Betaine HCL, Will It Improve Your Digestion, GERD, or LPR?

One of the many causes of reflux disorders appears to occur from having an elevated stomach pH. I know that is counter to everything you have heard from mainstream medicine. Most people are told that they have too much stomach acid, which causes reflux disorders like GERD and LPR. You see advertisements all the time on television for acid-reducing medications, including antacids and proton pump inhibitors (PPI’s). You have probably seen the television commercials with Larry The Cable Guy telling you if you take a PPI you can eat a million hot dogs, guzzle gallons of soda, ride four wheelers, and not suffer from any reflux. Betaine HCL supplementation improves reflux symptoms for most people compared to PPI use, yet PPI’s are advertised everywhere.

The primary cause of most reflux disorders is not from increased stomach acid production but instead occurs from elevated abdominal pressure. Elevated abdominal pressure weakens the lower esophageal sphincter (LES) and forces gastric contents more frequently into the esophagus and if the upper esophageal sphincter (UES) is weakened as well into the larynx and oral cavity. Upper gut dysbiosis and small intestinal bacterial overgrowth (SIBO) causes increased fermentation causing gas production, which will lead to bloating and increased abdominal pressure. Hiatal hernia’s and abdominal adhesion’s from surgeries can also weaken the LES from improper gastrointestinal alignment and lead to increased abdominal pressure causing reflux disorders. Generally, throughout the day, we occasionally reflux, from occasional natural esophageal pressure changes, swallowing, belching, bending over, and laughing loudly. That being said for most people, our esophagus can easily handle occasional reflux episodes and inflammation. For others, they cannot, and they develop reflux conditions, including GERD or LPR. There might be differences in the types of reflux materials which can lead to different reflux disorders which I have covered in the following linked Fix Your Gut YouTube video.1

So How Does Elevated Stomach pH Cause Reflux Disorders Including GERD and LPR?

Our stomach is meant to have an acidic environment. Increased stomach pH facilitates dysbiosis, bloating, improper stomach emptying (in severe cases gastroparesis), and protein fermentation and malabsorption. All of these listed issues from increased stomach pH increases abdominal pressure and causes the stomach to become displaced, which can lead to an hiatal hernia putting further pressure on the esophagus and LES. The increase in abdominal pressure primarily gastric pressure weakens the LES and causes reflux disorders including GERD and LPR.2 3

Stomach acid is produced by our stomach to lower the stomach pH to help limit pathogen overgrowth, digest protein, activate digestive enzymes, signal an increase in mucin production in the stomach to protect from gastritis, and facilitate proper absorption of vitamin B12 later within our gastrointestinal tract (intrinsic factor). So when we do not produce enough stomach acid or the stomach acid we produce is neutralized, what happens to our digestion?4 5 6

When you have a consistently elevated stomach pH microorganism dysbiosis occurs leading to further digestive issues. Our stomach is not sterile. However, a majority of the bacteria that live in our stomach including probiotic bacteria like Lactobacillus tend to be able to survive and thrive in acidic environments. Our stomach has a lower amount of microbes that live in it compared to other parts of our body because of the lower pH, exposure to enzymes, and constant exposure to oxygen. Most of the opportunistic bacteria that cause upper gut digestive issues have to be able to neutralize stomach acid and increase stomach pH to survive. Bacteria including H. pylori, for example, produce the enzyme urease to metabolize urea which is found minute amounts in stomach chyme, to produce carbon dioxide and ammonium ions which neutralize stomach acid and increase stomach pH. H. pylori cannot thrive in an acidic environment, and when one’s stomach pH is normal (between two to four at resting, one to three when eating), it tends to become dormant within biofilm within the mucosal barrier of the stomach. However, when your stomach pH is elevated, H. pylori becomes active, propagates, causing dysbiosis, which produces toxins depending on the strain that induces inflammation, reflux, gastritis, and ulcers. Maldigested protein in the stomach from an elevated stomach pH negatively influences the microbiome of the stomach as well. Maldigested protein leads to increased fermentation and possible dysbiosis producing excessive amounts of hydrogen gas, causing distension, esophageal pressure changes, and LES weakness. Upper gut bacteria are also able to use glucose from food ingestion for propagation and increase hydrogen production leading to gas, bloating, and increased abdominal pressure. A hiatal hernia may eventually develop from worsening abdominal pressure and increase further pressure on the LES and esophagus. The increased pressure would further weaken the LES and worsen GERD.7 8 9 10

Dysbiosis in the stomach and esophagus may lead to reduced probiotic Akkermansia muciniphila colonization, in the upper gut, which combined with increased stomach pH result in a reduction of mucosal barrier health in the stomach and esophagus. Increased endotoxin production from Gram-negative overgrowth can increase inflammation in the stomach, causing gastritis, and increase inflammation in the esophagus, causing the symptoms of reflux. The esophagus is also able to produce limited quantities of bicarbonate (using carbonic anhydrase) to protect itself from reflux; its capacity is reduced if repeated reflux events are occurring. The worsening combination of increased inflammation (endogenous cytokines and chemical injury) from constant refluxing (due to increased gastric pressure) into the esophagus, reduction of mucosal integrity, and endotoxin inflammation cause the symptoms of reflux from excessive esophageal inflammation.11 12 13 14 15 16 17

All of these issues occur from increased stomach pH. Most people with reflux and stomach disorders are then prescribed PPI’s which reduce stomach acid production further decreasing stomach pH (the higher reflux pH of the stomach chyme for a time, the less chemical injury to the esophagus). For a while, inflammation in the esophagus and stomach is reduced from a reduction of the pH of reflux. Dysbiosis worsens over time from elevated stomach pH and eventually, from increased inflammation (induced from continued reflux containing pepsin and endotoxins), reflux symptoms occur again, for some stronger than ever, and the cycle repeats itself. The PPI dosage is increased, symptoms abate, then later return worse than ever until the PPI’s dose is maxed out. A truly vicious cycle.

Betaine HCL, Does it Improve Digestion?

Maybe, there is not a lot of diagnostic information available that taking betaine HCL to reduce stomach pH and increase stomach acid production, but we do have promise. We do have an excellent study that measures gastric re-acidification using betaine HCL to try to improve the absorption of certain medications that require proper stomach acid for the breakdown. Prior studies have shown that absorption of certain drugs depends on a lower stomach pH, which explains why some medications like ketoconazole or antibiotics are recommended not to be taken with antacids. In a prior study, people taking the PPI omeprazole were given Coca-cola (pH of 2.5) and ketoconazole to see if it would increase absorption of the medication, which it did.18

In the study, volunteers were given the PPI rabeprazole for five days, and their gastric pH was monitored throughout the study using Heidelberg pH capsules. The pH of the stomach was more alkaline in most of the volunteers who took the PPI for five days. When the volunteers in the study took 1,500 mg of betaine HCL, their stomach pH decreased to around one for more than an hour with no noted side effects. In people with healthy digestion, this level of stomach pH frequently occurs when we ingest our meals. Also, it did appear that at least short term use of betaine HCL does not create a negative feedback loop of decreased gastrin production leading to reduced production of stomach acid, marked by standard blood gastrin tests results during the study. 19

In people with low stomach acid levels, the use of betaine HCL in the short term can help decrease stomach pH, reduce the overgrowth of opportunistic bacteria, and improve protein and food digestion. It is still best (until we get more data on long term gastric acid negative feedback loop and betaine HCL use) to trigger endogenous stomach acid production by supplementing with bitter herbs like gentian and ingesting enough pure salt (chloride is used to make HCL). If you have ulcers or severe gastritis supplementation with betaine HCL should be done with caution to prevent worsening of symptoms. Finally, in people with H. pylori, dysbiosis increasing stomach pH may cause severe inflammation from increased endotoxin and ammonia production from H. pylori and increased burrowing of the bacteria into the mucosal barrier. Use with caution in systemic stomach overgrowth, or if you have ulcers/gastritis. Supplementation with zinc carnosine to help repair the stomach mucosa, l-carnitine (supplement with l-ornithine instead if you are suffering from hypothyroidism) to detoxify ammonia, and activated charcoal to bind endotoxins may relieve these issues.20 21 22 23

Betaine HCL Protocol

The protocol for taking betaine HCL is simple and can improve your digestion. Start with two capsules taken during a meal. If you get severe gastritis or stomach pain, stop immediately! If your heartburn is worse, continue to increase the dose by one capsule every day for a week to see if it improves; if not, discontinue the betaine HCL. Increase the dosage of betaine HCL with every meal that contains protein (use betaine HCL only with meals that contain protein, if you are eating a salad do not supplement with and instead add some organic apple cider vinegar to your salad if it does not worsen your reflux [acid ingestion should be limited in people with silent reflux]) by one capsule until your digestion improves. Your stools should become dark brown if they are not, your stool should become better formed, you should have less indigestion, and your stomach should not be as bloated if the betaine HCL is helping. After a few days reduce the amount of betaine HCL taken with each meal to see if your stomach is producing more acid. Upper gut dysbiosis can produce ammonia which can increase stomach pH and decrease acid production. Lowering the pH of the stomach during meals with betaine HCL for a time can reduce ammonia producing dysbiosis, allowing your stomach pH to return to normal levels. Take one capsule less each meal and see if your digestion worsens, if not, continue decreasing the dosage. Never take more than fourteen capsules in one meal, which doses that high of betaine HCL has been known to cause side effects like gastritis. If you get gastritis or pain, consume 1/2 teaspoon of baking soda mixed well in a glass of filtered water to buffer the stomach pH for relief. Wait a few minutes after you have mixed the baking soda in water for the bubbles to dissipate before consuming to prevent ingesting excess gas. Consult with your gastroenterologist. Your stomach should be able to handle the small doses of HCL in the supplement, if it cannot, work on fixing your stomach lining.

Premier Labs betaine hcl without pepsin is the brand I recommend. If you cannot order it, consider using Doctor’s Best betaine HCL with pepsin and gentian.

If you are suffering from dysphagia make sure that you use betaine HCL with caution. You would not want one of the capsules to become “stuck” in your throat or esophagus, dissolving, and burning the lining causing pill esophagitis. Make sure you take the betaine HCL with filtered water and make sure you completely swallow the capsules to prevent this from happening as well.

Pepsin is an enzyme used by the stomach to digest protein. Pepsinogen activates and converts into the enzyme pepsin in the presence of stomach acid. Pepsin helps break down protein into amino acids the body can absorb and then becomes inactivated, by turning back into pepsinogen when it is mixed with bicarbonate released from the pancreas in the small intestine. This transformation protects the rest of the intestinal system from the pepsin and stomach acid. If you have silent reflux, pepsin is your main issue, and you want to avoid supplements with the enzyme. Some people also have adverse reactions to porcine based pepsin but can tolerate betaine HCL without it.24 25

Lower stomach pH will ensure that the stomach microbiome is kept in balance, and overall digestion improves!

  1. http://www.ncbi.nlm.nih.gov/pubmed/19191069
  2. http://www.ncbi.nlm.nih.gov/pubmed/19191069
  3. https://chriskresser.com/more-evidence-to-support-the-theory-that-gerd-is-caused-by-bacterial-overgrowth/
  4. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
  5. Smith, Margaret, Morton, Dion. The Digestive System: Systems of the Body Series, Churchill Livingstone, November 18, 2011.
  6. http://www.ncbi.nlm.nih.gov/pubmed/1775933
  7. http://onlinelibrary.wiley.com/doi/10.1002/mnfr.201100542/abstract
  8. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
  9. Smith, Margaret, Morton, Dion. The Digestive System: Systems of the Body Series, Churchill Livingstone, November 18, 2011.
  10. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4000497/
  11. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&cad=rja&uact=8&ved=0ahUKEwiMi7HAsInNAhVE5SYKHeTiC84QFgiIATAF&url=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%2F26100928&usg=AFQjCNHwDrV9jg-pkf-9V5-3xRNjSWd5Ew&sig2=LMZOEA5OYPL2ibKqew6YEg
  12. http://www.pnas.org/content/110/22/9066.full
  13. http://aem.asm.org/content/74/5/1646.full
  14. http://www.hindawi.com/journals/ijoto/2012/646901/
  15. http://www.nature.com/gimo/contents/pt1/full/gimo15.html
  16. http://www.voiceinstituteofnewyork.com/the-potential-use-of-pepsin-and-carbonic-anhydrase-isoenzyme-iii-ca-iii-as-diagnostic-markers-for-laryngopharyngeal-reflux-disease/
  17. http://jama.jamanetwork.com/article.aspx?articleid=2521970
  18. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3946491/
  19. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3946491/
  20. http://www.christopherhobbs.com/library/articles-on-herbs-and-health/gentian-a-bitter-pill-to-swallow/
  21. http://www.sciencedirect.com/science/article/pii/S0024320506005753
  22. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1297603/
  23. http://www.ncbi.nlm.nih.gov/pubmed/3719924
  24. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
  25. Smith, Margaret, Morton, Dion. The Digestive System: Systems of the Body Series, Churchill Livingstone, November 18, 2011.