The focus of my clinical practice and work is on cardiometabolic disorders (obesity, diabetes, cholesterol disorders, heart disease, insulin resistance, etc.), so why am I talking about acidity and digestion in this post?
As I started seeing patients with cardiometabolic disorders, I noticed that many of them happened to have problems with digestion as well. Symptoms like acidity, bloating, gas, constipation and/or diarrhea.
I didn’t make the connection initially, but over the years I’ve noticed that as we worked towards reversing insulin resistance through natural lifestyle changes, digestive symptoms also resolved. I now fully acknowledge the connection between the digestive system, popularly referred to as “gut health,” and overall health.
In fact, I often refer to the co-existence of gut symptoms and cardiac risk as “cardiodigestive disorders” or CDD to remind me of this intimate link. Recall how we’ve discussed multiple times how inflammation is the root cause for chronic health conditions like heart disease, cancer, Alzheimer's disease, and autoimmunity. Since inflammation is caused by immune system overactivation and most of our immune system resides in our gut, it’s no surprise that improper gut health is a primary trigger to inflammation-related diseases.
So even before your cholesterol or blood glucose becomes abnormal, your digestive symptoms may be an early warning sign for ongoing inflammation in the body. Listen to your gut and don’t just treat these symptoms as an annoyance.
This is nothing new and despite an explosion in new books and research studies on gut health, ancient Eastern medical practices like Traditional Chinese Medicine and Indian Ayurvedic medicine acknowledge the key role the gut plays in human disease. In fact, Hippocrates, the father of modern medicine said the following over 2,000 years ago:
“All disease begins in the gut.”
In today’s post we’ll discuss the basics of stomach acid and how “acidity” or “GERD” (Gastroesophageal Reflux Disease) symptoms are often misdiagnosed and mistreated as excess stomach acid, when it’s frequently due to low stomach acid.
You’ll also learn about the wide range of health conditions that are associated with low stomach acid (aka hypochlorhydria) and the side effects of acid blocking medications like the popular PPIs (Proton Pump Inhibitors). Our dietitian, Prerna Uppal, will then provide some natural remedies and lifestyle changes to help restore natural acid production.
The Role of Stomach Acid
Stomach acid, aka hydrochloric acid or HCL, plays a critical role in digestion. It breaks down food particles into smaller pieces that are sent to the small intestine for further processing and nutrient absorption. Stomach acid also triggers the release of digestive enzymes by the pancreas and small intestine. If food is not properly broken down by a sufficient amount of stomach acid and the additional downstream enzymes, your body will not extract nutrients from that food.
In other words, if you are going through the effort of investing in high quality, nutrient dense foods, but have low stomach acid, you are not benefiting from the essential vitamins and minerals in those foods. Stomach acid helps your body absorb a number of nutrients, including folate, vitamin B12, vitamin C, beta-carotene, iron, and some forms of calcium, magnesium, and zinc.
Nutrient dense foods potentially become nutrient deficient in the absence of adequate stomach acid and overall digestive function.
Stomach acid is also a critical part of our immune system function. When we produce insufficient amounts of acid, we are more susceptible to bacterial infections like H.Pylori (bacteria causing ulcers) and fungal infections like Candida to name a few.
Signs and Symptoms of Low Stomach Acid
Undigested food particles from insufficient stomach acid get digested by bacteria producing excess gas leading to symptoms like abdominal bloating, gas, nausea, cramping and acidity due to back pressure that sends acid up to the esophagus (swallowing tube). This type of “acidity” is commonly misdiagnosed as excess acid which is then mistreated with acid-blocking medications which we’ll discuss in a moment.
I mentioned the link between digestion and immunity, so it’s no surprise that low stomach acid is linked to some of the following conditions:
Asthma and allergies (food and airborne)
Digestive symptoms (mentioned above) including bloating after meals
Vitamin and mineral deficiencies (B12, Iron, and those already mentioned)
Intestinal hyperpermeability (aka “leaky gut”)
Skin conditions: eczema, hives, acne rosacea, dry skin
Anemia (from deficiencies in iron, B12, etc.)
Increased bone fractures (key minerals that are essential for bone strength, like calcium and magnesium, are often deficient with low stomach acid)
Hair loss (especially in women) or dry hair
Weak or cracked nails
How are so many diverse conditions connected to something like low stomach acid?
The combination of a disrupted immune system from improperly digested food particles and the potential for multiple nutrient (vitamin, mineral, etc.) deficiencies stemming from low stomach acid are sufficient to trigger all types of seemingly unrelated health conditions.
The reason food allergies are more prevalent with low stomach acid is because the undigested proteins from food are recognized as foreign invaders, which then trigger an immune sytem response by allergy-specific antibodies called “IgE” antibodies.
Read this review on the scientific basis for this mechanism. Dr.Evan Untersmayr is an authority on this topic and found that study subjects with lower stomach acid from acid-blocking medication had a 300 percent increase in production of the allergy-specific IgE antibodies and were over 10 times more likely to develop food and airborne allergies.
Fatigue is also a very common symptom of low stomach acid since the energizing nutrients in foods cannot get absorbed by undigested foods. Download my free e-book on fatigue which discusses the digestive link to energy production in addition to providing some key lifestyle changes that can help you recharge.
Risks of Acid-Blocking Medication Use
Unless you have a specific diagnosed condition like ulcers, you should question the long-term use of acid-blocking medications such as PPIs (Proton Pump Inhibitors), like Prilosec, Protonix, Aciphex, etc. You can imagine that if your digestive symptoms have been due to low stomach acid all along, then taking a medication that obliterates acid production would make a bad problem even worse.
There has been a growing number of research studies linking long-term PPI use to conditions like heart disease, dementia, bone fractures, and chronic kidney disease.
We already discussed the myriad other conditions related to autoimmunity and vitamin/mineral deficiencies, but there may be other underlying mechanisms specific to PPIs that increase the risk of disease. Proton pumps are not only found in our stomach but in virtually every other type of cell.
Although PPIs are supposed to be specifically targeted to our stomach, they are not as selective as we used to think, meaning they can affect other cells which require intact proton pumps to produce energy and function optimally.
Again, I want to emphasize that there are certain specific medical conditions that may require PPI therapy, so be sure to check in with your physician before stopping your medication. Also keep in mind that some of the risks reported are specific to PPIs and not other forms of acid-blocking medications like H2-blockers, although we discussed the overall risks of having chronically low stomach acid which can be triggered by the long-term use of any antacid medications.
As of October 2019, there has also been a recall of the popular acid-blocking drug Zantac (ranitidine) due to concerning amounts of the carcinogen (cancer-causing substance), NDMA (N-nitrosodimethylamine). This does not mean all drugs in this class known as H2 blockers have the same risk, but it is a reminder that we need to focus on lifestyle over medications when trying to fix the root cause of acid-related disorders. Medications, if needed, should be used for the shortest period of time possible while fixing lifestyle.
Diagnosing Low Stomach Acid
There is no easily accessible method of accurately testing for low stomach acid. The gold standard diagnostic test is the Heidelberg test, which involves swallowing a small capsule-like pH probe that sits in the stomach and measures acid levels. This is unnecessary in most individuals.
There are also some simple home tests that are often recommended by naturopaths and functional medicine doctors. These are not validated by scientific rigor, but are more anecdotal and safe enough for most people to try.
The first is the bicarb morning test where you mix ¼ teaspoon of baking soda in 4-6 ounces of cold water when you first wake and before you eat or drink anything. Now time how long it takes you to belch up to five minutes. If you have sufficient stomach acid, it should react with the baking soda (bicarb) by producing CO2 gas, causing you to belch within 2-3 minutes. If it’s longer than 5 minutes, you may have low stomach acid. Ideally you should repeat this test on 3 separate days for confirmation. Again, “belch times” can vary among individuals so this is not a highly accurate method but can provide some direction.
The next test is the betaine HCL challenge test which is generally more accurate than the bicarb test but not as accurate as Heidelberg probe test. This involves taking an acid supplement called Betaine HCL with a digestive enzyme called pepsin and then monitoring for symptoms. There are several brands available (Betaine HCl+pepsin).
Before getting into details of the protocol, it is not recommended to take this if you have stomach ulcers, gastritis or are taking drugs like NSAIDS or steroids. Talk to your doctor if you’re unsure. A typical protocol is as follows and you can find many similar ones online:
Take Betaine HCl with pepsin at the start of a meal that has at least 20-30 grams of protein. Some protocols ask to take it at the middle of the meal. Either approach works.
Complete your meal and then monitor for symptoms such as stomach pain, heaviness, and burning/heat as you go about your normal life. These symptoms would indicate that your body is producing sufficient stomach acid which means the HCl produced excess acid symptoms. So symptoms are actually a sign of NORMAL stomach acid production. If you have no symptoms, you likely have low stomach acid. See next step.
If you have no symptoms, increase to 2 capsules the next day with a protein-containing meal as specified in step 1. You can keep increasing by 1 capsule each day until you reach 6 capsules. At this stage I recommend you see a practitioner like a functional medicine doctor who is familiar with low stomach acid.
Individuals with low stomach acid may choose to supplement with betaine HCL at each protein-containing meal and may also consider additional digestive enzymes. Prerna will discuss some natural remedies next, but know there are multiple supplement and lifestyle changes that can help individuals restore normal acid production.
Natural remedies for treating low stomach acid
There are multiple natural strategies for treating low stomach acid, many of which are rooted in the ancient science of Ayurveda. Ayurveda refers to our digestive energy as “agni” (fire) and stomach acid is a key contributor to agni. For those of you who might be skeptical of these approaches, keep in mind that many of these interventions like the use of apple cider vinegar are only now becoming validated by research studies. Our ancient ancestors had an innate wisdom about digestion and overall health that today's scientist can't match. We've had this validated through our clinical experience. I’ve listed some of the natural remedies below but as Dr.Ron mentioned, you may need assistance from a dietitian, naturopathic doctor, or functional medicine practitioner familiar with effective treatment for low stomach acid.
Time Restricted Eating: Eating meals at regular times and finishing your last meal earlier (before 7p ideally) is one of the most effective ways to combat acidity. One type of intermittent fasting is called time restricted eating/feeding and a popular regimen is 16/8, where you fast for 16 hours (sleep counts!) and eat during an 8 hour window. For example, you can eat all your food between 11a-7p or 10a-6p (even more ideal for digestion) and then allow your liver and digestive system to recover during the remaining 16 hours.
Organic, raw apple cider vinegar: 1 tablespoon organic, raw apple cider vinegar (a popular brand is Bragg’s) mixed with 4 oz water can be taken first thing in the morning and 30 minutes before meals. The acetic acid in the vinegar helps restore the pH balance of the stomach. The vinegar has multiple other health benefits besides digestion. Be sure to rinse your mouth/teeth after drinking to avoid erosion of teeth enamel. If you are taking vinegar regularly for a few weeks, preferably drink through a straw to minimize contact with your teeth. Apple cider vinegar can also be used to marinate proteins and other meats.
Lemon Juice: Similar to apple cider vinegar but less potent, Ayurveda recommends you squeeze the juice of half a lemon in 8 oz of warm water and drink on an empty stomach first thing in the morning. Lemon juice can also be incorporated into marinades.
Hydration: The protective bicarbonate layer lining the stomach is made up of water so when we are dehydrated, the stomach lowers acid production to protect the stomach, so hydration is necessary to maintain normal acid release by the stomach. Warm water is preferred and it’s best not to drink water with meals since it can dilute the effects of stomach acid. Instead drink water between meals.
Eat Clean Foods: Eating unprocessed, natural, mostly plant-based foods while controlling sugar and excess carb intake will promote the optimal balance of bacteria in our digestive system which facilitates acid production.
Mindfulness: Stress, especially stress during eating, impairs acid production. It is a well-known belief in ayurveda that your state of mind when you eat, determines the nutritional fate of your meal. The same meal will be well assimilated if you are feeling happy and positive. Alternatively, it will be poorly digested if you are emotionally stressed. Eat slowly and chew your bites thoroughly. Eat slowly and chew your bites thoroughly until the food is almost broken down to a liquid form- aim for 30 chews! Read this post for guidelines on mindful eating. Dr.Ron and I have often found that despite all of the other recommended changes, it’s not until stress is managed that digestion is restored. Refer to prior posts on stress. It’s also recommended to eat your largest protein meal when you are most relaxed, not when you are on the run.
Ginger: Chewing a small piece of ginger or drinking ginger tea between meals can help stimulate acid production. Ayurveda suggests chewing on a piece of fresh ginger with “kaala namak” or black salt.
Protein timing: Since protein triggers acid production, eat protein first followed by vegetables and other non-protein foods.
Fermented Foods: Fermented foods like sauerkraut, kimchi, pickled foods, yogurt, kefir, etc. contain organic acids, enzymes and beneficial bacteria that can improve acid release. Eating these foods with your heavier protein meals can facilitate digestion.
Manuka Honey has antibacterial properties which kill harmful bacteria in your stomach that interfere with acid production. Use in moderation since any form of honey can raise blood sugar.
Dandelion Tea is another great way to increase stomach acid production.
Digestive enzymes and bitters: Digestive enzymes can help with bloating and acidity by replacing enzymes that might be deficient. Bitters enhance your own production of digestive enzymes which can also alleviate acidity and bloating.
The term “acidity” is vague and non-specific and can be attributed to either an overproduction or underproduction of stomach acid. It may seem like a relatively harmless, nuisance condition that can be bandaged with a medication like a PPI or H2 blocker, but as you've learned from this post, it can signal more significant root causes, and long-term use of medications carry its own set of health risks.
Acidity should be treated as an early palpable warning sign or “check engine light” that your digestion and gut health are under threat and need to be addressed immediately before this potentially turns into not just a more serious digestive issue, but possibly a chronic inflammatory condition like heart disease, cancer or dementia.