If you have heartburn, this one’s for you.
Heartburn, the typical sensation of gastroesophageal reflux occurring, is an extremely common experience shared by 1 in 5 Americans. Belching, heartburn, nausea, or regurgitation are symptoms that ride along with acid reflux, as well as a bitter taste, discomfort in upper abdomen or throat, or an irritating dry cough.
Regular use of acid blocking medication has become a common way to manage these symptoms of acid reflux. The problem with this approach is that it is a bandaid fix and doesn’t address the why behind the heartburn. This would be fine if blocking stomach acid was a benign strategy that took away the discomfort without digestive interference, but it’s not.
Before we talk about the problem with reducing or blocking stomach acid, let’s talk about why we need it.
Stomach acid or hydrochloric acid (HCl) maintains an acidic pH of about 1.5 - 3.5 in the stomach. It does this to support the adequate breakdown of foods, particularly proteins, so that absorption of those nutrients can occur down the line in the small intestine. HCl keeps that environment hostile to invasion by pathogens, killing bugs before they can travel into the rest of our GI tract and cause infections or changes in bacterial flora.
When you are suppressing your stomach acid, you are changing the environment of your digestion, impairing the necessary break down of what you eat, and potentially exposing yourself to changes in gut flora.
Acid reducing medications (called proton pump inhibitors or PPIs) are meant for short-term use. 14 days if you buy them over the counter, maybe 4-8 weeks if your doctor prescribes (can be longer under physician supervision for some conditions). Short-term, this can be an important strategy for individuals with excessive stomach acid production, esophagitis and gastritis, active ulcers, and as part of the eradication of H. Pylori infections (with antibiotics).
For individuals with acid reflux or GERD, these medications are often utilized daily for long periods of time (years) because heartburn is an everyday experience. When nothing is done to address the reason you are experiencing reflux, heartburn becomes a chronic symptom that needs suppression everyday. Unfortunately what isn’t discussed nearly enough, is that long-term use is associated with a host of negative repercussions for your health and digestion.
Long-term use of PPIs, is associated with increased risk of vitamin and mineral deficiencies, including lowered levels of calcium, magnesium, vitamin B12, vitamin C, and iron. (PMID: 25083257)
The consequences of calcium deficiency are decreased bone density, and increased risk of osteoporosis and fractures.
Severe magnesium deficiency can cause seizures, arrhythmias, hypotension, and tetany, and this is uncommon. A mild deficiency, which is difficult to test for in the blood, can cause vague symptoms such as fatigue, headaches, anxiety, muscle weakness, poor appetite and nausea.
B12 deficiency can cause symptoms related to anemia such as weakness, tiredness, lightheadedness, heart palpitations and shortness of breath, as well as damage peripheral nerve function and impaired cognition.
We all know about scurvy in sailors back in the day. In the US today, scurvy is a rare but serious deficiency in vitamin C. However, more commonly a mild deficiency occurs, which is linked to impaired wound healing, dry skin, fatigue, bleeding gums, and weight gain. Vitamin C has clinical use against colds and upper respiratory tract infections and may be immune stimulating, meaning that deficiency could be problematic for the immune system.
Iron malabsorption increases the risk of anemia, wherein your blood is not sufficiently stocked with iron and can’t carry and deliver oxygen efficiently. You could have symptoms as described above with vitamin B12 deficiency, through a different mechanism.
Beyond deficiencies in these areas, acid blocking medications can increase the risk of developing dysbiosis, an imbalance of the intestinal microbiome. PPI use changes the environment in the stomach, which can lead to the development of imbalances in your gut flora. Individuals who use acid blocking medications have a higher frequency of small intestinal bacterial overgrowth (SIBO), a condition that can cause digestive disturbances like bloating, gas, diarrhea and constipation. (PMID: 26078557)
With growing evidence for the role that intestinal bacterial flora plays in many diseases such as inflammatory bowel disease, diabetes mellitus, obesity, non-alcoholic fatty liver disease, and autoimmune diseases, it seems strange that medications linked to dysbiosis are a first choice and often used improperly for long stretches of time...
So what can be done about this?
Rather than suffering with heartburn and indigestion, avoiding an acid blocking strategy or neutralizing acid with antacids, you have to find a practitioner who is willing to get to the bottom of this with you.
Heartburn typically occurs because stomach acid is refluxing into the esophagus. Unless severe erosion of tissues is occurring (which your doctor will assess with imaging), reflux is typically not an issue of too much acid, rather it is acid in the wrong place or not enough acid for adequate digestion and stomach emptying.
Instead of suppressing stomach acid, we have to understand why reflux symptoms are happening. Here are some reasons for why heartburn may occur:
It can be due to an incompetent lower esophageal sphincter (LES), which is supposed to act like a clamp between the esophagus and stomach until food or liquids need to pass. If it is not working properly, it may be allowing acid upwards where it doesn’t belong. The LES needs robust stomach acid to function properly, and for adequate stomach emptying after meals, so LOW stomach acid or hypochlorhydria can be associated with reflux symptoms.
It could be due to a hiatal hernia. This is most commonly when the top portion of the stomach protrudes through diaphragm. The development of a hiatal hernia has been linked to obesity, pregnancy, increased abdominal pressure, hard valsalva maneuvers (like straining during a bowel movement), previous hiatal operation, genetics, lying down after meals, smoking, and stress.
It can be due to food sensitivities and intolerances. There is a connection between leaky gut or intestinal permeability and reflux symptoms. If there are foods in your diet that cause digestive symptoms, fatigue or headaches, these may also be contributing to reflux.
It can be due to duodenal bile reflux, which means that bile from the first part of your small intestine is backing up into the stomach. If you are someone who frequently experiences heartburn after a fatty meal, this could be happening as bile is secreted to help with the absorption of fats.
A holistic approach to reflux includes:
Eating hygiene: Choose smaller frequent meals, don't lie down after eating, don't eat within 3 hrs of bed, and avoid tight clothing.
Raise the head of your bed by 6 inches. This can help to clear refluxed matter and minimize damage to the esophagus. You can do this easily by placing several boards under the head of your mattress, or purchase a foam wedge for your side of the bed.
Weight loss is suggested if increased weight is compromising the function of the LES.
Determine if there are food sensitivities impacting digestion and overall health. Always work with a trained practitioner when evaluating food allergies and intolerances and making dietary changes. These can be an important part of optimal health, but should not be pursued without supportive evidence for investigation. What I mean by that, is don't just avoid gluten or dairy because it worked for someone else, because those foods may not be a problem for you. The gold standard test for food intolerances is an elimination re-challenge diet. Be wary of anyone who can promises that a food sensitivity test can tell you everything you need to know about your problem foods, they are leaving things out of the story.
Identify any triggers that may be relaxing the LES and causing that upward flow of acid. These are commonly: spicy foods, mints, onions, chocolate, citrus, coffee, tea, alcohol, nicotine, and certain medications. Determine if there are obstacles in the diet, such as excess problematic fats from fried or processed foods. A change in diet is a crucial holistic approach to acid reflux.
Identify with your health practitioner if a hiatal hernia is present. If so, work with them on a strategy for your reflux, and consider: "Heel drops" 10-20 after meals, stand on tippy toes and drop forcefully onto heels. Avoid valsalva maneuvers, consider visceral manipulation therapies — body work aimed at restoring proper structure and function, always breathe normally while eating, and incorporate the eating hygiene strategies (as specified above).
Botanical medicine under the care of a trained practitioner:
Herbs that support the function of the LES, such as Fumaria officinalis (fumitory), Dioscorea villosa (wild yam), Chelidonium majus (celandine), Chionanthus virginicus (fringe tree), and Ceanothus greggii (redroot).
Digestive enzymes and betaine HCl to support digestion and absorption of nutrients.
Demulcent and soothing herbs that support tissue healing such as Symphytum officinale (comfrey), Calendula officinalis (calendula), Althaea officinalis (marshmallow root), deglycyrrhizinated licorice, aloe vera gel, and fish oil.
When necessary, stomach acid blocking medications are required to manage symptoms and prevent damage to cells if exposed to excess HCl which can lead to erosion of tissues and dysplastic cellular changes.
Ask your doctor why you are on an acid blocking medication, there may be an important reason for being on one temporarily, and thus the benefits outweigh the harm.
If not, ask if there is another approach to managing your symptoms of reflux. Always speak with your doctor about your heartburn, especially how severe it is and how long it has been going on, as imaging or further investigations may be required. Let your doctor know about the over-the-counter medications you are using to treat your heartburn. ALWAYS seek medical advice before discontinuing medications. Acid blocking medications can cause a rebound excessive acid secretion, worsening symptoms if discontinued abruptly.
If an acid blocking strategy is indicated for you, ask your doctor for support with supplementing the nutrients you are missing due to use of a PPI.
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