastric juice.  Once HCl and pepsin have done their work, the food will be partially broken down into a thick liquid substance called chime, which has the consistency of split pea soup.  Next the pyloric valve which connects the lower stomach with the small intestine, will begin to open, letting chime through a little at a time.

As the chime enters the first part of the small intestine, or the duodenum, the intestine is triggered by the acidity of the chime to release the hormones secretin and cholecystokinin.  Secretin tells the pancreas to release digestive enzymes that finish breaking down proteins, fats, and carbohydrates into smaller units that can be absorbed through the intestinal wall.  Secretin also causes the pancreas to release bicarbonate, which neutralizes the acidity of the chime.  The normal pH of the intestines is 7 (neutral), so the bicarbonate is necessary to prevent the acid from eating away at the intestinal wall.  Cholecystokinin tells the gallbladder to release its bile, which emulsifies fats and allows for their absorption.  Once this chain of events has occurred, at least 90 percent of nutrient absorption will take place in the small intestine, with the remainder absorbed in the colon.

When things go wrong

That’s how digestion is supposed to work.  However, if there is not enough HCl, any number of things can go wrong.  First, protein digestion can be dramatically impaired.  In order to absorb protein, it must be broken down into individual amino acids.  Deficiencies in protein can produce bodily effects as varied as neurotransmitter imbalance in the brain, endocrine dysfunction, edema, muscle wasting, fatigue, frequent infections, and slow wound healing.

Second, a number of vitamins and minerals are dependent on a certain level of acidity for absorption- iron, calcium, zinc, B12, B6, and folate.  If there isn’t enough HCl, deficiencies of these nutrients can have far-reaching ill effects on health, including anemia, homocysteine buildup, poor bone health, immune dysfunction, birth defects, and permanent nerve damage.

Third, without the proper acidity, secretin and cholecystokinin will not be released, and there will be a lack of enzymes and bile to finish digestion, along with an absence of bicarbonate.  The lack of bile can lead to feelings of nausea, headaches, and even vomiting, as fats go undigested and become rancid.  The gallbladder is a rhythmical organ, designed to empty several times per day.  The liver will continue to make bile whether the gallbladder empties or not, and the bile can thicken and become concentrated in the gallbladder.  This is an important survival mechanism, but if it happens enough times, the bile becomes sludgy and can eventually form gallstones.  The lack of bicarbonate to neutralize the acid is also a serious problem because while the acidity may not be high enough to properly break down proteins or trigger the release of bicarbonate, it will still generally be high enough to damage the delicate lining of the small intestine.  Over time, this can cause or exacerbate duodenal ulcers.

Fourth, the body realizes what will happen if the chime is allowed to move into the small intestine, and so the stomach will try to hold onto the chime for as long as possible.  If the meal contained carbohydrates, they will begin to ferment in the warm environment of the stomach, producing gas.  This can lead to a bloated feeling after meals, as well as belching.  Under normal circumstances, the sphincter that connects the bottom of the esophagus to the stomach will open only when food is swallowed, to allow it to pass into the stomach.  The rest of the time, it will remain firmly closed to protect the esophagus.  Acid reflux can offer when the esophageal sphincter opens at inappropriate times, allowing acid to splash into the esophagus as the stomach churns the chime.  A buildup of gas in the stomach can put pressure on the sphincter and cause it to open at the wrong time.  Just as with the small intestine, the esophagus is not designed for even small amounts of acid.  In this way, insufficient stomach acid can result in acid reflux and heartburn.

Nutrient Absorption, H. Pylori, and Leaky Gut

Over time, low stomach acid can also lead to severe imbalances in the normal gut flora that populates our GI tract.  In the small intestine and colon, the incorrect pH creates an inhospitable environment for the beneficial gut flora, while favoring the growth of pathogenic bacteria, yeast, and fungi.  One of the many roles of beneficial gut flora is the production of certain B vitamins, especially those that are difficult to obtain through diet alone.  When these organisms are crowded out by pathogenic flora, deficiencies in vitamins are practically inevitable.  These pathogens feed on the food particles that we failed to digest because of low stomach acid.  They also secrete toxins that irritate the lining of the small intestine, and can eventually flatten the villi, dramatically decreasing the surface area available for nutrient absorption.  If this gut flora imbalance (also called dysbiosis) continues for long enough, the intestinal lining can actually develop holes, a scenario known as leaky gut.  Normally the lining will only allow very small particles through for absorption, but with leaky gut, undigested food particles can leak through into the bloodstream.  If the food particles contain proteins, the immune system will attack and form antibodies to them, believing them to be foreign invaders.  This is the beginning of a food allergy.

Even the stomach, normally acidic enough to kill practically everything that passes through, can fall prey to H. Pylori bacterial infections and other bacterial overgrowth.  H. Pylori is one of the few organisms that has a built-in mechanism for surviving the acidy of the stomach.  It is normally confined to certain areas of the stomach, but in the case of low stomach acid, it can infect the cells that secrete HCl and Cause them to atrophy, exacerbating the problem.  H. Pylori has been implicated as a strong contributor to gastric ulcers and gastric cancer, and infection of the stomach can further weaken the esophageal sphincter, increasing the likelihood of acid reflux.  Furthermore, stomach acidity serves as an essential barrier to disease-causing viruses, bacteria, and parasites that we ingest in our food and water.  When this barrier is weakened, these pathogens can pass into our intestines and make us sick, taxing our immune system.

Low HCl can set the stage for development of health problems.  Jonathan Wright, M.D., who operates the Tahoma Clinic in Washington State, is one of the few physicians who are aware of the pitfalls of low HCl, and he tests his patients for levels of stomach acid if they present with related symptoms.  Wright states that over 90 percent of patients who come to his clinic with heartburn are found to have below-normal production of stomach acid!  Many people with low stomach acid do not experience heartburn, so it’s probably a large percentage of the population suffers from low HCL.

Acid-Suppressing Drugs:  A Recipe for Disaster

When people with HCl-related symptoms go to the doctor, they are generally told that their stomach produces too much acid, and they are prescribed drugs that suppress acid production!  Few people question this assumption of too much HCl, because it seems to explain the burning they are experiencing.

Very few doctors test their patients; acid production before prescribing acid-blocking drugs.  These drugs simply add insult to injury when it comes to the cascade of dysfunction that results from low stomach acid.  Without the acid, the burning sensations no longer occur, giving patients a false sense of security.  Meanwhile, their nutrient deficiencies, digestive dysfunction, and gut flora imbalances continue unchecked, leading to even worse problems down the road.  These patients generally take acid-blocking drugs for many years of even for life, because if they stop, their painful symptoms will return.  Acid suppressants have been linked to increased risk of bone fractures, pneumonia, Clostridium difficile infection, and abnormally low levels of magnesium in the blood.

In addition of worsening the effects of low HCl we’ve already outlined, acid-blocking drugs represent an extra burden to the liver, which must metabolize them.  Some of the nutrient deficiencies caused by low HCl can prevent the liver from doing its detoxification duties properly, leading to liver toxicity in the long run.  Even those who manage their heartburn or ulcer symptoms with over-the-counter antacids are setting themselves up for future health problems.  As we’ve already seen, neutralizing the acid provides temporary relief from the burning but actually makes the root cause of the problem worse.  Many antacids contain aluminum, which has been implicated in Alzheimer’s disease and breast cancer.  Regular use of calcium carbonate antacids can cause milk-alkali syndrome, which leads to kidney failure if left untreated.  In addition, most commercial antacids contain questionable additives.  If you are experiencing painful acid reflux and need relief from the burning, a solution of baking soda in water is a much better and more affordable option for neutralizing acid.

It is important to note that in very rare cases, sensations of burning in the upper abdomen can be due to excessive stomach acid.  This condition is called Zollinger-Ellison syndrome, and it’s caused by malignant tumors in the pancreas, duodenum, or lymph nodes surrounding the pancreas.  If this syndrome is present, the use of a proton pump inhibitor (such as Prilosec) is indicated.  In the vast majority of cases, however, burning is caused by insufficient stomach acid.

Causes of Low Stomach Acid

What causes low stomach acid in the first place?  Deficiencies of B1, B6, and zinc, which are needed for acid production, definitely play a role.  All three of these nutrients are commonly deficient in many people, and they can be depleted by chronic stress or by the consumption of refined carbohydrates.  Many people are surprised to find that they present with clear deficiencies of B-vitamins in spite of taking large doses in their multivitamins.  This is because the B-vitamins found in nearly all supplements are the synthetic forms, and high doses must be used to get any effect.  Even then, many people find that their symptoms don’t respond even when using the synthetic forms.  Natural forms of vitamins are more effective at much lower doses, although they tend to be more expensive.

Those on exclusively vegetarian diets are at risk for zinc deficiency.  This is because zinc and copper must be maintained in a certain ration (8:1 in favor of zinc) in the body, and plant foods are invariably low in zinc and high in copper.  The only exception is pumpkin seeds.  The zinc found in plant foods also has much lower bio-availability than zinc from animal foods.  The best food sources of zinc include shellfish (especially oysters), red meat, dark meat turkey and chicken, cheese, yogurt, and eggs.

Chronic low-level dehydration is another major factor in low HCl, as water is required for its production.  Those who follow a low-salt diet (a terrible idea for the vast majority of people) are also depriving themselves of sodium and chloride, both needed to produce HCl.  It is difficult, if not impossible, to obtain adequate chloride from other foods in the diet.  And atrophic gastritis, a condition in which the stomach cells that produce acid become inflamed and atrophy, will definitely decrease the body’s ability to produce enough acid.

Solutions for Better Digestion

Digestion begins in the brain when we smell our food.  Optimal digestion requires a state of relative relaxation.  Stress, anger, frustration, and distraction put the body into a state of fight or flight, in which the body directs energy away from activities like digestion and reproduction.  For this reason, it’s important for those with digestive problems to cultivate a sense of appreciation and relaxation before eating a meal, and to avoid eating when upset of distracted by other activities (like driving a car or watching television).  It’s also imperative to chew your food well and resist wolfing it down quickly, to give the system a chance to function healthily.

Many people inadvertently dilute their stomach acid and enzymes by drinking too many liquids with meals.  One study showed that one glass of water increased stomach p by more than 4 points within one minute!  As a general rule, avoid drinking more than half a cup of water within 30 minutes before or 2 hours after eating a meal.  It’s a good idea to add a little lemon or lime juice or raw apple cider vinegar to your water to make it more acidic.  Some people find that a tablespoon or two of raw apple cider vinegar in a small amount of water before meals improves their digestion a lot.  Another option is Swedish bitters or other bitter herbs before meals, as the bitters stimulate acid and bile production.

Foods that normalize acid production include homemade bone broth, fermented vegetables, and unrefined sea salt.  Bone broth contains the amino acid glycine, which has been shown to increase acid production.  Traditionally fermented vegetables, especially kimchi and sauerkraut, contain probiotics that combat pathogenic overgrowth, including H. Pylori.  Kimchi in particular has been shown to significantly inhibit H. Pylori.  Probiotics also manufacture vitamins, providing a safeguard against deficiencies.  Sea salt contains chloride, and essential building block for stomach acid.  It’s also wise to consume a nutrient-dense diet and to avoid processed foods in general.

If the above measures have been tried without success, it’s likely that supplemental HCl is indicated.  For those with persistent digestive difficulties, acid supplements can make a world of difference.  To find the correct dose, either the patient’s own acid levels can be tested or a dosing protocol can be followed.  Both of these methods should only be used with the guidance of a health professional who is familiar with stomach acid supplementation.  In some cases, as with gastritis, it may be necessary to heal the lining of the stomach before supplemental acid can be tolerated.  At the same time, it’s essential to correct nutrient deficiencies that have been caused by years of insufficient acid or other factors.  Depending on the person, issues like gallbladder problems, dysbiosis, and leaky gut bay need to be addressed as well before digestion can return to normal.

People with low stomach acid often ask if they will have to take HCl supplements forever.  There is no easy answer to that question, as it depends entirely on the person.  Some people may be able to jump-start their body’s own acid production by supplementing for several months with HCl and correcting deficiencies.  Others may never completely recover their own acid production and may need to supplement HCl for life if they want to have normal digestion.  The vast majority of people will at least be able to reduce their dose over time.

For those who experience acid reflux, adopting a low-carbohydrate diet may be extremely helpful in controlling their symptoms.  One study examining 5 patients whose reflux had not responded to any of the conventional treatments found that their symptoms were completely eliminated within a week of adopting a low-carbohydrate diet (less than 20 grams per day).  These improvements were sustained even after they liberalized their carbohydrate intake to 70 grams per day.  Cutting intake of carbohydrates- especially refined- decreases intra-abdominal pressure; too much pressure can cause the lower esophageal sphincter to open at inappropriate times, allowing acid to splash into the esophagus.

Conclusion

Every cell in the body depends on proper digestion and absorption for the nutrients it needs to function.  With low HCl, even the most perfect diet or most high-quality supplements will not make much of a difference, because the nutrients they contain will not be absorbed.  It is far easier to address low HCl in its earlier stages than it is to correct the dysbiosis, food allergies, acid reflux, ulcers, and gastritis that can result from it.  The goal is a perfectly functioning digestive system, not just the elimination of pain.  We can benefit greatly by becoming knowledgeable about and taking responsibility for our own health.

Laurel Blair is a Nutritional Therapist Practitioner who is passionate about whole foods, traditional diets and nutrition.  She offers nutritional consultations personalized to her client’s specific health concerns.  More at www.dynamicbalancenutrition.com

Sources

Wright, Jonathan V., and Lane Lenard.  Why Stomach Acid Is Good for You.   New York: M. Evans and Company, Inc., 2001.

Tortora, Gerard J., and Bryan Derrickson.  Essential of Anatomy and Physiology.  Asia: John Wiley & Sons, 2010.

http://gut.bmj.com/content/34/8/1032labstract

USDA Continuing Survey of Food Intakes by Individuals, 1994-96

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See also…

http://www.livestrong.com/article/378534-foods-that-suppress-acid-in-the-stomach/