Heartburn is one of the most commonly reported symptoms, affecting 60 million people at least once a month, and about 15 million people who experience it daily. The burning sensation in the chest that often accompanies heartburn is caused by stomach acid traveling up the esophagus. This problem is often treated with medications that neutralize stomach acid, but what if the real root cause of heartburn isn’t high stomach acid? Integrative medicine can help identify the true cause of GERD and provide solutions to improve stomach acid levels. Diet and lifestyle changes are an important part of integrative medicine treatment for GERD, and can help reduce or eliminate symptoms for many people.

Gastroesophageal Reflux Disease (GERD) is a more serious form of chronic acid reflux, and is the most common digestive disorder in the U.S., followed by IBS. Chronic heartburn and GERD can have serious complications, including ulceration and cancer of the esophagus.

Learn more about conditions we treat: Digestive Health

What everyone should know about heartburn (but doesn't)

In the public and the media, the notion that heartburn is brought on by high stomach acid is still prevalent. But a review of scientific literature shows that GERD and heartburn are not conditions caused by high stomach acid (1).

Instead, the muscle valve that divides the stomach from the lower end of the esophagus is to blame for heartburn symptoms and GERD. The lower esophageal sphincter, or LES, is responsible for keeping acid from entering the esophagus. Normal LES opening allows for passage of liquids and food into the stomach. This is the only time the LES should be open, aside from belching associated with normal digestion.

Basically, varying levels of stomach acid don't matter if the LES is functioning properly, because the LES prevents acid from making its way into the esophagus. With GERD, the LES does not function normally, allowing acid to damage the sensitive tissues within the esophagus. More on this later in the post.

PPIs don't cure heartburn

Nearly 20 percent of adults regularly use acid-lowering drugs like proton pump inhibitors (1). Drugs to reduce stomach acid production are some of the most widely used and widely available medications in the U.S.

If antacid medications were actually curing acid reflux, the benefit to digestive health would be obvious. But in reality, as many as 70 percent of people experience no benefit from taking them, and they actually make the underlying condition (low stomach acid) worse (2).

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Stomach acid declines with age

While conventional medicine compels the public to focus on lowering gastric acid secretion to "cure" acid reflux, this approach neglects one obvious fact. The incidence of heartburn and GERD increases with age, while stomach acid levels generally decrease (3).

In one study researchers found that acid production was reduced by about 30 percent in men and women 65 and older (3). Some participants also suffered from atrophic gastritis, a condition marked by little to no acid secretion.

If stomach acid levels generally decrease with age, but the incidence of heartburn goes up, then it stands to reason that something other than high stomach acid is to blame for acid reflux and GERD.

Read: Is Dysbiosis the Missing Link Between SIBO & IBD?

The real root cause of heartburn

Tests to measure levels of stomach acid in people with heartburn and GERD usually show low stomach acid, not high. Truly excessive stomach acid production is found only in a few rare instances, such as with Zollinger-Ellison syndrome. GERD is rarely associated with excessive stomach acid.

One researcher states that “treating gastroesophageal reflux disease with profound acid inhibition will never be ideal because acid secretion is not the primary underlying defect”(4).

To support this point, supplements that can raise acid secretions in the stomach, such as HCL or pepsin, have been shown to help some patients resolve their heartburn symptoms and improve digestion.

Of course, it's important to work with a qualified integrative doctor while taking any supplements that can impact stomach acidity.

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Keeping stomach acid in the stomach

The root cause of GERD is actually a malfunctioning LES, not an excess of stomach acid (5).

By now, we’ve established that any amount of acid making its way up to the esophagus is bad. Unlike the stomach, the lining of the esophagus has no protection against acid.

If the LES is working properly, keeping acid in the stomach (and out of the esophagus), then digestion proceeds as normal. But if the doorway that separates the stomach from the sensitive esophagus—the LES—is malfunctioning, acid from the stomach gets back into the esophagus and damages its delicate lining.

So what causes the LES to malfunction? Let’s look at a few theories.

Bacterial overgrowth causes bloating & puts pressure on the LES

Low stomach acid (as seen in many adults with acid reflux) creates the perfect conditions for bacterial overgrowth.

Normally, stomach acid effectively inhibits bacterial overgrowth. The stomach has a pH of about 3 or less, making it quite acidic such that most bacteria can’t survive for more than several minutes. But when stomach acid is decreased, the overall pH of the stomach rises, and bacteria begin to proliferate.

Bacterial overgrowth as a result of low stomach acid then does two things:

Restricts carbohydrate breakdown and absorption
Creates a build up of gas

The resulting gas increases pressure against the LES which is the driving force behind acid reflux and GERD.

Increased pressure in the stomach causes LES malfunction and GERD

One review determined that bloating in the stomach, referred to as intra-abdominal pressure, is the primary mechanism responsible for GERD (6).

Other things can cause acid reflux stemming from bloating within the stomach, pushing gastric contents (including acid) past the LES and into the esophagus:

Overeating
Alcohol
Obesity
Hiatal hernia
Pregnancy
Reclining after eating
Eating spicy or fried (fatty) foods.

Newer studies also show that the damage from bacterial overgrowth and GERD overlaps with other digestive problems, like irritable bowel syndrome (IBS) (7).

Working on making diet changes but can’t quite reach your goals? Work with a qualified specialist for nutrition counseling.

Low stomach acid, bacterial infections, and GERD

Insufficient stomach acid also creates a host of problematic conditions, including fostering the exact environment necessary for bacterial infections, such as H. pylori, to take hold.

pylori is the most common chronic bacterial pathogen in humans, and its prevalence rises with age, suppressing stomach acid secretion even further. In fact, this is how it survives in the stomach’s hostile acidic environment, which would normally kill all bacteria.

Researchers believe that initial infection with H. pylori can take place when the acidity level in the stomach is decreased, even if only temporarily.

All roads lead to GERD

To sum up, declining stomach acid initially causes heartburn symptoms, for which most people begin antacid medications, whether prescribed or over-the-counter. Further reducing stomach acid sets up conditions for bacterial overgrowth and H. pylori infection, which then causes chronic acid reflux and GERD.

Treating acid reflux and GERD with integrative medicine

Each person’s digestive function and microbiome are unique. Because of this, if you have chronic heartburn or acid reflux symptoms, it’s best to work with an integrative physician who can tailor functional solutions to your specific needs.

Learn more about digestive health at CentreSpringMD.

In general, here are some guidelines to restore healthy acid levels in the stomach:

Reduce factors that decrease stomach acid and promote bacterial overgrowth

Limit certain carbohydrates such as FODMAPs, and high-fiber foods that can increase abdominal bloating. You may also want to avoid probiotic use for the time being.

Replenish enzymes that aid digestion and prompt gastric secretions

Your doctor can help you test your stomach acid levels, and provide guidance for supplements that can restore healthy gastric acid secretions, such as HCL with pepsin.

Re-establish beneficial bacteria and a healthy intestinal lining

Once stomach acid levels are on the rise, you can re-inoculate your digestive system with healthy bacteria from probiotic foods (or supplements), and prebiotic fiber. Bone broth, DGL, or glutamine supplements are also helpful to heal an inflamed intestinal lining.

Shop our selection of natural digestive aids>>

While antacids may provide temporary relief for acid reflux, they do nothing to address the root of the problem—which is often insufficient gastric acid. If you’re looking for a long-term solution to your heartburn and acid reflux woes, restoring healthy levels of stomach acid is key. There are a number of ways to do this, from dietary changes to supplements. We’ve outlined some simple tips that can help get your stomach acid levels back on track and banish those pesky heartburn symptoms.

If you find yourself needing extra support, don’t hesitate to reach out to a patient care coordinator so we can help you reach the optimal digestive health you deserve.

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About
the author

CentreSpring MD, formerly known as Atlanta Center for Holistic and Integrative Medicine, provides the best medical care by using an integrative approach to find a patient’s centre—their core—empowering them to spring forth into health.

Blog Reviewed By:

Dr. Taz Bhatia, M.D.

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At CentreSpringMD, we do medicine differently. Our focus is on giving you hope and your life back.

Our team of dedicated board-certified providers relentlessly pursue your health until you have the answers that you deserve to change the trajectory of your health—and your life.

Low Stomach Acid: The Real Cause of GERD? Integrative Medicine Solutions