We’re back (after a brief hiatus) with an update on Fukushima radiation and seafood, and answers to several of your questions.

In this episode, we cover:

2:41 Is There Really Fukushima Radiation in My Fish?
14:16 The truth about “eating too much meat”
18:50 Naturally healing cavities
23:50 Hepatitis C and Liver Disease
30:03 What to do about esophagitis and GERD
33:27 Is resistant starch useful?
37:18 Treating skin conditions with FMT

Full Text Transcript:

Steve Wright:  Hey, everyone.  Welcome to another episode of the Revolution Health Radio Show.  This show is brought to you by ChrisKresser.com, and I’m your host, Steve Wright from SCDLifestyle.com.  With me is integrative medical practitioner and healthy skeptic Chris Kresser.  So, Chris, how’s your day going?

Chris Kresser:  It’s pretty good, Steve.  How are you?

Steve Wright:  Mine is going very well as well.

Chris Kresser:  Great.

Steve Wright:  It’s just been a busy day.

Chris Kresser:  Yeah.  So, I’m sure folks have noticed that it’s been a while since we did a podcast.  We’ve been pretty regular about it the past few years, but life intervened and I’ve been so overwhelmingly busy with the book and putting the final touches on that, finishing the manuscript, responding to the copyedits and getting that ready, and then doing some media stuff related to it that I just couldn’t find the time to do a podcast, so here we are!  Know that I can’t guarantee an every-other-week, regular show between now and maybe February or March because of all the book activities, but I’ll do my absolute best to keep the show going during that time.  And we’re going to have lots of other great stuff for you, too, in the next few months related to the book, so hopefully you won’t miss it too much if we miss a week or two here and there.

Steve Wright:  Yeah, we appreciate everyone’s patience with Chris’ schedule and know that Chris puts a lot of time and effort into these podcasts.  I just talk, so it’s not a huge burden for me, but Chris works his butt off to get ready for these types of podcasts.  So, Chris, we’re going to start with a little talk of Fukushima, and then we’re going to transition over to some long-awaited Q&A.

Chris Kresser:  Sounds great.

Steve Wright:  All right.  Well, before we get into radioactive substances in seafood, let me tell you all about Beyond Paleo.  If you haven’t heard yet, Chris put together his best tips and tricks into a free 13-part email series that well over 30,000 people have already downloaded and basically subscribed to.  It’s an email series.  It’s going to blast you an email every so often, again, with Chris’ best tips and tricks on burning fat, boosting energy, and preventing and reversing disease without drugs.  So, it’s pretty simple.  If you’d like this and you don’t have this info yet, you just go over to ChrisKresser.com, look for the big red box, and go ahead and put your name and email in that box, and Chris will start sending you those free emails.

Is There Really Fukushima Radiation in My Fish?

So, Chris, there’s been a lot of talk about radioactive substances in the water and seafood.  What’s going on here?

Chris Kresser:  Yeah, so I’ve heard from a lot of people, both in my personal life, family members, friends, and then also on the blog, podcast questions, just people I meet here and there – everyone wants to know if they should be wary of eating seafood because of the Fukushima radiation.  And there has been a lot of fear-mongering type of articles on the Internet, sites like Natural Health News and other similar types of sites that claim that the levels of radiation in fish are harmful and we should be taking all kinds of detox supplements to try to get rid of this excess radiation and we should be avoiding any fish that’s caught in the Pacific Ocean.  As usual, we always want to look at all these kinds of claims with a grain of skepticism and look to the scientific literature to see if these claims can actually be substantiated by peer-reviewed evidence, and this is especially true when you’re talking about stopping consumption of a type of food that most people don’t get enough of and that’s extremely nutrient dense, that contains long-chain omega-3 fats that are really impossible to get anywhere else in the diet in their preformed state and one of the sole sources of vitamin D in the diet as well.  And if there’s anything most people need to be concerned with, it’s not eating enough fish rather than eating too much of it.  So, whenever there’s some kind of claim that we shouldn’t be eating fish, it has to, of course, be evaluated very seriously because there are actual health repercussions for not eating fish.  I mean, if there was a claim that we shouldn’t eat industrial seed oil or… I don’t know… eggplants?  If something happened to them where they became toxic and we couldn’t eat eggplants anymore, I think we could get by.  We’d still want to evaluate that claim because there’s no sense in removing a food like that from our diet if we don’t have to, but the seriousness of it isn’t at the level of telling someone to remove fish because we’ve spent so much time studying the health benefits of the nutrients that fish contain, and I think that it’s really, like I said, important that people continue to eat it if that makes sense.

It’s completely natural and appropriate to be concerned about radiation, and I think there’s also a little bit of hysteria around radiation that makes sense on a certain level as well.  It’s kind of a scary thing.  You can’t see it.  It’s potentially fatal, life threatening, it’s a way of getting sick and then perhaps dying that seems particularly egregious.  And for whatever reason, there’s just a very heightened level of concern about radiation for better or for worse.  And there is obviously a real issue here with Fukushima radiation.  In fact, some recent news reports suggest that the radiation is not only still occurring, but it’s actually possibly occurring at a greater rate than ever.  Steve actually just sent me a couple articles today about that.  So, this is a significant concern.  But the question that we’re talking about today is whether eating seafood that has been contaminated with radioactive isotopes from the Fukushima fallout will cause health problems.  That’s the only question that we’re talking about today.  And hopefully you’ll be relieved to know that all the peer-reviewed studies that have looked at this question have found that there’s not even a miniscule risk of getting sick from eating fish caught in the Pacific.

There was one large review in the Proceedings of the National Academy of Sciences, PNAS, the journal, and it evaluated the health risk of consuming Pacific Bluefin tuna that was caught in the Pacific after the Fukushima event around San Diego, I believe is where the fish were caught were for this study.  And the study was done by some researchers from the Woods Hole Oceanographic Institution and a couple other organizations around the world, and they’re all independent researchers.  There were no conflicts of interest, nobody that was working for the fish lobby!  And let me just highlight a few of the findings for you.  They estimated that a typical restaurant-sized portion of Pacific Bluefin tuna that was contaminated with radioactive isotopes cesium-134 and cesium-137 contains about 5% of the radiation you’d get from eating one uncontaminated banana and absorbing its naturally occurring radiation.

The really important thing to remember here is that all foods contain radiation because there’s radiation that’s just naturally a part of our planet.  Bananas contain much more radiation in them, despite not being contaminated by Fukushima fallout, than a restaurant-sized portion, a 7-ounce portion, of fish.  So, the issue is not whether we’re exposed to radiation, because we are, all of us, on a daily basis exposed to radiation in food, just walking around.  If we go on a cross-country flight, we’re exposed to radiation.  Like every other toxin, the question is what’s the dose?  A small amount of toxin we can handle.  A large amount of toxin causes problems.  That’s really important to keep in mind with this.  It is true that cesium-134 and cesium-137, which are these radioactive isotopes, have been found in fish because of Fukushima, but the levels are so low that they’re not going to cause any health problems, even in people who are eating fish at extremely high levels.  For example, if you ate three-quarters of a pound a day of this contaminated Bluefin tuna for an entire year, you’d still receive only 12% of the dose of radiation you’re exposed to during a single cross-country flight from LA to New York.  That should put it into perspective a little bit.  Also, at that same level of consumption, the excess relative risk of fatal cancers would only be two additional cases per 10 million similarly exposed people, and that’s such a low number that in statistics and health there’s really reason to believe that’s no more than chance.  And, in fact, statistically significant elevations in cancer risk are only observed typically at doses of radiation that are 25,000 times higher than what you’d expect to be exposed to by eating the three-quarters of a pound a day of Bluefin tuna.

The other thing – and I mentioned this before with the banana example – is that levels of naturally occurring radioactive isotopes, like polonium-210 and potassium-40, in Bluefin tuna are greater by several orders of magnitude than the radioactive isotopes from the Fukushima contamination in the fish, which is cesium-134 and cesium-137.  In fact, levels of polonium-210 in fish prior to the Fukushima event were 600 times higher than the levels of cesium from Fukushima that were found.  This suggests that the additional radiation in the form of cesium from Fukushima is completely insignificant from a health perspective.

Another thing I want to mention is that there are some bottom-feeding fish that are right off of where the reactor is in Japan, right off the coast, that contain extremely high levels of radiation, like 250 times more cesium in those fish or more than what are found in Pacific Bluefin tuna, and even if you consumed a third of a pound per day of this really highly contaminated fish, you’d still be below the international dose limit for radiation exposure from seafood.

And then the last thing that I want to point out is that Dr. Robert Emery at the University of Texas Health Center in one article said that you’d need to eat 2-1/2 to 4 tons of tuna in a year to get a dose of cesium-137 that exceeds the recommended health limit.  So, to put that in perspective, that’s 14 to 22 pounds of tuna a day that you would have to eat to have a problem from this radiation in fish.  All of that to say at least right now I have not seen any peer-reviewed, reliable evidence to suggest that there’s any problem eating seafood caught in the Pacific.  Of course, I’ll continue to evaluate this, and if anyone has seen any studies published in a reputable journal that contradict this, I would be happy to look at them, and I’ll be the first person to change my mind if I see such evidence.  But like I said before, articles on Internet sites that aren’t substantiated and don’t contain references to peer-reviewed research, you really can’t rely on those.  I don’t see any evidence of a conspiracy within the scientific community to cover this up.  Scientists that work at oceanographic institutes and other independent organizations don’t really have any reason to cover this up.  There’s no plausible motivation for it.  So, that’s my current take on it.

Steve Wright:  Yeah, thanks, everyone, for listening to this episode of myth-busters with Chris Kresser!

Chris Kresser:  Yeah, so keep eating that fish.  It’s good for you, and it’s going to improve your health, not harm it.

Steve Wright:  It’s always about the scale, isn’t it?  It’s always about in relation to other things.

Chris Kresser:  That’s right.  Even water can be a toxin at a high enough dose.

Steve Wright:  So, stop drinking water, everyone.  Just kidding.  OK, Chris, we really appreciate that AP bulletin you put out there.  It was very well done.  I had seen a lot of the fear mongering as well.  Hopefully they do get those reactors under control out there and can hopefully avert any more problems.

The truth about “eating too much meat”

Let’s roll on to some Q&A.  This first question, I think, a lot of listeners are going to identify with, and I thought it was really well put.  This comes from Lauren, and, Chris, she wants to know:  “Are there any concerns about excess meat consumption for those of us on an autoimmune diet or a similar plan who can’t have eggs or nuts for protein?  My main protein sources are grass-fed beef, salmon, and sardines with chicken occasionally.  I’m not sure what percentage of my diet comes from meat.  Are there potentially detrimental effects from this long-term high consumption of meat, and if so, is there anything I can do to mitigate these effects?”

Chris Kresser:  I’ve never seen any evidence that suggests that there would be any detrimental effect.  All of the concern about eating too much meat was primarily based on fear of saturated fat, and we now know that saturated fat isn’t a major contributor to cardiovascular disease or metabolic disease, and I haven’t really seen any evidence that it’s a major contributor to any disease.  And you’re eating beef, but you’re also eating sardines and chicken, other types of meat, so you’re getting different types of fatty acids there.  Meat is very nutrient dense.  It is, in fact, more nutrient dense than a lot of vegetables and fruits, especially when you’re considering the nutrients that are known to be essential for human health and not phytonutrients and antioxidants and things that are certainly beneficial, but not necessarily essential.  So, no, I don’t really see any problem with that.  The only thing that comes to mind is that some people have a genetic predisposition to accumulate excess iron, and if that’s the case, eating a lot of red meat could be problematic because it could increase iron levels, but that’s easily tested for just by getting your iron levels tests once a year or something like that, an iron panel and ferritin.  And that doesn’t affect everybody.  Most people just excrete any excess iron that they take in from food, so it’s not a concern that everybody needs to pay attention to.  It’s only for a small segment of the population.

Steve Wright:  Chris, I’m concerned Lauren didn’t mention bacon.

Chris Kresser:  She didn’t mention bacon, yeah.  You know, it’s not for everyone.  Amazing, huh?

Steve Wright:  I think there might be an underlying question here, Chris.  When you’re eating a high-meat diet like this, could there be a protein consumption problem?

Chris Kresser:  It’s really unusual for anyone to eat more protein than is healthy for them without trying hard.  Humans can generally deal with up to 30% to 35% of total calories from protein without experiencing any chronic long-term health problems.  Once you exceed 35% of total calories, you start to develop the possibility of ammonia toxicity or ammonia overload, urea ammonia issues, but that’s really, really rare and it usually happens with bodybuilders or people who are taking lots of lots of protein powder and eating super-high protein diets to try to put on muscle mass or something like that.  We have a system in our brain that kind of regulates protein intake, and when we need more, we crave more protein, and when we need less, we’re averse to it.  If you yourself have ever been pregnant, women listening to this show, or you know someone that has, you probably either yourself or know someone who experienced extreme protein aversion during some point during pregnancy.  That’s not an unusual symptom, and there’s some evolutionary reasoning behind that, and women generally crave less protein during pregnancy and can sometimes even feel nauseous when they think about protein or high protein foods during pregnancy.  That’s not always the case, but it does happen.  So, generally the brain will regulate it well, and even if you’re eating meat at every meal, it’s unlikely that you’re going to exceed 35% of total calories from protein.

Naturally healing cavities

Steve Wright:  Awesome.  Let’s move on to the next question, Chris.  This one comes from Josie.  She’s seen several claims that eating a diet similar to yours, Chris, plus taking grass-fed butter oil and fermented cod liver oil heals cavities.  Is this a fact or fiction?  And this continues our myth-busters episode.

Chris Kresser:  I haven’t looked into the evidence on this, like in the scientific literature, but certainly anecdotal evidence supports the idea that proper diet can help remineralize teeth.  There’s a book called Cure Tooth Decay by Ramiel Nagel, and he talks about using a nutrient-dense diet and superfoods like cod liver oil, raw milk or cheese, raw dairy, bone broth, and maybe grass-fed bone marrow, either raw or cooked, to remineralize teeth and prevent the progression of and, in some cases, even reverse cavities.  I know a lot of people and patients who’ve had issues with dental health and switched to a nutrient-dense diet and seen really big changes, so I think it’s possible, based on anecdotal experience.

There are also special probiotics that you can use for dental health.  Streptococcus salivarius K12 and M18 are two special species that have been shown in clinical studies to have benefits for dental health, and they work by attacking some of the bacteria and plaque, and also they break up the biofilm which plaque is formed from, and that can be really difficult to do otherwise.  Generally these probiotics, you get them and you put them in water, and then you swish them around in your mouth on a daily basis, and that can lead to significant benefits as well.

And then some people use xylitol chewing gum for reducing biofilm and cavities, but I’ve read a couple reviews that suggest that while it’s true that sugarless chewing gum has been shown to reduce cavities, it’s not the xylitol in the gum that’s doing it.  They did a study where they gave people xylitol lozenges rather than chewing gum and there was no reaction, no reduction in cavities.  The author speculated that it was maybe active chewing which increased the salivary flow that led to the benefit of reduced cavities rather than the xylitol itself, but nevertheless, some sugarless gum has been shown to help in that way.  You have to be careful with the sugarless gums, though, because, of course, a lot of them contain artificial sweeteners, and xylitol is a FODMAP and can be difficult for people with digestive issues.  And then some of the other artificial sweeteners have been shown potentially to have adverse health effects.  The research is a little mixed on that, and I’m not ready to make a definitive statement, but there are some studies that suggest that they may be harmful, so I think the better choice is to do the oral/dental probiotics and then the nutrient-dense superfoods, the fermented cod liver oil/butter oil blend has vitamin A, vitamin D, vitamin K2.  All the fat-soluble vitamins are especially helpful for dental health.  Then you have the grass-fed dairy, also a great source of K2 and vitamin A.  You have bone broth soup, which will have minerals, calcium, glycine, which is helpful for tissue rebuilding, and then the bone marrow and organ meats are also incredibly nutrient dense as well.  So, if you do all that and the dental probiotics, I think that’s a great place to start.

Steve Wright:  Yeah, and I think we couldn’t mention this without saying that if you haven’t read Weston A. Price’s book, you should probably just read that if you’re interested in this topic.

Chris Kresser:  Absolutely.  And that’s what Ramiel Nagel’s book is based on.  He’s a member or has been involved in the Weston A. Price Foundation, and he’s known in that community, and that’s what his approach is based on, although I think he’s more along the lines of paleo plus raw dairy because he’s not a fan of grains for people who have dental issues, grains or legumes.

Steve Wright:  Hmm, interesting.  I’m going to have to get that book.

Hepatitis C and Liver Disease

OK, let’s roll on to the next question, Chris.  This comes from Anonymous.  First off, they have hepatitis C, and they’re mostly asymptomatic with the exception of debilitating fatigue.  They follow a super-strict paleo diet and have never drank alcohol… well, at least lately.  The last drink that this person had was on December 31, 1999.  They’re now 46 years old and have had the virus for around 25 years.  Getting to the question, they would like to know, should they get a liver biopsy to determine if they have cirrhosis, so liver cirrhosis?  Their mom is adamant that sticking a needle into the liver is a bad idea and that once you start cutting and poking and doing these types of invasive things that it might lead to cancer.  It’s a wacky theory, but she’s adamant about this.  So, what this woman is looking into is a doctor named Dr. Sylvestre in Oakland who treats hepatitis C with ribavirin and interferon.  She treats everyone regardless of whether they have healthcare.  She has a remarkable cure rate unless cirrhosis is present, but even then, she still will recommend treatment.  She is somewhat of a hepatitis C guru.  But this person has a question, Chris.  She’s terrified of what these drugs will do to her gut, brain, and bones.  She would like to know what you would do if you were her.

Chris Kresser:  OK, so let’s break this up a little bit.  The first question was about liver biopsy and whether that’s a useful test.  It is useful in the sense that it can provide useful information, but her mom is correct in that it’s invasive and potentially dangerous.  There were adverse effects that can happen with liver biopsy, and actually many doctors are even hesitant to recommend it at this point because of that.  Sticking a large needle into your liver is definitely not risk free.  Luckily, there is a test called FibroSURE, which is a combination of six serum tests, six blood tests, and it generates a score that is correlated with the degree of liver damage in people with a variety of liver diseases, and it actually has been clinically validated to have the same prognostic value as a liver biopsy with a tiny fraction of the risk, and the risk is only the risk that you would be exposed to by getting blood drawn, which is very, very small now.  The six tests are A2-macroglobulin, haptoglobin, apolipoprotein A1, bilirubin, GGT, and ALT, and with the exception of A2-macroglobulin and apolipoprotein A1, they’re fairly commonly available tests, but when they put that together into a certain algorithm or score, that score is as good of a marker for liver issues as the liver biopsy.  And there’s a hep C FibroSURE that you can take that I would definitely recommend instead of a biopsy.

The other test that’s useful for tracking hep C over time is the reverse transcription polymerase chain reaction test, or HCV RT-PCR, and that’s used to monitor the status of hep C over time.  It basically tells you the viral load and the amount of disease activity that you’re experiencing, and you can use it as a barometer for how treatment is progressing, and that should go down over time if the treatment is working, so you could run it, like, every six months as a way of gauging the success of the treatment.  So, those are things to definitely talk to your doctor about.

In terms of treating hep C, it’s, of course, a virus, and like all viral infections, often the best approach is to strengthen your own innate immunity as much as possible and then to use additional things that are specifically antiviral on top of that.  We’ve on several shows, I think, talked about basic nutrients for immune support.  That would be vitamin C, glutathione – I like the liposomal forms of both of those.  Selenium and zinc.  There are some botanicals that have very impressive immune-boosting ability.  One combination that I like is equal parts of astragalus, Cordyceps, and rhodiola.  You just take 30 or 40 drops of that or maybe twice that dose three times a day.  And then you have antiviral nutrients, like Lauricidin, which is an extract of lauric acid, monolaurin.  That’s antiviral and also has activity against biofilm and gram-negative bacteria and fungi.  Apolactoferrin is antiviral.  EDTA, which is in InterFase Plus; it has activity against biofilm, but also it’s antiviral.  And then you have some antiviral herbs, like Chinese skullcap, elder, ginger.  Licorice, a lot of people don’t know, is strongly antiviral.  Lomatium, which is biscuitroot, another name for it, and rhodiola also has antiviral activity.

So, there are a lot of different alternative approaches to treating viral infections, including hep C.  I’m not familiar with that particular physician and her work, so I can’t really comment on that, but there are a lot of people around the Bay Area, if that’s where you are, herbalists and alternative practitioners that specialize in these kinds of treatments if you don’t want to go the drug route, but that’s, of course, something you’d need to discuss with your doctor.

What to do about esophagitis and GERD

Steve Wright:  OK, let’s roll on to the next question.  This one comes from Heather, Chris.  She’d like to thank you for all the wonderful articles that you’ve written on heartburn and GERD.  However, she did not see any mention of how to heal existing esophagitis.  She has a “15-year-old son who just recently had an endoscopy, and his GI doctor showed me the photos of his very inflamed tissue.  Apparently the biopsy came back negative for H. pylori, and the GI doc wants to put him on Prilosec.  I’m planning on finding someone to do a Heidelberg capsule test for him just so we can figure out what we’re truly dealing with, but I’m concerned about getting his existing damage healed.  Could you comment and provide any suggestions about this?”

Chris Kresser:  Yeah.  I mean, the best way to stop the tissue damage and reverse it is to stop the GERD from happening, and the body actually has a remarkable ability to heal tissue in many cases, so if you stop the insult from continuing to occur, then especially for a 15-year-old, their regenerative capacity is often quite a bit stronger than someone who’s a lot older, and it will often heal on its own.  But there are a few things you can do to help things along.  Marshmallow, slippery elm, and deglycyrrhizinated licorice – that’s DGL – they’re all botanical plant substances that are mucilaginous.  They have a really soothing and healing effect on tissue, mucosal tissue in particular.  Manuka honey – or any honey, actually – is one of the best wound-healing substances there is.  It’s even used in a lot of hospitals now.  There’s a lot of scientific literature on this.  A lot of people are surprised and they kind of consider it a folk remedy, but if you go on PubMed and do some research, you’ll see there’s a lot of studies on it, and there’s also an extremely long tradition in all different kinds of cultural traditional medicines of using honey for wound healing.  Manuka honey from New Zealand, I think, seems to work best, but other raw forms of honey will do it.  Zinc carnosine and MSM are both mucosal protective and anti-ulcerative.  And then glycine, which is an amino acid found in cartilaginous types of meat, tougher cuts like oxtail, shanks, brisket, chuck roast, and then drinking one to two cups of bone broth a day made from chicken – make sure to include the heads and feet – and femur bones and marrow bones from beef.  These are all things that can really help with rebuilding the tissue layer in the esophagus.  And one product that has a number of these things in it is GastroMend from Designs for Health.  That’s something I use.  So, you could do the GastroMend plus some honey plus glycine-rich foods, and I think that would be a great start.

Is resistant starch useful?

Steve Wright:  Yeah, sounds like a great protocol.  OK, let’s roll on to the next question.  This question comes from Joss.  “Chris, what’s your take on resistant starch?  Do you think it can be useful as a prebiotic?  How about other uses such as hunger control, etc.?”

Chris Kresser:  Yeah, I am pretty interested in resistant starch.  I’ve been studying it quite a bit lately and using it in my practice.  It’s a type of insoluble fiber that’s fermentable by gut bacteria.  There are several different types of fiber.  The two main categorizations are soluble and insoluble.  Soluble fiber is fermentable by gut bacteria, and I consider it to be more beneficial for that reason.  Insoluble generally isn’t, but resistant starch is a type of insoluble fiber that is fermentable, so it can be used as a prebiotic to increase the levels of beneficial bacteria in the gut, but it’s also – and I would say primarily – being used now for blood sugar management and metabolic issues.  It seems to have a pretty significant impact on especially fasting blood sugar.  I’ve seen 10-or-15-point drops and heard of even greater reductions in fasting blood sugar just by using resistant starch.

It’s difficult to obtain in food.  One way to get it is in potatoes that have been cooked and then cooled for 24 hours.  It’s the cooling that actually transforms the starch in potatoes to resistant starch, so cooked potatoes that haven’t been cooled don’t really have any resistant starch or very little, but potatoes that have been cooled for 24 hours do have a significant amount.  Another way is eating green plantains.  The only way to make green plantains edible without cooking them is dehydrating them into chips.  Green bananas have some resistant starch, but I don’t find them to be very appetizing myself, so the way that most people are using resistant starch is by taking potato starch and mixing it with water.  The Bob’s Red Mill variety is gluten free, and you can do 2 to 4 tablespoons a day.  If you have a really high fasting blood sugar, doing maybe 3 to 4 tablespoons at night before you go to bed mixed with water is one way you can get the benefits of it.

So, yeah, I think it’s promising and it’s cheap.  Potato starch is pretty darn cheap.  There’s no risk to it really, and I’ve been hearing about some other interesting metabolic effects, like increases in body temperature with people who have thyroid or adrenal issues.  Richard over at Free The Animal has been writing a lot about resistant starch, so if you want to learn more about it, you can go check out his blog, FreeTheAnimal.com.  It’s not for kids, let’s just say!  There is language.  Yeah, but if you’re a consenting adult, you can head over there, and there’s some great information on resistant starch.

And be careful with resistant starch if you have SIBO or other gut issues, like IBS, because as a prebiotic, it can cause some pretty profound changes in the gut flora pretty quickly, and that can, in some cases, increase gas and bloating and lead to some digestive difficulty.  The best way to mitigate that is just to go slowly.  So, instead of starting with 3 tablespoons, start with a teaspoon and see how you tolerate that and go from there.

Treating skin conditions with FMT

Steve Wright:  Awesome.  Great advice.  Let’s roll on to another digestion-related question, Chris.  This one comes from Simon.  He wants to know about fecal microbiota transplantation, FMT.  “This has been gaining a lot of attention lately, and most of it is regarding treating ulcerative colitis or IBS” – and I’ll add in C. difficile.  He wants to know specifically is it possible for FMT to be used for treating skin disorders, such as psoriasis?

Chris Kresser:  Yeah, so we’ve talked about fecal transplants on the show before, and I’ve written about them on my blog.  It’s a very exciting new treatment, and I think it could potentially benefit many different conditions, including skin conditions because of the gut-skin axis, but also depression and other kinds of cognitive behavioral issues, possibly even autism.  The gut-brain axis we’ve talked about a lot.  The fact is there isn’t really much in the body that’s not affected by gut and gut health, and every month there is an increasing number of studies published that directly link gut health to things that aren’t apparently related to the gut, like Parkinson’s disease, Alzheimer’s, like I said, depression and autism, all different types of autoimmune diseases, skin diseases.  It’s really difficult to find conditions that aren’t in some way affected by the gut microbiota now, and I think our awareness of that is only going to increase.  So, potentially FMT could affect a very broad range of medical conditions.

The problem is it’s inaccessible to most people.  In fact, it looked like it was going to become more accessible and that people were starting to use it and study it for a lot of other conditions, and it is still being studied for other conditions in research setting, but the FDA just come out with some rules that suggest that it can only legally be used for antibiotic-resistant C. difficile, which is a gut infection that can be lethal, especially if it’s antibiotic resistant.  So, the only case in which a doctor is legally allowed to perform it is with someone who has antibiotic-resistant C. diff, and in that case, it can certainly be a life-saving treatment almost overnight.  This means that we’re starting to see an underground where people are performing these procedures at home because they read about it and they’re really interested and they want to do it themselves and try to get some of the benefits.  And I completely understand that, and in some way, I’m in support of the idea behind it and the treatment itself, but I do want to caution people that it is not a risk-free treatment, and it is potentially dangerous if it’s not done correctly, and it’s potentially dangerous if the donor isn’t screened adequately, which, I think, almost always is the case when people are doing it at home.

A lot of diseases can be transmitted via the stool, and there are certain bacteria, parasites, etc., that might be in your donor that aren’t causing problems for your donor because their overall microbiota is strong enough that they keep those things in check, but when it’s transferred into someone who is immunocompromised and has a different baseline microbiota, then those organisms could become problematic.  And I’ve also heard and read about some reports of changes in mood and personality after receiving gut microbiota transplant, and if you think about it and we’ve talked a lot about how the gut microbiota affect behavior and the brain, getting someone else’s gut microbiota in your gut could potentially affect your behavior and your brain and your cognition.

So, there’s a lot more to it, I think, than some people realize in terms of what can go wrong, and while I’m extremely enthusiastic about its potential and I’ve seen it really work miracles in people, I’m a little bit more cautious than maybe some of my colleagues and a lot of people in the general public because I’m just a little bit more circumspect about it because of what can possibly go wrong.  And I know myself as a clinician, back before these FDA regulations when I was looking into it when people would be curious about it and wanted to find a donor and were going to be working with another doctor, perhaps, to find a donor, I would help them to screen their donors, and I’m telling you that probably 8 out of 10 times the donor would fail some aspect of the screening process.  I was using labs for screening stool that are more sensitive and specific than the typical stool tests that you get at, like, Quest or LabCorp, and so I probably was picking up on more stuff than someone who went through a more general screening process.  And then I was also excluding people if they had autoimmune disease, which I think should absolutely be done because we know that a lot of people with autoimmune disease have gut issues and vice versa.  So, my criteria were strict, but they weren’t any more strict than the new – You know, I just read a paper about the new criteria for donors, and my criteria was right in line with that, and it was really hard to find qualified donors.

So, my fear is that people will do this at home, they won’t adequately test the donor, they’re just kind of desperate to get well, which I completely understand, but then they transfer stool from a donor who’s not suitable for whatever reason, and even though that person’s not sick, the recipient gets sick or more sick because their own microbiota is not compatible with something that came into them from the donor.  As I’ve said before, I’m excited about it, I think it has great potential, but I think it also deserves caution, and if you’re thinking about doing it at home, please get proper supervision and do it with someone who knows how to screen a donor properly, etc.  That person will be doing it illegally, so I’m not advocating this, but I’m saying if you’re the kind of person who’s just going to do it anyway, really, please do it with supervision.

Steve Wright:  Yeah, I think that’s beautifully put, Chris, and I think everyone should definitely remember that the ways in which your gut microbiota, everywhere from your mouth all the way to the anus, how it works within your body is still misunderstood.  I mean, we don’t know how many ways it affects you, and so these changes in behavior and even what can happen from just wiping out that gut bacteria from a colonoscopy prep and/or an antibiotic route changes that forever, so when you’re thinking about overhauling everything with some sort of treatment like this, as Chris said, follow his idea.

Chris Kresser:  Yeah, you alluded to this, Steve, but the Human Microbiome Project has told us that every person’s gut flora is unique, like a snowflake or a fingerprint.  And so, the consequences of transferring someone else’s microbiome into you are unknown.  I mean, certainly there’s a lot of evidence that suggests it can be extremely beneficial, so I’m not diminishing that evidence.  And if it’s a life-threatening situation where someone has C. diff and they’re at death’s door, then the risk is deemed to be less than the potential benefit, which is staying alive, right?  I mean, there’s no question in that situation.  In fact, the paper that I read was suggesting that in those cases you don’t even need to screen the donor because if you have a healthy donor that’s available, the benefit of keeping that person alive is far greater than the potential risk of something else being introduced in that circumstance, especially if it’s a close family member.  So, yes, very promising, and I completely understand.  I mean, the people who are considering this procedure are generally people who have tried a lot of other stuff and haven’t had success, and it’s so alluring to think that you could do this one procedure and then literally overnight have a pretty profound change in your health, and that sometimes does happen, so it’s extremely appealing from that perspective, but I just want people to consider some of the potential risks that haven’t been articulated or talked about much in the alternative medical community regarding this procedure.

Steve Wright:  Yeah, and I don’t want people to get me wrong.  I think it’s an amazing procedure.  I’ve talked with many people who have had it and seen the same kind of benefits that Chris just talked about, but as Chris said, I think not enough people actually talk about the full range and scale of effects that treatments can have, whether they be alternative or conventional, so it was a great discussion.

Chris Kresser:  Exactly.  All right, well, I hope you enjoyed the show.  I hope it was worth the wait, and we’ll have another one for you soon.  Thanks, everyone, for your continued support.  I’m really excited about the book.  It’s now been copyedited and I’m about to get the final pages proofed – I think they call them pages, where I make any small, last-minute changes.  And then in mid-October, that’s it.  It goes into the print production process, and we’ll start doing a lot of cool stuff.

Steve Wright:  That’s when you go to the Bahamas, right?

Chris Kresser:  Yeah!  Not exactly!  That’s when a lot of other work starts related to the book, but you’ll be hearing more about it in the months to come.  I’m really excited about it.  I actually was in New York last week doing a media lunch that my publisher put together with some people from the media, and I got a chance to see the book bound in pre-pre-production form in a softcover form, but it was pretty exciting to see it in its bound form for the first time.

Steve Wright:  Well, I’m pretty excited to see it.  I know you’re working hard, Chris, and we’re going to continue to try to get these podcasts out as you have time.  So, thanks, Chris, for taking time today.  Thanks, everyone, for listening to this podcast.  Just so you know, you can always submit your questions for these Q&A episodes at ChrisKresser.com using the podcast submission link.  And Chris and I would really appreciate it if you enjoy these episodes to go over to iTunes, leave us a review, and let us know what we’re doing well and what we could do better.

Chris Kresser:  Thank you, Steve, and see you all next time.

This is a guest post by Laura Schoenfeld, a Registered Dietitian with a Master’s degree in Public Health, and staff nutritionist for ChrisKresser.com. You can learn more about Laura by checking out her popular blog or visiting her on Facebook. And if you need one-on-one help with your diet, click here to learn more about her nutrition consulting services. Recently, I wrote an article about the potential pitfalls of following an excessively low carb diet, and the symptoms to watch out for to know if you’d benefit from adding carbs back into your diet. While I repeatedly pointed out that there are many people who thrive on a very low carb or ketogenic approach, there were commenters who staunchly disagreed with my recommendations. While I stand by my original article (as well as Chris’s subsequent supporting articles here and here), I wanted to make sure that those who would benefit from a very low carbohydrate or ketogenic diet were aware of the positive impact this nutritional approach can have when implemented correctly. Yes, you read that correctly: there are many people who can do incredibly well on a properly designed, nutritionally adequate ketogenic diet.

Some people find that they thrive on a very low carb or ketogenic diet. Could you be one of them?

In this article, I’ll describe seven different classes of people who could experience improved health and wellbeing by following a ketogenic diet, as well as briefly explain the precautions you’ll need to take if choosing to experiment with this therapeutic diet strategy.

Overweight and Obesity

One of the biggest draws of a low carbohydrate diet is that it can be a highly effective tool for rapid weight loss, especially in those who are significantly overweight and/or obese. When compared to low fat diets, dozens of studies show that a very low carb approach can be help those who are overweight lose weight, maintain lean muscle mass, and improve many of the metabolic risk factors for diabetes and heart disease, including elevated triglycerides, low HDL, and chronically elevated blood sugar. There’s no denying that a low carb diet can be a highly effective obesity treatment. Most people believe low carb diets cause weight loss so rapidly by lowering circulating insulin, but another reason why low carb dieting may promote weight loss is because these diets frequently lead to a spontaneous reduction in overall food intake. Combining that with low insulin and high glucagon levels is generally a recipe for immediate weight loss, though this is not always sustainable for a variety of reasons. The longer a person stays on a low carb diet, the more they may start to find ways to make their diet more palatable, and thus increase their overall calorie intake. Also, as weight loss occurs, a person’s overall calorie expenditure will drop, meaning that the same amount of food that made them lose weight in the first place will eventually cause them to maintain their weight - the dreaded “plateau”. If you’re eating more calories than you’re expending, even on a low carb diet, you won’t lose weight. If you’re using low carb as a weight loss diet, this doesn’t give you license to eat high fat foods in unlimited quantities. Eat good quality protein, plenty of non-starchy vegetables, and enough fat to meet your daily needs without going overboard and you may find that a nutrient-dense low carb diet is the perfect strategy for sustainable weight loss and reversal of metabolic syndrome. And remember - obesity is a far different health situation than trying to “lose the last 10 pounds”, so many of the same weight loss principles that work well for people who are significantly overweight may not work so well for those trying to reach their ideal “look good naked” weight. Keep that in mind when considering how much weight you want to lose and whether or not it’s truly necessary for health purposes. Those who don’t really have much excess weight to lose may be more prone to the potential problems with a long term low-carb diet.

Blood Sugar Imbalances

Blood sugar control plays an important part in weight management as well as the prevention of chronic disease, including diabetes, heart disease, cancer, and possibly even Alzheimer’s disease, among others. If your blood sugar is always elevated, you’re at an exponentially higher risk for dozens of diseases, and you’re more likely to die earlier from these diseases as well. So if you have consistently high blood sugar, you’ll likely find that reducing your carbohydrate intake significantly can bring that number down quickly, particularly if you’re relatively sedentary. Low carb diets can also be helpful in reactive hypoglycemia, a condition where blood sugar drops too low following a meal, causing symptoms such as dizziness, anxiety, shakiness, hunger, and confusion. This issue can be made worse by caffeine and stress, and I find it more commonly in my clients with adrenal issues. A common cause of this reaction is when a meal too high in easily absorbed carbohydrates is consumed, and blood sugar rises rapidly, leading to a release of insulin. The insulin causes a subsequent drop in blood sugar, and this drop can sometimes go too low or happen too quickly, leading to the hypoglycemic symptoms. If you’re someone who eats a lot of sugar-laden foods, or generally is eating a high carb, low fat diet, you may be more prone to these blood sugar swings that can lead to hypoglycemia symptoms. In this case, a reduction in carbs and an increase in fat at meals will help keep your blood sugar levels steady, and get you off the blood sugar roller coaster. But if you’re already eating a very low carbohydrate diet, a bit of healthy carbs at each meal may actually help normalize your blood sugar too, so it’s important to consider your current dietary habits before dropping your carbs any lower. And if you’re completely unsure where you stand on this issue, it might be worthwhile getting some help with your diet!

Neurological Disorders

One of the oldest uses of a ketogenic diet has been the treatment of seizure disorders  - even the Bible refers to fasting as a treatment for “fits”, and the ketogenic diet has been used by doctors as a treatment for epilepsy since the early 1900s. Though the creation of anti-seizure medication significantly reduced the reliance on this treatment, there has been a surge in the demand for this therapeutic diet over the past 20 years. These days, there are even dietitians who specialize in the ketogenic diet who work with patients, mostly children, suffering from frequent seizures. Other neurological conditions that have been shown to respond well to a ketogenic diet are Parkinson’s disease, Alzheimer’s disease, ALS, stroke, and dementia. (1, 2, 3, 4, 5, 6) In fact, Alzheimer’s disease is now being referred to as Type 3 Diabetes, highlighting the importance of blood sugar control in managing this often devastating condition. Ketogenic diets may also be therapeutic in the treatment of traumatic brain injury, a major cause of mortality and morbidity in young adults. (6a) One of the most comprehensive books covering the role of a low carb and/or ketogenic diet in the treatment of neurological conditions is Grain Brain by Dr. David Perlmutter, a well known neurologist. Dr. Perlmutter has had a great deal of success using low carb, grain-free, and ketogenic diets in the treatment of thousands of patients with neurological disorders. However, it’s important to remember that while these very low carb diets are helpful in treating these conditions, it’s unknown whether or not these restrictive diets would be necessary to prevent these conditions. Ultimately, I’d personally reserve the use of a ketogenic diet as a treatment for neurological disorders rather than a long term preventative diet.

Mood Disturbances

Similar to the neurological conditions already discussed, low carb and/or ketogenic diets may be helpful in reducing or eliminating symptoms of mood disorders like anxiety or depression. Some preliminary evidence suggests that these diets can have similar effects as antidepressant drugs. (7) Most of the research has been conducted in animals, but there have been studies showing benefits in improving aggression, fear behavior, and overall mood and quality of life. (8, 9, 10, 11) On the contrary, one study demonstrated a decline in overall mood in subjects on a low carb diet, energy-restricted diet compared to a low fat diet, while another showed a decline in mood in female cyclists following a low carb compared to moderate and high carb diets. (12, 13) There hasn’t been a ton of research on this issue, so ultimately you’ll have to determine for yourself what the appropriate level of carb intake will be for your particular mood issues. I’ve seen plenty of clients (myself included) who find that their levels of anxiety skyrocket on an excessively low carb diet, so what works for one person (or a rat!) may not work for you. Whether or not carbs are at play in your anxiety or depression, there’s a major role for a healthy diet and ancestrally appropriate lifestyle. I do believe food is medicine when it comes to mood issues, and I’ve seen multiple clients get off their antidepressants after making targeted, individualized changes to their diets, even if they were already eating “Paleo”. And none of these improvements required strict carbohydrate restriction, so a moderate intake on a nutrient-dense diet may be enough to see positive changes.

Polycystic Ovarian Syndrome (PCOS)

PCOS is an incredibly common endocrine issue in young women, with a prevalence as high as 15%-20% of women. Typically, PCOS affects ovulation and menstrual function in women, and can also cause an androgen excess. These changes are the root cause of many of the most frustrating symptoms, including amenorrhea, acne, hirsutism (male-pattern body hair), weight gain, dandruff, thinning hair, and mood issues. One of the primary dietary recommendations for women with PCOS is to limit refined carbohydrates and sugars, and to generally follow a lower carb diet. (14, 15) Reduced carbohydrate diets can help improve body composition, increase fat loss, repair insulin sensitivity, and promote menstrual regularity in these women (16, 17, 18) One pilot study found that overweight women following a low-carbohydrate ketogenic diet lost weight, reduced their testosterone levels, and decreased their fasting insulin. (19) These women also experienced non-significant decreases in insulin, glucose, testosterone, HgbA1c, triglyceride, and perceived body hair. Two women even became pregnant during the study, when they had previously been experiencing infertility. But before those of you with PCOS jump straight on a ketogenic diet, it’s crucial to note that there was no control group in this study. So it’s hard to know if the ketogenic diet was really necessary to get these results, or if a significant reduction in sugar, processed carbs, and grains might have been adequate, while still allowing these women to get a substantial amount of carbs from Paleo-friendly fruit and starchy vegetables. You may find that the right diet for you allows for plenty of healthy variety, and that a reduced carbohydrate, whole foods diet is enough to get you on the right path towards healing from your PCOS.

Small Intestine Bacterial Overgrowth (SIBO) and Reflux (GERD)

SIBO and GERD seem to be increasingly common these days, likely stemming from our overuse of antibiotics, inadequate exposure to healthy bacteria, poor dietary choices, and high levels of stress. In my work with clients, I’ve also noticed an uncanny connection between SIBO or reflux and a history of binge eating or bulimia disorder, so I’d guess that overeating in general can put someone at higher risk for low stomach acid and an overgrowth of bacteria in their small intestine. You can get great information about reflux from Chris’s free eBook on the topic. And if you’ve never heard of SIBO and you don’t know what the primary treatment for this condition is, I’d suggest listening to this podcast that Kelsey Marksteiner and I recorded for a great primer on the subject. But I’m sure some of you reading this either know what SIBO is, or actually have SIBO yourself. SIBO and reflux are often found simultaneously, so that’s why I’m lumping these two conditions together. One of the primary dietary treatments for SIBO and reflux is the restriction of fermentable carbohydrates, often referred to as FODMAPs. But some practitioners even recommend using a completely low carbohdyrate or ketogenic diet, as some bacteria can feed off of low FODMAP carbs and starches. It may depend on the severity of your SIBO case, and some SIBO patients do just fine restricting FODMAPs and simple sugars. And if you’re eating too many high FODMAP veggies on a low-carb diet, you may actually make the problem worse! Generally for reflux and/or SIBO, I tend to recommend a lower carbohydrate diet which restricts fermentable carbohydrates and sugar, but allows for a moderate amount of starches such as white rice or potatoes, which are often well tolerated. So while a strict low carb or ketogenic diet may be useful in dealing with these digestive disorders, I don’t think that it’s necessary to stay on these diets indefinitely to get the results you’re looking for.

Cancer...?

At the risk of opening a giant can of worms, I’ll briefly mention that there are many scientists, doctors and clinicians who promote the use of a low carb ketogenic diet for cancer. The major argument is that unlike the majority of our body cells, cancer cells lack the ability to metabolize ketones, and require a significant amount of glucose to survive and replicate. Since a ketogenic diet can keep blood sugar low, the theory (in a nutshell) is that cancer cells won’t be able to survive and thus the cancer will not grow and metastasize. Some doctors have reported amazing results in the use of these diets in helping their patients go into remission. There are a few studies that show potential benefits for some (but not all) cancer patients, especially brain cancer. (20, 21, 22, 23, 24) But another study showed that in 16 patients with advanced metastatic cancer, only 5 of the 16 patients recruited could even stick to the diet, and none showed any remission of the cancer, so it likely depends on the type and severity of the cancer whether or not a ketogenic diet will make any difference to the outcome. (25) And none of these studies show any data that suggests a ketogenic diet would be necessary or helpful to prevent cancer. When it comes to dietary recommendations and carbohydrate restriction for cancer patients, I don’t know if there’s enough data on the subject to make a strong recommendation either way. Ultimately, we’ll always have some level of sugar circulating in our bloodstream, and while I agree that good blood sugar control is likely helpful in preventing cancer in the first place, I’m not entirely convinced that a ketogenic diet is the best diet in all cancer patients, especially for those who are in more advanced stages. And having had relatives die from advanced stage cancer, I can also understand the fear that would come from feeding a cachexic cancer patient a hypocaloric ketogenic diet if they’re already wasting away. For now, I’ll “plead the fifth” on this topic, and wait and see if more studies come out in the future supporting this particular therapeutic use of the ketogenic diet.

Important Considerations When Starting A Low Carb Diet

As you can see, a low carb diet can be a good choice for certain people, as long as they pay attention to several important factors that can ensure their nutritional status isn’t negatively impacted by this somewhat restrictive diet. The biggest issue I see with many people who first switch to a low carb diet is that they’re unintentionally undereating, largely due to their discomfort with eating enough fat to make up for the carbs they’re not consuming. While this can be okay in the short term, especially for weight loss, over time this can lead to malnutrition and unhealthy stress on various organs, and may even cause weight gain as the body tries to conserve energy. If you’re on a low carb diet, make sure you’re eating enough to support your daily activity and to get a wide range of nutrients. Also, even though some of your favorite foods might be low carb - like bacon, cheese, steak, and butter - make sure you’re still eating plenty of nonstarchy vegetables. These will help keep your gut bacteria healthy, as well as providing a variety of important minerals that can get deficient on a low carb diet. Potassium is a particular mineral that is prone to deficiency on a low carb diet, so eating a wide variety of vegetables and low carb plant foods at every meal (in addition to nutrient-dense animal foods) will help keep you nourished. Avoid low carb products sold in the grocery store. These products often have artificial sweeteners and other additives that make them taste similar to their high carb counterparts, and sometimes can cause digestive distress in larger quantities. If you’re going to do a low carb diet, make sure you’re still eating real food and not buying a ton of low carb packaged food to replace the junk food you used to eat. It’s important to keep an eye on your blood work as well, since not everyone experiences positive results on a low carb diet. Franziska Spritzler is a low carb dietitian who explained the adverse effects she experienced on a low carb ketogenic diet, with her LDL cholesterol and particle number shooting up to a potentially dangerous level. While this won’t happen to everyone, if it does happen to you it may be a sign that the diet isn’t a great choice for your long term health. Finally, pay close attention to how you look, feel, and perform while on a low carb diet. While you’ll need to give it some time to truly determine if the diet can support your activity, energy, and daily lifestyle, it’s hard to know who will thrive and who will crash and burn on a long term low carb diet. If you’re experiencing negative health effects like excess weight gain, sluggishness, mood issues, or poor athletic performance after trying the diet for several weeks, it may be a sign that you’d do better on a more moderate carb approach. Don’t let someone else’s experience with the diet dictate how you should expect to feel. You’ll be your own judge when it comes to figuring out the most appropriate diet for you. And if you need help figuring out how to optimize your carbohydrate intake, don’t hesitate to get in touch with me - I’ve worked with dozens of clients in this situation and can help you figure out if a low carb diet is right for you. You can sign up for a free 15 minute consult and we’ll discuss your nutrition and health concerns and determine if you’d benefit from professional and personalized guidance. Now I’d like to hear from you - what side of the carbohydrate “fence” are you on? Low carb? Moderate carb? High carb? How did you figure out the right diet for you? Share your story in the comments below! About Laura: Laura uses her knowledge of traditional and biologically appropriate diets to improve her clients’ health. Growing up with a family that practices Weston A. Price principles of nutrition, she understands the foods and cooking practices that make up a nutrient dense diet. With her strong educational background in biochemistry, clinical nutrition, and research translation, she blends current scientific evidence with traditional food practices to help her clients determine their ideal diet. You can find her at AncestralizeMe.com, on Facebook, and Twitter!

In conventional medicine, they start with the symptoms. So for example, if a baby has acid reflux, they prescribe a drug that just suppresses that symptom, without doing any investigation into why the reflux is occurring in the first place. There are so many problems with that approach. One of the main ones is that drugs don’t just have intended effects, they also have unintended effects. If a drug suppresses acid production, what else is it doing that may not be beneficial? What are the effects of acid that are beneficial? In this episode, we cover:

9:43  The causes of reflux 13:17  Four risk factors for reflux in infants 19:16  Why acid-suppressing drugs (PPIs) may not be the best treatment 29:06  How to prevent reflux and GERD in babies 32:24  How to address acid reflux and GERD

Links we discuss

• Heartburn/GERD eBook
• Gut Health eBook
• Can nutritional modulation of maternal intestinal microbiota influence the development of the infant gastrointestinal tract?

[powerpress] Steve Wright: Hey, everyone. Welcome to another episode of the Revolution Health Radio show. This show is brought to you by ChrisKresser.com. I’m your podcast host Steve Wright from SCDlifestyle.com. With me is integrative medical practitioner, New York Times bestseller, healthy skeptic, Chris Kresser. Chris, how are you doing? Chris Kresser: Hey. I’m doing well, Steve. It looks like you’re in a different location there. I see a guitar on the wall, a beautiful picture. What’s happening? Steve Wright: I just came out to visit our producer Jordan Reasoner, my business partner and great friend. I’m out here in Bozeman, Montana in his crib. Chris Kresser: Nice. What are you guys going to get up to? Steve Wright: We are going to just hang out with his kids and do some brainstorming together. Then we’re headed out into the woods this weekend to go elk hunting, four days, three nights. We’re going to backpack it way back into the Montana Mountains. We’ll just do some man stuff. Chris Kresser: Awesome. You guys are doing the whole hunter-gatherer thing to the hilt? Steve Wright: Yeah, we’re really both trying to get more in touch with the food chain. Chris Kresser: Nice. Steve Wright: Personally, my mission this year is to get an elk back in Colorado, and really honor the animals—from their habitat all the way to my plate. Chris Kresser: It sounds awesome. Have fun. Steve Wright: Thank you. What have you been up to? Chris Kresser: A lot. 14Four, the new diet and lifestyle change program, is coming along really well. It looks like it’s going to be an October 14 or October 21 launch. We’ll talk about that more soon. I’m really excited about it. I’m also taking a lot of steps forward with the clinician training program, which I’m super excited about. It looks like we’re targeting a spring launch for the first module in the program, but there will be other modules that come after that. The more I do this kind of work, the more I see the need for that. I get e-mails from people almost every day, asking about clinician training and what kind of opportunities there are to learn a Paleo-oriented approach to functional medicine. There just aren’t many right now. So I figured, why not make one? I’m really looking forward to teaching people how to do this work. There’s such a huge need for it, as you know, Steve, and there’s not a lot of options out there. So look for that, if you’re one of those people who are interested, keep an eye out on the blog and e-mail list. We’ll keep you posted as that unfolds. Steve Wright: Yeah, that’s really awesome. I know that people have been requesting that from you for many years now. There’s a huge gap there, and a lot of training needs to be developed. I’m very excited for this. Chris Kresser: We have a great question today that I think a lot of parents are going to appreciate, in particular. Let’s give that a listen. Lila: Hi. I was wondering if you could weigh in on the prevalence of acid blockers being prescribed to infants for GERD. This is commonly done in the pediatric practice that I work in as a nurse, and I kind of find it concerning. In addition to that, if you have any alternative theories on what the diagnoses and treatment should be for the GERD, that would be helpful. For instance, I don’t know if it’s possible for infants to develop SIBO or if it’s just gut dysbiosis, or what it is. But I have a hard time believing that we have an epidemic of GERD in newborn babies. Thanks. Chris Kresser: This is a really good question, as I said. It’s one that I think a lot of parents will be interested in, as well as a lot of healthcare providers who work in pediatrics, work with kids. I definitely agree that we’re not seeing an epidemic of PPI deficiency in babies all of a sudden, after several thousand generations of getting along just fine without PPI. It’s pretty safe to say that we haven’t developed a PPI deficiency in young babies. Steve Wright: What did we do before PPIs? I don’t know. Chris Kresser: Well, it’s probably true that babies have had colic for a very long time. But to me, this question really gets at the deficiencies of conventional medicine. It’s funny that we were just talking about clinician training for functional medicine. This is really kind of a prime example of why we desperately need training for functional medicine, and we need to change our healthcare system. That’s because in the conventional model, all too often, they work from the outside in. What I mean by that is, in a functional medicine perspective, we look at the core underlying causes of problems—we can call these mechanisms. Then as we move out from a mechanism like blood sugar dysregulation or a gut issue like SIBO or leaky gut, that then leads to certain disease patterns like maybe diabetes or hypothyroidism or IBS—you know, all the diseases that we hear about. Then from there, we go out to symptoms, like gas and bloating in the case of IBS; agitation and mood swings with diabetes and blood sugar issues; or high blood pressure. In functional medicine, we start at the core. We address the underlying mechanisms and the environmental triggers that cause those mechanisms to happen, and that’s how we deal with the symptoms. In conventional medicine, it often goes the other way around—they start with the symptoms. So for example, if a baby has acid reflux, they prescribe a drug that just suppresses that symptom, without doing any investigation into why the reflux is occurring in the first place. There are so many problems with that approach. One of the main ones is that number one, drugs don’t just have intended effects, they also have unintended effects. If a drug suppresses acid production, what else is it doing that may not be beneficial? Or even, what are the effects of acid that are beneficial? You know, there’s very little in our body that’s just there for the heck of it. It’s not like the only reason we have stomach acid is to make us suffer when we have reflux or GERD. There’s a reason we have stomach acid. So what happens when you prescribe a drug that reduces stomach acid production? It might alleviate the symptoms of reflux, but what else is it doing? We’re going to find out what it’s doing, and it’s not good. The other problem with this conventional approach is if you take a drug that suppresses a symptom without ever investigating what causes that symptom, then that underlying cause is just going to persist and probably even worsen over time, which can then lead to other symptoms. Then you end up taking a drug for that other symptom. That drug causes a side effect, and wouldn’t you know, there’s a drug for that too. So you’re playing Whack-a-Mole, taking drugs for all these different side effects and then by the time the average person is 65 years old, they’re on four or five different medications. Some people are on up to 12, 13 different medications at that point in their life. This is the system that we’ve created, and it’s completely broken. This is why there’s such a desperate need for functional medicine and new practitioners that are practicing this style of medicine, and also, current practitioners in the conventional system that are starting to integrate some of these principles into their practice. So that’s a little tangent as to why I’m so excited about the functional medicine training. This is actually a really good example of how that is needed. Steve Wright: Oh, it really is. Your enthusiasm is well-appreciated and I think that what we’re diving into today is going to be hitting home for a lot of people. Because I know even the people that have kids around me right now, some of them, I’ve watched their kids go through this exact scenario. And now they’re dealing with—you know, all of a sudden, they’re five, and now they have to put tubes in their ears. They have really crazy febrile seizures that seem like it’s just a kid who’s super sensitive. But when you back up and go right back to infant stage, already, right now, there’s kids presenting with a, “Hey, everything’s not okay yet.” So yeah, this is really important for young kids, all the way to old people. Chris Kresser: Let’s first talk about the causes of reflux. Then we’ll talk about risk factors for reflux in infants. Then we’ll talk about why PPIs, acid-suppressing drugs, might not be the best choice. We’ll talk about what might be a better choice.

The causes of reflux

I have a whole eBook on GERD and heartburn on my website. It’s available for free. If you haven’t read this, I really encourage you to do that. Go to ChrisKresser.com. Go to “LEARN” at the bottom of the page. There’s a drop-down menu there that says “eBooks.” Click on that, and you’ll find the heartburn eBook. I go into a lot of detail there about what the real causes of heartburn are, so we’re not going to spend too much time on that now. Essentially, what you need to know is that heartburn is rarely caused by excess stomach acid production. Heartburn is caused by a dysfunction of the lower esophageal sphincter (LES), which is what separates the esophagus from the stomach. Normally, that sphincter is supposed to stay closed. It opens when food goes down, when we eat food and swallow it, so that the food goes into the stomach. Then it’s supposed to shut, so that acid and bile don’t reflux back up into the esophagus. But what happens with reflux and GERD is that the competence of the lower esophageal sphincter is impaired. So it starts to open at inappropriate times, and acid reflux is up into the esophagus. That’s why acid-suppressing drugs can still work, even though the cause of heartburn is rarely excess stomach acid production. The PPI suppress acid production almost to nothing, in some cases, if the dose is high enough. So if you don’t have any acid at all in your stomach and your sphincter is still opening inappropriately, you’re not going to experience heartburn and reflux, because there is no acid left to reflux into the esophagus. I just want to clarify that, because sometimes people say, “Well, if heartburn is not caused by too much stomach acid, how come taking an acid-suppressing drug works?” That’s basically the answer. The next obvious question is, what causes this dysfunction of the lower esophageal sphincter? Again, there are a lot of different answers that I cover in the full eBook. But one of the main ones is actually SIBO—small intestinal bacterial overgrowth. This leads to an overproduction of gases in the small intestine and the stomach, which can then put pressure on the lower esophageal sphincter and make it open inappropriately. Any kind of dysbiosis anywhere in the gut can contribute to this as well. Another potential cause could be food intolerances. So if the infant is young enough and they’re being exclusively breastfed, this would be things that they might be exposed to like gluten in mother’s milk, if the mom is eating that and the baby is sensitive to it, or possibly dairy proteins, other food antigens. It’s less clear what gets into the mother’s milk or what doesn’t, but as I know, many mothers listening to this program can attest, the maternal diet does influence the baby in many ways. If a mother eats spicy food, for example, they might notice that their baby is really colicky or has digestive upset after that. Certainly, looking at the mom’s diet is a potential issue for infants that aren’t eating solid food. Then of course, for infants that are starting to eat food, we want to look at what they’re eating. Those are the basic underlying causes of reflux in infants. Again, there may be others, but these are the ones we’re going to focus on today. So what are the risk factors for reflux in infants?

Four risk factors for reflux in infants

One of the biggest ones is maternal antibiotic use during pregnancy. This can happen for a number of reasons: to deal with group B streptococcus (GBS), other infections that a mother might get, or even maternal antibiotic use prior to pregnancy. What we know now is that the mother’s gut flora profoundly influences the baby’s gut flora. Researchers used to think that the baby’s gut was completely sterile until they are born essentially, until they moved down the birth canal, where their first exposure to bacteria is in the vaginal canal—the baby gets exposed to both the vaginal microbiota and feces, and that was the initial colonization, and that totally determines the kind of imprint of gut flora that the baby gets. But there’s actually some recent research that suggests colonization of the baby’s gut actually happens in utero, or it begins in utero. So the status of the mother’s gut health, both prior to pregnancy and during pregnancy, is providing that initial imprint of the baby’s gut flora. So for people who are planning to conceive, women who are planning to conceive, it’s really crucial to do everything that they can to optimize their own gut microbiota prior to conceiving. That’s in an ideal world. Of course, not everyone knows this or has the opportunity to do this, so we always have to just start from where we can. But it’s never too late to pay attention to this. The second thing would be the method of birth. We know from many, many studies now that Caesarean birth, that kids born via C-section, have different gut flora and less optimal gut flora than kids who are born vaginally. The reason for that is what I just mentioned. Whether or not colonization of the gut begins in utero, we know without a doubt that a major aspect of how the gut flora develops in the baby is from that exposure in the birth canal. And in a C-section birth, that obviously doesn’t happen. The baby is removed surgically and the first exposure that that baby is going to get is to basically ambient bacteria in the hospital environment, which is very different than the bacteria they’d be exposed to in the birth canal. They’ve done lots of studies, and found that babies that are born via C-section are more likely to develop obesity, diabetes, and other problems later in life. Of course, many women don’t go into the birth process saying, “Gee, I want to have a C-section.” C-sections happen. They’re lifesaving, in some circumstances, for both the mother and the baby. I’m not condemning emergency C-sections at all, but I am suggesting that elective C-sections are not a good idea, which are on the rise. You know, women choose to have C-sections because of the convenience of knowing exactly when their delivery date will be. And I am suggesting that there may be ways, by optimizing nutrition—like we talk about in The Healthy Baby Code—to minimize the risk of C-sections, by making sure that the birth process happens as naturally and optimally as possible. Another risk factor would be how the baby is fed initially, so whether it’s breastfed or formula. Breast milk is the optimal prebiotic, probiotic food for infants, and that evolution over hundreds of thousands of generations has taken care of that. There’s not really any way that we can improve on breast milk. Breast milk, for example, contains galactooligosaccharides, which are prebiotic molecules that selectively stimulate the growth of bifidobacteria, which is one of the most important species of beneficial bacteria in the gut. Some formula producers are starting to get wise to this, and they’re adding some prebiotics to formula. But it’s never quite the same when you create a synthetic version. So far, I don’t think you can get the same outcome with formula that you can get from breastfeeding. Once again, there are a lot of women out there who want to breastfeed but can’t, for any number of reasons. This is not something to feel guilty about. There’s still a lot you can do to make sure that your baby’s getting what he or she needs. I’m more, again, addressing when we have a choice, when there’s a choice to breastfeed or feed formula. The research is abundantly clear, even in the conventional medical world now. Thankfully, they’ve gone back from the craziness of the ‘60s and ‘70s, where formula was the recommendation. They now pretty much universally recommend breastfeeding across the board. The World Health Organization (WHO), in fact, recommends six months of exclusive breastfeeding with no other food, and 22 months of complementary breastfeeding, which means continuing to breastfeed, at least in some level, for almost two years. Unfortunately, very few women do breastfeed for that long. But that’s what’s been determined to be optimal, even by groups like the World Health Organization. The last risk factor we already talked about a little bit, and that’s food intolerances. Those food intolerances are typically related to these other risk factors that we’ve already talked about, like poor maternal gut flora, poor infant gut flora, and then being born via C-section and being formula fed. Those kids that fit into those categories are more likely to develop food intolerances in the first place. Okay, so now that we’ve talked about the causes, the risk factors, let’s talk about treatment and why PPIs may not be such a good idea.

Why acid-suppressing drugs (PPIs) may not be the best treatment

As I’m sure almost everyone knows, who’s listening to the show, PPIs work by inhibiting stomach acid secretion. What some people may not know is that stomach acid, as I said before, is actually there for a reason. It plays some really important roles that don’t just involve making us double over in pain if it refluxes into the esophagus. Stomach acid initiates the process of digestion, when we eat protein in particular. All other foods get mixed around with stomach acid, and they become a substance called chyme, which is kind of a sludge-like substance, in a consistency that can then pass through into the small intestine, where the nutrients start to get pulled out even more. But nutrient absorption actually begins in the stomach. And there are numerous studies that show that acid-blocking drugs impair the absorption of all kinds of different vitamins and minerals. That’s not surprising when you know that stomach acid is required to absorb those nutrients in the first place. These include things like vitamin C, iron, magnesium, B12, folate, and other B vitamins. These nutrients are important for adults, but they’re even more important for developing babies. So folate and B12 in particular are needed to form new red blood cells, and they play an important role in methylation, which silences and activates gene expression, which, in turn, regulates just about anything in the body. Vitamin C is important for collagen development and the structural development of the body, in addition to immune function. Iron is also involved in red blood cell function. Without enough iron, babies will become anemic and not develop properly. Magnesium plays a role in over 300 different enzymatic reactions in the body, it’s one of the most important nutrients that we need. And all of the other B vitamins—B6; B5, which is pantothenic acid; B1, which is thamine; B2, which is riboflavin; B3, which is niacin—are all essential. Again, they’re all there for a reason. We need them. They’re all essential nutrients. And PPIs inhibit their absorption. We could potentially see an increase in things like neurological issues from B12 deficiency; problems with development, like I said, of the structural tissue in the body from vitamin C deficiency; behavioral disorders like ADHD, autism, et cetera because of folate and B12 deficiency. These things are on the rise in kids. There may not be enough kids now taking PPIs that this is making a significant contribution, but this could certainly happen if we continue with our current course. Another important role of stomach acid is to prevent infection. We’re exposed to bacteria, viruses, and fungi all the time. They’re all around us in the environment. But a lot of times, if we get exposed to them through food or water that we swallow, the stomach acid just takes care of that. Many of these organisms cannot survive in a really low pH, acidic environment like the stomach. The stomach acid is our first line of defense against these organisms entering through our mouth and when we swallow. As you might suspect, PPI use has been associated with an increased risk of infections of all types, but particularly gut infections and something like Clostridium difficile, which is a potentially fatal gut infection. Very serious. It’s a cause of concern. It’s been shown that there’s an increased risk of community-acquired pneumonia in people using PPIs. Back to the nutrient absorption issue, PPIs have been associated with decreased bone mineral density, because calcium absorption is impaired, and also maybe the fat-soluble vitamins—like vitamin D, which plays a role in calcium metabolism, and K2. Yeah, I know. It’s kind of ridiculous. It’s like one of those commercials, where at the end of the commercial, they say, “This drug is…” It goes on for like 30 seconds with the elevator music playing in the background. It’s like, I can’t believe anyone would buy this drug after hearing this. PPIs have been shown to increase the risk of SIBO. So that’s pretty ironic, right? SIBO is one of the underlying causes of reflux in the first place, and PPIs have been shown to increase the risk of SIBO. Then SIBO is also associated with everything from skin issues like eczema, to cognitive and behavioral issues, to malabsorption. A lot of things that show up in kids, right? A lot of kids have eczema. It’s one of the most common problems. In my work with young children, I found that eczema is almost always related to gut issues. And when we address the gut stuff, the eczema goes away. Perhaps most ironically, as I said, SIBO is associated with GERD and reflux. There’s even a paper in the scientific literature—I nearly spit on my coffee when I came across it—that was called Evidence That Proton Pump Inhibitor Therapy Induces the Symptoms It Is Used to Treat. I mean, that’s a paper you don’t even need to read, really, right? That’s such a great title. It pretty much says it all. But of course, I did read it. They talk about some other interesting mechanisms by which PPIs can actually induce acid reflux. PPIs increase gastric pH, which means they make it less acidic and more alkaline. This, in turn, substantially increases the concentration of something called gastrin. Then gastrin promotes the release of histamine, which, in turn, provokes increased acid secretion. This will lead to a rebound effect after stopping PPIs, where more acid is produced. The gastrin actually causes a growth in the tissue that produces stomach acid. So when you stop the PPIs, you’re producing more acid than you were before you started taking them. This rebound effect has been documented, and it’s been shown to last for at least four weeks, possibly longer, because they ended the follow-up period after four weeks, and many of the patients were still experiencing symptoms at that point. We could go on, but I’ll just mention a couple other things, and then we’ll talk a little bit about alternatives. PPIs are also associated with weight gain over the long term, in adults at least. One study in adults showed an average increase of about 10 lbs in weight in about 70% of patients that were taking PPIs over a two-year period, whereas only 9% of patients in the control group gained weight over that period. That’s pretty significant and alarming, especially given childhood obesity rates on the rise. I mean, even the FDA cautions against the long-term use of PPIs. It’s a real problem. They were never approved for long-term use. That’s an interesting little historical note about PPIs, is they were initially only approved for short-term use. They were never intended to be taken for years and years. I just got an e-mail this morning from someone who has been on Nexium for 30 years, 35 years I think he said. He’s wondering how to get off of it. That’s just a complete, huge mistake, an oversight by the FDA and other regulatory agencies, and just another problem with the way that our system is constructed. You know, doctors made those prescriptions, and people just kept taking them for years and years, with no approval for that kind of activity. Steve Wright: Last time I checked, eight weeks was the length. Chris Kresser: Yeah. Eight weeks maximum. Steve Wright: Yeah, maximum. Chris Kresser: Let’s talk a little bit about what else to do. Because one thing I want to say here is thankfully, Sylvie didn’t really ever deal with reflux or GERD. But like you, Steve, we’ve been around some friends and parents who have a baby that’s suffering from GERD, and it is not easy. It is extremely difficult to see anyone who has a kid, even just seeing a kid have a bad cold or something—it’s really hard to watch your child suffer. And it’s hard on the parents if it’s interrupting their kids’ sleep. I completely understand the desire, and the willingness, even, of parents to give their children PPIs if it will help relieve the pain and restore some sense of normalcy in the house. I’m not condemning parents for this at all. There’s just very little discussion of alternatives or the real causes in the community, which, of course, gets back to the whole thing about the need for functional medicine training. Okay. Let’s talk about how to prevent reflux and GERD for mothers who haven’t given birth yet or people who are still in the family planning stages. Then we’ll talk about how to address it if it’s already there.

How to prevent reflux and GERD in babies

Not surprisingly, how to prevent it is just sort of the reverse of the triggers and how to get it, which means optimize your gut flora. There’s a study that I just read called Can Nutritional Modulation of Maternal Intestinal Microbiota Influence the Development of the Infant Gastrointestinal Tract? Translation—can what a mom eat improve the gut flora of her baby? The short answer was a resounding yes. They went through all these different mechanisms for how a mom changing her diet actually directly impacts the gut flora of her baby. So that’s number one, is making sure that mom is doing everything that she can to optimize her gut health. I talk a lot about that in my book, Your Personal Paleo Code, which is going to be relaunched in paperback as The Paleo Cure at the end of this year. There’s another free eBook on my website that’s all about gut health. You can get some tips there if you’re new. Another thing is probiotics and prebiotics can be helpful for improving mom’s gut flora. In an ideal world, we wouldn’t need to take those. But let’s face it—we don’t live in that world, we live in a world that is hostile to gut health in so many different ways. And many of us took a lot of antibiotics when we were young. We might have been born by C-section. We might have been fed formula, especially if you’re in my generation that was raised in the ‘60s and ‘70s, where breastfeeding was kind of out. So some probiotics, prebiotics: things like Prescript-Assist, which I sell in my store, I have a lot of success with, and is a great choice; Prebiogen is a great prebiotic; resistant starch, which we talked about a lot, like potato starch; fermented foods like sauerkraut, kefir, kimchi, beet kvass. All this stuff can be really good for restoring good maternal gut health. Another thing would be vaginal birth whenever possible. Of course, there are situations where a C-section becomes necessary, but you want to do everything you can to have a natural birth. You want to breastfeed and you want to breastfeed exclusively for six months and in a complementary way for 22 months optimally, if you can. I realize that’s hard for some women who have full-time jobs outside of the home. You know, there’s always the ideal and the actual. But those are the guidelines, that’s the recommendation. Even if you can’t breastfeed, there is an increasing number of donor milk banks available, where you can actually purchase milk from women who have a surplus of milk. This is the preferred, what I would suggest investigating first, if for whatever reason, you can’t breastfeed and you can’t pump your own milk. Then, of course, mom needs to avoid any of her own food intolerances. If you’re gluten intolerant, you obviously don’t want to be eating gluten. If you’re dairy intolerant, you don’t want to be eating that. Then you would obviously want to remove those foods from your diet, to prevent any problems from occurring with the baby.

How to address acid reflux and GERD

So let’s say you’re here, you have a baby, your baby has GERD, and you want to know what to do about it. Obviously, you would do everything that I just mentioned for prevention, it’s still a good idea to do all of those things. But in terms of treatment, there are a few different options. Number one is there are several studies that have shown that probiotics can ease colic and reflux. One of these studies shows that babies who consumed probiotics during their first three months of life were significantly less likely to have colic in the first place. There have been other studies that have shown that probiotics have actually reduced colic, even after it exists. So some studies have found that it doesn’t, some studies have found that it does. Overall, the review papers suggest that probiotics are beneficial. One of the ones that I’ve recommended before on the show is Ther-Biotic Infant, which is Bifidobacterium infantis. It’s a probiotic that’s appropriate for kids under two years of age. Another probiotic that’s been studied quite a bit in infants is called Lactobacillus reuteri, R-E-U-T-E-R-I. That’s been shown to be effective for colic in some studies. Another thing to consider is putting a little galactooligosaccharide in the baby’s diet. If you’re just breastfeeding, there are a few different options to get these things into your baby. You can lightly dust the nipple with Ther-Biotic Infant powder and also galactooligosaccharides. One product is called Galactomune, from Klaire Laboratories. It has galactooligosaccharides and beta-glucans. Galactooligosaccharides are in breast milk, but additional galactooligosaccharides may be helpful for increasing beneficial gut bacteria in babies that are having trouble. So you can lightly dust the nipple, or you can take some out of the container and put it on your finger, and just put your finger in the baby’s mouth. They taste neutral and fairly pleasant, like a mildly sweet taste almost, babies actually like them. If the baby is eating solid food, you of course want to stick with a hypoallergenic, anti-inflammatory, Paleo type of approach. You want to probably try removing some of the foods that may cause problems, even if they’re healthy foods. Eggs is a big potential offender for really young babies. Even Sylvie, when she was six months old, egg yolks were one of the first foods that we introduced. She had a projectile vomiting episode after she ate her first soft-boiled egg yolk, which was pretty horrifying for us. Then we just waited. We said, “Okay, that doesn’t work.” We went on to liver, which she loved. Then we went back to egg yolks about a month later, and she had no problem then, and still has no problem with them. So sometimes kids are sensitive to foods initially. Things like eggs, dairy—all of the ones that we look for as adults are also likely to aggravate kids, in some cases. You want to do some experimentation there. Obviously, removing gluten, gluten-containing grains, grains in general, processed and refined flour, legumes, things that can aggravate poor digestion should be removed. That can often make a big difference as well. That’s where to start. Fortunately, babies and young kids in general tend to respond really well to dietary interventions and probiotics and prebiotics. They haven’t had as many years to become damaged as we have as adults. They’re easy to work with in a certain way, because they respond so quickly. They’re hard to work with in that they can’t tell you exactly how they’re feeling and what the response is, but they tell you one way or another. Anyone who’s been around a baby with GERD, they’re telling you if they have it. Steve Wright: So what happens, Chris, if the probiotics, the prebiotics, and the dietary changes don’t work? What’s the next best step, for a parent out there listening to this? Chris Kresser: Well, there’s not really a clear alternative to acid-suppressing drugs for the acid suppression itself. In adults, as you know very well, we do things like give hydrochloric acid (HCl) in pills. You obviously can’t do that with infants. Infants are not going to be able to swallow HCl capsules. And you certainly can’t open an HCl capsule and put it in the infant’s throat. Please do not do that. That’s corrosive. The acid will damage the esophagus. So there’s no easy way to get things into the baby that can replace stomach acid. Steve Wright: Is there any bitters that might work? Chris Kresser: Swedish bitters may be an option. Apple cider vinegar may be an option too. I would probably explore that before I considered PPIs. But to be honest, Steve, I’ve yet to have a baby that didn’t respond to diet intervention and probiotics and prebiotics, and also changes in mom’s food intake, probiotic, and prebiotic status. Steve Wright: Just one last thing in this. So it’s happening right now, you can’t change the diet right now, the baby is going nuts. I know in adults, we can give baking soda, to help with the acid suppression. Is that something that might be used in a pinch for a baby? Or is that another one of the adult things that we do not use in infants? Chris Kresser: Well, I don’t actually know the answer to that. I’ve never done that, and I would have to look into it before giving a clear answer. I don’t want to mislead anybody. But maybe we can come back to that. We can talk about that on a future show. I think ultimately, if you have to do a PPI for a period of time just to get some relief for everybody involved, you just want to minimize that as much as possible, because of the potential for rebound reflux that we talked about earlier, and because of the other issues with PPI use over the long term. And you want to make sure that they baby’s nutrient intake is adequate during that period or above adequate, because of the way that PPIs can interfere with nutrient absorption. I hope that helps. It does require a bit of trial and error in the whole process, but it’s worth it to avoid being on a long-term, acid-suppressing drug. Thanks again for your question. We’ll see you next week. Steve Wright: Thanks, Chris. I can tell you’re pretty passionate about this subject, and it was a very informative show. Thank you, everyone, for continuing to send us your questions. In-between episodes, if you haven’t already, make sure you’re on Chris’ e-mail list. That’s where he’s going to be sending out his latest articles. If you haven’t gotten things like his heartburn book or his gut health book, you’ll want to be on the e-mail list for updates regarding that kind of thing. Then you can also just Google Chris Kresser and gut health, or Chris Kresser and heartburn, and you’ll pull up those eBooks that we referenced in the show. They’ll also be in the show notes. Lastly, if you’re not following Chris yet on Facebook, go to Facebook.com/ChrisKresserLAc and Twitter.com/ChrisKresser, if you want to be up to date on these new studies that he’s always reading and staying up to date with. That’s where to go to get the latest research. In the meantime, thanks for listening.

This is the second article in a series on heartburn and GERD. If you haven't read the first one, I'd suggest doing that first. The idea that heartburn is caused by too much stomach acid is still popular in the media and the public. But as Daniel pointed out in the comments section of the last post, anyone familiar with the scientific literature could tell you that heartburn and GERD are not considered to be diseases of excess stomach acid. Instead, the prevailing scientific theory is that GERD is caused by a dysfunction of the muscular valve (sphincter) that separates the lower end of the esophagus and the stomach. This is known as the lower esophageal valve, or LES. The LES normally opens wide to permit swallowed food and liquids to pass easily into the stomach. Except for belching, this is the only time the LES should open. If the LES is working properly, it doesn't matter how much acid we have in our stomachs. It's not going to make it back up into the esophagus. But if the LES is malfunctioning, as it is in GERD, acid from the stomach gets back into the esophagus and damages its delicate lining. Here's the key point. It doesn't matter how much acid there is in the stomach. Even a small amount can cause serious damage. Unlike the stomach, the lining of the esophagus has no protection against acid.

We've been asking the wrong question

In a recent editorial published in the journal Gastroenterology, the author remarked:

Treating gastroesophageal reflux disease with profound acid inhibition will never be ideal because acid secretion is not the primary underlying defect.

I couldn't agree more. For decades the medical establishment has been directing its attention at how to reduce stomach acid secretion in people suffering from heartburn and GERD, even though it's well-known that these conditions are not caused by excess stomach acid. Instead, the question researchers should have been asking is, "what is causing the LES to malfunction?" Since it is universally agreed upon that this is the underlying mechanism producing the symptoms of GERD, wouldn't it make sense to focus our efforts here? That's exactly what we're going to do in this article.

GERD is caused by increased intra-abdominal pressure

It is well accepted in the literature that GERD is caused by an increase in intra-abdominal pressure (IAP). Acid reflux occurs when pressure causes gastric distention (stomach bloating) that pushes the stomach contents, including acid, through the LES into the esophagus. According to current thought, factors contributing to this include overeating, obesity, bending over after eating, lying down after eating, and consuming spicy or fatty foods. For example, several studies have indicated an association between obesity and GERD, and this recent paperin Gastroenterology concluded that increased intra-abdominal pressure was the causative mechanism. But while I agree that all of the currently accepted factors play a role, I do not think they are the primary causes of the increased IAP seen in GERD.

The two primary causes of increased intra-abdominal pressure

In his excellent book, Heartburn Cured, microbiologist Dr. Norm Robillard argues that carbohydrate malabsorption leads to bacterial overgrowth, resulting in IAP which drives reflux. Dr. Robillard makes a strong case that carbohydrate malabsorption plays a significant role in IAP, and I agree. But as I researched this issue I couldn't help asking: what might be causing the carbohydrate malabsorption in the first place, and are there any other causes of bacterial overgrowth that may precede carbohydrate malabsorption? I believe the one answer to both of those questions is low stomach acid. Low stomach acid can contribute to both bacterial overgrowth (independently of carbohydrate intake) and carbohydrate malabsorption, as I describe below. In a nutshell, the process looks like this: Let's look at each step in turn. Low stomach acid causes bacterial overgrowth As I will explain in the next article, one of the chief roles of stomach acid is to inhibit bacterial overgrowth. At a pH of 3 or less (the normal pH of the stomach), most bacteria can't survive for more than 15 minutes. But when stomach acid is insufficient and the pH of the stomach rises above 5, bacteria begin to thrive. The gastrin knockout mouse, which is incapable of producing stomach acid, suffers from bacterial overgrowth - as well as inflammation, damage and precancerous polyps in its intestines. It is also well documented that acid-suppressing drugs promote bacterial overgrowth. Long-term use of Prilosec, one of the most potent acid suppressing drugs, reduces the secretion of hydrochloric acid (HCL) in the stomach to near zero. In one trial, 30 people with GERD were treated with a high dose of Prilosec (40g/day) for at least 3 months. 11 of the 30 Prilosec-treated people had developed significant bacterial overgrowth, compared with only one of the ten people in the control group. Low stomach acid causes maldigestion of carbohydrates Stomach acid (HCL) supports the digestion and absorption of carbohydrates by stimulating the release of pancreatic enzymes into the small intestine. If the pH of the stomach is too high (due to insufficient stomach acid), the pancreatic enzymes will not be secreted and the carbohydrates will not be broken down properly.

Bacterial overgrowth + maldigested carbohydrates = GAS!

In Hearburn Cured, Dr. Robillard points out that though microbes are able to metabolize proteins and even fats, their preferred energy source is carbohydrate. The fermentation of carbohydrates that haven't been digested properly produces gas. The resulting gas increases intra-abdominal pressure, which is the driving force behind acid reflux and GERD. From Dr. Robillard's book:

According to Suarez and Levitt (17), 30 g of carbohydrate that escapes absorption in a day could produce more than 10,000 mL (ten liters) of hydrogen gas. That is a huge amount of gas!

When stomach acid is sufficient and carbohydrates are consumed in moderation, they are properly broken down into glucose and rapidly absorbed in the small intestine before they can be fermented by microbes. However, if stomach acid is insufficient and/or carbohydrates are consumed in excess, some of the carbs will escape absorption and become available for intestinal microbes to ferment.

Other supporting evidence

Dr. Robillard also argues that if gas produced by microbial fermentation of carbohydrates causes acid reflux, we might expect that reflux could be treated by either 1) reducing bacterial overgrowth or 2) reducing carbohydrate intake. He points to two studies which demonstrate this. In a study by Pehl, administration of erythromycin (an antibiotic) significantly decreased esophageal reflux. In another study by Pennathur, erythromycin strengthened the defective lower esophageal sphincter in patients with acid reflux. To my knowledge there have only been two small trials performed to test the effects of carbohydrate restriction on GERD. Both had positive results. A small case series showed a significant, almost immediate resolution of GERD symptoms in obese individuals initiating a very low-carb diet. A more recent study found that a very low-carb diet decreased distal esophagus acid exposure and improved the symptoms of GERD. Perhaps most importantly, the magnitude of the improvement was similar to what has been reported with treatment with proton-pump inhibitors (acid suppressing drugs). Some researchers now believe that Irritable Bowel Syndrome (IBS) is caused by bacterial overgrowth in the small intestine (SIBO). A studyperformed at the GI Motility Center in Los Angeles in 2002 found that 71% of GERD patients tested positive for IBS - double the percentage seen in non-GERD patients being examined. The high prevalence of IBS in GERD patients combined with the recognition that bacterial overgrowth causes IBS is yet another line of evidence suggesting that bacterial overgrowth is also a causative factor in GERD.

Final comments

To summarize, low stomach acid contributes to bacterial overgrowth in the bowel which in turn can lead to carbohydrate malabsorption (due to decreased pancreatic enzyme secretion). Malabsorption of carbohydrates, as Dr. Robillard has pointed out, increases intra-abdominal pressure and causes GERD. Reducing bacteria loads and limiting carbohydrate intake have both been shown to greatly improve, and in some cases completely cure, acid reflux and GERD. Where Dr. Robillard and I differ is that I believe low stomach acid is the primary problem with GERD, with carbohydrate malabsorption playing a secondary role. I do think that improper digestion of proteins can, in fact, lead to GERD whereas Dr. Robillard states in his book that putrefaction of proteins is more likely to cause flatulence. This may be so in most cases, but I've seen several patients in my practice on a very low carbohydrate diet that still experience heartburn, which improves upon restoring proper stomach acid secretion (which we'll cover in a future article in this series). In the Part III of the series I discuss the connection between GERD and H. pylori, and further evidence supporting the theory that GERD is caused by bacterial overgrowth. Read on!

Note: this is the third article in a series about heartburn and GERD. If you haven't done so already, you'll want to read Part I and Part II before reading this article. Right after publishing yesterday's article (The hidden causes of heartburn and GERD), I came across a new research (PDF) study hot off the presses that adds support to the theory that GERD is caused in part by bacterial overgrowth. Before moving on to my next planned article in the series, I want to take some time to review this study and discuss its implications. Malekzadeh & Moghaddam performed a retrospective study to investigate the prevalence of GERD in patients with IBS and vice versa. The data comes from a very large number of patients (6,476). To my knowledge it's the largest data set that has been reported about the overlap between GERD and IBS. The authors found that 64% of IBS subjects studied also had GERD, whereas 34% of the GERD patients also had IBS. They also found that the prevalence of all functional symptoms (such as nausea, changes in bowel movement, headache, etc.) was higher in overlapping GERD and IBS subjects than the prevalence in GERD subjects without IBS or IBS subjects without GERD.

Implications of the connection between GERD and IBS

What this correspondence suggests, of course, is exactly what I argued in the last article: that IBS and GERD may very well share a common etiology and underlying mechanism. From the conclusion:

This finding shows that in overlapping GERD and IBS, other functional abnormalities of the GI tract are also highly prevalent, suggesting a common underlying dysfunction.

The authors even speculate that the underlying cause may be an overgrowth of bacteria. Specifically, they mention H. pylori as a possible culprit. I think they're on to something!

Assessing the role of H. pylori infection in GERD and IBS patients could be a target of future research, as in the present study the prevalence of H. pylori infection in GERD patients was found to be greater than in non- GERD patients.

The role of H. pylori in GERD

I believe that H. pylori infection plays a significant role in the pathogenesis of GERD and other digestive disorders. H. pylori is the most common chronic bacterial pathogen in humans. Statistics indicate that more than 50% of the world population is infected. Infection rates increase with age. In general, the prevalence of infection raises 1% with every year of life. So we can expect that approximately 80% of 80 year-olds are infected with H. pylori. Second, we know that H. pylori suppresses stomach acid secretion. In fact, this is how it survives in the hostile acidic environment of the stomach, which would ordinarily kill all bacteria. Treating an asymptomatic H. pylori infection with antibiotics increases stomach acidity and eradicating H. pylori with antibiotics improves nearly all patients suffering from hypochlorhydria. Although it is commonly assumed that stomach acid production declines with age, recent studies suggest that the secretion of stomach acid doesn't decrease with age and that the trend is actually to increase, especially in men. However, this tendency for acid secretion to increase with age is completely nullified by the corresponding increase in H. pylori infection. Since the incidence of H. pylori infection increases with age, it follows that hypochlorhydria also increases with age.

Acid suppressing drugs increase risk of H. pylori infection

Perhaps most importantly for those taking acid suppressing drugs, researchers now believe that the initial infection with H. pylori can only take place when the acidity level in the stomach is decreased (albeit on a temporary basis). In two human inoculation experiments, infection could not be established unless the pH of the stomach was raised by use of histamine agonists. (1, 2) If low stomach acid is a prerequisite to H. pylori infection, we might expect acid suppressing drugs to worsen current H. pylori infections and increase rates of infection. That's exactly what studies suggest. Prilosec and other acid suppressing drugs increase gastritis (inflammation of the stomach) and epithelial lesions in the corpus of the stomach in people infected with H. pylori. A 1996 article published in the New England Journal of Medicine followed two groups of people who were being treated for reflux esophagitis for a period of five years. One group took Prilosec (20-40 mg/day) and the other underwent surgical repair of the LES. Among those who had documented H. pylori infections at the start of the study and who were treated with Prilosec, the rate of atrophic gastritis increased from 59 percent at the beginning of treatment to 81 percent by the end of the study. Among those who had no atrophic gastritis at the beginning of the study, 30 percent of those who took Prilosec later developed it. By contrast, just 4 percent of the surgically treated group developed atrophic gastritis.

Another vicious cycle you'd be smart to avoid

The connection between low stomach acid, h. pylori and acid suppressing drugs kicks off another nasty vicious cycle, similar to the one we discussed in the previous article. Low stomach acid >>> heartburn >>> acid suppressing drugs >>> H. pylori infection >>> further reduction of stomach acid >>> chronic heartburn & GERD The increased risk of H. pylori infection caused by acid suppressing drugs is especially significant because H. pylori infection is associated with a small but significant increase in the risk of stomach cancer. I'll have more to say about this in the next article. As I mentioned in the last article, fermentation of malabsorbed carbohydrates produces hydrogen gas in the intestines. Hydrogen gas is the preferred energy source for H. pylori. Elevated levels of hydrogen gas are also associated with other nasty bugs such as Salmonella, E. coli and Campylobacter jejuni, the leading cause of bacterial human diarrhea illnesses in the world. Excessive fructose, certain types of fiber and starch, and particularly wheat increase hydrogen production, and thus increase the risk of infection by H. pylori and other pathogenic bacteria. If you'd like to avoid heartburn, GERD and the many other unpleasant symptoms associated with bacterial overgrowth, it follows that you should minimize your intake of sugars, starches and grains. In the next article we'll examine the many important roles of stomach acid and the significant risks of long term hypochlorhydria.

Note: this is the fourth article in a series about heartburn and GERD. If you haven’t done so already, you’ll want to read Part I, Part II and Part III before reading this article. Believe it or not, stomach acid isn't there just to punish you for eating Indian food. Acid is in the stomach because it's supposed to be there. It is found in all vertebrates. And while it isn't necessary for life, it is certainly required for health. Most people have no idea how many vital roles stomach acid plays in our bodies. Such misunderstanding is perpetuated by drug companies who continue to insist that stomach acid is not essential. Meanwhile, millions of people around the world are taking acid suppressing drugs that not only fail to address the underlying causes of heartburn and GERD, but put them at risk of serious (and even life-threatening) conditions. There are four primary consequences of acid stopping drugs:

1. Increased bacterial overgrowth
2. Impaired nutrient absorption
3. Decreased resistance to infection
4. Increased risk of cancer and other diseases

I had originally intended to cover all four of these issues in this article, but as I started to write I realized it would be far too long. So I will cover increased bacterial overgrowth and impaired nutrient absorption in this article, and decreased resistance to infection and increased risk of cancer and other diseases in the next article.

A stomach full of germs

We're not going to spend much time on this here since the connection between low stomach acid and bacterial overgrowth was the focus of Part II and Part III. To review, low stomach acid causes bacterial overgrowth in the stomach and other parts of the intestine. Bacterial overgrowth causes maldigestion of carbohydrates, which in turn produces gas. This gas increases the pressure in the stomach, causing the lower esophageal sphincter (LES) to malfunction. The malfunction of the LES allows acid from the stomach to enter the esophagus, thus producing the symptoms of heartburn and GERD. Bacterial overgrowth has a number of other undesirable effects, including reducing nutrient absorption, increasing inflammation, and raising the risk of stomach cancer. Studies have confirmed that proton-pump inhibitors (PPIs) can profoundly alter the gastrointestinal bacterial population by suppressing stomach acid. Researchers in Italy detected small bowel bacterial overgrowth (SIBO) in 50% of patients using PPIs, compared to only 6% of healthy control subjects. The prevalence of SIBO increased after one year of treatment with PPIs.

Well-fed but undernourished

Stomach acid is a prerequisite to healthy digestion. The breakdown and absorption of nutrients occurs at an optimum rate only within a narrow range of acidity in the stomach. If there isn't enough acid, the normal chemical reactions required to absorb nutrients is impaired. Over time this can lead to diseases such as anemia, osteoporosis, cardiovascular disease, depression, and more.

Macronutrients

Stomach acid plays a key role in the digestion of protein, carbohydrates and fat. When food is eaten, the secretion of stomach acid (HCL) triggers the production of pepsin. Pepsin is the enzyme required to digest protein. If HCL levels are depressed, so are pepsin levels. As a result, proteins don't get broken down into their component amino acids and peptides. This can lead to a deficiency of essential amino acids, which in turn may lead to chronic depression, anxiety and insomnia. At the same time, proteins that escape digestion by pepsin may end up in the bloodstream. Since this is not supposed to happen, the body reacts to these proteins as if they were foreign invaders, causing allergic and autoimmune responses. I'll discuss this more below.

Micronutrients

We can eat the most nutritious diet imaginable, packed with vitamins, minerals and other essential nutrients, but if we aren't absorbing those nutrients we won't benefit from them. As acid declines and the pH of the stomach increases, absorption of nutrients becomes impaired. Decades of research have confirmed that low stomach acid - whether it occurs on its own or as a result of using antacid drugs - reduces absorption of several key nutrients such as iron, B12, folate, calcium and zinc.

Iron

Iron deficiency causes chronic anemia, which means that the body's tissues are literally starving for oxygen. In one study, 35 of 40 people (80 percent) with chronic iron-deficiency anemia were found to have below normal acid secretion. Iron-deficiency anemia is a well-known consequence of surgical procedures that remove the regions of the stomach where acid is produced. Researchers have found that inhibition of acid secretion by Tagamet, a popular acid stopping drug, resulted in a significant reduction of iron. At the same time, studies have shown that adding acid has improved iron absorption in patients with achlorydia (no stomach acid production).

B12

Vitamin B12 (cobalamin) is needed for normal nerve activity and brain function. B12 enters the body bound to animal-derived proteins. In order for use to absorb it, the vitamin molecules must first be separated from these proteins with the help of - you guessed it - stomach acid. If stomach acid is low, B12 can't be separated from its carrier proteins and thus won't be absorbed. In one study of 359 people aged 69-79 years with serious atrophic gastritis, a disease characterized by low stomach acid, more than 50 percent had low vitamin B12 levels. A number of studies have examined the negative effect of PPI therapy on B12 absorption. In a study on healthy subjects treated with 20 mg and 40 mg of Prilosec per day for two weeks, B12 absorption was reduced by 72% and 88% respectively.

Folate

Among other things, folate (folic acid) is vital for keeping the cardiovascular system healthy and for preventing certain birth defects. Low stomach acid levels can interfere with folate absorption by raising the pH in the small intestine. At the same time, when folate is given to achlorydric patients (with no stomach acid) along with an HCL supplement, absorption of the vitamin increases by 54 percent. Both Tagamet and Zantac reduced folate absorption in another study, though the reduction in the Zantac group was not statistically significant. The overall reduction of folate absorption was sixteen percent. This modest reduction is probably not enough to harm a healthy person consuming adequate levels of folate, but it may cause problems in those with folate deficiency (relatively common) or other health problems.

Calcium

Calcium makes our bones and teeth strong and is responsible for hundreds, if not thousands, of other functions in our body. The importance of stomach acid in the absorption of calcium has been known since the 1960s, when one group of researchers noted that some ulcer patients were barely absorbing any calcium at all (just 2 percent). When they investigated they found that these subjects had a high gastric pH (6.5) and very little stomach acid. However, when the researchers gave them HCL supplements, lowering the pH to 1, calcium absorption rose five-fold.

Zinc

Zinc takes part in several metabolic processes related to keeping cell membranes stable, forming new bone, immune defense, night vision, and tissue growth. In one controlled trial, Tagamet treatment reduced zinc absorption by about 50 percent. Another study found that Pepcid, which raises intragastric pH to over 5, had the same effect. Although there is little systemic research on the absorption of other nutrients, there is good reason to believe that low acid levels may also effect levels of vitamin A, vitamin E, thiamine (vitamin B1), riboflavin (vitamin B2), and niacin (vitamin B3). Theoretically, the absorption of any nutrient that is bound to protein will be inhibited (PDF). In Part B of this article I will explain how acid stopping drugs decrease our resistance to infection and increase our risk of stomach cancer and other diseases.

Note: this is the fifth article in a series about heartburn and GERD. If you haven’t done so already, you’ll want to read Part I, Part II, Part III, and Part IVa before reading this article. In the last article, we discussed the first two of four primary consequences of taking acid stopping drugs:

1. Bacterial overgrowth
2. Impaired nutrient absorption

In this article we'll cover the remaining two consequences:

3. Decreased resistance to infection
4. Increased risk of cancer and other diseases

Our first line of defense

The mouth, esophagus and intestines are home to between 400-1,000 species of bacteria. However, a healthy stomach is normally almost completely sterile. Why? Because stomach acid kills bacteria. In fact, that's one of it's most important roles: to provide a two-way barrier that protects the stomach from pathogenic bacteria. First, stomach acid prevents harmful bacteria that may be present in the food or liquid we consume or the air we breathe from entering the intestine. At the same time, stomach acid also prevents normal bacteria from the intestines to move into the stomach and esophagus, where they could cause problems. The low pH (high acid) environment of the stomach is one of the major non-specific defense mechanisms of the body. When the pH of the stomach is 3 or lower, the normal between-meal "resting" level, bacteria don't last more than fifteen minutes. But as the pH rises to 5 or more, many bacterial species can avoid the acid treatment and begin to thrive. Unfortunately, this is exactly what happens when you take acid stopping drugs. Both Tagamet and Zantac significantly raise the pH of the stomach from about 1 to 2 before treatment to 5.5 to 6.5 after, respectively. Prilosec and other PPIs are even worse. Just one of these pills is capable of reducing stomach acid secretion by 90 to 95 percent for the better part of a day. Taking higher or more frequent doses of PPIs, as is often recommended, produces a state of achlorydia (virtually no stomach acid). In a study of ten healthy men aged 22 to 55 years, a 20 or 40 mg dose of Prilosec reduced stomach acid levels to near-zero. A stomach without much acid is in many ways a perfect environment to harbor pathogenic bacteria. It's dark, warm, moist, and full of nutrients. Most of the time these bacteria won't kill us - at least not right away. But some of them can. People who have a gastric pH high enough to promote bacterial overgrowth are more vulnerable to serious bacterial infections. A recent systematic review of gastric acid-suppressive drugs suggested that they do in fact increase susceptibility to infections (PDF). The author found evidence that using acid stopping drugs can increase your chances of contracting the following nasty bugs:

• Salmonella
• Campylobacter
• Cholera
• Listeria
• Giardia
• C. Difficile

Other studies have found that acid stopping drugs also increase the risk for:

• Pneumonia
• Tuberculosis
• Typhoid
• Dysentery

Not only do acid stopping drugs increase our susceptibility to infection, they weaken our immune system's ability to fight off infections once we have them. In vitro studies have shown that PPIs impair nuetrophil function, decrease adhesion to endothelial cells, reduce bactericidal killing of microbes, and inhibit neutrophil phagocytosis and phagolysosome acidification.

A gateway to other serious diseases

As we discussed in the first article in this series, a decline in acid secretion with age has been well documented. As recently as 1996, a British physician noted that age-related stomach acid decline is due to a loss of the cells that produce the acid. This condition is called atrophic gastritis. In particular relevance to our discussion here, atrophic gastritis (a condition where stomach acid is very low) is associated with a wide range of serious disorders that go far beyond the stomach and esophagus. These include:

• Stomach cancer
• Allergies
• Bronchial asthma
• Depression, anxiety, mood disorders
• Pernicious anemia
• Skin diseases, including forms of acne, dermatitis, eczema, and urticaria
• Gall bladder disease (gallstones)
• Autoimmune diseases, such as Rheumatoid arthritis and Graves disease
• Irritable bowel syndrome (IBS), Crohn's disease (CD), Ulcerative colitis (UC)
• Chronic hepatitis
• Osteoporosis
• Type 1 diabetes

And let's not forget that low stomach acid can cause heartburn and GERD! In the interest of keeping this article from becoming a book, I'm going to focus on just a few of the disorders on the list above.

Stomach cancer

Atrophic gastritis is a major risk factor for stomach cancer. H. pylori is the leading cause of atrophic gastritis. Acid suppressing drugs worsen H. pylori infections and increase rates of infection. Therefore, it's not a huge leap to suspect that acid suppressing drugs increase the risk of stomach cancer in those infected with H. pylori (which, as we saw in Part III, is one in two people). In a recent editorial, Julie Parsonnet, M.D. of Standford University Medical School writes:

In principle, current [acid suppressing drug] therapies might be advancing the cancer clock by converting relatively benign gastric inflammation into a more destructive, premalignant process.

One way PPIs increase the risk of cancer is by inducing hypergastrinemia, a condition of above-normal secretion of the hormone gastrin. This is a potentially serious condition that has been linked to adenocarcinoma - a form of stomach cancer. Taking a standard 20 mg daily dose of Prilosec typically results in up to a three-to-fourfold increase in gastrin levels. In people whose heartburn fails to respond to the standard dose, long-term treatment with doses as high as 40 or 60 mg has produced gastrin levels as much as tenfold above normal. Another theory of what causes stomach cancer involves elevated concentration of nitrites in the gastric fluid. In a healthy stomach, ascorbic acid (vitamin C) removes nitrite from gastric juice by converting it to nitric oxide. However, this process is dependent upon the pH of the stomach being less than 4. As I discussed earlier in this article, most common acid stopping medications have no trouble increasing the pH of the stomach to 6 or even higher. Therefore, it's entirely plausible that acid stopping medications increase the risk of stomach cancer by at least two distinct mechanisms.

Gastric and duodenal ulcers

An estimated 90% of duodenal (intestinal) and 65% of gastric ulcers are caused by H. pylori. It is also recognized that the initial H. pylori infection probably only takes place when the acidity of the stomach is decreased. In a human inoculation experiment, infection could not be established unless the pH of the stomach was raised (thus lowering the acidity) by use of histamine antagonists. By lowering stomach acid and increasing stomach pH, acid suppressing drugs increase the risk of H. pylori infection and subsequent development of duodenal or gastric ulcers.

Irritable bowel syndrome, Crohn's disease and ulcerative colitis

Adenosine is a key mediator of inflammation in the digestive tract, and high extracellular levels of adenosine suppress and resolve chronic inflammation in both Crohn's disease and ulcerative colitis. Chronic use of PPIs has been shown to decrease extracellular concentration of adenosine, resulting in an increase in inflammation in the digestive tract. Therefore, it is possible that long-term use of acid stopping medications may predispose people to developing serious inflammatory bowel disorders. It has become increasingly well established that irritable bowel syndrome (IBS) is caused at least in part by small bowel bacterial overgrowth (SIBO). It is also well known that acid suppressing drugs contribute to bacterial overgrowth, as I explained in Part II and Part III. It makes perfect sense, then, that chronic use of acid suppressing drugs could contribute to the development of IBS in those that didn't previously have it, and worsen the condition in those already affected.

Depression, anxiety and mood disorders

While there is no specific research (that I am aware of) linking acid suppressing drugs to depression or mood disorders, a basic understanding of the relationship between protein digestion and mental health suggests that there may be a connection. During the ingestion of food stomach acid secretion triggers the release of pepsin. Pepsin is the enzyme responsible for breaking down protein into its component amino acids and peptides (two or more linked amino acids). Essential amino acids are called "essential" because we cannot manufacture them in our bodies. We must get them from food. If pepsin is deficient, the proteins we eat won't be broken down into these essential amino acid and peptide components. Since many of these essential amino acids, such as phenylalanine and tryptophan, play a crucial role in mental and behavioral health, low stomach acid may predispose people towards developing depression, anxiety or mood disorders.

Autoimmune diseases

Low stomach acid and consequent bacterial overgrowth cause the intestine to become permeable, allowing undigested proteins to find their way into the bloodstream. This condition is often referred to as "leaky gut syndrome". Salzman and colleagues have shown that both transcellular and paracellular intestinal permeability are substantially increased in atrophic gastritis sufferers compared to control patients. When undigested proteins end up in the bloodstream, they are considered as "foreign" by the immune system. The resulting immune response is similar to what happens when the body mobilizes its defenses (i.e. T cells, B cells and antibodies) to eradicate a viral or bacterial infection. This type of immune response against proteins we eat contributes to food allergies. A similar mechanism that is not fully understood predisposes people with a leaky gut to develop more serious autoimmune disorders such as lupus, rheumatoid arthritis, type 1 diabetes, Graves disease, and inflammatory bowel disorders like Crohn's and ulcerative colitis. The connection between rheumatoid arthritis (RA) and low stomach acid in particular has been well established in the literature. Examining the stomach contents of 45 RA patients, Swedish researchers found that 16 (36 percent) had virtually no stomach acid. Those people who had suffered from RA the longest had the least acid. A group of Italian researchers also found that people with RA have an extremely high rate of atrophic gastritis associated with low stomach acid when compared with normal individuals.

Asthma

In the last ten years, more than four hundred scientific articles concerned with the connection between asthma and gastric acidity have been published. One of the most common features of asthma, in addition to wheezing, is gastroesophageal reflux. It is estimated that between up to 80 percent of people with asthma also have GERD. Compared with healthy people, those with asthma also have significantly more reflux episodes and more acid-induced irritation of their esophageal lining. When acid gets into the windpipe, there is a tenfold drop in the ability of the lungs to take in and breathe out air. Physicians who are aware of this association have begun prescribing acid stopping drugs to asthma patients suffering from GERD. While these drugs may provide temporary symptomatic relief, they do not address the underlying cause of the LES dysfunction that permitted acid into the esophagus in the first place. In fact, there is every reason to believe that acid suppressing drugs make the underlying problem (too little stomach acid and overgrowth of bacteria) worse, thus perpetuating and exacerbating the condition.

Conclusion

As we have seen in the previous articles in the series, heartburn and GERD are caused by too little - and not too much - stomach acid. Unfortunately, insufficient stomach acid is also associated with bacterial overgrowth, impaired nutrient absorption, decreased resistance to infection, and increased risk of stomach cancer, ulcers, IBS and other digestive disorders, depression and mood disorders, autoimmune disease, and asthma. Chronic use of acid stopping medication dramatically reduces stomach acid, thus increasing the risk of all of these conditions. What's more, acid suppressing medications not only do not address the underlying cause of heartburn and GERD, they make it worse. Is the temporary symptom relief these drugs provide worth the risk? That's something only you can decide. I hope the information I've provided here can help you make an educated decision. In the next and final article of the series, I will present a plan for getting rid of heartburn and GERD once and for all without drugs.

Note: this is the sixth and final article in a series about heartburn and GERD. If you haven’t done so already, you’ll want to read Part I, Part II, Part III, and Part IVa, and Part IVb before reading this article. In this final article of the series, we're going to discuss three steps to treating heartburn and GERD without drugs. These same three steps will also prevent these conditions from developing in the first place, and keep them from returning once they're gone. To review, heartburn and GERD are not caused by too much stomach acid. They are caused by too little stomach acid and bacterial overgrowth in the stomach and intestines. Therefore successful treatment is based on restoring adequate stomach acid production and eliminating bacterial overgrowth. This can be accomplished by following the "three Rs" of treating heartburn and GERD naturally:

1. Reduce factors that promote bacterial overgrowth and low stomach acid.
2. Replace stomach acid, enzymes and nutrients that aid digestion and are necessary for health.
3. Restore beneficial bacteria and a healthy mucosal lining in the gut.

• Reduce factors that promote bacterial overgrowth and low stomach acid

Carbohydrates

As we saw in Part II and Part III, a high carbohydrate diet promotes bacterial overgrowth. Bacterial overgrowth - in particular H. pylori - can suppress stomach acid. This creates a vicious cycle where bacterial overgrowth and low stomach acid reinforce each other in a continuous decline of digestive function. It follows, then, that a low-carb (LC) diet would reduce bacterial overgrowth. To my knowledge there have only been two small studies done to test this hypothesis. The results in both studies were overwhelmingly positive. The first study was performed by Professor Yancy and colleagues at Duke University. They enrolled five patients with severe GERD that also had a variety of other medical problems, such as diabetes. Each of these patients had failed several conventional GERD treatments before being enrolled in the study. In spite of the fact that some of these patients continued to drink, smoke and engage in other GERD-unfriendly habits, in every case the symptoms of GERD were completely eliminated within one week of adopting a very low carbohydrate (VLC) diet. The second study (PDF) was performed by Yancy and colleagues a few years later. This time they examined the effects of a VLC diet on eight obese subjects with severe GERD. They measured the esophageal pH of the subjects at baseline before the study began using something called the Johnson-DeMeester score. This is a measurement of how much acid is getting back up into the esophagus, and thus an objective marker of how much reflux is occurring. They also used a self-administered questionnaire called the GSAS-ds to evaluate the frequency and severity of 15 GERD-related symptoms within the previous week. At the beginning of the diet, five of eight subjects had abnormal Johnson-DeMeester scores. All five of these patients showed a substantial decrease in their Johnson-DeMeester score (meaning less acid in the esophagus). Most remarkably, the magnitude of the decrease in Johnson-DeMeester scores is similar to what is reported with PPI treatment. In other words, in these five subjects a very low carbohydrate diet was just as effective as powerful acid suppressing drugs in keeping acid out of the esophagus. All eight individuals had evident improvement in their GSAS-ds scores. The GSAS-ds scores decreased from 1.28 prior to the diet to 0.72 after initiation of the diet. What these numbers mean is that the patients all reported significant improvement in their GERD related symptoms. Therefore, there was both objective (Johnson-DeMeester) and subjective (GSAS-ds) improvement in this study. It's important to note that obesity is an independent risk factor for GERD, because it increases intra-abdominal pressure and causes dysfunction of the lower esophageal sphincter (LES). The advantage to a low-carb diet as a treatment for GERD for those who are overweight is that LC diets are also very effective for promoting weight loss. I don't recommend VLC diets for extended periods of time, as they are unnecessary for most people. Once you have recovered your digestive function, a diet low to moderate in carbohydrates should be adequate to prevent a recurrence of symptoms. An alternative to a VLC is something called a "specific carbohydrate diet" (SCD), or the GAPS diet. In these two approaches it is not the amount of carbohydrates that is important, but the type of carbohydrates. The theory is that the longer chain carbohydrates (disaccharides and polysacharides) are the ones that feed bad bacteria in our guts, while short chain carbohydrates (monosacharides) don't pose a problem. In practice what this means is that all grains, legumes and starchy vegetables should be eliminated, but fruits and certain non-starchy root vegetables (winter squash, rutabaga, turnips, celery root) can be eaten. These are not "low-carb" diets, per se, but there is reason to believe that they may be just as effective in treating heartburn and GERD. See the resources section below for books and websites about these diets, which have been used with dramatic success to treat everything from autism spectrum disorder (ASD) to Crohn's disease. Another alternative to VLC that I increasingly use in my clinic is the Low FODMAP diet. FODMAPs are certain types of carbohydrates that are poorly absorbed by some people, particularly those with an overgrowth of bacteria in the small intestine (which, as you now know, tends to go hand-in-hand with heartburn). See this article and my book for more information. Be careful to avoid the processed low-carb foods sold in supermarkets. Instead, I suggest what is known as a "paleolithic" or "primal" approach to nutrition.

Fructose and artificial sweeteners

As I pointed out in Part II, fructose and artificial sweeteners have been shown to increase bacterial overgrowth. Artificial sweeteners should be completely eliminated, and fructose (in processed form especially) should be reduced.

Fiber

High fiber diets and bacterial overgrowth are a particularly dangerous mix. Remember, Almost all of the fiber and approximately 15-20% of the starch we consume escape absorption. Carbohydrates that escape digestion become food for intestinal bacteria. Prebiotics, which can be helpful in re-establishing a healthy bacterial balance in some patients, should probably be avoided in patients with heartburn and GERD. Several studies show that fructo-oligosaccharides (prebiotics) increase the amount of gas produced in the gut. The other problem with fiber is that it can bind with nutrients and remove them from the body before they have a chance to be absorbed. This is particularly problematic in GERD sufferers, who may already be deficient in key nutrients due to long term hypochlorydria (low stomach acid).

H. pylori

In Part III we looked at the possible relationship between H. pylori and GERD. While I think it's a contributing factor in some cases, the question of whether and how to treat it is less clear. There is some evidence that H. pylori is a normal resident on the human digestive tract, and even plays some protective and health-promoting roles. If this is true, complete eradication of H. pylori may not be desirable. Instead, a LC or specific carbohydrate diet is probably a better choice as it will simply reduce the bacterial load and bring the gut flora back into a state of relative balance. The exception to this may be in serious or long-standing cases of GERD that aren't responding to a VLC or LC diet. In this situation, it may be worthwhile to get tested for H. pylori and treat it more aggressively. Dr. Wright, author of Why Stomach Acid is Good For You, suggests using mastic (a resin from a Mediterranean and Middle Eastern variety of pistachio tree) to treat H. pylori. A 1998 in vitro study in the New England Journal of Medicine showed that mastic killed several strains of H. pylori, including some that were resistant to conventional antibiotics. Studies since then, including in vivo experiments, have shown mixed results. Mastic may be a good first-line therapy for H. pylori, with antibiotics as a second choice if the mastic treatment isn't successful.

• Replace stomach acid, enzymes and nutrients that aid digestion and are necessary for health

HCL with Pepsin

If you have an open-minded doctor, or one that is aware of the connection between low stomach acid and GERD, ask her to test your stomach acid levels. The test is quite simple. A device called a Heidelberg capsule, which consists of a tiny pH sensor and radio transmitter compressed into something resembling a vitamin capsule, is lowered into the stomach. When swallowed, the sensors in the capsule measure the pH of the stomach contents and relay the findings via radio signal to a receiver located outside the body. In cases of mild to moderate heartburn, actual testing for stomach acid production at Dr. Wright's Tahoma clinic shows that hypochlorydria occurs in over 90 percent of thousands tested since 1976. In these cases, replacing stomach acid with HCL supplements is almost always successful. Although testing actual stomach acid levels is preferable, it is not strictly necessary. There is a reasonably reliable, "low-tech" method that can be performed at home to determine whether HCL supplementation will provide a benefit. To do this test, pick up some HCL capsules that contain pepsin or acid-stable protease. HCL should always be taken with pepsin or acid-stable protease because it is likely that if the stomach is not producing enough HCL, it is also not producing enough protein digesting enzymes. To minimize side effects, start with one 650 mg capsule of HCL w/pepsin in the early part of each meal. If there are no problems after two or three days, increase the dose to two capsules at the beginning of meals. Then after another two days increase to three capsules. Increase the dose gradually in this stepwise fashion until you feel a mild burning sensation. At that point, reduce the dosage to the previous number of capsules you were taking before you experienced burning and stay at that dosage. Over time you may find that you can continue to reduce the dosage, or you may also find that you may need to increase the dosage. In Dr. Wright’s clinic, most patients end up at a dose of 5-7 650 mg capsules. In my experience, this dose is too high for many people. In fact, some have trouble with even a single 650 mg capsule. I’ve also found that the addition of cholagogues (agents which promote bile flow from the gall bladder into the small intestine) and pancreatic enzymes can help tremendously, especially in the initial stages. For these reasons, I created by own combination of HCL and enzymes called the AdaptaGest Duo. AdaptaGest Core contains acid-stable protease (to support protein digestion and complement HCL), cholagogues, and enzymes. AdaptaGest Flex contains HCL, but in a lower dose (200 mg per capsule) than is typical for standalone HCL products. This allows better fine-tuning of your HCL dosage. In my clinic, I prescribe AdaptaGest Duo for anyone struggling with heartburn and other digestive issues related to low stomach acid production. If you’d like to try it, you can order it here.

Bitters

Another way to stimulate acid production in the stomach is by taking bitter herbs. "Bitters" have been used in traditional cultures for thousands of years to stimulate and improve digestion. More recently, studies have confirmed the ability of bitters to increase the flow of digestive juices, including HCL, bile, pepsin, gastrin and pancreatic enzymes. [1. Wright, Jonathan M.D. Why Stomach Acid is Good For You. M Evans 2001. p.142] Unsurprisingly, there aren't many clinical studies evaluating the therapeutic potential of unpatentable and therefore unprofitable bitters. However, in one uncontrolled study in Germany, where a high percentage of doctors prescribe herbal medicine, gentian root capsules provided dramatic relief of GI symptoms in 205 patients. The following is a list of bitter herbs commonly used in Western and Chinese herbology:

• Barberry bark
• Caraway
• Dandelion
• Fennel
• Gentian root
• Ginger
• Globe artichoke
• Goldenseal root
• Hops
• Milk thistle
• Peppermint
• Wormwood
• Yellow dock

Bitters are normally taken in very small doses - just enough to evoke a strong taste of bitterness. Kerry Bone, a respected Western herbalist, suggests 5 to 10 drops of a 1:5 tincture of the above herbs taken in 20 mL of water. An even better option is to see a licensed herbalist who can prescribe a formula containing several of the herbs above as appropriate for your particular condition. Apple cider vinegar, lemon juice, raw (unpasteurized) sauerkraut and pickles are other time-tested, traditional remedies that often relieve the symptoms of heartburn and GERD. However, although these remedies may resolve symptoms, they do not increase nutrient absorption and assimilation to the extent that HCL supplements do. This may be important for those who have been taking acid suppressing drugs for a long period. It is also important to avoid consuming liquid during meals. Water is especially problematic, because it literally dilutes the concentration of stomach acid. A few sips of wine is probably fine, and may even be helpful. Finally, for those who have been taking acid stopping drugs for several years, it may be necessary to replace the nutrients that are not absorbed without sufficient stomach acid. These include B12, folic acid, calcium, iron and zinc. It's best to get your levels tested by a qualified medical practitioner, who can then help you replace them through nutritional changes and/or supplementation.

• Restore beneficial bacteria and a healthy mucosal lining in the gut

Probiotics

Because bacterial overgrowth is a major factor in heartburn and GERD, restoring a healthy balance of intestinal bacteria is an important aspect of treatment. Along with performing several other functions essential to digestive health, beneficial bacteria (probiotics) protect against potential pathogens through "competitive inhibition" (i.e. competing for resources). Researchers in Australia have shown that probiotics are effective in reducing bacterial overgrowth and altering fermentation patterns in the small bowel in patients with IBS. Probiotics have also been shown to be effective in treating Crohn's disease, ulcerative colitis, and other digestive conditions. Probiotics have also been shown to significantly increase cure rates of treatment for H. pylori. In my practice I always include a probiotic along with the anti-microbial treatment I do for H. pylori. I am often asked what type of probiotics I recommend. First, whenever possible I think we should always attempt to get the nutrients we need from food. This is also true for probiotics. Fermented foods have been consumed for their probiotic effects for thousands of years. What’s more, contrary to popular belief and the marketing of commercial probiotic manufacturers, foods like yogurt and kefir generally have a much higher concentration of beneficial microorganisms than probiotic supplements do. For example, even the most potent commercial probiotics claim to contain somewhere between one and five billion microorganisms per serving. (I say "claim" to contain because independent verification studies have shown that most commercial probiotics do not contain the amount of microorganisms they claim to.) Contrast that with a glass of homemade kefir, a fermented milk product, contains as many as 5 trillion beneficial microorganisms! What's more, fermented milk products like kefir and yogurt offer more benefits than beneficial bacteria alone, including minerals, vitamins, protein, amino acids, L-carnitine, fats, CLA, and antimicrobial agents. Studies have even shown that fermented milk products can improve the eradication rates of H. pylori by 5-15%. The problem with fermented milk products in the treatment of heartburn and GERD, however, is that milk is relatively high in carbohydrates. This may present a problem for people with severe bacterial overgrowth. However, relatively small amounts of kefir and yogurt are therapeutic and may be well tolerated. It's best to make kefir and yogurt at home, because the microorganism count will be much higher. Lucy's Kitchen Shop sells a good home yogurt maker, and Dom's Kefir site has exhaustive information on all things kefir. If you do buy the home yogurt maker, I suggest you also buy the glass jar that Lucy's sells to make it in (rather than using the plastic jar it comes with). If dairy doesn’t work for you, but you’d like to get the benefits of kefir, you can try making water kefir. Originating in Mexico, water kefir grains (also known as sugar kefir grains) allow for the fermentation of sugar water or juice to create a carbonated lacto-fermented beverage. You can buy water kefir grains from Cultures for Health. Another option is to eat non-dairy (and thus lower-carb) unpasteurized (raw) sauerkraut and pickles and/or drink a beverage called kombucha. Raw sauerkraut can easily be made at home, or sometimes found at farmer's markets. Bubbies brand raw pickles are sold at health food stores, as is kombucha, but both of these can also be made quite easily at home. All of that said, probiotic supplements are sometimes necessary and can play a crucial role in treatment and recovery. But not all probiotics are created alike, and in the case of small intestinal bacterial overgrowth (or SIBO, which is commonly present with GERD), certain probiotics may make things worse. SIBO often involves an overgrowth of microorganisms that produce a substance called D-lactic acid. Unfortunately, many commercial probiotics contain strains (like Lactobacillus acidophilus) that also produce D-lactic acid. That makes most commercial probiotics a poor choice for people with SIBO. Soil-based organisms do not produce significant amounts of D-lactic acid, and are a better choice for this reason. In my clinic, I use a product called Prescript Assist when treating SIBO and GERD. You can purchase it here. Other popular choices include Gut Pro from Organic 3 and D-Lactate Free Powder from Custom Probiotics. I used these in the past, but have much better success with Prescript Assist so I now use that exclusively.

Bone broth and DGL

Restoring a healthy gut lining is another important part of recovering from heartburn and GERD. Chronic stress, bacterial overgrowth, and certain medications such as steroids, NSAIDs and aspirin can damage the lining of the stomach. Since it is the mucosal lining of the stomach that protects it from its own acid, a damaged stomach lining can cause irritation, pain and ultimately, ulcers. Homemade bone broth soups are effective in restoring a healthy mucosal lining in the stomach. Bone broth is rich in collagen and gelatin, which have been shown to benefit people with ulcers. It's also high in proline, a non-essential amino acid that is an important precursor for the formation of collagen. Bone broth also contains glutamine, an important metabolic fuel for intestinal cells that has been shown to benefit the gut lining in animal studies. See this article and this one for more information about the healing power of bone broth, and how to make it. Although I prefer obtaining nutrients from food whenever possible, , as I explained above, supplements are sometimes necessary – especially for short periods. Deglycyrrhizinated licorice (DGL) has been shown to be effective in treating gastric and duodenal ulcers, and works as well in this regard as Tagamet or Zantac, with far fewer side effects and no undesirable acid suppression. In animal studies, DGL has even been shown to protect the stomach lining against damage caused by aspirin and other NSAIDs. DGL works by raising the concentration of compounds called prostaglandins, which promote mucous secretion, stabilize cell membranes, and stimulate new cell growth - all of which contributes to a healthy gut lining. Both chronic stress and use of NSAIDs suppress prostaglandin production, so it is vital for anyone dealing with any type of digestive problem (including GERD) to find ways to manage their stress and avoid the use of NSAIDs as much as possible.

Conclusion

The mainstream medical approach to treating heartburn and GERD involves taking acid stopping drugs for as long as these problems occur. Unfortunately, because these drugs not only don't address the underlying cause of these problems but may make it worse, this means that people who start taking antacid drugs end up taking them for the rest of their lives. This is a serious problem because acid stopping drugs promote bacterial overgrowth, weaken our resistance to infection, reduce absorption of essential nutrients, and increase the likelihood of developing IBS, other digestive disorders, and cancer. The manufacturers of these drugs have always been aware of these problems. When acid-stopping drugs were first introduced, it was recommended that they not be taken for more than six weeks. Clearly this prudent advice has been discarded, as it is not uncommon today to encounter people who have been on these drugs for decades - not weeks. What is especially disturbing about this is that heartburn and GERD are easily prevented and cured by making simple dietary and lifestyle changes, as I have outlined in this final article. Unfortunately, the corruption of our "disease-care" system by the financial interests of the pharmaceutical companies virtually guarantees that this crucial information will remain obscure. Drug companies make more than $7 billion a year selling acid suppressing medications. The last thing they want is for doctors and their patients to learn how to treat heartburn and GERD without these drugs. And since 2/3 of all medical research is sponsored by drug companies, it's virtually guaranteed that we won't see any large studies on the effects of a low-carb diet on acid reflux and GERD. So once again it's up to us to discover the truth and be our own advocates. I hope this series of articles has served you in that goal. I have created a "myth busing report" page for heartburn and GERD which contains an index of these articles, as well links to books and other offsite resources. If anyone you know is suffering from heartburn and GERD, please direct them to http://chriskresser.com/heartburn.

This article is part of an ongoing series comparing prescription medication with a Paleo diet as a means of treating common diseases and health problems. Click here to read the other articles in the series.

Gastroesophageal Reflux Disease (GERD), a more serious form of acid reflux, is the most common digestive disorder in the United States. Sixty percent of the adult population will experience some type of GERD within a 12-month period, and 20 to 30 percent will have weekly symptoms. The diagnosis of GERD increased by an unprecedented 216 percent between 1998 and 2005.

Drugs for acid reflux and GERD are cash cows for the pharmaceutical companies. More than 60 million prescriptions for GERD were filled in 2004. Americans spent $13 billion on acid stopping medications in 2006. Nexium, the most popular, brought in $5.1 billion alone – making it the second highest selling drug behind Lipitor.

Got heartburn? Find out why acid-stopping drugs are a bad idea, and what to do instead.

As sobering as those statistics are, it’s likely that the prevalence of GERD is underestimated because of the availability of antacids over-the-counter. This permits patients to self-medicate without reporting their condition to a doctor.

What really causes GERD and heartburn? (Hint: it’s not too much stomach acid.)

If you ask the average Joe on the street what causes heartburn, he’ll tell you “too much stomach acid.” That’s what most of the ads seem to suggest too.

However, anyone familiar with the scientific literature could tell you that heartburn and GERD are not considered to be diseases of excess stomach acid. Instead, the prevailing scientific theory is that GERD is caused by a dysfunction of the muscular valve (sphincter) that separates the lower end of the esophagus and the stomach. This is known as the lower esophageal valve, or LES.

In GERD, the LES malfunctions because of an increase in intra-abdominal pressure. This pressure causes distention (i.e. bloating) in the stomach, which pushes the stomach contents—including acid—through the LES into the esophagus.

But what causes the increase in abdominal pressure in the first place? Ironically, one of the main causes may be too little stomach acid, which in turn contributes to an overgrowth of bacteria in the small intestine. This idea is supported by studies on mice that have been genetically altered so that they are incapable of producing stomach acid. They develop bacterial overgrowth in their intestines—as well as inflammation, damage, and precancerous polyps. (1)

The understanding that not enough—rather than too much—stomach acid may be to blame for heartburn and GERD has important implications when it comes to determining what the safest, most-effective, and longest lasting treatment would be.  With this in mind, let’s see how conventional treatment of heartburn and GERD measures up.

Conventional treatment of heartburn and GERD

Conventional treatment of heartburn and GERD involves the use of drugs that suppress the production of acid in the stomach. There’s no doubt that these drugs can be effective in reducing the symptoms of GERD. After all, if there’s no acid in the stomach, then no acid will escape into the esophagus.

But is suppressing stomach acid production really the best approach—especially if low stomach acid is one of the potential underlying causes of GERD in the first place?

Believe it or not, stomach acid isn’t there just to punish you for eating Indian food. Acid is in the stomach because it’s supposed to be there. It is found in all vertebrates. And while it isn’t necessary for life, it is certainly required for health.

Most people have no idea how many vital roles stomach acid plays in our bodies. Such misunderstanding is perpetuated by drug companies who continue to insist that stomach acid is not essential. Meanwhile, millions of people around the world are taking acid suppressing drugs that not only fail to address the underlying causes of heartburn and GERD, but put them at risk of serious (and even life-threatening) conditions, including:

• Reduced absorption of essential nutrients (including B12, magnesium, calcium, iron, folate, and zinc)
• Increased risk of bone fractures (likely a consequence of impaired nutrient absorption)
• Increased bacterial overgrowth in the intestines
• Decreased resistance to infections (including life-threatening ones like pneumonia and clostridium difficile)
• Increased risk of cancer and other diseases, such as irritable bowel syndrome (IBS), Crohn’s disease, depression, anxiety, autoimmune disease, and asthma.

It’s worth noting that proton-pump inhibitors (PPIs), the most commonly used class of acid-suppressing drugs, were only approved by the FDA for 8 weeks of use. They were never intended to be prescribed for years or even decades, as is often done today.

Perhaps this is why the FDA has issued a series of reports cautioning against the prolonged use of PPIs, citing increased risk of infection, bone fractures, and life-threatening infection (clostridium difficile) as the primary concerns. (2, 3, 4)

So if acid-suppressing drugs aren’t the answer, then what is?

A (relatively low-carb) Paleo diet for heartburn and GERD

If GERD is caused—or at least contributed to—by low stomach acid and bacterial overgrowth in the intestines, it follows that the best way to treat it is to improve stomach acid production and reduce bacterial overgrowth. This strategy actually addresses the underlying causes of the problem, whereas the conventional approach (acid-stopping drugs) merely suppresses the symptoms.

In his excellent book, Heartburn Cured, microbiologist Dr. Norm Robillard argues that carbohydrate malabsorption leads to bacterial overgrowth, resulting in the increase in intra-abdominal pressure that drives reflux. When stomach acid is sufficient and carbohydrates are consumed in moderation, they are properly broken down into glucose and rapidly absorbed in the small intestine before they can be fermented by microbes. However, if stomach acid is insufficient and/or carbohydrates are consumed in excess, some of the carbs will escape absorption and become available for intestinal microbes to ferment.

The standard American diet is high in carbohydrates—particularly refined carbohydrates like flour and sugar that feed bacteria in the small intestine. It shouldn’t come as a surprise, then, to find that low-carbohydrate diets have been shown to be effective in managing the symptoms of GERD.

For example, in one study at Duke University, patients who had failed conventional GERD treatment (i.e. acid-stopping drugs) experienced a complete resolution of their symptoms within one week of adopting a low-carbohydrate diet. This was true in spite of the fact that some of the patients continued to drink alcohol, smoke, and engage in other “GERD-unfriendly” lifestyle habits. (5)

In another study, also at Duke, a low-carbohydrate diet was just as effective as PPIs in a group of obese patients with GERD. (6)

There are many ways to do a low-carbohydrate diet. I suggest a low-carb version of the Paleo diet for my patients with GERD, since it restricts gluten and other foods that may be problematic, in addition to reducing carbohydrate intake. (For more tips on how to treat GERD naturally, see this article.)

In most cases, once you’ve addressed the GERD and improved your digestive function, a Paleo diet that includes a moderate amount of “real-food” carbohydrates like fruit and starchy plants such as sweet potatoes should be adequate to prevent a recurrence of symptoms. A very low-carbohydrate diet is not only unnecessary for most people over the long-term, it may cause problems of its own.

I’ve found Paleo to be remarkably effective for reversing GERD in my work with patients, and I’ve also heard success stories from literally hundreds of readers, like this one from Laura L.:

I found the paleo/ancestral community initially by reading Dr. Loren Cordain's book; my further research lead me to Chris Kresser. At the time I was readying myself for a surgical procedure for my unremitting GERD. I was taking 80mg of Nexium per day and two extra-strength Tagamet pills prior to going to bed. Under the care of one of the leading Gastroenterologists from Columbia Presbyterian in NYC; I was given no alternative but to go through a drastic procedure which had a 40% sucess rate. Not the best odds, for sure. My other alternative would be to stay on PPIs the rest of my life (I had already taken them for 3 years); destroying my bones; and leaving me open to infections, etc. that occur when you reduce necessary stomach acid over long periods of time. From time to time I would try to stop taking my meds but the rebound reflux was unbearable.

After reading as many Paleo books as I could get my hands on and following more blogs than I can count; I started the Paleo diet removing all sources of grains, dairy, and industrial seed oils from my diet. In the meantime I gradually reduced the Nexium, etc.. As the weeks went on I could feel myself getting better and better. It took me a year to get off those nasty drugs and I could not have done it without the diet. I've been Paleo since 2008 and I've never looked back. I've been able to add safe starches to my diet but never anything containing gluten (activates my reflux within hours).

So what will it be for you? Pills, or Paleo?

If your answer is Paleo, make sure to check out my book (just published in paperback with a new name: The Paleo Cure) for a detailed explanation of how to use the Paleo diet and lifestyle to prevent and reverse disease and feel better than you have in years.

As always, check with your doctor before starting or stopping any new treatment plan—including what I’ve suggested in this article. This is not intended to be medical advice, and is not a substitute for being under the care of a physician.

Heartburn, also called gastroesophageal reflux disease (GERD), is the most common digestive disorder in the US, and the acid-suppressing drugs used to treat it can have dangerous side effects after long-term use.

The prevailing belief by the public, and even many conventional doctors, is that reflux is caused by having too much stomach acid, hence the standard treatment with antacids and PPIs. But we now know that GERD is not a disease of excess stomach acid, and many GERD patients actually produce lower levels of stomach acid than normal.

In light of this evidence, it seems logical that heartburn must be caused by stomach acid inappropriately entering the esophagus. And indeed, tests for esophageal acid contact time have confirmed that most patients with GERD do have above-normal acid contact time over a 24 hour period. (1)

As I’ve discussed in the past, one cause of increased acid reflux into the esophagus is dysfunction of the lower esophageal sphincter (LES), a valve that separates the esophagus from the stomach. This dysfunction can be caused by increased intra-abdominal pressure, which often results from bacterial overgrowth in the small intestine. This has been one of the prevailing theories about the underlying cause of reflux for several years now, but it has some limitations.

Not all GERD patients have abnormal amounts of acid reaching their esophagus

As I just mentioned, most GERD patients do have above-normal acid contact time. But most is not all. In fact, 24-hour acid contact tests have found that up to 30% of GERD patients actually have normal acid contact time. (2, 3)

Some patients with GERD symptoms even have normal endoscopy results - their esophagus looks the same as a healthy person’s esophagus. These patients are considered to have ‘non-erosive reflux disease,’ or NERD, and up to half of NERD patients have normal acid contact time. (4)

So, what separates a healthy individual from a GERD or NERD patient with normal acid contact time? If there isn’t too much stomach acid reaching the esophagus, what is causing the heartburn?

One theory gaining traction in the scientific community to describe this phenomenon is the idea of impaired epithelial barrier function. In other words - GERD might be a result of “leaky esophagus.”

Is a “leaky esophagus” the cause of your acid reflux? #gerd #heartburn

What is “leaky esophagus”?

You’ve probably heard of “leaky gut” before. Cells in the epithelial lining of the intestine are held together by tight junctions, and if these tight junctions are disrupted, particles that wouldn’t normally be absorbed make their way through the lining of the intestine and into the bloodstream. This can cause a host of problems, from food allergies to autoimmunity and more.

“Leaky esophagus” is a similar concept. It’s actually normal for acid and stomach contents to reflux into the esophagus occasionally. (5) In a healthy esophagus, this acid can’t penetrate the cell membrane of the epithelial cells, and tight junctions prevent it from getting in between the cells.

In fact, normal esophageal tissue is remarkably resistant to acid. In acid perfusion (or “Bernstein”) tests, acid is dripped directly onto the esophagus through a tube that is inserted through the nose (sounds pleasant, right?), and healthy people don’t experience any pain or heartburn, even after half an hour. (6)

However, if those tight junctions are disrupted, acid can make its way between the epithelial cells, decreasing the pH of the intercellular space. Since even small pH changes in this area are threatening to the body, there are pain receptors located close to the epithelial lining, and they send pain signals to the brain in response to the lower pH. These signals are interpreted by the brain as heartburn. Unsurprisingly, patients with NERD or GERD who receive the Bernstein test experience discomfort almost immediately.

As further evidence of the presence of leaky esophagus, biopsies of GERD and NERD patients almost always reveal dilated intercellular spaces, which is a marker for impaired barrier function. (7) These dilated spaces are increasingly being accepted as a hallmark symptom of both NERD and GERD.

Is leaky esophagus a cause or a symptom of reflux?

It appears that leaky esophagus is present in most cases of GERD. But it’s not clear whether leaky esophagus is a cause of reflux, or just another side effect.

Even though a healthy esophagus is resistant to acid, high levels of acid exposure over time will eventually lead to inflammation and impaired barrier function. In this case, increased acid exposure comes first - most likely due to a dysfunctional LES - and leaky esophagus is not the root cause; it’s just another symptom.

However, there maybe some reverse causality, particularly in GERD patients who have normal acid contact time. In this case, something other than acid exposure disrupts the epithelial tight junctions, which causes heartburn even at normal acid levels. Over time, this “leaky esophagus” can lead to the visible epithelial tissue damage observed in GERD patients.

This happens because the “back” side of an epithelial cell is not as resistant to acid as the “front” is, so once the acid seeps through the tight junctions, it can enter cells from the back and cause cell death and tissue damage. (8)

Unfortunately, this process can actually lead to LES malfunction and increased acid exposure, creating a vicious cycle. Now, increased acid exposure in the esophagus is a symptom of GERD, rather than the root cause.

What causes leaky esophagus?

So if leaky esophagus happens first in some cases of GERD, what causes leaky esophagus in the first place?

One possibility lies in the esophageal microbiome. The esophagus houses a community of microbiota similar in complexity to the intestinal microbiome, and the makeup of this bacterial community is different in healthy people compared to people with GERD. The microbes found in the esophagus of GERD patients are primarily gram-negative, while the microbes in the esophagus of healthy people are primarily gram-positive. (9)

Increased numbers of gram-negative bacteria can trigger inflammation by exposing epithelial cells to lipopolysaccharides (LPS), a component of gram-negative bacteria that causes immune responses in the body. (10) The inflammatory cytokines released in response to LPS can then lead to loss of tight-junction integrity, resulting in esophageal permeability. (11, 12)

Exposure to LPS can also cause the LES to relax, promoting reflux and increasing acid exposure time - again, creating a vicious cycle. (13)

Unfortunately, there isn’t a lot of research yet that clarifies the causes of increased esophageal permeability. But if the mechanisms at work in the esophagus are similar to those in the intestines, other probable causes could be stress, excessive alcohol consumption, and excessive use of non-steroidal anti-inflammatory drugs (NSAIDS). (14, 15, 16, 17)

All of these factors can contribute to leaky gut, so it wouldn’t be surprising if they contributed to leaky esophagus as well.

What does this mean for heartburn sufferers?

As you can see, GERD is a complex and multifaceted disorder with no single cause or presentation. Luckily, all of the strategies for healing heartburn and GERD that I’ve been recommending for years would also be expected to heal leaky esophagus.

A low-carb Paleo diet, gut-healing foods like bone broth and fermented foods, regular stress-management, and a focus on balancing the intestinal (and esophageal) microbiome with probiotics and prebiotic foods are always good approaches to treating the root cause of GERD.

Now I’d like to hear from you. Have you cured your heartburn using a Paleo diet? What other strategies have worked for you? Share your story below!

PPIs have become one of the most commonly prescribed classes of drugs in the industrialized world, despite increasingly frequent warnings by researchers about potential risks and complications. A 2010 study found that of 946 patients receiving PPI therapy in a hospital setting, only 35 percent were prescribed PPIs for an appropriate upper GI diagnosis (1). In 2014, Americans filled more than 170 million prescriptions for acid blockers, falling only behind statins in total cost expenditure worldwide (2). PPIs are the most common of the acid blockers. They go by a variety of names but typically end in the suffix “-prazole” (omeprazole, pantoprazole, esomeprazole, etc.). The purpose of this article is to provide an update to these earlier articles on heartburn and antacids, focusing on a number of scientific studies published in just the last few years. If you haven’t already, be sure to check out these previous blog posts.

The many roles of proton pumps in the body

Before we get into the potential harmful effects associated with PPIs, it’s important to understand what they do in the body. PPIs are inhibitors of proton pumps, specifically the proton/potassium pump of parietal cells in the stomach. The theory is that heartburn is caused by excess production of stomach acid by these cells, so inhibiting this proton pump will reduce the acidity of the stomach and prevent the burning sensation of acid reflux or the formation of peptic ulcers. But proton pumps aren’t limited to the stomach; they are present in just about every cell in your body. All of your cells, with the exception of red blood cells, have mitochondria that allow your body to metabolize carbohydrates and fat to produce energy. They do this by pumping protons across the membrane to generate a source of electric potential that can be harnessed to form ATP, the body’s main storage form of energy. Without an efficient proton-pumping system, the body must rely on anaerobic systems for energy production, leading to rapid fatigue. Proton pumps are also important in the transport of various substances in the body, as we will see in detail in later sections. And while proton pump inhibitors are designed to interact specifically with the hydrogen/potassium pump in parietal cells of the stomach, research suggests that they likely have nonspecific binding capabilities (3). In other words, their chemical structure enables them to bind to other proton pumps as well. Though PPIs don’t stay in the blood for very long, their binding to proton pumps is essentially irreversible—they will continue to inhibit the proton pump until the master antioxidant glutathione is able to facilitate dissociation (4).

PPIs can harm your heart, brain, kidneys, and gut. There are other alternatives.

PPIs alter the gut

The composition of microbes that inhabit your gut is incredibly sensitive to changes in the local environment. pH, a measure of the acidity of an environment, is an important facet of gut health and a particularly potent regulator of microbial communities (5). PPI use reduces the amount of acid produced in the stomach, and ultimately the amount of stomach acid that reaches the gut. This causes a significant shift in the pH of the intestines. Indeed, several recent studies have shown that PPI alters the gut microbiota by reducing its overall diversity (6,7). Opportunistic pathogens, including Enterococcus, Streptococcus, Staphylococcus, and E. coli, tended to be more prevalent in the guts of PPI users. As stomach pH becomes less acidic, many ingested microorganisms that would normally be destroyed are able to make their way into the gut (8). Imhann and colleagues found that oral bacteria, such as the genus Rothia, were over-represented in the gut microbiota of PPI users (7). Those who used acid blockers also had an increased chance of acquiring Clostridium difficile, Campylobacter, Salmonella, Shigella, Listeria, and community-acquired pneumonia than those using other medications (9,10). A 2013 study also found a significantly increased percentage of individuals with small intestinal bacterial overgrowth (SIBO) among PPI users (11). Together, these studies point to the vital importance of sufficient stomach acid for protecting against bacterial influx into the GI tract and maintaining an intestinal pH that supports GI health.

PPIs impair nutrient absorption

Another consequence of long-term PPI use is impaired nutrient absorption, which I discussed extensively in a previous article. Stomach acid is essential for the absorption of many macro- and micronutrients. PPI users have been shown to have an increased risk of vitamin and mineral deficiencies, including vitamin B12, vitamin C, calcium, iron, and magnesium (12,13). Achlorhydria (a lack of stomach acid) and atrophic gastritis (stomach inflammation) allow for the overgrowth of bacteria, which compete with the host for consumption of micronutrients like vitamin B12 (14). These micronutrients are particularly important for bone health. Studies have found an association between PPI use and total bone fractures in the elderly (15). While the association was modest, the findings were significant enough that the FDA felt it necessary to issue a news release in 2010 warning of the possible increased fracture risk (16). Since then, a more recent study has shown a similar association in young adult PPI users (17). The effects of PPIs on bone health may be more nuanced than simply causing nutrient deficiency. Osteoclasts, the bone cells responsible for the resorption of calcium, also possess proton pumps, and their activity is thought to be directly affected by PPIs (18,19).

PPIs increase the risk of cardiovascular events

Several recent studies have also shed light on PPIs and the cardiovascular system. PPI users have been shown to have a significantly greater risk of heart attack than those on other antacid medication (20, 21). PPIs also reduce production of nitric oxide, a natural substance that promotes the dilation of blood vessels and improves blood flow (22). PPIs may also damage blood vessel cells, as shown by a study published in May 2016. When researchers exposed cultured human blood vessel endothelial cells to esomeprazole, the cells seemed to age much more quickly, losing their ability to split into new cells. PPIs, which are designed to work especially well in acidic environments, seemed to inhibit an acidic compartment of the cell called the lysosome, which can be thought of as the cell’s “garbage disposal.” Without the ability to break down old proteins and other waste products of metabolism in lysosomes, “garbage” built up in the cells and inhibited their function (23).

PPIs harm the kidneys

The kidneys are also affected by PPIs. A study published in 2016 compared patients using PPIs to patients using H2 blockers, another common antacid drug. They showed that over the course of five years, those in the PPI group were 28 percent more likely to develop chronic kidney disease and 96 percent more likely to develop end-stage renal disease (24). While the mechanism by which this occurs is unclear, we do know that proton pumps are present in the intercalated cells of the kidney. These proton pumps are responsible for moving protons into the urine, creating a gradient that allows for bicarbonate reabsorption into the blood (25). Bicarbonate is vitally important to maintaining proper blood pH.

PPIs negatively affect cognitive function

PPIs also impair cognitive function. A 2016 study found that regular PPI users had a 44 percent increased risk of dementia compared with those not using the drugs (26). A different study published in 2015 that assessed cognitive function in PPI users versus controls found statistically significant impairment in visual memory, attention, executive function, and working and planning function among PPI users (27). Several commonly prescribed PPIs, such as lansoprazole and omeprazole, have been reported to cross the blood-brain barrier. In mice, PPIs were observed to affect β- and γ-secretase enzymes, resulting in increased levels of amyloid β, a protein fragment that forms the plaques characteristic of Alzheimer’s disease (28). Furthermore, communication between brain cells requires the action of proton pumps. Simplistically, neuron cells contain small vesicles, or pockets, of neurotransmitters. When a neuron is stimulated, the vesicle releases these neurotransmitters into the synaptic space, where they can then interact with receptors on other nearby neurons, transmitting the signal down the line. The neurotransmitters must then be taken back up by the neuron so that they can be released again in response to the next stimulus. The energy required for this reuptake process is driven by proton pumps (29). If PPIs bind to these proton pumps, cognitive abilities would certainly be impaired.

PPI withdrawal can lead to rebound reflux

Your body is acutely sensitive changes in your physiology and is constantly trying to maintain a stable equilibrium, often termed homeostasis. In the case of PPIs, when it senses reduced stomach acid production, your body produces the hormone gastrin to try to compensate. Gastrin normally stimulates gastric (stomach) acid production. Excess gastrin has in turn been shown to lead to an expansion of enterochromaffin-like cells (ECLs) (30). ECLs are found in the mucosa of the stomach in close proximity to parietal cells. A greater number of ECLs results in a greater amount of ECL hormones released that can interact with parietal cells. Parietal cells, as you may recall, are the cells responsible for stomach acid production via proton pumps. These parietal cells undergo hypertrophy, or an expansion in the size of each cell (31). Larger parietal cells have more proton pumps and can produce larger amounts of stomach acid. This is termed “rebound hypersecretion,” or an overproduction of stomach acid after taking PPIs (32). This is why getting off PPI therapy is so difficult, because long-term use fundamentally changes the physiology of stomach cells. It also points to yet another instance where simply treating the symptoms of a condition fails to recognize and treat the underlying root cause. Luckily, parietal cells are constantly undergoing renewal, with an average lifespan of only 54 days (33). So just because you took PPIs does not necessarily mean you are destined to rebound hypersecretion forever, as after a few months your stomach cells should have largely turned over. However, the repair mechanisms after PPI discontinuation have not been widely studied, and it is entirely possible that there are lasting effects.

Alternatives to PPIs

Collectively, these and many other studies suggest that PPIs are not as safe as they are made out to be. Frankly, it’s bordering on criminal that the FDA continues to allow these drugs to be prescribed as frequently as they are, and for durations of years or even decades in some cases, given the overwhelmingly large body of evidence documenting the potential harms associated with long-term PPI use. If you’re convinced you should avoid PPIs, there are some alternatives (see my previous article for a more detailed discussion of these). Always consult with your medical practitioner before discontinuing the use of PPIs and be sure to reduce your dose gradually to avoid any withdrawal symptoms.

1. Eat a low-carb Paleo diet Malabsorption of carbohydrates can lead to bacterial overgrowth, resulting in the bloating and increased abdominal pressure that drives acid reflux.
2. Resolve low stomach acid and treat bacterial overgrowth Contrary to conventional wisdom, acid reflux is often due to too little stomach acid, which results in bacterial overgrowth.

Now I’d like to hear from you. Have you taken PPIs? Did you know about the long-term dangers? Did you notice improvement in your acid reflux by switching to a Paleo diet or reducing your carbohydrate intake? Share your experience in the comments section!

Note: this is the fourth article in a series about heartburn and GERD. If you haven’t done so already, you’ll want to read Part I, Part II and Part III before reading this article. Believe it or not, stomach acid isn't there just to punish you for eating Indian food. Acid is in the stomach because it's supposed to be there. It is found in all vertebrates. And while it isn't necessary for life, it is certainly required for health. Most people have no idea how many vital roles stomach acid plays in our bodies. Such misunderstanding is perpetuated by drug companies who continue to insist that stomach acid is not essential. Meanwhile, millions of people around the world are taking acid suppressing drugs that not only fail to address the underlying causes of heartburn and GERD, but put them at risk of serious (and even life-threatening) conditions. There are four primary consequences of acid stopping drugs:

1. Increased bacterial overgrowth
2. Impaired nutrient absorption
3. Decreased resistance to infection
4. Increased risk of cancer and other diseases

I had originally intended to cover all four of these issues in this article, but as I started to write I realized it would be far too long. So I will cover increased bacterial overgrowth and impaired nutrient absorption in this article, and decreased resistance to infection and increased risk of cancer and other diseases in the next article.

A stomach full of germs

We're not going to spend much time on this here since the connection between low stomach acid and bacterial overgrowth was the focus of Part II and Part III. To review, low stomach acid causes bacterial overgrowth in the stomach and other parts of the intestine. Bacterial overgrowth causes maldigestion of carbohydrates, which in turn produces gas. This gas increases the pressure in the stomach, causing the lower esophageal sphincter (LES) to malfunction. The malfunction of the LES allows acid from the stomach to enter the esophagus, thus producing the symptoms of heartburn and GERD. Bacterial overgrowth has a number of other undesirable effects, including reducing nutrient absorption, increasing inflammation, and raising the risk of stomach cancer. Studies have confirmed that proton-pump inhibitors (PPIs) can profoundly alter the gastrointestinal bacterial population by suppressing stomach acid. Researchers in Italy detected small bowel bacterial overgrowth (SIBO) in 50% of patients using PPIs, compared to only 6% of healthy control subjects. The prevalence of SIBO increased after one year of treatment with PPIs.

Well-fed but undernourished

Stomach acid is a prerequisite to healthy digestion. The breakdown and absorption of nutrients occurs at an optimum rate only within a narrow range of acidity in the stomach. If there isn't enough acid, the normal chemical reactions required to absorb nutrients is impaired. Over time this can lead to diseases such as anemia, osteoporosis, cardiovascular disease, depression, and more.

Macronutrients

Stomach acid plays a key role in the digestion of protein, carbohydrates and fat. When food is eaten, the secretion of stomach acid (HCL) triggers the production of pepsin. Pepsin is the enzyme required to digest protein. If HCL levels are depressed, so are pepsin levels. As a result, proteins don't get broken down into their component amino acids and peptides. This can lead to a deficiency of essential amino acids, which in turn may lead to chronic depression, anxiety and insomnia. At the same time, proteins that escape digestion by pepsin may end up in the bloodstream. Since this is not supposed to happen, the body reacts to these proteins as if they were foreign invaders, causing allergic and autoimmune responses. I'll discuss this more below.

Micronutrients

We can eat the most nutritious diet imaginable, packed with vitamins, minerals and other essential nutrients, but if we aren't absorbing those nutrients we won't benefit from them. As acid declines and the pH of the stomach increases, absorption of nutrients becomes impaired. Decades of research have confirmed that low stomach acid - whether it occurs on its own or as a result of using antacid drugs - reduces absorption of several key nutrients such as iron, B12, folate, calcium and zinc.

Iron

Iron deficiency causes chronic anemia, which means that the body's tissues are literally starving for oxygen. In one study, 35 of 40 people (80 percent) with chronic iron-deficiency anemia were found to have below normal acid secretion. Iron-deficiency anemia is a well-known consequence of surgical procedures that remove the regions of the stomach where acid is produced. Researchers have found that inhibition of acid secretion by Tagamet, a popular acid stopping drug, resulted in a significant reduction of iron. At the same time, studies have shown that adding acid has improved iron absorption in patients with achlorydia (no stomach acid production).

B12

Vitamin B12 (cobalamin) is needed for normal nerve activity and brain function. B12 enters the body bound to animal-derived proteins. In order for use to absorb it, the vitamin molecules must first be separated from these proteins with the help of - you guessed it - stomach acid. If stomach acid is low, B12 can't be separated from its carrier proteins and thus won't be absorbed. In one study of 359 people aged 69-79 years with serious atrophic gastritis, a disease characterized by low stomach acid, more than 50 percent had low vitamin B12 levels. A number of studies have examined the negative effect of PPI therapy on B12 absorption. In a study on healthy subjects treated with 20 mg and 40 mg of Prilosec per day for two weeks, B12 absorption was reduced by 72% and 88% respectively.

Folate

Among other things, folate (folic acid) is vital for keeping the cardiovascular system healthy and for preventing certain birth defects. Low stomach acid levels can interfere with folate absorption by raising the pH in the small intestine. At the same time, when folate is given to achlorydric patients (with no stomach acid) along with an HCL supplement, absorption of the vitamin increases by 54 percent. Both Tagamet and Zantac reduced folate absorption in another study, though the reduction in the Zantac group was not statistically significant. The overall reduction of folate absorption was sixteen percent. This modest reduction is probably not enough to harm a healthy person consuming adequate levels of folate, but it may cause problems in those with folate deficiency (relatively common) or other health problems.

Calcium

Calcium makes our bones and teeth strong and is responsible for hundreds, if not thousands, of other functions in our body. The importance of stomach acid in the absorption of calcium has been known since the 1960s, when one group of researchers noted that some ulcer patients were barely absorbing any calcium at all (just 2 percent). When they investigated they found that these subjects had a high gastric pH (6.5) and very little stomach acid. However, when the researchers gave them HCL supplements, lowering the pH to 1, calcium absorption rose five-fold.

Zinc

Zinc takes part in several metabolic processes related to keeping cell membranes stable, forming new bone, immune defense, night vision, and tissue growth. In one controlled trial, Tagamet treatment reduced zinc absorption by about 50 percent. Another study found that Pepcid, which raises intragastric pH to over 5, had the same effect. Although there is little systemic research on the absorption of other nutrients, there is good reason to believe that low acid levels may also effect levels of vitamin A, vitamin E, thiamine (vitamin B1), riboflavin (vitamin B2), and niacin (vitamin B3). Theoretically, the absorption of any nutrient that is bound to protein will be inhibited (PDF). In Part B of this article I will explain how acid stopping drugs decrease our resistance to infection and increase our risk of stomach cancer and other diseases.

Note: this is the fifth article in a series about heartburn and GERD. If you haven’t done so already, you’ll want to read Part I, Part II, Part III, and Part IVa before reading this article. In the last article, we discussed the first two of four primary consequences of taking acid stopping drugs:

1. Bacterial overgrowth
2. Impaired nutrient absorption

In this article we'll cover the remaining two consequences:

3. Decreased resistance to infection
4. Increased risk of cancer and other diseases

Our first line of defense

The mouth, esophagus and intestines are home to between 400-1,000 species of bacteria. However, a healthy stomach is normally almost completely sterile. Why? Because stomach acid kills bacteria. In fact, that's one of it's most important roles: to provide a two-way barrier that protects the stomach from pathogenic bacteria. First, stomach acid prevents harmful bacteria that may be present in the food or liquid we consume or the air we breathe from entering the intestine. At the same time, stomach acid also prevents normal bacteria from the intestines to move into the stomach and esophagus, where they could cause problems. The low pH (high acid) environment of the stomach is one of the major non-specific defense mechanisms of the body. When the pH of the stomach is 3 or lower, the normal between-meal "resting" level, bacteria don't last more than fifteen minutes. But as the pH rises to 5 or more, many bacterial species can avoid the acid treatment and begin to thrive. Unfortunately, this is exactly what happens when you take acid stopping drugs. Both Tagamet and Zantac significantly raise the pH of the stomach from about 1 to 2 before treatment to 5.5 to 6.5 after, respectively. Prilosec and other PPIs are even worse. Just one of these pills is capable of reducing stomach acid secretion by 90 to 95 percent for the better part of a day. Taking higher or more frequent doses of PPIs, as is often recommended, produces a state of achlorydia (virtually no stomach acid). In a study of ten healthy men aged 22 to 55 years, a 20 or 40 mg dose of Prilosec reduced stomach acid levels to near-zero. A stomach without much acid is in many ways a perfect environment to harbor pathogenic bacteria. It's dark, warm, moist, and full of nutrients. Most of the time these bacteria won't kill us - at least not right away. But some of them can. People who have a gastric pH high enough to promote bacterial overgrowth are more vulnerable to serious bacterial infections. A recent systematic review of gastric acid-suppressive drugs suggested that they do in fact increase susceptibility to infections (PDF). The author found evidence that using acid stopping drugs can increase your chances of contracting the following nasty bugs:

• Salmonella
• Campylobacter
• Cholera
• Listeria
• Giardia
• C. Difficile

Other studies have found that acid stopping drugs also increase the risk for:

• Pneumonia
• Tuberculosis
• Typhoid
• Dysentery

Not only do acid stopping drugs increase our susceptibility to infection, they weaken our immune system's ability to fight off infections once we have them. In vitro studies have shown that PPIs impair nuetrophil function, decrease adhesion to endothelial cells, reduce bactericidal killing of microbes, and inhibit neutrophil phagocytosis and phagolysosome acidification.

A gateway to other serious diseases

As we discussed in the first article in this series, a decline in acid secretion with age has been well documented. As recently as 1996, a British physician noted that age-related stomach acid decline is due to a loss of the cells that produce the acid. This condition is called atrophic gastritis. In particular relevance to our discussion here, atrophic gastritis (a condition where stomach acid is very low) is associated with a wide range of serious disorders that go far beyond the stomach and esophagus. These include:

• Stomach cancer
• Allergies
• Bronchial asthma
• Depression, anxiety, mood disorders
• Pernicious anemia
• Skin diseases, including forms of acne, dermatitis, eczema, and urticaria
• Gall bladder disease (gallstones)
• Autoimmune diseases, such as Rheumatoid arthritis and Graves disease
• Irritable bowel syndrome (IBS), Crohn's disease (CD), Ulcerative colitis (UC)
• Chronic hepatitis
• Osteoporosis
• Type 1 diabetes

And let's not forget that low stomach acid can cause heartburn and GERD! In the interest of keeping this article from becoming a book, I'm going to focus on just a few of the disorders on the list above.

Stomach cancer

Atrophic gastritis is a major risk factor for stomach cancer. H. pylori is the leading cause of atrophic gastritis. Acid suppressing drugs worsen H. pylori infections and increase rates of infection. Therefore, it's not a huge leap to suspect that acid suppressing drugs increase the risk of stomach cancer in those infected with H. pylori (which, as we saw in Part III, is one in two people). In a recent editorial, Julie Parsonnet, M.D. of Standford University Medical School writes:

In principle, current [acid suppressing drug] therapies might be advancing the cancer clock by converting relatively benign gastric inflammation into a more destructive, premalignant process.

One way PPIs increase the risk of cancer is by inducing hypergastrinemia, a condition of above-normal secretion of the hormone gastrin. This is a potentially serious condition that has been linked to adenocarcinoma - a form of stomach cancer. Taking a standard 20 mg daily dose of Prilosec typically results in up to a three-to-fourfold increase in gastrin levels. In people whose heartburn fails to respond to the standard dose, long-term treatment with doses as high as 40 or 60 mg has produced gastrin levels as much as tenfold above normal. Another theory of what causes stomach cancer involves elevated concentration of nitrites in the gastric fluid. In a healthy stomach, ascorbic acid (vitamin C) removes nitrite from gastric juice by converting it to nitric oxide. However, this process is dependent upon the pH of the stomach being less than 4. As I discussed earlier in this article, most common acid stopping medications have no trouble increasing the pH of the stomach to 6 or even higher. Therefore, it's entirely plausible that acid stopping medications increase the risk of stomach cancer by at least two distinct mechanisms.

Gastric and duodenal ulcers

An estimated 90% of duodenal (intestinal) and 65% of gastric ulcers are caused by H. pylori. It is also recognized that the initial H. pylori infection probably only takes place when the acidity of the stomach is decreased. In a human inoculation experiment, infection could not be established unless the pH of the stomach was raised (thus lowering the acidity) by use of histamine antagonists. By lowering stomach acid and increasing stomach pH, acid suppressing drugs increase the risk of H. pylori infection and subsequent development of duodenal or gastric ulcers.

Irritable bowel syndrome, Crohn's disease and ulcerative colitis

Adenosine is a key mediator of inflammation in the digestive tract, and high extracellular levels of adenosine suppress and resolve chronic inflammation in both Crohn's disease and ulcerative colitis. Chronic use of PPIs has been shown to decrease extracellular concentration of adenosine, resulting in an increase in inflammation in the digestive tract. Therefore, it is possible that long-term use of acid stopping medications may predispose people to developing serious inflammatory bowel disorders. It has become increasingly well established that irritable bowel syndrome (IBS) is caused at least in part by small bowel bacterial overgrowth (SIBO). It is also well known that acid suppressing drugs contribute to bacterial overgrowth, as I explained in Part II and Part III. It makes perfect sense, then, that chronic use of acid suppressing drugs could contribute to the development of IBS in those that didn't previously have it, and worsen the condition in those already affected.

Depression, anxiety and mood disorders

While there is no specific research (that I am aware of) linking acid suppressing drugs to depression or mood disorders, a basic understanding of the relationship between protein digestion and mental health suggests that there may be a connection. During the ingestion of food stomach acid secretion triggers the release of pepsin. Pepsin is the enzyme responsible for breaking down protein into its component amino acids and peptides (two or more linked amino acids). Essential amino acids are called "essential" because we cannot manufacture them in our bodies. We must get them from food. If pepsin is deficient, the proteins we eat won't be broken down into these essential amino acid and peptide components. Since many of these essential amino acids, such as phenylalanine and tryptophan, play a crucial role in mental and behavioral health, low stomach acid may predispose people towards developing depression, anxiety or mood disorders.

Autoimmune diseases

Low stomach acid and consequent bacterial overgrowth cause the intestine to become permeable, allowing undigested proteins to find their way into the bloodstream. This condition is often referred to as "leaky gut syndrome". Salzman and colleagues have shown that both transcellular and paracellular intestinal permeability are substantially increased in atrophic gastritis sufferers compared to control patients. When undigested proteins end up in the bloodstream, they are considered as "foreign" by the immune system. The resulting immune response is similar to what happens when the body mobilizes its defenses (i.e. T cells, B cells and antibodies) to eradicate a viral or bacterial infection. This type of immune response against proteins we eat contributes to food allergies. A similar mechanism that is not fully understood predisposes people with a leaky gut to develop more serious autoimmune disorders such as lupus, rheumatoid arthritis, type 1 diabetes, Graves disease, and inflammatory bowel disorders like Crohn's and ulcerative colitis. The connection between rheumatoid arthritis (RA) and low stomach acid in particular has been well established in the literature. Examining the stomach contents of 45 RA patients, Swedish researchers found that 16 (36 percent) had virtually no stomach acid. Those people who had suffered from RA the longest had the least acid. A group of Italian researchers also found that people with RA have an extremely high rate of atrophic gastritis associated with low stomach acid when compared with normal individuals.

Asthma

In the last ten years, more than four hundred scientific articles concerned with the connection between asthma and gastric acidity have been published. One of the most common features of asthma, in addition to wheezing, is gastroesophageal reflux. It is estimated that between up to 80 percent of people with asthma also have GERD. Compared with healthy people, those with asthma also have significantly more reflux episodes and more acid-induced irritation of their esophageal lining. When acid gets into the windpipe, there is a tenfold drop in the ability of the lungs to take in and breathe out air. Physicians who are aware of this association have begun prescribing acid stopping drugs to asthma patients suffering from GERD. While these drugs may provide temporary symptomatic relief, they do not address the underlying cause of the LES dysfunction that permitted acid into the esophagus in the first place. In fact, there is every reason to believe that acid suppressing drugs make the underlying problem (too little stomach acid and overgrowth of bacteria) worse, thus perpetuating and exacerbating the condition.

Conclusion

As we have seen in the previous articles in the series, heartburn and GERD are caused by too little - and not too much - stomach acid. Unfortunately, insufficient stomach acid is also associated with bacterial overgrowth, impaired nutrient absorption, decreased resistance to infection, and increased risk of stomach cancer, ulcers, IBS and other digestive disorders, depression and mood disorders, autoimmune disease, and asthma. Chronic use of acid stopping medication dramatically reduces stomach acid, thus increasing the risk of all of these conditions. What's more, acid suppressing medications not only do not address the underlying cause of heartburn and GERD, they make it worse. Is the temporary symptom relief these drugs provide worth the risk? That's something only you can decide. I hope the information I've provided here can help you make an educated decision. In the next and final article of the series, I will present a plan for getting rid of heartburn and GERD once and for all without drugs.

Note: this is the sixth and final article in a series about heartburn and GERD. If you haven’t done so already, you’ll want to read Part I, Part II, Part III, and Part IVa, and Part IVb before reading this article. In this final article of the series, we're going to discuss three steps to treating heartburn and GERD without drugs. These same three steps will also prevent these conditions from developing in the first place, and keep them from returning once they're gone. To review, heartburn and GERD are not caused by too much stomach acid. They are caused by too little stomach acid and bacterial overgrowth in the stomach and intestines. Therefore successful treatment is based on restoring adequate stomach acid production and eliminating bacterial overgrowth. This can be accomplished by following the "three Rs" of treating heartburn and GERD naturally:

1. Reduce factors that promote bacterial overgrowth and low stomach acid.
2. Replace stomach acid, enzymes and nutrients that aid digestion and are necessary for health.
3. Restore beneficial bacteria and a healthy mucosal lining in the gut.

Reduce factors that promote bacterial overgrowth and low stomach acid

It follows, then, that a low-carb (LC) diet would reduce bacterial overgrowth. To my knowledge there have only been two small studies done to test this hypothesis. The results in both studies were overwhelmingly positive. The first study was performed by Professor Yancy and colleagues at Duke University. They enrolled five patients with severe GERD that also had a variety of other medical problems, such as diabetes. Each of these patients had failed several conventional GERD treatments before being enrolled in the study. In spite of the fact that some of these patients continued to drink, smoke and engage in other GERD-unfriendly habits, in every case the symptoms of GERD were completely eliminated within one week of adopting a very low carbohydrate (VLC) diet. The second study (PDF) was performed by Yancy and colleagues a few years later. This time they examined the effects of a VLC diet on eight obese subjects with severe GERD. They measured the esophageal pH of the subjects at baseline before the study began using something called the Johnson-DeMeester score. This is a measurement of how much acid is getting back up into the esophagus, and thus an objective marker of how much reflux is occurring. They also used a self-administered questionnaire called the GSAS-ds to evaluate the frequency and severity of 15 GERD-related symptoms within the previous week. At the beginning of the diet, five of eight subjects had abnormal Johnson-DeMeester scores. All five of these patients showed a substantial decrease in their Johnson-DeMeester score (meaning less acid in the esophagus). Most remarkably, the magnitude of the decrease in Johnson-DeMeester scores is similar to what is reported with PPI treatment. In other words, in these five subjects a very low carbohydrate diet was just as effective as powerful acid suppressing drugs in keeping acid out of the esophagus. All eight individuals had evident improvement in their GSAS-ds scores. The GSAS-ds scores decreased from 1.28 prior to the diet to 0.72 after initiation of the diet. What these numbers mean is that the patients all reported significant improvement in their GERD related symptoms. Therefore, there was both objective (Johnson-DeMeester) and subjective (GSAS-ds) improvement in this study. It's important to note that obesity is an independent risk factor for GERD, because it increases intra-abdominal pressure and causes dysfunction of the lower esophageal sphincter (LES). The advantage to a low-carb diet as a treatment for GERD for those who are overweight is that LC diets are also very effective for promoting weight loss. I don't recommend VLC diets for extended periods of time, as they are unnecessary for most people. Once you have recovered your digestive function, a diet low to moderate in carbohydrates should be adequate to prevent a recurrence of symptoms. An alternative to a VLC is something called a "specific carbohydrate diet" (SCD), or the GAPS diet. In these two approaches it is not the amount of carbohydrates that is important, but the type of carbohydrates. The theory is that the longer chain carbohydrates (disaccharides and polysacharides) are the ones that feed bad bacteria in our guts, while short chain carbohydrates (monosacharides) don't pose a problem. In practice what this means is that all grains, legumes and starchy vegetables should be eliminated, but fruits and certain non-starchy root vegetables (winter squash, rutabaga, turnips, celery root) can be eaten. These are not "low-carb" diets, per se, but there is reason to believe that they may be just as effective in treating heartburn and GERD. See the resources section below for books and websites about these diets, which have been used with dramatic success to treat everything from autism spectrum disorder (ASD) to Crohn's disease. Another alternative to VLC that I increasingly use in my clinic is the Low FODMAP diet. FODMAPs are certain types of carbohydrates that are poorly absorbed by some people, particularly those with an overgrowth of bacteria in the small intestine (which, as you now know, tends to go hand-in-hand with heartburn). See this article and my book for more information. Be careful to avoid the processed low-carb foods sold in supermarkets. Instead, I suggest what is known as a "paleolithic" or "primal" approach to nutrition. Fructose and artificial sweeteners As I pointed out in Part II, fructose and artificial sweeteners have been shown to increase bacterial overgrowth. Artificial sweeteners should be completely eliminated, and fructose (in processed form especially) should be reduced. Fiber High fiber diets and bacterial overgrowth are a particularly dangerous mix. Remember, Almost all of the fiber and approximately 15-20% of the starch we consume escape absorption. Carbohydrates that escape digestion become food for intestinal bacteria. Prebiotics, which can be helpful in re-establishing a healthy bacterial balance in some patients, should probably be avoided in patients with heartburn and GERD. Several studies show that fructo-oligosaccharides (prebiotics) increase the amount of gas produced in the gut. The other problem with fiber is that it can bind with nutrients and remove them from the body before they have a chance to be absorbed. This is particularly problematic in GERD sufferers, who may already be deficient in key nutrients due to long term hypochlorydria (low stomach acid). H. pylori In Part III we looked at the possible relationship between H. pylori and GERD. While I think it's a contributing factor in some cases, the question of whether and how to treat it is less clear. There is some evidence that H. pylori is a normal resident on the human digestive tract, and even plays some protective and health-promoting roles. If this is true, complete eradication of H. pylori may not be desirable. Instead, a LC or specific carbohydrate diet is probably a better choice as it will simply reduce the bacterial load and bring the gut flora back into a state of relative balance. The exception to this may be in serious or long-standing cases of GERD that aren't responding to a VLC or LC diet. In this situation, it may be worthwhile to get tested for H. pylori and treat it more aggressively. Dr. Wright, author of Why Stomach Acid is Good For You, suggests using mastic (a resin from a Mediterranean and Middle Eastern variety of pistachio tree) to treat H. pylori. A 1998 in vitro study in the New England Journal of Medicine showed that mastic killed several strains of H. pylori, including some that were resistant to conventional antibiotics. Studies since then, including in vivo experiments, have shown mixed results. Mastic may be a good first-line therapy for H. pylori, with antibiotics as a second choice if the mastic treatment isn't successful.

Replace stomach acid, enzymes and nutrients that aid digestion and are necessary for health

HCL with Pepsin If you have an open-minded doctor, or one that is aware of the connection between low stomach acid and GERD, ask her to test your stomach acid levels. The test is quite simple. A device called a Heidelberg capsule, which consists of a tiny pH sensor and radio transmitter compressed into something resembling a vitamin capsule, is lowered into the stomach. When swallowed, the sensors in the capsule measure the pH of the stomach contents and relay the findings via radio signal to a receiver located outside the body. In cases of mild to moderate heartburn, actual testing for stomach acid production at Dr. Wright's Tahoma clinic shows that hypochlorydria occurs in over 90 percent of thousands tested since 1976. In these cases, replacing stomach acid with HCL supplements is almost always successful. Although testing actual stomach acid levels is preferable, it is not strictly necessary. There is a reasonably reliable, "low-tech" method that can be performed at home to determine whether HCL supplementation will provide a benefit. To do this test, pick up some HCL capsules that contain pepsin or acid-stable protease. HCL should always be taken with pepsin or acid-stable protease because it is likely that if the stomach is not producing enough HCL, it is also not producing enough protein digesting enzymes. To minimize side effects, start with one 650 mg capsule of HCL w/pepsin in the early part of each meal. If there are no problems after two or three days, increase the dose to two capsules at the beginning of meals. Then after another two days increase to three capsules. Increase the dose gradually in this stepwise fashion until you feel a mild burning sensation. At that point, reduce the dosage to the previous number of capsules you were taking before you experienced burning and stay at that dosage. Over time you may find that you can continue to reduce the dosage, or you may also find that you may need to increase the dosage. In Dr. Wright’s clinic, most patients end up at a dose of 5-7 650 mg capsules. In my experience, this dose is too high for many people. In fact, some have trouble with even a single 650 mg capsule. I’ve also found that the addition of cholagogues (agents which promote bile flow from the gall bladder into the small intestine) and pancreatic enzymes can help tremendously, especially in the initial stages. For these reasons, I created by own combination of HCL and enzymes called the AdaptaGest Duo. AdaptaGest Core contains acid-stable protease (to support protein digestion and complement HCL), cholagogues, and enzymes. AdaptaGest Flex contains HCL, but in a lower dose (200 mg per capsule) than is typical for standalone HCL products. This allows better fine-tuning of your HCL dosage. In my clinic, I prescribe AdaptaGest Duo for anyone str uggling with heartburn and other digestive issues related to low stomach acid production. If you’d like to try it, you can order it here. Bitters Another way to stimulate acid production in the stomach is by taking bitter herbs. "Bitters" have been used in traditional cultures for thousands of years to stimulate and improve digestion. More recently, studies have confirmed the ability of bitters to increase the flow of digestive juices, including HCL, bile, pepsin, gastrin and pancreatic enzymes. [1. Wright, Jonathan M.D. Why Stomach Acid is Good For You. M Evans 2001. p.142] Unsurprisingly, there aren't many clinical studies evaluating the therapeutic potential of unpatentable and therefore unprofitable bitters. However, in one uncontrolled study in Germany, where a high percentage of doctors prescribe herbal medicine, gentian root capsules provided dramatic relief of GI symptoms in 205 patients. The following is a list of bitter herbs commonly used in Western and Chinese herbology:

• Barberry bark
• Caraway
• Dandelion
• Fennel
• Gentian root
• Ginger
• Globe artichoke
• Goldenseal root
• Hops
• Milk thistle
• Peppermint
• Wormwood
• Yellow dock

Bitters are normally taken in very small doses - just enough to evoke a strong taste of bitterness. Kerry Bone, a respected Western herbalist, suggests 5 to 10 drops of a 1:5 tincture of the above herbs taken in 20 mL of water. An even better option is to see a licensed herbalist who can prescribe a formula containing several of the herbs above as appropriate for your particular condition. Apple cider vinegar, lemon juice, raw (unpasteurized) sauerkraut and pickles are other time-tested, traditional remedies that often relieve the symptoms of heartburn and GERD. However, although these remedies may resolve symptoms, they do not increase nutrient absorption and assimilation to the extent that HCL supplements do. This may be important for those who have been taking acid suppressing drugs for a long period. It is also important to avoid consuming liquid during meals. Water is especially problematic, because it literally dilutes the concentration of stomach acid. A few sips of wine is probably fine, and may even be helpful. Finally, for those who have been taking acid stopping drugs for several years, it may be necessary to replace the nutrients that are not absorbed without sufficient stomach acid. These include B12, folic acid, calcium, iron and zinc. It's best to get your levels tested by a qualified medical practitioner, who can then help you replace them through nutritional changes and/or supplementation.

Restore beneficial bacteria and a healthy mucosal lining in the gut

Probiotics Because bacterial overgrowth is a major factor in heartburn and GERD, restoring a healthy balance of intestinal bacteria is an important aspect of treatment. Along with performing several other functions essential to digestive health, beneficial bacteria (probiotics) protect against potential pathogens through "competitive inhibition" (i.e. competing for resources). Researchers in Australia have shown that probiotics are effective in reducing bacterial overgrowth and altering fermentation patterns in the small bowel in patients with IBS. Probiotics have also been shown to be effective in treating Crohn's disease, ulcerative colitis, and other digestive conditions. Probiotics have also been shown to significantly increase cure rates of treatment for H. pylori. In my practice I always include a probiotic along with the anti-microbial treatment I do for H. pylori. I am often asked what type of probiotics I recommend. First, whenever possible I think we should always attempt to get the nutrients we need from food. This is also true for probiotics. Fermented foods have been consumed for their probiotic effects for thousands of years. What’s more, contrary to popular belief and the marketing of commercial probiotic manufacturers, foods like yogurt and kefir generally have a much higher concentration of beneficial microorganisms than probiotic supplements do. For example, even the most potent commercial probiotics claim to contain somewhere between one and five billion microorganisms per serving. (I say "claim" to contain because independent verification studies have shown that most commercial probiotics do not contain the amount of microorganisms they claim to.) Contrast that with a glass of homemade kefir, a fermented milk product, contains as many as 5 trillion beneficial microorganisms! What's more, fermented milk products like kefir and yogurt offer more benefits than beneficial bacteria alone, including minerals, vitamins, protein, amino acids, L-carnitine, fats, CLA, and antimicrobial agents. Studies have even shown that fermented milk products can improve the eradication rates of H. pylori by 5-15%. The problem with fermented milk products in the treatment of heartburn and GERD, however, is that milk is relatively high in carbohydrates. This may present a problem for people with severe bacterial overgrowth. However, relatively small amounts of kefir and yogurt are therapeutic and may be well tolerated. It's best to make kefir and yogurt at home, because the microorganism count will be much higher. Lucy's Kitchen Shop sells a good home yogurt maker, and Dom's Kefir site has exhaustive information on all things kefir. If you do buy the home yogurt maker, I suggest you also buy the glass jar that Lucy's sells to make it in (rather than using the plastic jar it comes with). If dairy doesn’t work for you, but you’d like to get the benefits of kefir, you can try making water kefir. Originating in Mexico, water kefir grains (also known as sugar kefir grains) allow for the fermentation of sugar water or juice to create a carbonated lacto-fermented beverage. You can buy water kefir grains from Cultures for Health. Another option is to eat non-dairy (and thus lower-carb) unpasteurized (raw) sauerkraut and pickles and/or drink a beverage called kombucha. Raw sauerkraut can easily be made at home, or sometimes found at farmer's markets. Bubbies brand raw pickles are sold at health food stores, as is kombucha, but both of these can also be made quite easily at home. All of that said, probiotic supplements are sometimes necessary and can play a crucial role in treatment and recovery. But not all probiotics are created alike, and in the case of small intestinal bacterial overgrowth (or SIBO, which is commonly present with GERD), certain probiotics may make things worse. SIBO often involves an overgrowth of microorganisms that produce a substance called D-lactic acid. Unfortunately, many commercial probiotics contain strains (like Lactobacillus acidophilus) that also produce D-lactic acid. That makes most commercial probiotics a poor choice for people with SIBO. Soil-based organisms do not produce significant amounts of D-lactic acid, and are a better choice for this reason. In my clinic, I use a product called Prescript Assist when treating SIBO and GERD. You can purchase it here. Other popular choices include Gut Pro from Organic 3 and D-Lactate Free Powder from Custom Probiotics. I used these in the past, but have much better success with Prescript Assist so I now use that exclusively. Bone broth and DGL Restoring a healthy gut lining is another important part of recovering from heartburn and GERD. Chronic stress, bacterial overgrowth, and certain medications such as steroids, NSAIDs and aspirin can damage the lining of the stomach. Since it is the mucosal lining of the stomach that protects it from its own acid, a damaged stomach lining can cause irritation, pain and ultimately, ulcers. Homemade bone broth soups are effective in restoring a healthy mucosal lining in the stomach. Bone broth is rich in collagen and gelatin, which have been shown to benefit people with ulcers. It's also high in proline, a non-essential amino acid that is an important precursor for the formation of collagen. Bone broth also contains glutamine, an important metabolic fuel for intestinal cells that has been shown to benefit the gut lining in animal studies. See this article and this one for more information about the healing power of bone broth, and how to make it. Although I prefer obtaining nutrients from food whenever possible, , as I explained above, supplements are sometimes necessary – especially for short periods. Deglycyrrhizinated licorice (DGL) has been shown to be effective in treating gastric and duodenal ulcers, and works as well in this regard as Tagamet or Zantac, with far fewer side effects and no undesirable acid suppression. In animal studies, DGL has even been shown to protect the stomach lining against damage caused by aspirin and other NSAIDs. DGL works by raising the concentration of compounds called prostaglandins, which promote mucous secretion, stabilize cell membranes, and stimulate new cell growth - all of which contributes to a healthy gut lining. Both chronic stress and use of NSAIDs suppress prostaglandin production, so it is vital for anyone dealing with any type of digestive problem (including GERD) to find ways to manage their stress and avoid the use of NSAIDs as much as possible.

Conclusion

The mainstream medical approach to treating heartburn and GERD involves taking acid stopping drugs for as long as these problems occur. Unfortunately, because these drugs not only don't address the underlying cause of these problems but may make it worse, this means that people who start taking antacid drugs end up taking them for the rest of their lives. This is a serious problem because acid stopping drugs promote bacterial overgrowth, weaken our resistance to infection, reduce absorption of essential nutrients, and increase the likelihood of developing IBS, other digestive disorders, and cancer. The manufacturers of these drugs have always been aware of these problems. When acid-stopping drugs were first introduced, it was recommended that they not be taken for more than six weeks. Clearly this prudent advice has been discarded, as it is not uncommon today to encounter people who have been on these drugs for decades - not weeks. What is especially disturbing about this is that heartburn and GERD are easily prevented and cured by making simple dietary and lifestyle changes, as I have outlined in this final article. Unfortunately, the corruption of our "disease-care" system by the financial interests of the pharmaceutical companies virtually guarantees that this crucial information will remain obscure. Drug companies make more than $7 billion a year selling acid suppressing medications. The last thing they want is for doctors and their patients to learn how to treat heartburn and GERD without these drugs. And since 2/3 of all medical research is sponsored by drug companies, it's virtually guaranteed that we won't see any large studies on the effects of a low-carb diet on acid reflux and GERD. So once again it's up to us to discover the truth and be our own advocates. I hope this series of articles has served you in that goal. I have created a "myth busing report" page for heartburn and GERD which contains an index of these articles, as well links to books and other offsite resources. If anyone you know is suffering from heartburn and GERD, please direct them to http://chriskresser.com/heartburn.

I was interviewed last week on Joanne Unleashed about the recent series of articles I wrote on heartburn and GERD. We cover the following subjects:

• Why acids leave the stomach and enter the esophagus
• The harmful effects of taking antacids and acid stopping drugs
• How antacids perpetuate heartburn and actually make it worse over time
• The role of stomach acid in digestion
• The bacterial component in acid reflux
• Why you get gas and belch
• Which nutritional deficiencies are common with acid reflux
• The association between acid reflux and IBS, Crohn’s, and other intestinal diseases
• Which inexpensive supplement will help reduce indigestion
• Which foods cause heartburn
• Which foods you should eat to heal the gut

Click here to listen to the MP3 file, or right-click to download it.

In a shockingly rare example of the FDA actually doing its job, a report was issued on Tuesday cautioning against the prolonged use of a class of acid stopping drugs called proton-pump inhibitors (PPIs). Who knows, maybe someone at the FDA read my series on heartburn and GERD, especially this article and this one detailing the dangers of acid stopping drugs? This is a really big deal. PPIs are one of the most popular classes of drugs prescribed. Doctors wrote 114 million prescriptions for them last year. Americans spend $5.1 billion on Nexium, the most popular PPI, alone. The FDA report cautions against high doses or prolonged use of PPIs, because they've been shown to increase the risk of infection, bone fractures and dementia. But the danger doesn't stop there. As I pointed out in my series, all acid stopping drugs (not just PPIs) inhibit nutrient absorption, promote bacterial overgrowth, reduce resistance to infection and increase the risk of cancer and other serious diseases. Don't get me wrong - I'm glad the FDA finally issued this warning. But I can't help wondering how someone who has been taking a PPI for 20 years is going to feel about it. If I were one of those people, I'd be incredibly angry. Especially because researchers who studied these drugs before they were approved by the FDA years ago sounded a similar warning. In fact, when the drugs were first approved, it was recommended that they be taken for no longer than six weeks because of these same concerns the FDA is only now warning us about! Looks like someone dropped the ball on that one, because it's not at all uncommon to encounter people who've been on a PPI for two decades. After writing the GERD series, I heard from several people in that group. So please forward this article to anyone you know who has been taking one of these dangerous drugs for any longer than six weeks. And believe me, you know one of these people. We all do. You may even be one of them. If you or a loved one wants to get off these drugs and treat GERD naturally, the the series on my blog clearly explains how to do that.

GERD is an extremely common problem in the U.S.. 44% of Americans suffer from it at least once a month, and 20% suffer from it weekly. (1) Drug companies make $7 billion a year selling acid suppressing drugs - primarily proton pump inhibitors (PPIs) like Prilosec and Aciphex. The popularity of these drugs is predicated on the idea that GERD is caused by stomach acid burning the esophagus. This is known as the "chemical burn" theory. It holds that GERD develops from caustic, chemical injury that starts at the surface layers of the esophagus and progresses through the tissue to the deeper layers (the lamina propia and submucosa). (2) Early animal research seemed to support this. Studies showed large quantities of stomach acid with a pH of less than 2 does damage the esophagus. (3) However, the concentrations of acid used in these studies are much higher than those normally found in human episodes of reflux. In fact, the vast majority of human reflux episodes have a pH of more than 2 and are incapable of causing esophageal damage. (4)

What if GERD is not caused by acid burning the esophagus?

In a 2009 study Souza and colleagues connected the esophagus directly to the duodenum (the upper part of the small intestine) in a group of rats, thus permitting acid to reflux freely into the esophagus. (5) To their surprise, it took 3 weeks for damage to the esophagus to occur. Commenting on the results, senior author Stuart Spechler said:

That doesn't make sense if GERD is really the result of an acid burn, as we were all taught in medical school. Chemical injuries develop immediately. If you spill battery acid on your hand, you don't have to wait a month to see the damage.

If acid itself caused the damage, we'd expect to see the damage start at the superficial layers of the esophageal tissue, and then progressively deepen. Instead, this study found the opposite. 3 days after the initial acid exposure, there was no surface damage - but inflammation had already begun to develop at the deepest layer of the tissue. This inflammation didn't rise to the surface layers until about 3 weeks after the initial acid exposure.

This suggests that GERD is an autoimmune disease.

Acid refluxing into the esophagus doesn't damage the mucosal lining. Instead, it causes the esophagus to release inflammatory cytokines that attract inflammatory cells like interleukin-8, interleukin-6, and others. It is this inflammatory process - and not the initial exposure to stomach acid - that causes the tissue damage characteristic of GERD.

Do you have GERD - or NERD?

The theory that GERD is not caused by chemical injury is supported by the fact that 70% of westerners diagnosed with GERD have no visible tissue damage. In fact, these people don't have GERD at all. They have NERD, or Non-Erosive Reflux Disease. Tissue biopsy of their esophagus shows inflammation developing at the base layers of the esophagus like GERD sufferers, but no damage to the surface layers as the conventional theory would predict. It's unclear at this point why the tissue injury progresses to the superficial layers in GERD - but not NERD - sufferers, but this study suggests that the answer may be an autoimmune mechanism.

So what does this mean for you? How do you avoid GERD and NERD in the first place?

Even if GERD is caused by an autoimmune process as this study suggests, the initial trigger seems to be acid inappropriately moving from the stomach to the esophagus. But that does not mean GERD & NERD are caused by too much stomach acid, as the common dogma holds. In an earlier series of articles I presented evidence that acid reflux is caused not by too much stomach acid, but by not enough. I argued that low stomach acid causes bacterial overgrowth in the gut, which in turn produces gas that puts pressure on the lower esophageal sphincter, causing it to open and inappropriately allow acid into the esophagus. I also offered a simple, 3-step protocol for treating reflux and GERD without drugs that thousands of people have now successfully used (check out the 190 comments) - including people that had been on acid suppressing drugs for 20 years or more. This is important because acid-suppressing drugs have numerous side effects and complications.

Why you should think twice about taking acid-suppressing drugs.

Acid stopping drugs promote bacterial overgrowth, weaken our resistance to infection, reduce absorption of essential nutrients, and increase the likelihood of developing IBS, other digestive disorders, and cancer. The pharmaceutical companies have always been aware of these risks. When acid-stopping drugs were first introduced, it was recommended that they not be taken for more than six weeks. Clearly this prudent advice has been discarded, as it is not uncommon today to encounter people who have been on these drugs for decades – not weeks. What's more, a recent study showed that proton-pump inhibitors (PPIs) - the most popular class of acid-suppressing drugs - induce "rebound acid reflux" in healthy people. The researchers took a group of people without any history of reflux and put them on PPIs for 8 weeks (where did they find these volunteers???) More than 40% of the healthy volunteers developed rebound acid-related symptoms like heartburn, acid regurgitation and dyspepsia once they stopped taking the drugs. (6) The authors of the study stated:

If rebound acid hypersecretion (RAHS) induces acid-related symptoms, this might lead to PPI dependency and thus have important implications.

I'd say! If you suffer from acid reflux, make sure to read the entire series, and then follow the 3-step protocol I laid out. In a future article I'll be covering some additional natural treatments that studies have shown to be just as effective as PPIs, with virtually no side effects or risks.

Well, folks, I blew it with the audio this time.  My recording settings weren't set properly, so we had to use the Skype back-up.  Sorry! Pork has been getting a bad rap in the blogosphere lately.  In this episode we explore whether pork deserves the harsh treatment, or whether it's merely a victim of misunderstanding.  We also discuss a novel treatment for chronic sinusitis, which by some measurements is the most common chronic disease in the U.S., as well as a few other great questions.  Enjoy! In this episode, we cover: 4:38  Is pork a “dirty meat” that causes liver disease? 17:20  What do you recommend for chronic sinus infections? 27:58  Does high intra-abdominal pressure always cause GERD? 35:11  Are “properly prepared” grains OK to eat? 45:45  Is postnasal drip a sign of a bigger problem? 47:35  Should pregnant moms supplement with folic acid?

Links We Discuss:

• Ned Kock – Health Correlator Pork and Liver Disease Article
• Chronic Rhinosinusitis (CRS) and Biofilm Studies:

http://www.ncbi.nlm.nih.gov/pubmed/21739098 http://www.ncbi.nlm.nih.gov/pubmed/21814734 http://www.ncbi.nlm.nih.gov/pubmed/22144052 http://www.ncbi.nlm.nih.gov/pubmed/21865700 http://www.ncbi.nlm.nih.gov/pubmed/22088282 http://www.ncbi.nlm.nih.gov/pubmed/22182736 http://www.ncbi.nlm.nih.gov/pubmed/22241786 http://www.ncbi.nlm.nih.gov/pubmed/22287462

• Xlear Nasal Spray
• Histamine and Tyramine Diet Changes - Gut-Skin Axis Episode
• Pure Encapsulations Nutrient 950 Vitamins

[powerpress]

Full Text Transcript:

Steve Wright:  Hi everyone, and welcome to the Revolution Health Radio Show.  I’m Steve Wright from SCDlifestyle.com, and with me is Chris Kresser, health detective and creator of ChrisKresser.com.  How’s it going today, Chris? Chris Kresser:  It’s going pretty well, Steve.  How are you? Steve Wright:  I’m doing great, man.  I got my sling off yesterday, so I’m finally back to two arms. Chris Kresser:  Glad to hear it.  I bet that’s liberating. Steve Wright:  It is, it is; however, I have a bunch of new pains now, and I’m gonna have to learn how to sleep again.  So. Chris Kresser:  Right.  Ah, well, it’s all part of the fun, huh? Steve Wright:  Yeah.  Only like four more months, right?  So. Chris Kresser:  Ha-ha.  You’ll hardly remember it in a few years. Steve Wright:  Exactly! Chris Kresser:  Cool.  So, we have some good questions.  We’re gonna do a 100% Q&A episode today, which is a little unusual, but lots going on for me right now, and didn’t have time to prepare anything for the show, and I actually like doing these Q&A episodes every now and then.  Before we do that, though, I want to tell everyone -- I’m sure most of you have already heard of this, but in case you haven’t, I want to tell you about a really cool event that’s coming up starting on February 26 and running through March 4.  It’s put on by my good buddy, Sean Croxton, over at Underground Wellness, and it’s called The Paleo Summit.  So, this is an online conference with tons of great speakers in the Paleo/Primal niche, a lot of familiar names:  Mark Sisson, Jack Kruse, Erwin Le Corre from MovNat, Paul Jaminet, Diane Sanfillipo, myself, Sarah Fragoso, Mat Lalonde, Amy Kubal, Denise Minger.  So, it’s a great group of speakers.  And then even Matt Stone is gonna be there for the anti-Paleo perspective, so Sean is really interested in hearing from a number of different voices.  I think that’s great.  I enjoy that.  And it’s really cool because it’s free.  Free is good.  It’s gonna be accessible to everybody, and all you have to do is go there and register and you get a couple of bonus videos:  an interview with Mark Sisson and Sean and another with Sean interviewing Gary Taubes.  So, definitely check it out.  It kicks off on Sunday, February 26, and go to CKPaleoSummit.com to register.  So that’s CKPaleoSummit.com.  And I hope you enjoy it.  It’s a great opportunity to get exposed to some cool stuff, and unlike the Ancestral Health Symposium and PaleoFX, which are awesome events too that I’m speaking at this year, this one’s totally free, and you can participate from the comfort of your own home. Steve Wright:  Yeah, I’m pretty jacked about this.  I’m all signed up, and I think it’s gonna be great.  I think the speaker lineup is just amazing.  There are 24 people, right? Chris Kresser:  Yeah, 24 people.  I think eight days and three people on each day, and then there’s gonna be full transcripts and PDFs and videos and a whole package.  That part is not free, but if you want to have the whole thing so you can refer back to it afterwards, you’ll be able to do that.  So, it’s a cool format.  I think Sean is doing a great thing, and I’m looking forward to being a part of it.  My talk actually is gonna be -- it’s called An Update on Cholesterol, so I take a lot of the information that we discussed in the three-part series with Chris Masterjohn, and I distill it down into a really practical framework of what to do -- if anything -- if you have high cholesterol, when is it a problem, when is it not a problem, and what do you do about it from a natural perspective.  So, yeah, check it out.  It’s pretty exciting. Steve Wright:  All right, so should we roll on to the first question? Chris Kresser:  Yeah, let’s do it.

Is pork a “dirty meat” that causes liver disease?

Steve Wright:  OK, so here’s question number one from Marianne:  “I would love to hear what you think about pork consumption and liver disease, as referenced from an article this week from the Perfect Health Diet website.” Chris Kresser:  Yeah, this has caused a little bit of a stir.  So, for those of you that didn’t see it, Paul wrote an article quoting a 2009 study by Bridges showing a stronger correlation between liver cirrhosis and pork than liver cirrhosis and alcohol.  And Paul’s argument was, therefore, that eating pork may cause liver cirrhosis.  But, of course, correlation is not causation.  We talk about this a lot.  That’s research 101.  Two things occurring together does not necessarily mean that one thing causes the other.  So, it’s really crucial and important to understand that basic principle.  And Ned Kock, who has a blog called Health Correlator, which is pretty technical -- he’s a statistician and sometimes it’s over my head.  I’m not a statistician.  I get basic statistics, but when it gets really advanced, my eyes start to glaze over.  But this article is pretty easy to follow, and you should check it out if you are concerned about pork consumption after reading Paul’s article.  Ned did a more sophisticated multivariate analysis on the same study, and he found that the total effect of alcohol consumption on cirrhosis was actually 94% stronger than the total effect of pork consumption on cirrhosis.  He also pointed out that another factor that’s associated with liver cirrhosis is obesity, so in countries where pork is a staple, you might think it’s reasonable to assume that pork consumption may be correlated with obesity, but people who consume a lot of junk food also consume a lot of saturated fat, and they show up in the disease stats, but this is exactly the kind of confusion that led to the mistaken idea that saturated fat causes heart disease, right?  So, that idea rose out of epidemiological studies that saw:  Oh, these people are eating a lot of saturated fat and they have heart disease.  But what they didn’t control for was the fact that those people were also eating tons of other processed junk food that could very well have been contributing to heart disease, and it had nothing to do with the saturated fat, because later when they looked at studies that isolated those variables and they just compared saturated fat with other types of fat, they found that saturated fat did not increase the risk of heart disease.  So, we don’t want to make that same mistake here with pork and liver cirrhosis, and that’s why we can’t look at epidemiological data like this and draw causal relationships from it.  So, Ned went on to -- just for the other side of the coin -- to look at evidence that pork might be good for you.  And he took some data from NationMaster.com on pork and alcohol consumption and life expectancy, and it was a much larger list of countries than was used in the Bridges study, so it included Australia, Brazil, Canada, China, Denmark, France, Germany, Hong Kong, Hungary, Japan, Mexico, Poland, Russia, Singapore, Spain, Sweden, the UK, and the US -- so a broad representative sample from all different parts of the world.  And in that study, the link between pork consumption and life expectancy is actually positive, with a 0.36 correlation.  So, according to this data set, the more pork is consumed in a country, the longer people live.  And in fact, the data suggested that each additional gram of pork consumed per person per day adds an extra 13 days to their life expectancy.  Now before everyone runs off and goes on a 100% pork diet, you have to realize that this is merely a correlation too, so we can’t draw conclusions about causal relationships from this data either, but we can say that the data don’t prove that pork consumption causes liver cirrhosis unless, perhaps, you become obese from eating it.  Now there was a second part to that question, which was:  What about the idea that pork is a “dirty meat”, which is somewhat prevalent in the mainstream?  Conventionally raised pigs or pigs raised in confinement feeding operations are given a lot of antibiotics because of the conditions of their confinement, and the problem with this is that just like in humans, if you give animals a lot of antibiotics, they’ll develop antibiotic-resistant super strains of bacteria.  So, Canadian researchers have found antibiotic-resistant staph bacteria in conventionally raised pork products, and that could, indeed, be a problem.  Also improperly cooked and prepared pork may harbor parasites that can cause disease in humans, and there are two helminths or worms that we have in common.  Both humans and pigs can be affected by them, and they cause the same diseases in pigs and in us.  One is the nematode Trichinella spiralis, which causes trichinosis.  That’s the disease most people have heard of associated with pork.  And then a tapeworm, Taenia solium.  And both of these diseases were known to ancient cultures, including the Egyptian and Greek cultures, and then later on Jews and Muslims, which is probably why both Judaism and Islam proscribe the eating of pork.  But today, I mean, if you completely cook pork, if you cook it thoroughly, that should effectively kill the parasites if they’re present, and that’s probably why trichinosis has become pretty rare in the US, because cooking pork thoroughly has become a widespread practice.  And traditionally pork was marinated or cured, i.e. bacon, before cooking because the marinating and curing helped kill the pathogens, as well.  So, if you’re concerned about the potential of pathogens in pork, (1) don’t eat conventionally raised pork.  Get grass-fed, pasture-raised pork from a local farmer or a farmers’ market or a store that sells that.  And that will reduce the risk of super strains of antibiotic-resistant staph that you would find in conventionally raised pork.  (2)  You can marinate or cure pork before eating it.  One way to do that without using nitrates or nitrite salts is just to use a little bit of salt and a natural sweetener, like maple sugar, to treat the meat, to marinate it for a period of time, maybe 18 hours, 24 hours, and some spices with flavor, and then just make sure to cook it all the way through, and it shouldn’t be an issue.  So, you know, based on the evidence that I’ve seen, I don’t think that you can make an argument that pork is unhealthy or is associated with disease.  I think you can make an argument that undercooked pork or improperly prepared pork that’s raised in confinement feeding operations can contribute to that, but I think we need to be a little more specific, you know, when we make these kinds of statements. Steve Wright:  I’m glad you cleared that up, because I was really sweating about my bacon. Chris Kresser:  Ha-ha, I know!  A lot of people out there were freaking out.  Don’t mess with their bacon. Steve Wright:  Do you eat pork on a regular basis at all? Chris Kresser:  I do eat pork.  I like pork, and we get it from a local farm, and we do marinate it and prepare it that way, and we often, you know, we cook it for -- we’ll usually slow cook pork, like, if we get a pork shoulder roast or something like that, and we’ll turn it into carnitas, and we’ll roast it for a long period of time at a low temperature, and that will kill any potential pathogens in there.  I do eat bacon.  I’m not, you know, I don’t eat it every day, but I have it probably two or three times a week.  And I love pork chops, actually.  That’s one of my favorite kinds of meat.  So, I think, like I said, as long as you prepare it well and as long as you cook it thoroughly, it shouldn’t be a problem.  Now the other issue with pork is the omega-6 content, and this has less to do with how the pork is raised, although certainly pork that’s raised in confinement feeding operations is likely to have more omega-6 because of the food that they’re given, but even pasture-raised pork will have more omega-6 than beef or lamb or any other kind of wild game meat, of course.  But it has less omega-6 than chicken, than dark-meat chicken, so I don’t think the omega 6 issue is a reason to completely avoid pork.  I just think it’s probably a reason not to make it your staple meat that you eat every day, twice a day, but I don’t think it’s a reason to avoid it completely. Steve Wright:  I’m glad you brought that up, because I think most people hold chicken to be like the super-safe meat, but little do they know that it might not be so safe. Chris Kresser:  Yeah, I mean, it’s all in moderation.  Like, we have the ability to deal with some amount of omega-6, and eating dark-meat chicken, you know, once or twice a week, I don’t think it’s gonna cause any serious health problems for anybody.  I think that the risk in doing what I do and making people aware of these things is it’s sometimes difficult to convey the -- What am I trying to say?  It’s easy, I think, sometimes for it to come across too literally, and I’d like to find a way of communicating it where that’s less likely to happen.  But, you know, if I write an article that says omega-6 is proinflammatory in excess and contributes to various disease states, then sometimes that gets interpreted like I shouldn’t eat any omega-6; you know, like even half of an avocado is gonna make me keel over and die of a heart attack.  And I just don’t think that’s the case.  I don’t see evidence really to support that, and I don’t see it clinically in my practice.  I think it’s wise to reduce our omega-6 consumption significantly, as I’ve pointed out several times, but that doesn’t mean we can’t have dark-meat chicken or avocados or walnuts or things like that occasionally as part of an overall healthy diet.  And so, I think the same is true with pork, provided you follow the guidelines that I just mentioned. Steve Wright:  Yeah, I’m glad you brought that up.  I didn’t mean to demonize chicken in favor of pork or anything, because I think you’re right.  It’s hard for us as we read what you write and as we all do our own research, we’re always looking for a black-and-white answer.  And I think I’ve learned as you get deeper and deeper, you start to become more appreciative of the body we have and its systems, and you start to realize that everything is kind of on a continuum. Chris Kresser:  Um-hum. Steve Wright:  And there’s usually never a supremely right or supremely wrong way to eat some things. Chris Kresser:  Um-hum.  Very well said. Steve Wright:  Or natural foods, that is. Chris Kresser:  Um-hum.  Yeah, and it depends on a lot of factors too, like how healthy you are now, what your goals are, you know, where you’re coming from, and I think there’s a question later where we’ll get into more detail about this, but it’s just good to point out in the context of the whole pork thing.

What do you recommend for chronic sinus infections?

Steve Wright:  Cool.  Well, let’s roll on for the next question from David.  He asks, “What do you recommend for chronic sinus infections?  This is, according to some reports, the most common chronic disease in the United States.  Research by Mayo Clinic in 1999 found that virtually all (96%) cases of chronic sinusitis are caused not by bacteria but by fungus.  So, what is your approach to this?” Chris Kresser:  Yeah, this is a big topic, and maybe we’ll do an entire show on it, and we’ll have Kurt Harris come and help us out.  He is somewhat of an expert on this topic, and I’ve consulted him about it a few times.  And, yeah, I’ve read that Mayo Clinic thing, and it turns out to be a little bit of a red herring.  The consensus that I respect on fungus is that except for true fungal rhinosinusitis -- which is what the technical term is for chronic sinus infections, chronic rhinosinusitis or CRS -- true fungal CRS is easily diagnosable by the presence of eosinophilic mucin, but that’s actually pretty rare, and fungus in the nose is commensal, meaning it’s just part of the body’s natural terrain, and most cases of CRS have nothing to do with fungus being present, and furthermore, there is no good evidence that antifungal agents help in the treatment for fungal rhinosinusitis, which is relatively rare.  So, I don’t actually buy the fungus hypothesis for that reason, and my view on it is that it’s probably more like chronic, recalcitrant, difficult-to-treat sinus infections are more related to biofilm than fungus, and particularly in those who have had surgery and those who have poor immune function.  And there’s a bunch of studies that I’ve looked at connecting CRS to biofilm -- and we can put those studies in the show notes for anybody that’s interested -- but there are some pretty interesting emerging treatments for chronic sinusitis that relate to this biofilm hypothesis, and one of them is nasal irrigation with Johnson’s baby shampoo solution. Steve Wright:  What?! Chris Kresser:  Ha-ha, yeah, no joke.  This is in the scientific literature.  You’ll find studies in PubMed about this.  So, it’s a 1% Johnson’s baby shampoo solution, so you do kind of like a Neti or a nasal irrigation with the 1% baby shampoo.  And in the study, 60% of patients noted a significant improvement in symptoms, you know, reduction of thickened mucus and postnasal drainage. Steve Wright:  Is this biofilm, is this in the gut or is this in the nose or the cavities? Chris Kresser:  Biofilm is everywhere.  Biofilm is an extracellular matrix that bacteria reside in, and most pathogens actually we think now.  One really good example of biofilm is plaque, you know, the thin film that covers our teeth.  And this extracellular matrix allows the bacteria to share nutrients and also even DNA, and it protects them from our own innate immune defenses and also from any external antimicrobials that we might take.  So, it’s kind of like a protective community, strength in numbers, and as long as the bacteria are in the biofilm, a lot of the antibacterial agents that we use don’t really work.  So, that explains why some people take antibiotic after antibiotic after antibiotic with sinus infections and they just don’t recover.  So, one therapeutic approach is to disrupt the biofilm, and there are ways to do that topically, and there are ways to do that systemically.  So topically, one way is this Johnson’s baby shampoo irrigation, and the way it works is that Johnson’s baby shampoo has chemical surfactants in there, and you can think of them as like a therapeutic detergent to break up and assist in the eradication of biofilms, and that’s been known for a while.  That’s been used in the orthopedic literature, this use of chemical surfactants to break up biofilm.  But in chronic sinusitis, it probably has two benefits:  One is as a mucoactive agent, and mucoactive agents work either to increase the ability to expectorate sputum or to decrease mucus hypersecretion.  Or, number two, it has potential bactericidal activity; in other words, antibiotic activity.  So, that’s one.  Another solution that’s maybe a little bit more accessible to people and a little bit easier to get your head around are xylitol nasal drops.  Now xylitol is a sugar alcohol, but it has activity against biofilm, and this is one of the reasons why xylitol chewing gum has become popular amongst dentists.  As I just mentioned, plaque is a biofilm, so if you chew xylitol gum, that can actually help break up plaque.  So, these xylitol nasal drops, or there’s actually a nasal spray that’s called -- I’m not sure how to pronounce it.  It’s a very bad name.  Anyways, Xlear nasal spray.  And I’ve read a couple studies that use a similar solution and some accounts from doctors who are working with this stuff, and the consensus seems to be that it needs to be used pretty frequently, like up to three to four times a day, for it to work.  But unlike steroid sprays, which are often used in nasal sprays, xylitol doesn’t dry out the nasal passages, and it doesn’t inhibit the immune defense of the body.  Instead, it acts more as a lubricant, which makes it easier for natural mucus secretions to occur that kind of eliminate the pathogens.  I mean, the way it should work is that the mucus forms, and then you blow your nose and it carries the pathogens out of the nasal passage, and xylitol helps that to happen by lubricating them and acting as a surfactant that allows the nasal passages to clear.  So, another potential avenue, although I haven’t seen any research on this, is using a systemic biofilm disruptor, which would be something like InterFase Plus, and that’s a product that has EDTA and some enzymes that chelate -- Well, EDTA chelates some of the minerals that are needed to produce biofilm, that biofilm formation depends on.  And then there are some systemic enzymes that have been shown to break up biofilm.  So, that needs to be taken on an empty stomach, because if you take it with food, the enzymes in there will help digest the food, which is nice but it’s not really, you know, what you’re taking it for.  So, InterFase Plus needs to be taken on an empty stomach a couple hours after a meal or a half hour before a meal.  And, like I said, I haven’t seen any studies on systemic biofilm agents like this in chronic rhinosinusitis, but I do use InterFase for other kinds of infections, and I’ve found it to be extremely effective in most cases.  In fact, it seems to cause more of a Herxheimer or die-off reaction in treating infections than a lot of the botanical antimicrobials, which is indicative that it’s working. Steve Wright:  Interesting.  So, let’s back up to the very beginning of the question just to clarify this for everyone.  Chronic rhinosinusitis, you said, was kind of rare, so what’s -- Chris Kresser:  No, chronic rhinosinusitis is actually pretty common.  It might be one of the most common diseases there is, but the fungal chronic rhinosinusitis or fungal RS, as it is called, which is caused by a fungus, that’s rare. Steve Wright:  OK. Chris Kresser:  And that is easily diagnosed by looking for eosinophilic mucin, and there’s been an idea that -- I don’t know if it started with that Mayo Clinic article, but it’s been bounced around a lot in the blogosphere that all sinus infections are fungal in origin, and what I’m saying is I don’t think the evidence really supports that. Steve Wright:  All right, I gotcha. Chris Kresser:  Yeah, it’s more about biofilm than it is about fungus. Steve Wright:  OK.  That makes much more sense now. Chris Kresser:  Yeah, so I mean, of course, all of the other things apply, like all of the other things that you would do to regulate your immune system and not eating food toxins and making sure you have the micronutrients that support immunity, like vitamin C and iodine and selenium and, you know, exercise, all the basics apply here.  But I am assuming a lot of people are already doing that who are listening to this show, and they’re already eating a Paleo/Primal type of diet, and if they’re still having sinusitis, then you might want to investigate this biofilm angle.  I think the easiest way to do that is the Xlear -- or however you say that -- nasal spray and then possibly a systemic biofilm agent like InterFase Plus. Steve Wright:  OK, and don’t forget to check your vitamin D if this is a problem for you, as well. Chris Kresser:  Absolutely.

Does high intra-abdominal pressure always cause GERD?

Steve Wright:  All right.  So, let’s move on to the next one.  This comes from Brendan:  “I’ve got one regarding your position on GERD.  In my medical nutrition therapy class at school my professor taught us that increased pressure from the other side of the lower esophageal sphincter actually helps to keep the sphincter closed and that a lack of pressure allows it to relax and allows the reflux to occur.  This seems to conflict with your idea that bacterial overgrowth leads to increased intra-abdominal pressure and causes reflux.  I tend to trust your information more, but I wanted to get your opinion on this.” Chris Kresser:  A real tongue-twister, huh? Steve Wright:  Man!  Got me all messed up. Chris Kresser:  Ha-ha.  So, I think the first thing I want to say is I don’t believe that all GERD is caused by one thing.  GERD is a pretty vast landscape of varying conditions, and a lot of what is referred to as GERD, gastroesophageal reflux disease, is actually NERD, which is non-erosive reflux disease.  There are lots of different presentations, lots of ways that it shows up and manifests, and I don’t think they’re all caused by the same thing.  In fact, some people do produce excess stomach acid, and that is the cause of their problem.  That’s a minority.  According to the scientific literature, it’s a small number of people, but it doesn’t mean that, you know, the fact that I wrote that series suggesting that GERD is caused by low stomach acid primarily and bacterial overgrowth doesn’t mean that that’s true in 100% of cases.  So, just wanted to clarify that.  The main pathology involved in GERD or NERD is transient lower esophageal sphincter relaxations or TLESRs, as they are referred to in the literature.  And so, just a little anatomy/physiology here:  The esophagus is separated from the stomach by the lower esophageal sphincter, and that sphincter should most of the time be closed, and it opens, of course, when we eat and when we burp and things like that.  One of things, I mean, the main thing that happens with GERD or NERD is that you get these transient relaxations of that sphincter at inappropriate times, so the sphincter will open or relax when it should be closed, and then you get a reflux of acid or bile into the esophagus, and that causes the symptoms associated with reflux.  So, studies have shown that gastric distension increases the number of TLESRs, the number of these transient relaxation events.  And, of course, gas can increase gastric distension and thus can increase the number of transient relaxations and reflux.  So, I think you can make an argument -- I understand where the question is coming from, and it’s true that pressure could, in theory, keep the sphincter closed, but it turns out that, according to the studies, that this gas and gastric distension actually increases the number of relaxations that happen.  And if you do a search on PubMed for gastric distension and TLESRs, you’ll see the study come up, and you can take it in and show it to your professor.  Also, I think it’s important to look at actual clinical results.  I’ve talked about this three-legged framework I use for determining whether something is valid or for testing a hypothesis.  And one of those legs is modern scientific research; that’s important.  Another leg is traditional wisdom, evolutionary medicine, which is also important.  You know, does it check out according to what we know about ancestral health?  And then the third leg, which I think is also very important, is clinical experience.  And, so, for something to really check out for me, it has to pass all three of those tests.  And if you look at the comments on some of those GERD articles, particularly the three steps to curing GERD article, you’ll see literally hundreds of people that have tried this protocol and that were suffering tremendously and had been on PPIs in some cases for as much as 20 years or acid-suppressing drugs for 20 years and were able, using this protocol, which is geared, you know, towards reducing the bacterial overgrowth in the small intestine and improving, increasing stomach acid production via HCl, have been able to stop for the first time in their lives their acid-suppressing drugs and have been able to eat food without reflux for the first time in their lives.  So, I think that’s highly significant and shouldn’t be ignored as part of this whole picture of figuring out reflux and GERD.  I will say that there are some people that that protocol doesn’t work for, and they very well may be the people that do produce excess stomach acid for other reasons, and in those cases something like melatonin and methylation precursors, serotonin precursors might be a better option because melatonin has been shown to regulate the contractility of the lower esophageal sphincter, and that’s probably why it works in a couple studies as well as PPIs, a combination of melatonin and serotonergic nutrients like 5-HTP and methyl donors like B6 and B12 and folate.  So, I think that’s it.  That’s how I’m tying together the gastric distension and gas and the transient lower esophageal relaxations. Steve Wright:  You know, the one thing I’ve never really understood, Chris, is with the lower esophageal sphincter, is that like a flap, like a trapdoor flap, or is it more like an opening and closing of, like, a hole?  How does it actually work? Chris Kresser:  It’s more like a flap, I think. Steve Wright:  OK. Chris Kresser:  I’m not totally sure, actually.  It would be interesting to see a picture. Steve Wright:  Yeah, I’ve never seen one, and I was just curious because with some of these, you know, low pressure / high pressure kind of is determinant upon how it actually mechanically works. Chris Kresser:  Yeah, I’m pretty sure it’s a flap.

Are “properly prepared” grains OK to eat?

Steve Wright:  Interesting.  OK.  Let’s more on to the next one.  This comes from Monica, and she would like to know your thoughts regarding several real food bloggers who are recently posting about wheat, grains, and even gluten and the fact that they are not inherently bad and if properly prepared after having undergone a gut-healing protocol, can be consumed without ill effects. Chris Kresser:  I bet she’s talking about Matt Stone. Steve Wright:  Yeah, I’ve seen some from, I think, Cheeseslave, as well. Chris Kresser:  Yeah.  Just getting a little sip of water here.  Let’s get back to what you and I were talking about at the end of the first question on pork.  Health is a continuum, so if you have on the one hand death, which is the end of health, and on the other hand you have perfect health, then there’s a huge, huge spectrum of what you can experience in between those two extremes.  And I just assume that most people who are listening to the show and who are reading my website are interested in optimizing their health, and so that’s the audience that I’m speaking to.  I’m also, because I’m a health care practitioner, I’m speaking in particular to an audience that’s dealing with chronic health issues and disease, so you know, above and beyond just people who want to optimize their health, I’m really more focused on people who have health problems, and I’m trying to help them recover.  So, a lot of what I speak and write about is geared towards that audience, and that’s important to understand because that audience is more likely to experience difficulties with foods that may not be problematic for people that are otherwise healthy, and I think grains and wheat and even gluten fall into this category, where -- Well, let’s break them down separately.  So, gluten, I think, is an inflammatory protein on its own, and so I don’t actually recommend that even healthy people eat it for that reason, but does that mean if someone who is very healthy, has a really healthy gut and no real health issues to speak of is gonna keel over and die if they eat a piece of bread a few times a week?  I don’t think so.  Probably not.  And, you know, we can handle some amount of inflammation.  We can handle some amount of toxicity, of toxins.  You know, there’s a concept called hormesis where a small amount of toxin actually sensitizes our immune system and our ability to cope with larger amounts of toxins.  So, I think that you really have to consider who is asking the question, where are they coming from, again, what are their goals, are they trying to optimize their health to the greatest possible degree and feel as good as they possibly can?  Most people in that situation do better without wheat and gluten, in my experience.  That doesn’t mean there aren’t people that are exceptions.  It doesn’t mean that you can’t eat some wheat and gluten if you’re healthy and still feel fine.  But if you’re interested in absolutely optimizing your health, I think you’re better off without it.  Now, with grains -- and there is a distinction here between grains that are not properly prepared and grains that are properly prepared.  Grains that are not properly prepared have a number of food toxins in them that are part of the plant’s natural defense system, and of course, people who are following a Paleo and Primal type of diet are well aware of all of this.  But again, you know, for someone who is basically healthy, some small amount of grain may not be that big of a deal.  And even for people who are not that healthy, if you properly prepare the grains and break them down, break down the phytic acid, break down some of the food toxins by soaking or fermenting or sprouting, then grains may not present any problem at all, even for someone who is not at the top of their health.  But I’ll say in my experience as a clinician that most people who are sick or who are dealing with gut issues or immune dysregulation or any number of other conditions generally feel better without grains, as a general rule.  But these are all general guidelines, and they’re all subject to all of the variables that I’ve mentioned.  You know, what’s the current health status, what’s the constitutional health, what are the goals?  So, I think that’s why I get a little bit irritated about all of the debating because it’s kind of nonsensical unless you know what the context is. Steve Wright:  That makes sense, and I think you brought up something really important there, which is the toxic load.  You know, if you’re pretty healthy and you recovered your health, if you keep the toxic load pretty low and you eat a non-prepared grain every once in a while, it’s likely that you probably wouldn’t see a problem because your body is designed to handle that load. Chris Kresser:  That’s right.  Exactly.  And then let’s take it a step further:  I’ve said this in the Beyond Paleo, previously the 9 Steps series, but there’s more to health than food.  You know, there is!  There’s a lot more to health than food.  There’s movement and exercise.  There’s sleep.  There’s stress management.  There’s cultivating pleasure.  There’s having a purpose and feeling like your life is meaningful and you’re serving others or some higher purpose that goes above and beyond just, you know, getting what you want.  I think that’s actually a really crucial element that contributes to health.  There’s relationships, how you relate to your partner, your kids, your colleagues at work.  There’s connection with nature, and you know, this whole earthing movement that’s kind of taken on steam lately in the Paleosphere; there’s concern with that.  So, there are so many things that contribute to whether we feel healthy on a daily basis and whether we prevent disease or recover from disease, and food is a huge part of that equation, of course.  I think it’s pretty clear that I believe that from what I write.  But it’s not the only variable, and when obsession with food happens at the expense of all of those other things that contribute to health, then actually even eating really healthy food can become problematic.  I think we talked about this on a previous episode, my beer and pizza story. Steve Wright:  Yeah, I’m not sure I remember that, but sounds like a fun diet, maybe?  I don’t know.  Ha-ha! Chris Kresser:  Ha-ha!  OK, I’ll tell it again.  It’s not my beer and pizza story, but I’ll tell it briefly again for people who are new to the show.  So, I was in San Diego way back when I was in school, and I was interning with a holistic doctor, and he specialized in, you know, treating people who were dealing with chronic mysterious kind of diseases.  And we had a young guy, I think he was like in his early 20s, and he came to us and he was really emaciated, really sick, and just couldn’t eat anything.  And, so, the doctor further restricted his diet, and I mean, he got down to the point where he was eating like boneless, skinless chicken breasts, broccoli, and quinoa, I think were the only three foods he was eating.  And each time he came back to the office, he was just literally wasting away in front of our eyes.  He looked like death.  You know, he looked so sick.  And he was this young guy, you know, like totally in the prime of his life.  So, he disappeared, stopped coming.  We didn’t see him for, like, six to seven months, and then he came back to the office and he was literally -- We didn’t even recognize him.  He looked like a different person.  He had gained like 40 pounds, no dark circles under his eyes, really good complexion, you know, looking extremely healthy.  And the doctor and I were both like, “Whoa!  What happened here?  What was it?  Was it diet?”  And he’s like, “Yeah, it was diet.”  And we said, “Well, what was it?  The anti-candida diet or the macrobiotic diet?  Which one was it?”  And he said, “It was the beer and pizza diet!”  Ha-ha, and we were like, “What?”  And he said, “Yeah.  I just got to the point where I thought if I’m gonna die,” which he though he might, “I’m gonna just forget about all these dietary restrictions and have some fun before I check out.”  And so, he decided that at three days a week he would go out with his friends and have beer and pizza and the rest of the time he would eat whatever he wanted.  And after, you know, several months of doing that, he was completely transformed and completely well.  And, you know, there are a lot of caveats to the story, but in his case, I think, a lot of what was happening was social isolation and he had broken up with his girlfriend because she just, you know, couldn’t handle being with him, and there was a lot going on behind the scenes there, and I’m not suggesting that it’s as simple as just, you know, having fun and eating whatever you want.  That’s ridiculous.  It doesn’t work that way for everybody.  But I am suggesting that that’s how powerful the mind and the heart can be in the healing process and that sometimes eating the wrong food with the right attitude is a better choice than eating the right food with the wrong attitude. Steve Wright:  Hmm.  Good advice.  OK, well I know we don’t have that much more time here, so let’s ask at least one more question. Chris Kresser:  All right.

Is postnasal drip a sign of a bigger problem?

Steve Wright:  This one comes from Warren, and he’s wondering -- and it kind of might relate to a previous question -- he’s wondering about postnasal drip.  Is it a sign of a larger problem, and could it be helped by just eliminating dairy? Chris Kresser:  Uh, yes, it is a sign of a larger problem.  That’s not a normal physiological process.  And eliminating dairy is certainly a good step.  I think if you’re not already eliminating wheat and grains, that’s important too.  Wheat tends to have a really strong connection with sinus problems, in my experience.  And, so, a Paleo type of diet as a starting place, maybe a 30-day challenge where you eliminate dairy and -- I don’t really know necessarily that an autoimmune version is necessary, but if you wanted to be really thorough, you could do that and eliminate eggs and nightshades and all dairy for 30 days and then start adding those things back in sequentially.  And if you’re still having the postnasal drip at that point, it’s possible that there’s a histamine issue there.  You could try a low histamine and tyramine diet, which we’ve talked about before on the show when we talked about skin problems, the gut-skin issues.  And then if you’re still, after that, having issues, it’s probably time to seek out some help and see what’s happening with the immune system. Steve Wright:  So, if you’re already on a Paleo diet and you don’t think you have a histamine problem, it’s indicative of an immune system dysregulation? Chris Kresser:  Yeah, immune dysregulation, some inflammation there in the sinuses.  Yeah, definitely. Steve Wright:  OK. Chris Kresser:  We can do one more.  I see that the next one is pretty short, too.

Should pregnant moms supplement with folic acid?

Steve Wright:  All right.  This one comes from Sally, and she would like some advice on the whole folic acid issue.  Is there any prenatal vitamin you do recommend?  And if so, which? Chris Kresser:  Yeah, so, folic acid is a synthetic form of the active methyltetrahydrofolate, or there are different versions of active folates other than that.  But folic acid -- the important thing to realize is it’s a synthetic chemical that’s not found in nature in the body, and it has to be converted via several steps into the active forms of folates, which are what the body needs and can utilize.  So, the problem is that most multivitamins, including prenatal vitamins, use folic acid, and what happens in a lot of people is that that conversion is poor from folic acid to active folates, and you get a buildup of unmetabolized folic acid.  And unmetabolized folic acid has been linked with cancer and other health problems, and this can happen at doses as low as 400 mcg a day.  It certainly is more likely to happen at higher doses of 800 mcg per day, which is often what’s in pregnancy multis.  So, you want to make sure if you’re taking supplemental folate that it’s an active form of folate.  So, sometimes it’s abbreviated as L-5-MTHF, which is 5-methyltetrahydrofolate.  There’s a brand name called Metafolin.  It is used in Thorne products and Pure Encapsulations and some other products.  You just want to make sure on the bottle that it says “folates” on there and not “folic acid.”  But in terms of a prenatal that I do recommend, there aren’t that many because most multivitamins, in my opinion, have too much of the wrong thing and not enough of the right thing.  But the one I would recommend is Nutrient 950 with Vitamin K, and that’s by Pure Encapsulations, and you can find it online.  It’s more expensive than other choices, but it’s definitely worth it.  There’s not much that’s more important than nourishing your body with the right nutrients if you’re trying to conceive.  That said, I think prenatals are not strictly necessary if you’re getting all of the nutrients that you need from food.  Additional folate is one of the few things that I think is crucial even if you’re eating a Primal/Paleo type of diet because it’s so important for the development of the fetus and the prevention of neural tube defects that I think it just makes sense to take some extra folate during prenatal period and during pregnancy. Steve Wright:  And you couldn’t really get that from food or you’d have to eat too much greens or anything probably? Chris Kresser:  Yeah, I mean, you can get some folate from foods, but folate is highest in chicken liver, lentils, and leafy greens.  You’d have to eat a lot of, you know, like, six to eight cups of dark leafy greens a day to get the recommended folate amount.  You’d only have to eat 3 ounces or so of chicken liver, but I don’t know that many people that are eating 3 ounces of chicken liver.  And then grains and legumes are other sources of folate, and those are not happening on the Paleo and Primal type of diet, so I think supplemental folate is a good idea. Steve Wright:  OK, awesome.  Good to know.  I think that will help a lot of people. Chris Kresser:  Yeah, and if, you know, folks need more guidance on this specifically, you can check out The Healthy Baby Code, HealthyBabyCode.com.  That’s my whole program with a lot of detailed information about fertility and pregnancy nutrition. Steve Wright:  If someone is thinking about getting pregnant, how soon should they begin supplementing?  Is it a couple months or a year? Chris Kresser:  Well, yeah, probably.  I mean, honestly, in some ways the sooner the better.  I mean, to an extent.  There’s no need to start 10 years in advance, but if you started a year in advance, you would just improve your chances of conceiving easily probably.  And, you know, there’s no reason not to do that maybe other than expense because folate at the kind of dose I’m recommending is well tolerated and is not gonna cause any problems.  So, you know, six months to a year before, I think, starting the special fertility stuff is a good idea. Steve Wright:  You definitely want to pick up The Healthy Baby Code so you get all the info about what you should be doing. Chris Kresser:  All right.  I think that’s it. Steve Wright:  Yeah, I think that’s what we got for questions this time. Chris Kresser:  Let’s call it a wrap. Steve Wright:  All right.  It’s been a good show.  If you’re new to the Paleo Diet or you’re just interested in optimizing your health, check out Beyond Paleo.  It’s a free 13-part email series on burning fat, boosting energy, and preventing and reversing disease without drugs.  To sign up, go to ChrisKresser.com and look for the big red box.  Chris and I want to thank you for listening today, and please keep sending us your questions at ChrisKresser.com using the podcast submission link.  If you enjoyed listening to the show today, head over to iTunes and leave us a review.

Instead of opting for PPIs, GERD can be reversed by managing gut health. This article will walk through how to replenish stomach acid and other digestive aids and how to restore the balance of good and bad GI bacteria through the Paleo diet, lifestyle changes, and possibly supplements. Keep reading to learn how to cure GERD without medication.

The Most Common Digestive Disorder in America

Almost everyone experiences occasional acid reflux when stomach acid manages to make its way up into the esophagus. However, if this happens frequently and causes uncomfortable symptoms or complications, you could receive a GERD diagnosis. Symptoms of GERD can include:

• Heartburn
• Regurgitation
• Difficulty swallowing
• Laryngitis
• Chronic cough
• Asthma
• Dental erosions

As the most common digestive disorder in the United States, GERD affects an astonishingly large portion of Americans. Up to 40 percent experience symptoms once a month and 20 percent experience them once a week. (1, 2) That growing problem has been a boon for pharmaceutical companies, as Americans spend over $13 billion on acid-stopping medications each year. In 2010, sales of esomeprazole, a PPI prescribed to manage GERD, among other conditions, alone exceeded $5 billion in sales. (3)

Gastroesophageal reflux disease (GERD) causes uncomfortable, painful symptoms—but the health risks of the drugs used to treat it can be even more distressing. Check out this article for tips on how to cure GERD without PPIs, H2 blockers, and other medication.

Aside from an uncomfortable and frequent burning sensation, GERD also carries some long-term complications. Unlike the stomach, the esophagus doesn’t have a protective layer to prevent acid damage. As a result, GERD can lead to:

• Scarring
• Constriction
• Ulceration
• Cancer of the esophagus

In addition, research demonstrates a strong link between GERD and irritable bowel syndrome (IBS), which is now the second-leading cause of missed work in the nation.

What Causes GERD? It Isn’t What You Think

Too much stomach acid is not the driving cause of GERD. Don’t get me wrong; I agree that hydrochloric acid (HCl) in the esophagus is bad news. Stomach acid itself is a good thing, but only when it stays in the stomach. When it escapes upwards into the esophagus, something has gone awry.

However, instead of trying to figure out why acid isn’t properly staying in the stomach, pharmaceutical companies blame GERD on too much stomach acid and make billions from selling acid-suppressing drugs like PPIs, H2 blockers, and antacids. Meanwhile, the problem of why gastric acid reaches the esophagus is never addressed. That creates a lifelong dependency on medication for millions of Americans, which is incredibly profitable for the pharmaceutical industry.

Disproving the Stomach Acid Theory

When you look at the data, blaming GERD on too much stomach acid doesn’t make sense. Stomach acid actually tends to decline, not rise, with age, while GERD risk increases with age. (4) In fact, 40-year-olds, on average, generate about half as much as stomach acid as 20-year-olds do. (5) And, according to one study, over 40 percent of people age 80 and up may be producing almost no stomach acid at all. (6) What’s more, my patients with GERD or heartburn have responded very well to HCl supplementation, which actually increases their stomach acid. That’s the opposite of what we would expect if excess stomach acid were to blame for the problem.

You need adequate stomach acid to kill opportunistic pathogens, help properly digest food, and maintain optimal health. Reduced stomach acid correlates with a wide range of health problems, and PPIs can easily exacerbate the condition.

The Real Cause of GERD

So if “too much acid” isn’t the driving force behind heartburn, what is? The real cause of GERD is an increase in intra-abdominal pressure (IAP). (7, 8, 9)

Here’s how it normally works. A bundle of muscles at the end of the esophagus, called the lower esophageal sphincter (LES), keeps your stomach contents from traveling up into your esophagus as acid reflux. Aside from swallowing and burping, the LES remains closed. However, if you’re experiencing changes in your IAP, the sphincter relaxes and opens at inappropriate times. That allows GERD to become a problem.

How Extra Pressure Builds in Your Abdomen

Several different factors could contribute to an increase in your IAP. According to current consensus, these include:

• Overeating
• Obesity
• Bending over after eating
• Lying down after eating

While these factors do play a role, I don’t believe they’re the primary drivers behind the increased pressure I see in patients with GERD. As microbiologist Dr. Norm Robillard argues in his book, Heartburn Cured: The Low Carb Miracle, carbohydrate malabsorption could be to blame. Malabsorption of carbs can cause bacterial overgrowth, which generates excess gas and increases IAP. That manifests as GERD.

The Surprising Role Stomach Acid Plays in GERD

If malabsorption of carbs can cause increased abdominal pressure—which leads to heartburn—what’s the reason for the absorption problem in the first place? Interestingly enough, this question brings us right back to healthy stomach acid levels.

Low stomach acid can cause malabsorption of carbs and bacterial overgrowth. In many cases, low stomach acid may be the driving force behind increased IAP and GERD. Let’s explore how.

How Low Stomach Acid Leads to Increased IAP and GERD

Stomach acid is part of the body’s innate immune system, the first line of defense against pathogens. Most bacteria can’t survive the stomach’s highly acidic environment. If you don’t have enough stomach acid, many of the pathogens that would normally be destroyed may survive the stomach and make their way into the rest of the GI tract. (10) This can lead to chronic gut infections, impaired digestion, and an increase in IAP and GERD.

Stomach acid also helps your body absorb many macro- and micronutrients. HCl stimulates the release of pancreatic enzymes and bile into the small intestine to help metabolize carbohydrates and fats. Without enough acid, your body can’t digest carbohydrates properly. Those undigested carbs are then fermented by bacteria in a process that generates excess hydrogen gas. Again, that excess gas increases IAP and contributes to GERD.

PPIs Suppress Heartburn Symptoms, but Worsen the Problem

Despite the dangers of PPIs, American filled over 170 million acid-blocker prescriptions in 2014. (11) When it comes to total cost expenditure, only statins beat out PPIs.

How Acid-Blockers Work

The parietal cells in your stomach normally release HCl through a proton potassium pump to maintain a very low pH. PPIs inhibit the enzyme required for the pump for up to three days after you take them. (12, 13) When that pump is inhibited, your stomach pH rises as less acid is released.

Since PPIs reduce the acid in your stomach, you feel fewer of the uncomfortable symptoms associated with GERD. However, despite that quick relief, the medication actually worsens the underlying problem. Your decreased stomach acid can lead to bacterial overgrowth and malabsorption of carbs, and so GERD perpetuates—and your reliance on PPIs continues.

Other acid-blockers are not much better. Histamine H2 receptor antagonists, or H2 blockers, block the histamine receptors in your parietal cells. The cells become less responsive to acid-promoting stimuli, and they release less stomach acid. Though they are less effective than PPIs, H2 blockers like cimetidine, ranitidine, and famotidine still lower stomach acid.

These Medications Can Affect the Whole Body

Although PPIs are designed specifically to target parietal cells in the stomach, accumulating evidence shows that they can impact the proton potassium pumps in other body tissues. (14)

Are PPIs Putting Your Health at Risk?

When PPIs were first marketed, patients were advised to take them for a maximum of six to eight weeks. But now, it’s not uncommon for patients to be on PPIs for decades. (15) The outcome? Potentially dangerous health consequences.

Recently the FDA has issued several warnings concerning the long-term risks of PPIs, including bone fractures and even life-threatening infections. (16, 17, 18) New research articles pop up every few weeks with evidence linking PPIs to various health problems. I could write a whole book on the subject. But, as I want this article to focus on how to avoid PPIs altogether, I’ll only focus on some of the risks associated with acid-suppressing medications.

Increased Risk of Infection

As I discussed above, stomach acid serves as a first-line defense against pathogens. The ideal pH for the stomach can approach 1 but should be below 3, where most pathogens cannot survive. When the pH rises above 5, several dangerous bacterial species are able to survive.

Acid-blockers can increase the stomach’s pH and worsen the risk of a bacterial infection. In one study, Tagamet and Zantac, two H2 blockers, raised the stomach pH from 1–2 to 5.5 and 6.5, respectively. (19) PPIs can raise the pH even more. In one study, a 20- or 40-mg dose of Prilosec reduced stomach acid levels to almost zero—and increased the pH to almost 7—in 10 healthy men. (20)

Without stomach acid, pathogens can thrive. Oral bacteria such as the genus Rothia are over-represented in the gut microbiota of PPI users, indicating that bacteria entering the through mouth are better able to survive in the stomach. (21)

Compared to people on other medications, PPI users have a greater risk of acquiring infectious bacteria like: (22, 23, 24)

• Clostridium difficile
• Campylobacter
• Salmonella
• Shigella
• Listeria

Gastroenteritis, which results in millions of lost work days each year, is also more likely in PPI users. (25, 26, 27)

Long-term PPI use also increases the risk of other infections, including:

• Pneumonia (28)
• Tuberculosis (29)
• Typhoid (30)
• Dysentery (31)

Small intestinal bacterial overgrowth, or SIBO, is another possible result of PPI usage. (32) SIBO can inhibit nutrient absorption, damage the bowel lining, and cause diarrhea and other GI symptoms. One research study found that 50 percent of PPI users tested positive for SIBO through the hydrogen breath test, compared to only 6 percent of non-users. (33) Meta-analyses have mostly confirmed this association. (34, 35)

PPIs not only increase the risks of infections, but they independently reduce the body’s ability to fight them. (36, 37)

Impaired Nutrient Absorption

Gastric acid increases after a meal to help with nutrient absorption in a number of ways. HCl activates proteases, which break apart the bonds between amino acids, the building blocks of proteins. An acidic environment also helps your body dissociate mineral ions from salts, such as magnesium and calcium. A low stomach pH also kills most bacteria, which can compete with the body for nutrients if the bacteria count is too high. (38)

In theory, low stomach acid could impair the absorption of many dietary nutrients—and that’s exactly what the research indicates. A growing number of studies show correlations between PPIs—and lower stomach acid—and lower nutrients status for many vitamins and minerals:

• Vitamin B12 (39, 40, 41, 42)
• Iron (43, 44, 45, 46)
• Magnesium (47, 48, 49, 50)
• Calcium (51, 52, 53)
• Folate (54, 55)
• Vitamin C (56)
• Zinc (57)

Many health professionals believe that because deficiencies are relatively rare, they are not worth worrying about due to the health “benefits” of PPIs. The American Gastroenterological Association reported in 2017 that PPI users should not be routinely screened for bone mineral density, magnesium, or vitamin B12, which is mind-boggling to me. (58) Not all studies have confirmed correlations between nutrient deficiencies and acid-suppressing drugs, but patients need to be informed about the real risks of PPI use, especially as more and more take them for extended periods of time.

Bone Fractures

In 2010, the FDA changed PPI labeling to indicate bone fractures as a possible risk. (59) These drugs may impact bone health by reducing calcium absorption or by inhibiting bone resorption, a process that’s required for long-term bone integrity. (60) After the 2010 label change, even more large analyses found associations between PPI use and fractures. (61, 62, 63)

Cardiovascular Events

A number of studies from different countries show that PPIs are an independent risk factor for heart attack. (64, 65, 66, 67) In a retrospective cohort study of over 50,000 participants, those on PPIs had a 30 percent increased chance of cardiovascular death, recurrent heart attack, or stroke within the first month of discharge after a first-time myocardial infarction. (68) A 2018 article went so far as to call PPI a “cardiovascular bomb” for its associated heart risks. (69)

We don’t fully understand how PPIs are able to affect heart health. Some possible mechanisms might involve:

• Hypomagnesemia
• Lysosome inhibition
• Reduced nitric oxide production (70, 71, 72, 73)

Kidney Disease

PPI metabolites may deposit in kidney cells, causing an immune response that ultimately can lead to kidney dysfunction. Proton pumps are present in kidney cells, although it’s unclear if these drugs can target kidney cells specifically. (74)

Compared to patients using H2 blockers, PPI users were almost two times as likely to develop end-stage renal disease over a five-year study period. (75) The risk of acute interstitial nephritis (a type of kidney inflammation) was two to five times higher in PPI users versus non-users in three large separate analyses from the United States, Canada, and New Zealand. (76, 77, 78)

Cognitive Decline

PPI users also have higher risks of dementia, Alzheimer’s disease, and general cognitive impairment compared to those not using these drugs. (79, 80, 81) PPIs could be interfering with the reuptake of neurotransmitters, and mouse models indicate that PPIs increase the production of amyloid beta, the protein that accumulates into the hallmark plaques of Alzheimer’s disease. (82, 83) A third mechanism may involve vitamin B12 deficiency, which is associated with cognitive decline and also PPI use.

Other Health Problems

The research concerning the dangers of PPIs could fill an entire book. I have only briefly covered some of the risks of PPIs, but other problems associated with low stomach acid or PPI use include the following:

• Liver problems (84, 85, 86)
• Stomach cancer (87, 88)
• Asthma (89, 90)
• Celiac disease (91)

How to Cure GERD without Medication

I hope I’ve convinced you that PPIs and other acid-blocking drugs are not going to cure GERD, will only perpetuate the symptoms, and may have serious health consequences. But, if you are willing to put in the work, you can cure GERD using this basic plan:

• Reduce factors that promote bacterial overgrowth and low stomach acid
• Replace stomach acid, enzymes, and nutrients that aid digestion and are necessary for health
• Restore beneficial bacteria and the healthy mucosal lining of the gut

Increase Your Stomach Acid

As long as your low stomach acid levels are low, you’ll continue to experience acid reflux and other distressing GERD symptoms.

Supplement Your HCl

Because your acid reflux will continue if your low HCl isn’t fixed, I recommend HCl supplementation. While it’s possible to test the pH of your stomach, very few doctors have the equipment or are willing to do the test. However, my patients have great success increasing their stomach acid using iterative HCl supplementation. Here’s the general protocol:

• Take one 650 mg capsule of HCl with pepsin at the beginning of each meal
• After two or three days, increase to two capsules each meal
• After two more days, increase your dosage to three capsules
• Keep increasing until you feel a slight burning sensation (or until you reach five or six capsules; I don’t suggest taking more than this)
• Dial back your dose by one capsule

Take Bitter Herbs

The next step is to take bitter herbs. Because herbs can’t be patented, they aren’t often studied in clinical trials without the cash incentive for pharmaceutical companies. But, in Chinese medicine, bitter herbs are known to increase the flow of digestive juices including HCl, bile, pepsin, gastrin, and pancreatic enzymes. (92, 93) Examples of bitters include:

• Barberry bark
• Caraway
• Dandelion
• Fennel
• Gentian root
• Ginger
• Globe artichoke
• Goldenseal root
• Hops
• Milk thistle
• Peppermint
• Wormwood
• Yellow dock

Bitter herbs probably won’t help with nutrient absorption to the same extent as HCl supplementation will, so this route is better suited for someone who hasn’t been taking PPIs for long or hasn’t even started taking them.

Avoid Drinking Water While You Eat

It’s also important to avoid drinking water during meals. This literally dilutes stomach acid further, which will hinder your digestion and nutrient absorption.

Treat Your Bacterial Overgrowth

The next step in understanding how to cure GERD without drugs is addressing bacterial overgrowth. Low stomach acid allows bacteria to thrive in the stomach, compete for nutrients, and generate excess gas. Treating the problem can involve several steps, depending on your individual underlying issues.

Treat SIBO

As I mentioned, the data show strong correlations between GERD and SIBO. While this chronic disease can be particularly difficult to address, it’s essential that you treat SIBO. Antibiotics are somewhat successful, but recurrence develops in almost half of all patients within one year. (94) Studies using probiotics to treat SIBO have been mixed. Many commercial probiotics contain strains that produce D-lactic acid (like L. acidophilus), which might make the digestion problems even worse.

Because it’s so challenging to treat effectively, I deal with a lot of unanswered questions about SIBO in my practice. You do have several treatment options, including a low-FODMAP diet, a botanical antimicrobial protocol, a prokinetic agent supplement, and, in some cases, low-dose naltrexone. Often, diet alone is not enough to treat SIBO.

Take Probiotics

Probiotics are quite the buzzword lately, but not all probiotic foods and supplements are created equal. Quality probiotics have the potential to reduce bacterial overgrowth by protecting and competing against pathogenic strains. Yogurt and kefir generally have higher concentrations of beneficial microorganisms than probiotic supplements. For example, a glass of homemade kefir may have 5 trillion units versus the 5 billion per capsule claimed by many supplements. If dairy or the high carbohydrate density of dairy is an issue, water kefir may be a suitable alternative. Fermented vegetables like sauerkraut and kimchi are great options. Seed is my favorite probiotic for general use, as it’s backed by extensive research and a unique delivery system that allows the probiotics to reach the colon, where they are needed.

Treat H. pylori

An estimated 50 percent of the population harbors H. pylori in their GI tracts. H. pylori is inversely associated with GERD in many studies, possibly because of its acid-suppressing effect. (95, 96) However, it is also associated with gastric cancer and stomach ulcers, and in my clinic I’ve seen many patients with GERD improve after successful treatment of H. pylori. (97) Specific probiotics and mastic (a resin from the pistachio tree) are two possible treatment options. (98, 99)

Eat a Low-Carb Diet

If you have GERD, you probably don’t have enough stomach acid to fully digest carbs. By decreasing the carbs in your diet, you can reduce the amount of malabsorbed carbs left behind. Following a low-carb diet can help alleviate some of the gas and increased pressure associated with GERD. (100)

With so many low-carb diet options available, selecting the “best” one may involve a little trial and error. In any case, don’t buy low-carb processed foods that contain additives, preservatives, and other artificial ingredients that could make the gut situation worse. Instead, maximize your nutrient intake by preparing and eating nutrient-dense, real food that’s closer to what our ancestors would’ve eaten.

And, despite what you may have heard in recent news stories, eating a low-carb diet won’t shorten your life.

Very Low-Carb Diets

A very low-carb diet might be a good first option to alleviate your symptoms. This type of diet restricts carbohydrates to under 50 grams, and sometimes as low as 20 grams, per day. Under this basic plan, there are no restrictions on carbohydrate types.

You can also follow the keto diet. A full ketogenic diet restricts carbohydrates to the point where the body runs on ketones, and it can be helpful and even necessary for complete resolution in some cases.

The Low Fermentation Potential (FP) Diet

Pioneered by Dr. Norm Robillard of the Digestive Health Institute, a low-FP diet restricts the fiber and prebiotics that increase gas production in the gut.

About 15 to 20 percent of the starch we generally consume escapes absorption. Instead, it’s used as food for our gut bacteria or it’s excreted. (101) When bacterial overgrowth persists—as it does with GERD—excess fiber can do more harm than good.

Low-FODMAP Diets

If your digestive issues still aren’t resolved, try removing FODMAPs in addition to FP foods. FODMAPs are a particular type of fermentable carbs found in a long list of foods. Low-FODMAP diets can do wonders for improving digestive help, especially for IBS patients. (102)

It’s important to note that you don’t have to follow a low-carb diet forever. Once your gut is healed, your microbiota restored, and your stomach acid replenished, you can start a moderate-carb diet and reintroduce many restricted foods.

Heal the Gut Lining

Each section of the digestive tract is lined with a site-specific protective barrier. In the stomach, the lining prevents ulcers by protecting the stomach from its own acid. If your gut lining is damaged from stress, medications, or other factors, you might still feel the effects of GERD—even if you’ve taken steps to cure it.

As you may know, I’ve been a proponent of the benefits of bone broth for years. Due to its collagen and gelatin content, it’s highly beneficial for people with ulcers. (103) In animal studies, glutamine and proline, also abundant in bone broth, help restore the gut lining. (104) Deglycyrrhizinated licorice (DGL) in the short term has helped treat gastric and duodenal ulcers and can help protect and heal the stomach lining. (105)

However, if you have a sensitivity to FODMAPs, you should avoid bone broth, DGL, and collagen.

Still Need Help Learning How to Cure GERD Without Drugs? Follow These Tips

If you’ve followed the tips above and you’re still experiencing heartburn symptoms, here are a few additional strategies to try.

Lose Weight

Although it’s usually not the primary impetus, excess weight—especially in the abdominal region—can contribute to increased IAP and GERD. For many of my patients, following a Paleo diet has helped them lose weight without trying.

Avoid Fructose and Artificial Sweeteners

Fructose and artificial sweeteners can increase bacterial overgrowth and worsen your GERD symptoms. Steering clear of sugary foods can help improve your condition.

Avoid NSAIDs

Ibuprofen, aspirin, and other NSAIDs increase the risk of acid-related disorders and can further damage the gut lining.

Share Your Thoughts on GERD

GERD can severely impact quality of life. Instead of taking medication to relieve symptoms, it is possible to cure GERD from the inside out. By optimizing all aspects of gut health, including the microbiome, acid content, gut lining, and digestion, my patients have learned how to cure GERD without the need for medication.

Now I’d like to hear from you. Did you know about the underlying causes of GERD? Have you had any success treating it with the strategies above? What else have you tried? Let me know in the comments.

The post How to Cure GERD without Medication appeared first on Chris Kresser.

There’s no one-size-fits-all approach to diet, but there are foods that will worsen GERD symptoms and others that will help you heal. Find out what to eat and what to avoid with a GERD diet.

The post The GERD Diet: What to Eat (and What Not to Eat) appeared first on Chris Kresser.