Why Your Stomach Acid Is Important
by Mike Bauerschmidt, MD, CCT
I am reasonably certain that, from time to time, most of us have suffered from acid reflux. Here I am talking about the simple indigestion that may come from a meal too rich in fats or meats or perhaps too much alcohol. However, for many of us, when simple indigestion becomes a chronic daily problem that can lead to serious illness, this is called gastroesophageal reflux disease (GERD). There are two camps in the medical community as to the causes of GERD. Both sides agree that a lowered esophageal sphincter (LES) pressure is common to everyone with GERD. Both sides also recognize that lack of local protection in the esophagus also contributes to symptoms. However, that is where the commonality ends. The traditional medical model suggests that too much acid secretion, in conjunction with lowered LES pressure, and lack of local protection are the causes of the reflux symptoms. From this perspective the use of agents to reduce hydrochloric acid (HCl) secretion makes perfect sense. However, there is another model that suggests that over 90% of GERD related symptoms are related to too little HCl. Therefore, the use of agents to further reduce your stomach acid makes absolutely no sense AND may cause serious problems. I would like to share with you some basic physiology and offer a little common sense that may change your attitude toward GERD, as well as the careless attitude we seem to have developed toward altering one of our most important aids to digestion, our stomach acid.
A Trip Down Memory Lane
I remember back in medical school when a brand new drug was released that was going to save countless lives by preventing death from ulcer disease. It was considered to be so potent that only specialists had permission at the hospital to use it, and it was strictly limited for no more than 6 weeks of use to prevent achlorhydria, a condition that causes stomach cancer. It was called Tagamet! Well, once that horse left the stable there was no reining it in. Hydrochloric acid (HCl) became the newest archenemy of our health and was to be mercilessly stamped out of existence. And so it was. However, Tagamet, once considered the icon of treatment, is now no more than a small ornament hanging on the back of the medical Christmas tree. It, and all the rest of the H2 blocker family, have been relegated to over the counter (OTC) status, having been replaced by the much more potent (and dangerous) proton pump inhibitors. Even some of these PPIs are now considered so safe your child can purchase them OTC. We are succeeding in stamping out stomach acid in the name of preventing reflux, but what are we reaping in return?
How Stomach Acid Works
Your HCl has four major jobs: 1) proteolysis, the process by which proteins are broken down to the point that they can be digested; 2) activation of pepsin, another enzyme necessary for protein digestion; 3) chemical signaling so the food can pass from the stomach to the small intestine as well as alerting the pancreas to secrete its enzymes; and 4) inhibiting the growth of the bacteria that came down with the food, preventing infection.
When you put this all together, what is supposed to happen when you eat? The very act of smelling food activates a complex neural pathway that stimulates the parietal cells in your stomach to secret hydrogen ions (the basis for your HCl). Tasting and chewing further stimulate this pathway so that by the time you swallow your food your stomach has enough acid to begin digesting food (pH of 1–2)! Now for the process of digestion to continue, the food that you have swallowed and mixed with your stomach acid (called chyme) must pass through the pyloric valve and enter the duodenum (first part of your small intestine). In order for that valve to open, the chyme must have the proper acid content. Further, in order for the pancreas to be stimulated to release bicarbonate as well as digestive enzymes, the pH of the chyme must not be greater than 3.0 (still quite acidic). So what happens when we take our acid away with the use of drugs such as Tagamet, Zantac, Omeprazole and the like?
Leave My Acid Alone!
Take away the acid and all sorts of bad things begin to happen. First, whatever proteins you are now eating won’t begin the process of digestion. Second, another very important stomach enzyme called pepsin remains inactive so your protein still isn’t digested. Third, B12 that is tagging along with your protein can’t be separated from its carrier and therefore cannot be linked to intrinsic factor and absorbed in the small intestine. Fourth, without enough acid the pyloric sphincter does not open, and the food simply sits in your stomach for longer periods of time, being fermented by the bacteria that the now absent HCl was supposed to kill. Fifth, the chyme that does slowly leak through the valve avoids the pancreatic enzymes and bile, which are no longer secreted in response to the now absent acidic state of the chyme.
In short, you have destroyed a major part of your ability to digest your food. Further, you have significantly impaired your body’s ability to absorb your food, as the only partially digested molecules are too large for transport across the intestinal lining. You suddenly can find yourself protein, magnesium and vitamin B12 deficient! And, just as an added bonus, with prolonged use of acid inhibitors and blockers you are 150 to 800 times more likely to develop an intestinal infection, like small intestinal overgrowth syndrome (SIBO), C. Difficile or even peritonitis. Your likelihood of pneumonia increases by 120 – 160%, bone fractures go up by 120 to 310%, and stomach cancer goes up by 150 to 230%! All for want of a little acid that might not even be the problem to begin with.
What Is the Real Problem?
We all agree that the effects of chronic exposure of the esophagus to acid can readily be seen by endoscopy. We also agree that a low LES pressure and poor local protection are part of the problem. The debate is whether it is too little or too much acid that results in the symptoms. Consider a basic fact of anatomy and physiology: the esophagus does not have the degree of protection that the stomach does, with respect to acid. In fact, no organ has the acid resistance of the stomach, so even small amounts of acid in the esophagus can result in major symptoms and damage. In short, ANY amount of acid can cause symptoms! If it is too little acid (as it appears to be in 90% of people with GERD), the problem is with the prolonged gastric emptying time, leading to fermentation as opposed to digestion. Imagine a smoldering lava pool. It sits and heats and occasionally “burps up” a bit of lava. That is your stomach erupting into your esophagus when you have too little acid.
Does it make sense that the vast majority of time we are treating a problem of too little acid/enzyme production by reducing any hope of making acid or activating enzymes? I hope not.
What of the 10% of people who truly have increased acid production? Do they have to have the strongest of the drugs? Maybe for the short term, as chronic GERD, left untreated, could lead to changes in the esophagus that could lead to cancer. However, even the drug companies won’t say they are safe to use beyond 12 months. And here is another side effect: long-term acid suppression can lead to increased gastrin levels. Gastrin is the hormone the body makes to stimulate acid production. The longer you are on suppressive therapy, the higher the gastrin levels may go. Imagine what happens when you stop your acid medication suddenly. REBOUND- your stomach acid production, prodded by the supraphysiologic levels of gastrin, has you reaching for the pills again in a New York minute, AND it doesn’t make any difference if you were low or high acid to begin with. In short you are “hooked on Aciphex” (or whatever your preference). So, you may be thinking, “Okay, Doc, this is all very interesting, and I certainly don’t want to end up with pneumonia, broken bones, vitamin deficiencies or stomach cancer, but, MY STOMACH STILL HURTS! What can I do?”
It All Begins with Chewing
In today’s hurried world, we often eat on the run and forget to chew. “So what? I’m in a hurry.” Let me tell you “what.” Chewing is crucial. The mechanical breakdown of the food is essential to good digestion by providing a greater surface for the HCl and pepsin to work. Better digested food leads to less reflux. Further, saliva contains various other factors that increase the protection of the esophageal barrier. One study published in Gastroenterology showed that the simple act of chewing on waxed film increased saliva (and related factors) production in patients with GERD by 132%! So your mother was right, take your time and chew your food.
Avoid the Bad Boys
There are several foods that are known to aggravate GERD. Caffeine is the clear winner in this category, as it not only lowers LES pressure, it may also promote stomach acid secretion. Chocolate is also on the “Most Unwanted” list of foods, probably due to its content of methyl xanthenes, which work like caffeine. There are several studies that implicate alcohol in various forms and amounts, probably because of its muscle relaxant effects on the LES pressure.
Other foods that may be problematic are citrus fruits, tomatoes, onions, peppermint and spearmint. There are still others not mentioned here that can be problematic for many of us. This is likely due to food sensitivity or intolerance. These foods are best identified by a food elimination diet or food sensitivity testing.
Meal Timing and Quantity
People who eat two hours before going to bed have been shown to have more reflux when lying down than people who ate the same meal six hours before going to bed. Also, it is thought that a meal high in fat is more likely to trigger symptoms. In fact, it has as much to do with the total calories as the makeup of the calories. The fat content of the meal has more to do with the frequency of the symptoms, while the calories are related to the severity of the symptoms. So eating a high fat, high calorie meal is the worst possible option. Anybody for a Big Mac, fries and shake?
Eat small, frequent meals with low to moderate fat as opposed to the usual Standard American Diet (SAD).
Calcium carbonate remains the most often used OTC for acute symptoms because it works. The calcium carbonate itself neutralizes the stomach acid while the elemental calcium may increase muscle tone and improve peristalsis (emptying the esophagus).
In a Swedish study, the use of beta-carotene, 25 mg daily for 6 months, was associated not only with symptomatic improvement but with histologic improvement noted on biopsy. It could not be determined if the cells got healthier because of the direct effect of the beta-carotene or simply because they were not exposed to as much acid.
Alginate is another option. This seaweed-derived supplement acts as a blanket floating on top of the stomach contents. This barrier prevents the contents from erupting up into the esophagus.
My personal favorite is a good digestive enzyme with a little Betaine HCl. This improves digestion and gastric emptying by giving the body back what it needs to work properly.
The choice is yours. You may chew your food, give your body what it needs, eat small, frequent meals with low to moderate fat well before your bedtime, avoid caffeine, alcohol and other known triggers and use your beta-carotene, alginate and the occasional TUMS, and be the healthier for it. Or you can take your proton pump inhibitor, become malnourished, get an infection that makes you weak so you fall and break your hip, then get pneumonia while you are lying in a hospital bed waiting for the stomach cancer to kick in. Seems like a “no brainer” to me.
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