My patient Susan has GERD.  Heartburn, upper abdominal pain, the whole package.  She’s been taking acid-blocking medications for years and figures she’s going to be taking them for the rest of her life.  As long as she takes her medicine she’s pretty comfortable so she considers the problem solved.

My other patient Casey has GERD symptoms too.  However, in her case acid-blocking medicines don’t help.  She’s tried high doses of every acid reducer, tried combining different classes of medications, and she has her GI doctor stumped.

A third patient, Marie, has pernicious anemia.  Her immune system has attacked the cells that make both stomach acid and a protein that helps her absorb vitamin B12 from her diet.  She doesn’t have any stomach symptoms.  She was diagnosed because she felt tired and her labs showed anemia and vitamin B12 deficiency.

All these patients have one thing in common:  low stomach acid, called hypochlorhydria.  Actually in Marie’s case she probably has achlorhydria, or NO stomach acid, since the cells that make acid have been destroyed.

Susan’s hypochlorhydria is caused by her medications.  Casey, ironically enough, has hypochlorhydria which is MIMICKING reflux disease.  It’s a bit of a cosmic joke that hypochlorhydria can cause heartburn, upper abdominal pain and trouble digesting food.  How’s a poor doc to know?  Even on endoscopy it’s tough to tell the difference.

What can be done to help Casey?  I’m lucky my patients, including Casey, trust me so much!  I was able to get her to try apple cider vinegar which produced a remarkable improvement in her symptoms.  Within a few days she found that her symptoms were essentially gone.

Can you guess Casey’s main issue with this treatment plan?  Yep!  Apple cider vinegar tastes TERRIBLE!  Luckily there’s a supplement that can be used to provide acid to the stomach:  Betaine HCL,  1-3 capsules with meals based on the meal’s protein content. (More on this later.)

Why should Marie and Susan care that they have low stomach acid?  They don’t have any stomach symptoms, after all.  Stomach acid is important for proper digestion and also helps protect against infection.  People with hypochlorhydria have been found to have changes in the intestinal bacteria that can lead to small intestine bacterial overgrowth and irritable bowel syndrome symptoms, among others.

OK, so I’ll just take a probiotic and be done, right?  Not so fast!  Proper digestion of protein requires stomach acid, since pepsin (one of the three enzymes that digest protein) is activated by stomach acid.  If the pH is high (remember high school chemistry?  Acid has a low pH) pepsin doesn’t work and protein digestion isn’t effective.  This may lead to lack of proper protein nutrition, and worse, can expose food proteins to the immune system later in the digestive tract and possibly trigger food allergies.

Also, low stomach acid interferes with absorption of calcium and magnesium.  Calcium salts don’t dissolve if the pH is high.  Taking calcium supplements while taking strong acid-blocking medications is pretty ineffective.  Low stomach acid increases the risk of osteoporosis and hip fractures in women.

OK, so hypochlorhydria interferes with calcium, magnesium and protein digestion.  What do you do?  If you’ve got a history of stomach ulcers and life-threatening GI bleeding, you need the acid suppression so that your stomach doesn’t digest itself.

Turns out betaine HCL is effective at creating stomach acid even in patients taking powerful acid blocking medications.  If you think you might have low stomach acid or if you take acid reducing medications, consider a trial of betaine HCL with meals.  The first capsule is taken with the first few bites of food (NOT on an empty stomach!), and 1-2 capsules can be taken later in the meal if you’re eating a lot of protein.  Betaine HCL works quickly (it takes 5-6 minutes) and lasts about an hour.

Low stomach acid is very common.  For instance, it’s estimated at least 50% of diabetics have hypochlorhydria.  How do you know?  You can test yourself at home by mixing a small amount (a half teaspoon or so) of baking soda in water and drinking it first thing in the morning.  If you don’t belch a few times soon afterwards it indicates you may not have much acid in your stomach, since acid combines with baking soda to form carbon dioxide.

Proton pump inhibitors and other strong acid-blocking medications are great for short-term treatment but have consequences for long-term use.  Poor protein digestion, calcium and magnesium absorption issues, osteoporosis and hip fractures are known risks.  Using a well-tolerated supplement that temporarily restores acid to the stomach for meals can be a great measure to improve digestive function.

If you are under the care of a GI specialist for ulcers, reflux, Barrett’s esophagus or other acid-related problems, please be sure to discuss this with your doctor BEFORE starting a new medication or supplement.  You can print this post or email it to him/her with the research links for consideration.

Betaine HCL is available from health food stores and online.  Unfortunately I haven’t been able to find any guidance about which brand(s) to choose.

Hypochlorhydria is common, it often has no symptoms or has symptoms which mimic GERD, and causes some pretty serious long-term health problems.  Luckily the treatment is readily available and well tolerated, we just have to recognize it!

QUESTION:  Are you going to do the baking soda test?  If so, please post a comment letting me know what your results are!