By Dr. Mercola
If you suffer from frequent heartburn, chances are you've been prescribed a proton pump inhibitor (PPIs) such as Prilosec, Prevacid or Nexium to inhibit acid production. This, despite the fact they were never intended to treat heartburn in the first place.
PPI drugs were originally designed to treat a very limited range of severe problems,1 including bleeding ulcers, Zollinger-Ellison syndrome (a rare condition in which tumors in the pancreas cause your stomach to produce excess acid) and severe acid reflux concomitant with esophageal damage. But that hasn't stopped them from becoming the go-to solution for everyday indigestion.
Research clearly shows PPIs are outrageously overprescribed and misused, and do far more harm than good.2,3,4,5,6,7 There are many alternative treatment strategies that can help ease this painful problem without the serious side effects associated with PPIs, which include kidney disease, pneumonia, osteoporosis, hip fractures, dementia and an increased risk for heart disease,8 heart attacks9 and premature death.10
The long-term answer to heartburn and acid indigestion is to restore your natural gastric balance and function. The most important step is to eat real food, as processed foods and sugars are a surefire way to exacerbate acid reflux. Reseeding your gut with beneficial bacteria, either from traditionally fermented foods or a high-quality probiotic supplement, is also important. Aside from that, there are a number of natural substances that can help address the root of the problem.
What Causes Heartburn?
Digestion of food begins in your mouth as the food is broken into smaller pieces and mixed with saliva before traveling down your esophagus and into your stomach. Once in your stomach the food mixes with hydrochloric acid, which is required to break the food down into even smaller pieces from which your small intestines can extract nutrients.11
Heartburn, also referred to as acid reflux, gastroesophageal reflux disease (GERD) or peptic ulcer disease, is characterized by a burning sensation originating behind your breastbone, sometimes traveling up into your throat. In some cases, this burning pain can be severe enough to be mistaken for a heart attack.
When food passes through your esophagus into your stomach, a muscular valve called the lower esophageal sphincter (LES) closes, preventing food or acid from moving back up. The painful effect associated with heartburn occurs when the LES relaxes inappropriately, allowing acid from your stomach to reflux backward into your esophagus and burn tissue that cannot withstand the low pH of the acid.
While the conventional rationale states that this reflux is caused by excessive amounts of acid in your stomach, that's actually an extremely rare situation, typically occurring only if you have the rare disease known as Zollinger-Ellison syndrome. Instead, the vast majority of acid reflux cases are related to one or more of the following:
• Insufficient amounts of stomach acid.12
• Helicobacter pylori (H. pylori) imbalance. One of the explanations for why suppressing stomach acid is so ineffective — and there are over 16,000 articles in the medical literature attesting to this — is that when you decrease the amount of acid in your stomach, you suppress your body's ability to kill the helicobacter bacteria.
While H. pylori can be part of your normal healthy microbiome, it can cause problems, including symptoms of acid reflux, if there's an overgrowth of it. This typically occurs as a result of a poor diet. Taking a betaine hydrochloric supplement (available in health food stores without prescription) will not only improve digestion, but will also help kill the helicobacter, thereby normalizing your symptoms.
• Food allergies can also be a contributing factor to acid reflux, so eliminate common culprits such as caffeine, alcohol and nicotine.
Is It Acid Reflux or Gallbladder Disease?
Acid reflux can also imitate symptoms of gallbladder disease.14 Your gallbladder is located beneath your liver on the right side of your abdomen. Pain stemming from your gallbladder is typically felt just under your lower ribs on the right side, and/or in the pit of your stomach. Depending on the severity of your problem, the pain can radiate into your upper back on the right side, your chest or even your shoulder.
While heartburn will typically occur right after a meal and tends to get worse if you lie down, gallbladder pain usually sets in several hours after eating and gets worse on the in-breath. For proper diagnosis, your doctor may need to do an ultrasound on your gallbladder or other tests.
Important Considerations If You've Had Your Gallbladder Removed
Over 700,000 people have their gallbladder removed every year in the United States. If you happen to be one of them, it is important to realize that your gallbladder stores bile, which helps you digest and emulsify the fat you eat. If you've had your gallbladder removed, it's really important to take ox bile, lipase or pancreatin — digestive enzymes that digest fat — anytime you eat a meal containing fats.15,16
Your gallbladder holds and excretes bile produced in your liver, and this bile contains the necessary enzymes to digest fats. Common signs and symptoms that your body is not digesting fats well include diarrhea, loose stools, light-colored or pale stools, bloating, nausea and indigestion after a meal.
Certain fatty foods (such as steaks or salmon) tend to be more problematic than others, but for proper digestion and absorption of fat-soluble nutrients, you really need to take a lipase or ox bile supplement with each meal. To learn more, see "Five Important Tips If You've Had Your Gallbladder Removed."
Simple Test to Evaluate Your Stomach Acid Level
A simple test can be used to determine if your stomach acid level is low, and this knowledge will help you develop a plan to reduce your chronic pain. This simple test is a rough indicator of how much acid your stomach produces:
1. Mix 1 teaspoon of baking soda in 8 ounces of cold water and drink it first thing in the morning, before eating or drinking anything. The combination of baking soda and hydrochloric acid in your stomach creates carbon dioxide gas, causing you to belch.17
2. Time yourself for up to five minutes for how long it takes you to form enough gas in your stomach to belch. Belching in two to three minutes is normal; earlier and repeated belching indicates an excess of acid. If you don't belch after five minutes, you likely don't produce enough acid.
More accurate testing involves taking a stool sample to determine whether you might have an enzyme and/or hydrochloric acid deficiency.18 It could also identify bacterial or fungal imbalances that might contribute to your condition. If you aren't making enough stomach acid you can take a betaine HCL with pepsin supplement. Start with one or two tablets and work your way up to around five or seven with each large meal, but make sure you don't have any burning in your stomach. If you do, you're taking too much.
The Problem With PPIs
PPIs inhibit the proton pump that produces hydrochloric acid. However, excess stomach acid is rarely the primary trigger of heartburn and indigestion. On the contrary, heartburn is typically indicative of insufficient amounts of hydrochloric acid. If your acid levels are low, PPIs will exacerbate the problem by decreasing acid further.
And, since hydrochloric acid (and pepsin) are necessary to break down protein in your intestinal tract, reducing acid can alter your body's ability to absorb nutrients. Without adequate protein breakdown, you also increase your risk of dysbiosis,19 an imbalance in gut microbiome between harmful and friendly bacteria.
As these undigested protein molecules ferment in your intestines, they become food for pathogens such as H. pylori, C. difficile and Candida. An overgrowth of these bacteria may also lead to leaky gut and associated health problems. A recent study20 confirmed this risk. Compared to those not taking PPIs, participants who did had a 1.7 to 3.7 times increased risk of developing C. difficile or Campylobacter infection.
Although both of these bacteria trigger abdominal pain and diarrhea, C. difficile tends to be the more serious of the two. According to the Centers for Disease Control and Prevention (CDC), an estimated 29,000 Americans die from C. difficile infection each year.21 A meta-analysis22 looking at studies published between 1990 and 2010 also found a significant link between C. difficile infection and PPI use.
PPIs Associated With Increased Risk of Dementia
Research has linked PPIs to a number of other devastating health effects as well, including dementia. Disturbingly, cognitive changes can occur even with short-term use. In one study,23 PPIs were found to cause statistically and clinically significant impairments in the participants' executive functions, visual memory and planning function after just one week of use.
According to research24,25,26 published in JAMA Neurology, seniors over the age of 75 who use PPIs on a regular basis had a 44 percent increased risk of dementia compared with non-users. Men were at greater risk, raising their dementia risk on average by 52 percent, compared to 42 percent for women.
One characteristic of dementia is the accumulation of beta-amyloid plaques in the brain that provoke inflammation and ultimately kill brain cells. There is now strong scientific evidence that PPIs not only increase production of beta-amyloid plaques in the brain, but slow your body's ability to eliminate them as well.27,28,29 Two other studies concluded those taking PPIs were at greater risk of developing Alzheimer's disease.30,31
PPIs Raise Your Risk of Heart Attack and Premature Death
Research has also linked long-term PPI use to an increased risk for heart disease32 and heart attacks — even if you have no prior history of cardiovascular disease.33,34 In one study,35 patients with GERD who took PPIs had a 16 percent increased risk of heart attack, and a two-fold increased risk of cardiovascular mortality.
The reason for this effect is thought to be due to the drug reducing nitric oxide (NO) in your blood vessel walls. NO relaxes your blood vessels, so by reducing the amount of NO, PPIs may raise your risk of a heart attack. Recent research also found PPI users were nearly 20 percent more likely to die from any cause compared to nonusers over the course of six years, and the longer the use, the greater the risk.36,37,38,39 As reported by Reuters:40
"The most likely explanation for the increased mortality risk is the side effects associated with PPIs … In terms of the mechanisms that could be involved … laboratory experiments have shown that lysosomes — tiny organs within cells that act like garbage disposals to get rid of waste — don't function well in people taking PPIs. Other research has shown that PPIs may shorten the protective chromosome ends known as telomeres, in effect speeding up cell aging."
Other Health Hazards Associated With PPI Use
Studies have also linked PPIs to the development of chronic kidney disease,41 increased risk of bone fractures42,43 and vitamin B12 deficiency, which in turn may lead to anemia, nerve damage, psychiatric problems and dementia. Researchers at Houston Methodist Hospital think they've discovered one of the reasons why PPIs can have such devastating effects on your brain, kidneys and other systems.
When different cells were grown in culture and exposed to PPIs, cells that line blood vessels demonstrated significant change.44 PPIs are taken orally and affect the proton pump in more than just your stomach walls. Blood vessels also produce small amounts of acid to break down and eliminate damaged protein molecules. When acid levels drop, microscopic debris begins to build up on the arterial walls, resulting in problems where many blood vessels are found, such as your brain, heart and kidneys.
Lead author Dr. John Cooke, chair of cardiovascular disease research at Houston Methodist Research Institute, noted:45 "I'm perplexed that the pharmaceutical industry didn't run across this first. This is something that should have been apparent a long time ago and should have been investigated."
How to Properly Wean Yourself Off PPIs
If you're currently taking a PPI, do NOT quit cold turkey. Doing so can result in severe rebound effects known as rebound acid hypersecretion. It's important to spend time detoxifying and eliminating the drug from your system. To do that, you need to gradually wean yourself off the drug.
Once you're down to the lowest dose, start substituting with an over-the-counter H2 blocker, like Cimetidine, Zantac, Ranitidine or Tagamet. Once you've been taking the H2 blocker for a couple of weeks, you may start weaning yourself off these drugs as well, while introducing the alternative options to reduce your heartburn outlined below.
How to Heal GERD and Avoid Heartburn
One simple strategy to address a hydrochloric acid deficiency is to swap out processed table salt for an unprocessed version like Himalayan salt. By consuming enough of the raw material, you will encourage your body to make sufficient amounts of stomach acid naturally. Research46 has also shown that sauerkraut or cabbage juice is among the strongest stimulants for your body to produce stomach acid.
It will also provide you with valuable bacteria to help balance and nourish your gut. Having a few teaspoons of fermented cabbage juice from sauerkraut before your meal will do wonders to improve your digestion. Fresh, raw cabbage juice can also be very useful to heal resistant ulcers. To restore your natural gastric balance and function, also be sure to eat lots of vegetables and other high-quality, ideally organic, unprocessed foods.
Reseeding your gut with beneficial bacteria, either from traditionally fermented foods or a high-quality probiotic supplement is also important, as this will not only help balance your bowel flora, but can also help eliminate helicobacter bacteria naturally. Probiotics and fermented foods, especially fermented vegetables, also aid in proper digestion and assimilation of your food.
Also, beware of lectin-rich foods such as grains and legumes, as lectins are potent enzyme inhibitors.47,48 By inhibiting digestive enzymes, your digestive system will not function properly and foods will not be broken down, thereby producing or exacerbating heartburn.
Among the most problematic lectin-containing foods are wheat and other seeds of the grass family, any dairy that has A1 casein protein, beans, soy and other legumes, peanuts and members of the nightshade family such as eggplants, potatoes, tomatoes and peppers. Grains and legumes such as black beans, soybeans, lima beans, kidney beans and lentils contain the highest amounts of lectin.
It is also crucial to avoid eating processed foods as much as possible. Be sure to concentrate on eating real foods as that is one of the most powerful strategies you have to activate biological homeostasis in your gut.
Effective Alternatives to Treat Heartburn, GERD and Indigestion
✓ Raw, unfiltered apple cider vinegar
Acid reflux typically results from having too little acid in your stomach. You can easily improve the acid content of your stomach by taking 1 tablespoon of raw unfiltered apple cider vinegar in a large glass of water.
✓ Betaine hydrochloric acid with pepsin
You'll want to take as many as you need to get the slightest burning sensation and then decrease by one capsule. This will improve digestion and help kill the H. pylori bacteria. As a general dosing guideline, an effective adult dose is typically five to seven capsules containing 650 milligrams (mg) of betaine with pepsin.
The only time a pepsin-free betaine supplement is recommended is if you're sensitive to pepsin. That's rare, however, and without pepsin the betaine will not work well, because if your stomach does not produce enough hydrochloric acid, it also will not make sufficient amounts of pepsin (the enzyme that breaks down proteins).
According to Dr. Jonathan Wright, betaine is contraindicated if you're taking any kind of anti-inflammatory medication, such as corticosteroids, aspirin, Indocin, ibuprofen or other NSAIDs.56
The reason for this is because these drugs can damage your gastrointestinal lining. Taking a hydrochloric acid supplement can aggravate the area, raising your risk of gastric bleeding or an ulcer.57 Digestive bitters may be a safer choice in this case.
✓ Papaya fruit or papain supplement
Papaya fruit contains papain, an enzyme that helps break down both protein and carbohydrates. It even helps break down gluten, making it particularly valuable for those struggling with gluten sensitivity.58
✓ Pineapple or bromelain supplement
Bromelain is a proteolytic enzyme found in pineapple, and like papain, it also helps digest proteins. It also has anti-inflammatory activity and helps maintain more regular bowel movements.59
✓ Baking soda
One-half to 1 full teaspoon of baking soda (sodium bicarbonate) in an 8-ounce glass of water may ease the burn of acid reflux as it helps neutralize stomach acid. I would not recommend this is a regular solution, but it can sure help in an emergency when you are in excruciating pain.
✓ Aloe juice
The juice of the aloe plant naturally helps reduce inflammation, which may ease symptoms of acid reflux. Drink about one-half cup of aloe vera juice before meals. If you want to avoid its laxative effect, look for a brand that has removed the laxative component.
✓ Ginger root
Ginger has been found to have a gastroprotective effect by suppressing Helicobacter pylori.60 It also tightens your LES, thereby preventing the reflux of stomach acid61 and reduces inflammation.62 According to a 2007 study,63 it's also far superior to lansoprazole for preventing the formation of ulcers, exhibiting up to eight-fold greater potency over the drug.
Add two or three slices of fresh ginger root to 2 cups of hot water. Let steep for about a half-hour. Drink about 20 minutes or so before your meal.
✓ Vitamin D
Vitamin D is important for addressing any infectious component. Once your vitamin D levels are optimized, you're also going to optimize your production of about 200 antimicrobial peptides that will help your body eradicate any infection that shouldn't be there.
This exceptionally potent antioxidant was found to reduce symptoms of acid reflux in patients when compared to a placebo, particularly in those with pronounced helicobacter pylori infection.64 Best results were obtained at a daily dose of 40 mg.
✓ Slippery elm
Slippery elm coats and soothes your mouth, throat, stomach and intestines, and contains antioxidants that can help address inflammatory bowel conditions. It also stimulates nerve endings in your gastrointestinal tract. This helps increase mucus secretion, which protects your gastrointestinal tract against ulcers and excess acidity. The University of Maryland Medical Center65 makes the following adult dosing recommendations:
• Tea: Pour 2 cups boiling water over 4 grams (roughly 2 tablespoons) of powdered bark, then steep for three to five minutes. Drink three times per day
• Tincture: 5 milliliters (mL) three times per day
• Capsules: 400 to 500 mg three to four times daily for four to eight weeks. Take with a full glass of water
• Lozenges: Follow dosing instructions on label
✓ Deglycyrrhizinated licorice root
Deglycyrrhizinated licorice (DGL) may also be helpful, as it helps block inflammatory prostaglandins.66 As noted by Livestrong,67 "Licorice (Glycyrrhiza glabra) has been … used to treat a variety of maladies … Its ancient reputation as a folk remedy for gastric problems does have a scientific basis. This is especially true for functional dyspepsia, a condition that frequently overlaps with acid reflux.
Like acid reflux, it presents symptoms of pain in the upper abdomen, discomfort, burning and belching. Iberogast, or STW 5, and GutGard, two products whose primary ingredient is an extract of DGL licorice, have been shown to relieve symptoms of both dyspepsia and acid reflux; however, these products have many other ingredients …
Licorice must be approached cautiously because it contains the active metabolite glycyrrhiza. In large quantities glycyrrhiza can cause a syndrome called hyperaldosteronism, which affects the adrenal glands and can cause numbness, high blood pressure and muscle weakness."
DGL supplements contain licorice from which a substantial amount of the glycyrrhiza has been removed, making it safer for use.68 Dr. Andrew Weil recommends chewing two DGL tablets or taking half a teaspoon of DGL powder before or between meals and at bedtime. Once your symptoms are under control, taper down your dose.69
Licorice is contraindicated if you're on diuretics or stimulant laxatives. Also, beware that licorice may reduce your potassium level, and has estrogenic activity, so women on hormone therapy or who have estrogen-dependent cancers or other reproductive conditions such as endometriosis should avoid it.70
Research71 published in 2009 found that gastrointestinal damage caused by H. pylori can be addressed with the amino acid glutamine, found in many foods, including beef, chicken, fish, eggs, dairy products and some fruits and vegetables. L-glutamine, the biologically active isomer of glutamine, is also widely available as a supplement.
✓ Folate or folic acid (vitamin B9) and other B vitamins
Research72 suggests B vitamins can reduce your risk for acid reflux. Higher folic acid intake was found to reduce acid reflux by approximately 40 percent. Low vitamin B2 and B6 levels were also linked to an increased risk for acid reflux. The best way to raise your folate levels is by eating folate-rich whole foods, such as liver, asparagus, spinach, okra and beans.
✓ Melatonin, l-tryptophan, vitamin B6, folic acid, vitamin B12, methionine and betaine
A dietary supplement containing melatonin, l-tryptophan, vitamin B-6, folic acid, vitamin B-12, methionine and betaine was found to be superior to the drug omeprazole in the treatment of GERD.73 Part of the success is thought to be due to melatonin's inhibitory activity on NO biosynthesis, which plays an important role in transient LES relaxation, which, as I mentioned earlier, is part of the real underlying problem of heartburn.
Impressively, 100 percent of patients receiving this supplement reported a complete regression of symptoms after 40 days of treatment, compared to just under 66 percent of those taking omeprazole. The authors concluded that "this formulation promotes regression of GERD symptoms with no significant side effects."