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GERD part 2


By Renata Trister DO

GERD and reflux symptoms are more likely the result of too little acidity (hypochloridia), bacterial overgrowth and increased intra-abdominal pressure (IAP). The following treatments focus on restoring adequate stomach acid production and eliminating bacterial overgrowth.

This can be accomplished by following the “three Rs”:

1. Reducing the factors that promote bacterial overgrowth and low stomach acid.
2. Replenish stomach acid, enzymes and nutrients that aid digestion.
3. Restore the micro biome of beneficial bacteria to the GI tract and restore a healthy mucosal lining in the gut.

How to reduce bacterial overgrowth and replenish low stomach acid


A high carbohydrate diet contributes to bacterial overgrowth. H. pylori can actually suppress stomach acid . A cycle of bacterial overgrowth and low stomach acid reinforce each other creating a progressive decline of digestive function.
As bacteria prefer and thrive on fermentation of carbohydrates for energy, a very low-carb (VLC) diet can be beneficial.

A small study performed by Professor Yancy and colleagues at Duke University. 5 patients with severe GERD that also had a variety of other medical problems, such as diabetes were enrolled. Each of these patients had failed several conventional GERD treatments before being enrolled in the study and for all 5 the symptoms of GERD were completely eliminated within one week of adopting a very low carbohydrate (VLC) diet.

Another small study done by Yancy 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. All five of these patients showed a substantial decrease in their Johnson-DeMeester score (meaning less acid in the esophagus). Furthermore, the decreases in Johnson-DeMeester scores were similar to decreases reported by patients taking PPIs. All eight patients reported improvement in symptoms – evidenced through their GSAS-ds scores. The GSAS-ds scores decreased from 1.28 prior to the diet to 0.72 after initiation of the VLC. These results demonstrate both objective (Johnson-DeMeester) and subjective (GSAS-ds) improvement.

Obesity is a risk factor for GERD, because it increases intra-abdominal pressure. This increased pressure overwhelms the lower esophageal sphincter (LES) and causes a dysfunction of the LES. An added benefit of a VLC diet is weight loss.
Another diet that can be used instead of a VLC called a “specific carbohydrate diet” (SCD), or the GAPS diet. On this kind of plan, is not the amount of carbohydrates, but the type of carbohydrate that is important. The theory is that the longer chain carbohydrates (disaccharides and polysaccharides) are the ones that feed bad bacteria in our guts, while short chain carbohydrates (monosaccharide’s) 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.

Fructose and artificial sweeteners

Fructose and artificial sweeteners contribute to bacterial overgrowth. Artificial sweeteners simply should be avoided completely, and fructose (in processed form especially) should be reduced.


High fiber diets and bacterial overgrowth are a particularly dangerous mix. 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.
Therefore adding various fiber supplements is not beneficial and may actually be harmful to GERD sufferers. However, eating green vegetables is not something to avoid.


Bitter herbs stimulate acid production in the stomach. “Bitters” have been used in traditional medicine for thousands of years in an effort to stimulate and improve digestion. Today, studies have actually confirmed the ability of bitters to increase the flow of digestive juices, including HCL, bile, pepsin, gastrin and pancreatic enzymes. Unfortunately, these studies are small as evaluating the therapeutic potential of un-patentable and unprofitable bitters has little incentive.
The following is a list of bitter herbs commonly used in Western and Chinese herbology:

Barberry bark
Gentian root
Globe artichoke
Goldenseal root
Milk thistle
Yellow dock

Bitters are normally taken in very small doses – just enough to sense a strong taste of bitterness – 5 to 10 drops of a 1:5 tincture of the above herbs taken in 20 mL of water.

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.

Patients 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 your doctor, who can then help you replace them through nutritional changes and/or supplementation.

How to restore good bacteria and healthy mucosal lining


Bacterial overgrowth is a major contributor to heartburn and GERD, therefor restoring healthy intestinal bacteria is important. Beneficial bacteria (probiotics) protect against potential pathogens by competing for resources – competitive inhibition. These good bacteria perform several other functions essential to digestive health as well.

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 increase cure rates of treatment for H. pylori when supplemented to an antimicrobial treatment.

It is easy to become confused when facing the vast options of probiotics on the market. As mentioned earlier, it is best to attempt to get the nutrients needed from food. Probiotics are no exception. Fermented foods have been eaten for their digestive benefits for thousands of years. Contrary to popular belief and marketing, foods like yogurt, kimchi and kefir generally have a much higher concentration of beneficial microorganisms than supplements.

For example, even the most potent commercial probiotics claim to contain somewhere between one and five billion microorganisms per serving. In comparison, a glass of homemade kefir (fermented milk) contains as many as 5 trillion beneficial microorganisms!

Fermented milk products like kefir and yogurt also contain 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, 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. Dom’s Kefir website has lots of information on this topic.

Non-dairy (and thus lower-carb) options include unpasteurized (raw) sauerkraut and pickles and a fermented tea 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, both can also be easily made at home.

Probiotic supplements are sometimes necessary and can play a crucial role in treatment and recovery. But not all probiotic supplements are the same, and in the case of small intestinal bacterial overgrowth (or SIBO, which is commonly present with GERD), certain probiotics may make things worse. SIBO involves an overgrowth of microorganisms that produce a substance called D-lactic acid. There are a very small number of people who do not respond well to D-lactate—an acid produced by some probiotic bacteria, including lactic acid bacteria like Lactobacillus acidophilus. These patients would do better with a probiotic that contains strains of Bifidobacteria.

Restoring a healthy gut lining

Bone broth and DGL

Restoring the mucosal gut lining to a healthy state is another important aspect of recovering from GERD. Chronic stress, bacterial overgrowth, and certain medications such as steroids, NSAIDs and aspirin damage the mucosal lining of the stomach. The mucosal lining of the stomach that protects it from acid, a damaged stomach lining can cause irritation, pain and ulcers.

Homemade bone broths are effective in restoring a healthy mucosal lining in the stomach. These broths are rich in gelatin and collagen and proline, a non-essential amino acid that is an important precursor for the formation of collagen. Gelatin and collagen have both been beneficial in treatment of ulcers. Bone broth also contains glutamine, important for intestinal cells, glutamine has been shown to benefit the gut lining in animal studies. Please see link at end of this article for more information and recipes for bone broths.

Although it is best to obtain nutrients from food whenever possible, 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 increasing 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. Important note, licorice products that contain glycyrrhizin and whole licorice (in contrast to DGL- Deglycyrrhizinated licorice) may increase the effects of corticosteroids, cause sodium and water retention and increase blood pressure, increase the effect of digitalis preparations, alter the effect of estrogens/progesterone, and decrease the effect of anti-hypertensive medications. Avoid whole or licorice root if you have high blood pressure, kidney or liver disease, diabetes or heart disease, are pregnant or are breastfeeding.

There are no known side effects for DGL products and it is a safer alternative to whole licorice supplements.


The general medical approach to treating heartburn and GERD involves taking acid stopping drugs for as long as these problems occur. Although these drugs work incredibly well to relieve symptom quickly. This temporarily relief is analogous to “sweeping dirt under the rug”. These medications do not address the actual pathology of behind the symptoms. In many cases they make the condition worse, while masking the symptoms. This means that many patients initiating treatment with antacid drugs end up taking them for the rest of their lives.

A serious problem arises as 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. Unfortunately, this recommendation has been largely discarded. There are many patients 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. The vast marketing of pharmaceuticals overshadows this crucial information. Drug companies make more than $7 billion a year selling acid suppressing medications. Teaching doctors and their patients to learn how to treat heartburn and GERD without these drugs would cut into these profits. Furthermore, any treatment protocol with out “data” to support its effectiveness is generally seen as unacceptable in our medical system. Although gathering evidence for safety and efficacy is very important, roughly 2/3 of all medical research is sponsored by drug companies – meaning that most of the research is focused on showing how well a product works. Large studies on the effects of a low-carb diet on acid reflux and GERD are unlikely. In this environment it is important to remember just because a treatment used for thousands of years has little published research, does not mean it is to be discarded.

Recommended Resources

Why Stomach Acid is Good For You, by Jonathan Wright, M.D. and Lane Lenard, Ph.D. The title says it all. Great book.
Heartburn Cured – The Low-Carb Miracle, by Norm Robillard, Ph.D. Good information on the connection between bacterial overgrowth and GERD.
The GAPS Diet Book and The GAPS Diet Guide. Excellent resources for a specific-carbohydrate diet that reduces bacterial overgrowth and repairs the gut lining.
The 30-day Heartburn Solution, by Craig Fear NTP. A 30day plan that uses real food to heal your body. Book contains practical information and a simple meal planning methods.
Brodo: A Bone Broth Cookbook, by Marco Canora. New York City chef Marco Canora has been credited for the recent explosion of interest in medicinal broths after improving his own health by integrating bone broth into his diet.
Link to information and recipes for bone broths

Cooking with Bones

Important links for physicians:

1. Overutilization of proton-pump inhibitors: what the clinician needs to know.
Joel J. Heidelbaugh, Andrea H. Kim, Robert Chang, and Paul C. Walker

2. Common gastrointestinal symptoms: risks of long-term proton pump inhibitor therapy. Fashner J, Gitu AC. Discusses risks of long term ppi use and includes step down regimens to prevent or minimize the discomfort that can occur with abrupt ppi discontinuation.

3. Disruption of the gastroesophageal junction by central obesity and waist belt: role of raised intra-abdominal pressure. Lee YY, McColl KE.