The following list is a non-comprehensive collection of the 12 things that contribute to acid reflux. There are usually 2 sides the acid reflux and gastroesophageal reflux disease (GERD) equation, low and high stomach acid. We often associate heartburn with high stomach acid, but more often than not, we are experiencing low stomach acid.
You might ask, “How would low stomach acid cause heartburn?” Let’s look at this another way. If you have a jar of water that is mostly empty and then fill it with coins, what happens? The water eventually pours out of the lid. A similar thing happens with your stomach. When you are not producing enough stomach acid to breakdown your food, it fills your stomach, and the released stomach acid hits your esophagus.
Our modern lifestyle is the biggest contributor to low stomach acid (4, 11). Stomach acid is necessary not only to breakdown food but also to chelate elemental minerals (3). Individuals with low stomach acid are prone to severe mineral deficiency. When minerals remain in their elemental forms, they can also cause harm when not properly absorbed. Calcium is the most acid hungry mineral we know of and because of how much stomach acid calcium requires for absorption, calcium carbonate is the most popular antacid on the market.
Autoimmune conditions and Allergies
Low stomach acid can also contribute to autoimmunity and allergies. When there is not enough stomach acid to breakdown food, undigested proteins make it to the gut. These undigested proteins can irritate the gut lining and potentially enter the bloodstream undigested. Best-case scenario undigested proteins are left unabsorbed and passed directly into stools. Although, this can cause further nutritional deficiencies.
Low stomach acid can also contribute to small intestinal bacterial overgrowth (SIBO). Just like the esophageal sphincter protects the digestive system above your stomach, stomach acid protects your lower digestive system. Stomach acid prevents intestinal bacteria from making its way into the stomach. Also, when undigested food enters the small intestine it can damage the sensitive balance of the healthy bacteria in the small intestine. When this occurs, bacteria from the large intestine can colonize the small intestine and these misplaced bacteria will attempt to survive by absorbing nutrients from our foods, making them unavailable to the rest of the body. Symptoms of SIBO include pain in the stomach (especially after eating), bloating, cramps, diarrhea, constipation, indigestion, a regular feeling of fullness, and gas.
High stomach acid is also a possibility. This is usually due to consuming too many acidic foods and/or hereditary. Generally, high stomach acid can be the easier one to fix. Both high and low stomach acid can contribute to GERD, acid reflux, ulcers, esophageal irritation, etc. This is because low and high stomach acid usually results in the same outcome. Acid gets up into the esophagus.
Whether you have issues with low or high acid levels, you will also want to avoid foods that relax the lower esophageal sphincter (LES). The relaxation of the LES allows acid to come back up into the esophagus and gradually damage the esophagus. Once the esophagus is damaged, it can no longer protect the sensitive lining of the esophageal tissue.
Treating the wrong problem
The problem is that if you are attempting to treat low acid with high acid remedies, this can be disastrous to your health. If you try to treat high acid with low acid remedies, the immediate feedback you get will help you determine which one it is. It’s important to know which one to treat, especially since the pH balance of the stomach can, directly and indirectly, affect the pH balance of the entire body.
One thing I noticed while reading through research and various blogs, is that there isn’t much consistency regarding what causes high vs low stomach acid. I’m hoping somewhat clear that up and I might write a follow-up when more information is available.
Here are the 12 things to avoid if you have acid reflux
Low Stomach Acid
As we get older, we simply produce less stomach acid. After a while, we might even lose the taste for meat if we can’t produce enough acid to break it down. Older individuals also seem to be less sensitive to the symptoms of acid reflux which can contribute to the development of GERD and other more serious concerns (10). As this problem gets worse, we gradually lose our ability to experience the symptoms, which may cause people not to seek care.
Perimenopause and menopause can also contribute to low stomach acid, which is why hormone replacement therapy can improve digestive upset during this time of life. Researchers examined the prevalence of GERD symptoms in 497 women and found that almost 42% of perimenopausal and 47% of menopausal participants complained of upper GI symptoms (7). The protection that estrogen provides women is why women are less likely than men to develop GERD early in life and why this relationship flips after menopause (1, 4). This is also part of why mineral absorption is so poor for this age group, which research has found to be somewhat alleviated with hormone replacement (3).
Researchers have demonstrated that stress hormones increase when acid levels are low and individuals are more sensitive to gastroesophageal reflux (9). It is a well-established finding that the sympathetic nervous system becomes active under stress and activates the 4 F’s (fight, flight, freeze, and fu…reproduction). Activation of the sympathetic nervous system causes a lowering of activity in the parasympathetic system in charge of rest, recovery and digestion. Digestion grinds to a halt in the presence of chronic and acute stress.
As we learned last Friday, the decrease in estrogen and progesterone that occurs during menstruation can promote pain, bloating and decreased stomach acid production (1). Aside from it’s effects on stomach acid, estrogen and progesterone can dull pain related to digestive discomfort. In the absence of both hormones, many women will experience hypersensitivity where the slightest pain-inducing alterations in the esophagus, small intestine, colon, and pancreatic/biliary region can be more painful.
There is really is no good place for sugar in the human diet. The ability of sugar negatively affect hormone balance through excess insulin production can cause a significant decrease in stomach acid. Sugar can also contribute to the production of uric acid, contribute to issues with gout, and inhibit relaxation throughout the vascular system, causing an increase in blood pressure (12).
5. Calcium-fortified foods
As I mentioned earlier, minerals require a great deal of stomach acid for absorption and out of all the minerals calcium requires the most. Because we avoid foods naturally high in minerals including calcium, food producers have fortified many of your staple foods with cheap calcium. This form of calcium can directly recruit stomach acid for absorption and not leave much for digesting food.
High Stomach Acid
If you find that having a high amount of stomach acid is the culprit, you will want to avoid the following foods. Any foods on this list that relax the LES, you might also want to avoid if you have reflux caused by low stomach acid as well.
These anti-inflammatory OTC’s decrease inflammation by lowering the activity of cyclo-oxygenase 1 & 2 (COX1 and COX2) proinflammatory enzymes (15). Although decreasing the production of these enzymes can lower pain, inflammation, and fever, they also prevent the production of prostaglandins required to protect the lining of the stomach. These prostaglandins promote a low-level inflammatory response that makes the stomach resilient to its own acid production. NSAIDs are also a mild acid, besides making the stomach more susceptible to damage, they can lower bicarbonate production (our natural antacid), and damage the liver.
The combination of phosphoric acid and carbonation can contribute quite a bit of acid to the stomach content of those predisposed to higher levels of acid. The acid in soda can also demineralize teeth, causing cavities (8). The caffeine in soft drinks also contributes to the relaxation of the LES (11).
8. Coffee and Tea
Like soda, Coffee is especially high in acid compounds and can deactivate the enzyme necessary to slow gastric emptying, meaning that food will leave the stomach before being fully digested. The tannins in both tea and coffee will bind to minerals and prevent their absorption. As with soda, the caffeine content in coffee and tea can cause the LES to relax and allow stomach acid to come up into the esophagus. If you can’t do without coffee, here are some way to lower the acid content.
9. Fruit Juice
Juices, especially of the citrus variety, can contribute significantly to stomach acid. Drinking or eating citrus continuously can also contribute to demineralizing teeth (8). Non-citrus drinks aren’t as bad, but they can still cause issues because of the abundant sugar present in these beverages.
Research has shown that alcohol can also promote the relaxation of the LES. This is a big problem if you are prone to the overproduction of stomach acid. If you know that you have issues with acid reflux, skip having booze with your meal. Wine can be especially problematic because the alcohol and the nitrate content can further relax the LES.
11. Spicy Food
The alkaloids in hot peppers, especially capsaicin, can make your stomach more sensitive the effects of excess acid. What’s interesting is that researchers have found that spicy food doesn’t affect the esophagus, gastric pH profiles, gastric emptying, dyspepsia or severity of heartburn (14). Although it does sensitize the nerves that promote the experience of heartburn. Researchers also found that foods high in capsaicin decreased the latency to experience heartburn from 247 min to 120 min. Meaning that spicy food can substantially speed up the rate at which you experience heartburn.
Food manufactures us nitrates are used to preserve meats and various other processed foods. They are also added to fresh food for the purpose of preserving color, something not allowed in organic foods. The nitrates in these foods directly cause the LES to relax and significantly contribute to acid reflux (6, 13). Although, nitric oxide production within our body is generally a good thing. Nitric oxide is an essential compound your body uses to manage blood pressure and support vascular health. In essence, it is good when your body can make and use nitrate but it may not be a good idea to eat or drink nitrate.
Acid Reflux and GERD are difficult problems to solve as you can see and there are 3 mechanisms that can synergistically work against you. Through Low stomach acid, high stomach acid, and various compounds that relax the LES, these factors can contribute significantly to the development of acid reflux. Hopefully knowing these 12 things that contribute to acid reflux can help you make better decisions related to your digestive health.
How do you test whether you have low stomach acid or not? This article is a great resource for information on how to test whether you are suffering from low or high stomach acid. One way you can test to see if you’re dealing with low stomach acid is to mix 1/4 teaspoon of baking soda in 4-6 ounces of cold water prior to eating or drinking anything. Drink the baking soda solution and time how long it takes to belch. The time limit for this test is up to five minutes. Any belching after 3 minutes might indicate low stomach acid, belching before that can indicate adequate stomach acid levels. If you find that this test indicates low stomach acid, you can look into a more accurate test called The Heidelberg Stomach Acid Test.
In Thursday’s article, I will provide recommendations that can help you manage acid reflux and GERD.
- Asanuma, K., Iijima, K., & Shimosegawa, T. (2016). Gender difference in gastro-esophageal reflux diseases. World journal of gastroenterology, 22(5), 1800.
- Borrelli, F., & Tavares, I. A. (2003). Effect of nimesulide on gastric acid secretion in the mouse stomach in vitro. Life sciences, 72(8), 885-896.
- Bureau, I., Anderson, R. A., Arnaud, J., Raysiguier, Y., Favier, A. E., & Roussel, A. M. (2002). Trace mineral status in post-menopausal women: impact of hormonal replacement therapy. Journal of trace elements in medicine and biology, 16(1), 9-13.
- Dore, M. P., Maragkoudakis, E., Fraley, K., Pedroni, A., Tadeu, V., Realdi, G., … & Malaty, H. M. (2008). Diet, lifestyle and gender in gastro-esophageal reflux disease. Digestive diseases and sciences, 53(8), 2027-2032.
- Fass, R.O., Pulliam, G.L., Johnson, C.I., Garewal, H.S., & Sampliner, R.E. (2000). Symptom severity and oesophageal chemosensitivity to acid in older and young patients with gastro-oesophageal reflux. Age and ageing, 29(2), 125-130.
- Iijima, K., & Shimosegawa, T. (2014). Involvement of luminal nitric oxide in the pathogenesis of the gastroesophageal reflux disease spectrum. Journal of gastroenterology and hepatology, 29(5), 898-905.
- Infantino, M. (2008). The prevalence and pattern of gastroesophageal reflux symptoms in perimenopausal and menopausal women. Journal of the American Academy of Nurse Practitioners, 20(5), 266-272.
- Jarvinen, V. K., Rytomaa, I. I., & Heinonen, O. P. (1991). Risk factors in dental erosion. Journal of dental research, 70(6), 942-947.
- Lee, H. S., Noh, C. K., & Lee, K. J. (2017). The Effect of Acute Stress on Esophageal Motility and Gastroesophageal Reflux in Healthy Humans. Journal of neurogastroenterology and motility, 23(1), 72.
- Lee, J., Anggiansah, A., Anggiansah, R., Young, A., Wong, T., & Fox, M. (2007). Effects of age on the gastroesophageal junction, esophageal motility, and reflux disease. Clinical Gastroenterology and Hepatology, 5(12), 1392-1398.
- Meining, A., & Classen, M. (2000). The role of diet and lifestyle measures in the pathogenesis and treatment of gastroesophageal reflux disease. The American journal of gastroenterology, 95(10), 2692.
- Nakagawa, T., Hu, H., Zharikov, S., Tuttle, K. R., Short, R. A., Glushakova, O., … & Patel, J. M. (2006). A causal role for uric acid in fructose-induced metabolic syndrome. American Journal of Physiology-Renal Physiology.
- Nasseri-Moghaddam, S., Nokhbeh-Zaeem, H., Saniee, P., Pedramnia, S., Sotoudeh, M., & Malekzadeh, R. (2012). Oral nitrate reductase activity and erosive gastro-esophageal reflux disease: a nitrate hypothesis for GERD pathogenesis. Digestive diseases and sciences, 57(2), 413-418.
- Rodriguez-Stanley, S., Collings, K. L., Robinson, M., Owen, W., & Miner, J. P. (2000). The effects of capsaicin on reflux, gastric emptying and dyspepsia. Alimentary pharmacology & therapeutics, 14(1), 129-134.
- Russell, R. I. (2001). Non-steroidal anti-inflammatory drugs and gastrointestinal damage—problems and solutions. Postgraduate medical journal, 77(904), 82-88.