Adapted from episode 125 of The Perfect Stool podcast with Lindsey Parsons, EdD, and edited for readability.
Heartburn is one symptom of acid reflux, which is where the stomach acid travels back up your esophagus. The term heartburn can be deceptive, as it implies that the heart is involved in the discomfort, but in fact heartburn actually occurs within the digestive system, specifically in the esophagus. GERD is a chronic and more severe form of acid reflux. GERD is the typical culprit in people who frequently suffer from heartburn. According to the National Institutes of Health, more than 60 million Americans experience heartburn at least once a month, and that number is continuing to rise. However, many people who have GERD do not experience that burning sensation, but rather have what’s called silent reflux or LPR, laryngopharyngeal reflux. People with LPR may have symptoms that they might confuse for a variety of other conditions, such as a sore throat, hoarseness, a chronic cough, a bitter taste in the mouth, phlegm, or a lump in the throat, and a need to clear the throat and/or post nasal drip. I had a chronic cough for years and post nasal drip and was put on asthma inhalers, which didn’t help that much at all until finally a doctor realized I had reflux. For me, giving up dairy was a big part of decreasing those symptoms, although when SIBO flares, I do sometimes experience the cough still, especially when I cheat and eat dairy. GERD, no matter how it manifests, involves the regurgitation of food and stomach acid into the esophagus, leading to the sensation of a burning-type discomfort in the chest, neck or throat, which people refer to as heartburn, or the symptoms of LPR mentioned above.
Can children have GERD?
Although GERD is more prevalent in adults, children or adolescents, even infants can suffer from gastroesophageal reflux disease. Children who have risk factors, particularly a hiatal hernia, asthma, or a strong family history of GERD, may experience recurring and long lasting GERD later in life. So identifying and treating GERD early in those at risk children can result in fewer complications and potentially prevent the development of GERD in adulthood. Untreated GERD can pose a significant concern, as the continuous reflux of stomach acid can result in harm to the esophageal lining, leading to inflammation and discomfort in adults. If prolonged and unmanaged, it may result in Barrett’s esophagus, a reddening and thickening of the wall of the esophagus, which is a precursor to esophageal cancer. In order to prevent this, gastroenterologists will often prescribe long-term use of PPIs (proton pump inhibitors) or a surgical intervention called fundoplication. This surgery entails wrapping the upper part of the stomach around the esophageal sphincter muscle in order to strengthen the sphincter and prevent reflux. Obviously, these options are best avoided if possible.
Additional symptoms of GERD, aside from the burning discomfort of heartburn or symptoms mentioned with LPR, may include a frequent sour taste of acid in your throat, especially when lying down, a sensation of burping acid into the mouth, difficulty swallowing, a feeling of food being stuck in the throat, a choking sensation that may disrupt sleep, the wearing away of teeth and/or halitosis, aka “bad breath.”
Why are more young people suffering from GERD or heartburn?
So why might otherwise healthy, young people get heartburn? Research has indicated that the prolonged presence of GERD, or its onset during early stages of life, are contributing factors to the development of Barrett’s esophagus and esophageal cancer. In fact, one out of every four adolescents suffer from GERD, according to the National Institute of Diabetes and Digestive and Kidney Diseases. So why are more and more children and teens suffering from a disease that usually targets older, more unhealthy populations? Some research points to the fact that more and more teenagers are overweight, a product of a society with too little exercise, too much time indoors, and the constant eating of ultra processed foods.
Also, teenagers have a fondness for junk food and these foods are commonly offered at school and at events. Junk food like french fries, pizza and burgers and other high fat, deep fried foods are exactly the type of foods that trigger GERD. But changing habits is often difficult for children and teens, and food restrictions can distance them socially from their friends when they need to avoid things like pizza, fries and tacos, as those are foods that most teens are eat commonly. Further, teenagers are known to frequently snack during the later hours of the day and also stay up late. This type of late night snacking mixed with lying down is another trigger for GERD. Even lack of sleep can impact GERD symptoms, as sleep is so critical for overall health. Treating GERD means the managing of a new lifestyle, and this is often too difficult for adolescents to face, potentially explaining the increasing numbers of young people with GERD.
What are the physiological causes of GERD?
So what causes these symptoms? The esophagus functions by carrying food from the mouth to the stomach and is only separated by a small muscle known as the lower esophageal sphincter. This muscle will open to allow food and liquid to enter the stomach and then is supposed to close to prevent any contents from leaking back up into the esophagus. Typically GERD is caused by the sphincter muscle improperly closing or relaxing when it’s not supposed to. The mechanism of this muscle dysfunction varies from person to person. For some people, the muscle simply does not tighten correctly. For others, the muscle doesn’t close quickly enough after eating, allowing stomach contents to move up the esophagus.
What dietary changes help reduce GERD?
The treatment for GERD depends on the severity of symptoms, but for most people, simple lifestyle changes can make a huge difference, such as changing your diet. There are many foods reported to make GERD symptoms worse. The common culprits cited are citrus fruits, chocolate, caffeinated drinks or foods, carbonated beverages, fatty or fried foods, garlic and onions, peppermint, spicy foods and tomato-based foods. Those are the typical foods you’ll be recommended to avoid as you try and figure out the root cause of your symptoms.
In my experience, however, it’s often an underlying case of dysbiosis, either small intestinal bacterial overgrowth or SIBO, or the bacteria H. Pylori, or other issues that lie at the root of the problem. And in the case of SIBO, a diet high in fermentable carbohydrates along with excess bacteria in the small intestine may actually be causing the issue because those are the most fermentable foods. If a low FODMAP diet, which stands for Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols, eases your symptoms, you may want to seek out a gastroenterologist knowledgeable about SIBO and try to get a SIBO breath test. Or you could order a FoodMarble device and test yourself (and you can email me to get the medical FoodMarble device with the testing medium at a discount). I’ve also seen a recent study that showed that just eliminating gluten and dairy (because wheat and lactose are two of the biggest components of a typical diet that are high in FODMAPs), is almost as successful as a full blown low FODMAP diet, and it’s much easier to implement. So if eliminating those two, plus also eliminating added sugar, brings you a lot of relief and you’re having bloating after eating, I’d pursue SIBO testing aside from diet changes.
What lifestyle changes help with GERD? What are the underlying cause of GERD?
There are many other lifestyle changes that can be implemented to provide GERD relief. Some of these changes include quitting smoking, avoiding alcohol and losing weight. Other more serious reasons for GERD or heartburn could be pregnancy, scleroderma, autoimmune disease or hiatal hernia, so these should also be considered when you have symptoms. A hiatal hernia is when part of the stomach slips up through the lower esophageal sphincter into the esophagus, it may be possible to feel this as a bulge under your left breastbone. Hernias are actually incredibly common, with an estimated 60% of adults having one, although they’re often asymptomatic. Hernias can be caused by obesity, pregnancy, heavy lifting, excessive coughing or even straining on the toilet when constipated, as well as things that weaken the diaphragm, which normally prevents the movement of the stomach into the esophagus, like smoking, poor diet, lack of exercise, alcoholism and chronic stress. Some hiatal hernias can result in gastrointestinal bleeding, which would show up as vomiting or bloody stools and can lead to iron deficiency, aka anemia. So if you can’t seem to get your iron levels to normal and have heartburn or GERD symptoms, you should be examined by a doctor for hernia. There are ways to naturally pull a hernia down.
Other symptoms of scleroderma, another possible cause of GERD, are hard, thickening or tight skin, hair loss, inability to sweat through your skin, dry skin, itching, sores, changes to skin color, salt and pepper looking skin, stiff joints, muscle shortening and weakness, sores and pitted scars in the fingers, visible blood vessels showing up as tiny red spots, usually on the hands and face, calcium deposits beneath the skin and extreme sensitivity to cold or stress. So if you have heartburn or GERD symptoms, plus any of those symptoms, you may want to see a rheumatologist to get a diagnosis. And if you do, don’t neglect dealing with your gut health as a hyperpermeable or leaky gut is a precursor to all autoimmune disease. Finally, GERD is a side effect of many prescription drugs. So if you started a new prescription recently, do check the insert and make sure that your new drug isn’t your root cause beyond what you eat.
Can proper meal hygiene help with GERD?
How you eat and proper meal hygiene may be at the root of heartburn or GERD symptoms. My son, for example, has complained of years of stomach pain and heartburn type issues. However, his diet, consisting almost entirely of gluten and dairy, along with the fact that he inhales his food within less than five minutes of sitting down, no doubt has a huge impact on his symptoms. Don’t be asking yourself how I could have a son with such terrible eating habits. Anyone with kids knows they are very hard to control. So starting with the obvious, eating slowly and calmly, taking small bites and chewing your food adequately, which for some people is supposedly 25 chews per bite. I can never quite get there, but that will depend on how large the bite is and how hard to chew the food is. But basically chew until the food is mush. Taking time between bites by putting down your fork and not working or multitasking while you eat are also good meal hygiene practices.
And of course you want to be in a parasympathetic state before you even start eating. Your parasympathetic nervous system is responsible for stimulation of rest and digest activities that occur when the body’s at rest. These activities include digestion, bowel movements, urination and salivation. The other part of the autonomic nervous system is the sympathetic nervous system, which is responsible for fight or flight reactions. The body can only be in one or the other state at a time. So to properly digest food, the body needs to ensure optimal blood flow to the digestive organs in order to absorb nutrients efficiently. This process is hindered when the body’s in motion, stressed or physically agitated, as the sympathetic nervous system redirects blood flow to the extremities rather than the digestive system. This is why eating while working, walking or when under stress can lead to indigestion. In a relaxed, parasympathetic state, the mere thought of food can trigger the initial stages of digestion. In this state, cranial nerves stimulate the salivary glands to release enzymes in your saliva which aid in breaking down food, while also prompting the stomach to release gastric juices, hydrochloric acid and additional enzymes crucial for proper digestion and nutrient absorption.
Its important to consider your mental and emotional state before a meal, as it significantly impacts food choices, eating habits and portion sizes. Eating while stressed restricts blood flow to the stomach resulting in poor digestion. When digestion is compromised, symptoms like heartburn, bloating, gas, constipation, low energy and weight gain may occur. To make sure your parasympathetic nervous system is activated prior to eating, you can try sitting in silence for 1 minute before you eat, taking deep breaths from your diaphragm. And then it’s important to eat without distractions like television, your phone, a computer or a book. Just focusing on eating alone can aid in digestion. As I said earlier, even the simple act of consciously eating slowly can help the body enter its parasympathetic state, which is crucial for proper digestion.
What other factors might influence GERD symptoms?
Other things that may influence heartburn or GERD symptoms include your clothes, your body position after eating, and your meal size and timing. Tight fitting clothes tend to push your stomach upwards even slightly, which can cause your stomach to push its contents towards the esophagus, either causing heartburn or exacerbating it. You should also avoid lying down or sleeping after a meal for at least two to three hours. While it won’t address the root cause of your issue, one way to get gravity on your side is to raise the head of your bed six to eight inches by putting blocks or books under the legs of the bed, so that the body is less horizontal during sleep. The human metabolism is more active earlier in the day, so establishing a daily cutoff time in the evening for eating, maybe 7:00 p.m., is a good idea to allow your stomach to empty before you sleep. As well as being much better for blood sugar regulation, these simple bedtime tweaks may help alleviate your symptoms.
Reducing your meal size can also be very impactful in reducing heartburn. Large meals expand the stomach, which can prevent the sphincter muscle from completely closing, resulting in acid reflux. Usually, people are advised to eat only until they are 75% full, which will allow the stomach to empty more quickly and reduce the risk of heartburn. Using smaller plates and bowls can make you feel more satisfied despite the smaller portion you’re consuming. I also have made a habit of keeping the food in the kitchen during meals, filling up the plates with reasonable portion sizes, and then requiring people to get up to get seconds rather than putting the food on the table. It usually takes about 20 minutes for your body to perceive fullness, so I also recommend waiting until 20 minutes are up before getting seconds, as what you perceive as hunger will pass if you just give it a few more minutes. Also, eating smaller meals every three to four hours throughout the day, rather than a few large meals, may alleviate heartburn and help you to avoid overeating.
In addition, eating high fiber foods that make you feel full lowers your risk of overeating. This includes whole grains like oatmeal, brown rice, and quinoa, as well as beans, lentils, root vegetables, and winter squashes. Vegetables like peas, carrots, asparagus, broccoli, brussels sprouts, and green beans are also a great source of fiber as well as most fruits.
What natural remedies and over-the-counter treatments help with GERD?
People suffering from heartburn often look for quick relief, typically reaching for antacids and over the counter medications like Alka Seltzer, Maalox, Tums or Rolaids to neutralize stomach acid, but there are natural home remedies that can offer the same relief without the risk of medications that may be taxing on the body. Drinking a glass of water can be a quick fix as it will quickly dilute stomach acid. Milk is known to coat the stomach lining and protect it from acidic stomach contents, and a half teaspoon of baking soda in 4 ounces of warm water can also have a quick alkalinizing effect. Try those home remedies next time you have heartburn instead of reaching for an antacid or potentially damaging over-the-counter medication.
Most conventional doctors will recommend antacids for heartburn (over-the-counter medications that mix aluminum, magnesium or calcium with hydroxide or bicarbonate ions to neutralize the acid in the stomach). Next level treatments include histamine 2 blockers, which target histamine, a component of stomach acid, lowering stomach acid and cutting down heartburn. Common H-2 blockers are Famotidine, (which is Pepcid or Pepcid AC), Simetine, (which is Tagamet or Tagamet HB) and Nizatidine, if those are unsuccessful. Proton pump inhibitors are often prescribed to block the pumping of hydrogen ions into the stomach from the intestinal lining. Common PPIs are Dexlansoprazole or Dexilant, Lansoprazole or Prevacid, and Omeprazole or Prilosec.
What are the dangers of antacids, H2 blockers and PPIs?
Unfortunately, treating GERD with antacids, H2 blockers and PPIs has been linked to adverse effects like pneumonia, SIBO or gastroenteritis, although PPIs have the most potential side effects. Short-term side effects of PPIs include constipation, diarrhea, dizziness, dry mouth, headaches, fever, gas, abdominal pain, lightheadedness, itching and rashes. However, long-term use can lead to protein maldigestion as they inhibit stomach acid production from something like 65% to as much as 99%, as stomach acid is essential for breaking proteins into amino acids. This can lead to osteoporosis-related fractures, thrombocytopenia, which is a low platelet count, iron deficiency, B12 deficiency, reduced absorption of other vitamins and minerals, rhabdomylosis or muscle breakdown, death, kidney damage or dementia.
The typical recommended course of PPIs is two weeks. I wouldn’t worry too much about short-term PPI use, but some people do end up with gastroenteritis and even SIBO post PPI use. So I’d recommend the probiotic L. reuteri DSM 17938 at the same time, which is in Biogaia Protectis* and Biogaia Gastrus*, the latter being a probiotic I often recommend for constipation as well. In a study of 128 children with GERD on PPIs after twelve weeks of treatment, 56.2% of the children from the placebo group had SIBO, versus only 6.2% of the children on the probiotics. If you can’t find relief without PPIs and end up taking them longer term, I’d also recommend taking free form amino acids like Designs for Health Amino Acid Supreme* or Pure Encapsulation’s Amino Replete* each day to make sure you’re getting enough of the building blocks of proteins, and periodically testing your amino acid levels using a test like the Metabolomx+ in my Rupa Health Lab Shop* or a simpler amino acid test.
What are other root causes of GERD and how can I test for them?
Helicobacter pylori or H. pylori and otherwise commensal bacteria present in the stomach can become overgrown, especially following periods of chronic stress when gut immune defenses are down. When it overgrows, it can cause either high or low stomach acid, depending on its location, and is often the root cause of GERD and heartburn. When overgrown, it can also develop virulence factors that put you at additional risk of stomach cancer or ulcers. But I found in testing clients that these virulence factors are relatively rare. There are tests done by gastroenterologists like Urea Breath Tests for H. pylori, stool antigen tests, and upper endoscopy exams, which usually include biopsies for H. pylori to diagnose it, and esophageal pH tests, although the latter is harder to come by, to check if you have low or high stomach acid. I use stool tests including the GI Map or the US Bioteck GI-Advanced Profile* to see if there is H. pylori, which I’m particularly suspicious of if there’s stomach pain, often on an empty stomach, and/or constipation. Both tests include the virulence factors for H. pylori.
So what’s counterintuitive is that low stomach acid can manifest similar symptoms to excessive stomach acid. When the pH in the stomach gets too high or alkaline, this can trigger the opening of the lower esophageal sphincter. Often taking supplemental stomach acid in the form of Betaine HCL or apple cider vinegar in water before meals helps resolve the issue. I’ve had a number of clients who had heartburn that was relieved when we addressed their low stomach acid this way. However, this is contraindicated if you have extreme burning or pain in your stomach or blood in your stool, which may be indicative of an ulcer.
A good place to start is trying the Betaine HCL challenge to test your stomach acid. To begin, take one capsule per meal alongside animal protein, usually sold in the 500 to 750 milligram range. Gradually increase your dosage by one capsule per meal every two days until you experience heartburn or a warm sensation in your chest, up to a maximum of five capsules. Once you reach this point, reduce your dosage back to the previous amount. If you experience the immediate burning, it could indicate an excess of stomach acid or a potential hiatal hernia or other problems. In such cases, you can alleviate the discomfort by taking an antacid or consuming baking soda in water to neutralize the acid.
Another alternative to taking Betaine HCL is one to two tablespoons of apple cider vinegar or lemon juice mixed in water prior to meals. If you’ve been diagnosed with Barrett’s esophagus, esophageal strictures or reflux esophagitis, it’s not recommended to use these products. In such cases, it’s advisable to opt for digestive enzymes that do not contain Betaine HCL*. However, if you still wish to try the Betaine HCL approach, it’s best to find a product that includes pepsin, an enzyme naturally produced by the cells in your stomach. I also like one that includes Gentian Bitters*, which also helps promote bioflow. However, with conventional medical practitioners, low stomach acid is rarely a consideration, but only high stomach acid, leading to a diagnosis of GERD and the prescription of PPIs usually. If you have low stomach acid, PPIs may worsen GERD by hindering the adequate breakdown of foods, particularly protein, which requires HCL for digestion, and straining the enzymatic function of the pancreas and other digestive organs that are stimulated to release enzymes based on stomach acid levels. This could result in calcium, iron, B12, or vitamin A deficiencies, resulting in heightened inflammation and intestinal harm, and protein deficiency, all of which contribute to additional health complications.
Some people do, in fact, have excess stomach acid and not low stomach acid. So if taking apple cider vinegar or betaine HCl creates immediate heartburn, then you may need a temporary course of antacids, H2 blockers or PPIs while trying to get at the root cause of your problem. Ideally, PPIs should only be used as a treatment for a 14-day period, as prolonged use can lead to other problems, as I already mentioned.
Conclusion
So that was a lot to absorb, so I’m going to stop there. If you have follow up questions, a great place to ask them is in my Facebook group called Gut Healing. And if you are struggling with GERD, bloating, gas, burping, nausea, constipation, diarrhea, soft stool, acid reflux, IBS, IBD, SIBO, candida overgrowth, fatigue or migraines and want to get to the bottom of it, that’s what I help my clients with. You’re welcome to set up a free, 30-minute breakthrough session with me. We’ll talk about what you’ve been going through and I’ll tell you about my 3- and 5- appointment health coaching programs in which I recommend lab tests, educate you on what the results mean and the protocols used by doctors to fix the problems revealed. Or if you’re ready to jump in right away or can just afford one appointment at a time, you can set up an 1-hour consultation with me.
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