Do You Struggle With Low Stomach Acid?
We usually link heartburn and upset stomach to soaring levels of stomach acid. But the truth is many digestive complaints result from low stomach acid. And most people have no idea. Get to know this important part of your digestive system a little better so you can keep the juices flowing.
What does your stomach acid do?
Stomach acid has a number of important jobs to play in digestion and overall health. This watery digestive fluid (also known as hydrochloric acid) is one of the main solutions secreted by your stomach and works to:
Break proteins into digestible amino acids (a process known as proteolysis)
Activate pepsin, the primary enzyme in your stomach
Stimulate the pancreas to release enzymes that break down food
Kill potentially harmful bacteria before it reaches our intestines
Prevent food from backing up into the esophagus (a tube that connects the throat with the stomach)
It’s important to have healthy stomach acid levels in your system so all these key processes can keep moving smoothly. If you come up short, your digestion will suffer, possibly leading to a number of unpleasant symptoms and even chronic conditions.
What are the symptoms of low stomach acid?
When your stomach acid levels get too low (a condition known as hypochlorhydria), you may notice various symptoms—and not all of them are in your gut. These are some of the most common symptoms of low stomach acid to look out for:
Bloating, belching, burning, and flatulence immediately after meals
Indigestion, diarrhea, or
constipation
A sense of fullness after eating
Acid reflux or heartburn
Upper digestive tract gassiness
Acne
Iron Deficiency
Undigested food in the stool
Nausea while taking supplements
Nutrient deficiencies
Multiple food allergies
Itching around the rectum
Chronic candida infections
Chronic intestinal parasites or abnormal flora
Hair loss or brittle fingernails, which can signal nutrient deficiency
DISEASES ASSOCIATED WITH HYPOCHLORHYDRIA
Addison’s disease
Asthma
Celiac disease
Chronic autoimmune disorders
Chronic hives
Dermatitis herpetiformis (gluten sensitivity)
Diabetes
Eczema
Gallbladder disease
Graves’ disease
Hepatitis
Hyper- and hypothyroidism
Lupus erythematosus
Myasthenia gravis
Osteoporosis
Pernicious anemia
Psoriasis
Rheumatoid arthritis
Rosacea
Sjögren’s syndrome
Thyrotoxicosis
Vitiligo
What Causes Hypochlorhydria (Low Stomach Acid)?
Processes that damage the stomach or inactivate stomach acid can cause hypochlorhydria. These include things like
Atrophic Gastritis
Damage to the stomach's mucosal lining can result in the loss of cells that normally produce stomach acid.
Alcoholism can cause atrophic gastritis.
Surgeries
Surgeries like gastric bypass can cause a reduction in the amount of stomach acid that they can produce.
Treatments for gastric cancer can damage the stomach lining and result in hypochlorhydria.
Autoimmune conditions
Conditions like pernicious anemia involve autoimmune activity against parietal cells or intrinsic factors in the stomach and can result in hypochlorhydria or achlorhydria.
Autoimmune thyroid conditions can cause low stomach acid.
Infections
Helicobacter Pylori (also known as H. Pylori) is a type of bacteria that neutralizes stomach acid. People with H. Pylori infections can develop hypochlorhydria that does not resolve until the underlying infection is treated.
Campylobacter pylori is another bacteria that can cause hypochlorhydria.
Medications
Proton pump inhibitors (PPIs) can reduce stomach acid.
Medical Disorders
Hypothyroidism and autoimmune thyroid conditions can cause low stomach acid.
Cancers of the stomach, pancreas, and GI tract can impact stomach acid production, as can radiation of the stomach and other procedures used to treat cancer.
What happens if your stomach acid is too low?
One of the most noticeable effects of low stomach acid is how it messes with your ability to digest nutrients—especially protein.
Without enough stomach acid, your body can’t break proteins into digestible amino acids. This can create a protein deficiency, which then leads to a deficiency in vitamin B12, magnesium, and iron. When you don’t get enough of these nutrients, both mild and severe health issues can crop up.
Vitamin B12, for example, needs help from stomach acid to detach from the protein that carries it. If it doesn’t detach, it can’t bind with other substances that carry it through your intestinal wall and into your bloodstream.
Your body needs both B12 and iron for healthy red blood cells, and if you’re extremely low in these nutrients, you may develop anemia, a condition that happens when you lack enough healthy red blood cells. You may feel weak and fatigued, experience constipation, and in more serious cases, numbness and tingling in the hands and feet.
Another common side effect of low stomach acid is heartburn. That slow, painful burn you feel in your chest happens when your stomach acid back flows into your esophagus.
Contrary to popular belief, heartburn isn’t usually caused by an acidic stomach. Instead, that burn is likely connected to GI symptoms caused by low stomach acid. As Mary Stratos, PA-C, stated, “Without enough of this helpful stomach acid to break down food, maldigested food gets into the GI tract, and GI pathogens overgrow, perpetuating the problem.”
At healthy levels, stomach acid also has disinfecting properties, helping prevent harmful bacteria from invading the rest of your GI tract. This means that as your stomach acid levels dip, your risk of GI infections (ex. E. coli, salmonella, H. pylori) goes up, according to a review in the Journal of Food Protection .
If low stomach acid goes untreated, it can even lead to conditions like allergies, asthma, autoimmune disorders, and skin problems, including acne and psoriasis. When hydrochloric acid levels are hampered, there is a trickle down effect in the GI tract, including leading to leaky gut, a condition in which tiny holes develop in the lining of the intestinal tract, or dysbiosis, an imbalance between the good and bad bacteria in your gut. These gastrointestinal issues can actually confuse your immune system, making you more susceptible to autoimmunity and skin issues, she says.
How do you know if you have low stomach acid?
If you recognize any of the symptoms of low stomach acid, you try an easy at-home test to gauge whether stomach acid is at play.
One gentle approach to test for low stomach acid is known as a baking soda challenge. [With this challenge], we are looking to see how long it takes for you to burp.
Simply mix a ¼-teaspoon of regular ol’ baking soda with 4-6 ounces of water and drink on an empty stomach (like first thing in the morning). Start a timer as soon as you drink the baking soda water. If you have sufficient levels of stomach acid, the baking soda will be converted into carbon dioxide gas, which should cause belching about three minutes after drinking.
If you haven’t belched within five minutes, stop the timer. You may have low stomach acid.
Advanced testing
Blood Tests
Antiparietal cell antibodies can detect autoimmunity against the cells that produce stomach acid.
Anti-intrinsic factor antibodies can detect antigens made against the substance produced by the stomach that helps to absorb B12.
Serum pepsinogen.
Pepsinogen is a product produced by chief cells in the gastric fundus (top part of the stomach) and is abnormal in conditions associated with altered stomach acid.
Measuring the ratio of pepsinogen I/II can help to identify gastritis.
Serum gastrin levels that are low may indicate that the stomach is damaged.
Thyroid hormones and TSH can help to detect thyroid conditions that may be impacting stomach acid production.
Stool Tests
H. Pylori infections can be detected using stool, breath, and serum testing.
Campylobacter testing can be done using stool or blood.
Breath Tests
SIBO testing can help to identify if SIBO is present in people with hypochlorhydria.
How to treat low stomach acid
The treatment for hypochlorhydria will depend on the root cause. In cases where hypochlorhydria can not be resolved or reversed, stomach acid or betaine hydrochloride supplementation can be a helpful strategy.
1. Eat your (bitter) greens
My favorite first step to treat low stomach acid is to use bitter foods and digestive bitters. Bitters can stimulate the vagus nerve and may aid in the cephalic phase of stomach acid production. Bitter flavors excite the digestive system and alert the body that a complex food is being eaten. It’s like an alarm clock for the digestive system; when this “alarm clock” sounds, it signals the body to secrete stomach acid, digestive enzymes, and bile.
Try to incorporate more wild plants (spinach, kale, arugula, dandelion) into your diet, as many of these feature a rich, bitter flavor. You can also try digestive bitters. Digestive bitters are a liquid derived from bitter plants that you can take orally before meals to stimulate your digestive system.
2. Introduce some acid
Supplementing with raw apple cider vinegar—a food with acidic properties—may also improve acid levels in the stomach by lowering the pH, allowing for better digestion. Try diluting a small amount of apple cider vinegar with water and drinking it at least five minutes before meals. Never drink undiluted apple cider vinegar, as it can damage the enamel on your teeth.
Supplementing Betaine hydrochloride can be taken with meals to replace stomach acid and acidify the gastric environment. One study showed that 1500mg of betaine hydrochloride could reduce gastric pH from 5.0 to 1 for over one hour. Another study showed that betaine taken before a meal could more rapidly acidify the gastric environment than betaine taken on an empty stomach. This has led to the recommendation that people take supplemental betaine 10 minutes before a meal to have the ideal effect. To find their ideal dose of betaine hydrochloride, a person can work with their doctor to do the betaine challenge, baking soda test, or another method to identify how much betaine is right for them. People will need more betaine with larger meals and meals that contain fat than they will need with snacks and low-fat meals.
3. Cut down on processed foods
Cleaning up your diet is another great way to improve your stomach acid. Limit processed foods (like pizza, chips, and packaged meats) and sugars, as these can cause inflammation in your stomach, lower acid, and even trigger acid reflux. Meanwhile, a diet rich in fruits and vegetables may lower inflammation and boost stomach acid.
4. nutrition
High protein meals trigger hydrochloric acid release. Choosing higher protein meals can help improve digestion.
Fat depresses hydrochloric acid release. People with hypochlorhydria may find their symptoms improve when they choose lower-fat dietary options.
Smaller, frequent meals increase the surface area of digested food, which allows hydrochloric acid and enzymes to work more effectively.
Taking vitamin C and betaine with medications that require stomach acid to activate them is one way to improve the chemical digestion of prescriptions like thyroid hormone.
Supplementing sublingual B12 or even B12 shots can help to prevent B12 deficiency, which is commonly associated with hypochlorhydria.
Ensuring adequate consumption of iron, magnesium, and calcium-rich foods and supplementing iron where appropriate can help prevent the deficiencies resulting from hypochlorhydria.
Top sources of iron include foods like oysters, white beans, beef liver, lentils, spinach, tofu, and iron-fortified cereals. Iron can also be taken as a supplement or IV if someone is anemic.
Top calcium sources include yogurt, cheese, milk, sardines, tofu, salmon, calcium-fortified orange juice, and soy milk. Calcium can also be taken as a supplement.
Top magnesium sources include pumpkin seeds, chia seeds, almonds, spinach, cashews, peanuts, soymilk, and black beans. Magnesium can also be taken as a supplement or in IV form.
5. Chew slowly
Digestion begins with the salivary enzymes in your mouth, which start their work the moment you take a bite. Chewing thoroughly allows enough contact time for these enzymes to start breaking down your food; it also helps prime your body to make adequate stomach acid for the meal ahead, she adds.
6. Find calm
Digestive function and mental well-being are closely linked. Therefore, practicing stress management strategies can play a pivotal role in restoring your gut health.
Written and edited by: The Institue for Functional Medicine, Erica Zellner, MS, Cameron Gildea INHC, and Lauren Bedosky
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