What You Need to Know About Heartburn
Heartburn is medically known as acid reflux. If it occurs chronically two or more times per week, it is medically known as gastroesophageal reflux disease (GERD). Acid reflux is one of the most common gastrointestinal concerns in the US. You've likely experienced this unpleasant symptom at some point in your life or know someone who does. It’s estimated that 60 million Americans experience heartburn at least once a month and more than 15 million experience acid reflux symptoms every day (1). In 2016, Prilosec, a medication to treat GERD was the 4th most common filled prescription in the US (2).
So what is acid reflux? It's when stomach acid travels from the stomach up the esophagus. There is a little muscle called the lower esophageal sphincter (LES), that sits between the esophagus and stomach and is supposed to prevent this from happening. The most common symptoms of acid reflux include heartburn or a burning sensation in your chest, as well as regurgitation of food or a sour taste in your mouth. Some people experience less obvious symptoms called silent acid reflux, which is an absence of heartburn but can include:
feeling like something is stuck in the throat or difficulty swallowing
hoarse voice
coughing (especially at night when lying down)
frequent throat clearing
The conventional treatment for heartburn is typically acid blocking or neutralizing medication. Acid blocking medications, aka proton inhibitors such as Nexium, decrease production of stomach acid. Antacids such as Tums and Rolaids, neutralize stomach acid.
The issue with antacids is that you actually need stomach acid to properly break down food and absorb nutrients, so long-term use can lead to nutrient deficiencies. Stomach acid also acts as your digestive tracts first line defense against infections. Therefore, antacid use predisposes for small and large bowel infections (food poisoning, SIBO, H. pylori parasitic infections, etc).
What most people don’t know is that it’s very rare for someone to make too much stomach acid and, in fact, it is more common that too little stomach acid is the cause of acid reflux. Consider this: we actually start to make less stomach acid as we age, and acid reflux occurs in increasingly larger numbers among the elderly. If reflux was primarily caused by overproduction of stomach acid, we’d see more children and teenagers with this issue - but we don’t. A grandpa who pops Rolaids like candy is a stereotype in our culture, not an elementary school student.
So why does this happen? There are a number of things can can predispose for acid reflux and decrease the tone of the LES. Here are a few that I commonly see:
Low stomach acid is a big contributor. Low stomach acid can be caused by aging and I also often see high stress contribute to this as well.
Low pancreatic enzymes, an essential component to digestion.
An infection of the stomach by the bacteria h. pylori.
An over growth of bacteria in the small intestines (small intestinal bacteria overgrowth or SIBO)
Gastritis (essentially inflammation of the stomach lining) can cause reflux. Gastritis can be caused by food allergies or sensitiviites, stress (cortisol our stress hormone thins the stomach lining), too much alcohol or coffee, h. pylori, inflammatory foods.
A hiatal hernia is a structural issue where part of the stomach protrudes up through the diaphragm. If you’re not really sure what that means, here is an image.
Testing: To determine if any of the above are the root cause of your acid reflux or GERD, I recommend the following:
H. pylori testing: H. pylori is a bacteria that can infect the stomach and is a fairly common cause of acid reflux. You can test for this bacteria through stool, blood or a breath test.
Breath test for small intestinal bacteria overgrowth (SIBO): SIBO as the name implies is a condition where there are too many bacteria in the small intestine. These bacteria produce gas which increases the pressure in the abdomen. This causes an award pressure and food refluxes up the esophagus.
Hidelberg test which measures stomach acid production or a trial of supplemental stomach acid.
Comprehensive stool analysis: this includes analysis of digestive tract flora (bacteria, yeast, parasites, probiotics) and also identifies and problems breaking down or absorbing nutrients.
It’s unlikely you’d need all of these tests, the order of importance depends on your exact symptoms and health history so work with your functional medicine doctor to determine what’s right for you. In the meantime here are some natural remedies for heartburn.
Raw apple cider vinegar (ACV): this helps stimulate digestion and the breakdown of food. Mix 1 tbsp in a small amount of room temp or warm water before each meal. ACV is also great for occasional heartburn and can be taken as needed. I like Bragg’s brand.
Organic aloe vera juice: this reduces inflammation in the stomach (gastritis) and esophagus (esophagitis). Have 1-3 ounces per day. Make sure you buy one that is inner fillet only, the outer portion is a laxative (unless you're into that sort of thing). I like recommend this one.
Fermented foods which contain probiotics: my favorite are sauerkraut and kimchi. You need to buy these in the refrigerated section of the grocery store (not self stable) or farmers market and they should say raw fermented on the label. Have 2 forkfuls 1-3 x per day before meals. Other probiotic foods include kombucha and cultured dairy (yogurt, kefir).
