HCl + You: Is Low Stomach Acid Making You Sick?

When life hands you lemons...squeeze 'em hard and squeeze 'em good. Take that, hypochlorhydria!

You don't need to be a chemistry whiz to understand the importance of stomach acid for good digestion. In simple terms, hydrochloric acid (HCl) is a gastric acid secreted by parietal cells of the stomach, and supports multiple physiological processes including gut health, immunity and radiant skin. On the digestion front, gastric acid is instrumental in protein catabolism via enzymatic activation of pepsin, and participates in the metabolism of nutrients such as vitamin B12, folic acid, calcium, magnesium, zinc and iron (Banoo & Nusrat, 2016).

HCl also has a stimulating effect on the pancreas, which then releases the necessary digestive enzymes to further aid carbohydrate, protein and fat breakdown (Banoo & Nusrat, 2016). Any reduction in stomach acid (also known as hypochlorhydria) adversely affects nutrient metabolism and overall digestion, resulting in widespread nutritional deficiencies and symptoms such as loss of appetite, gas, bloating, acid reflux, constipation and bad breath. Poor gastric acidity also exerts its influence outside the digestive tract, and is associated with skin diseases such as psoriasis, acne and eczema; weak, brittle fingernails; and hair loss.

In addition to optimising digestion, HCl also has an important immune-modulating role, and acts as a buffer against pathogens contained in food. Healthy gastric acid production helps the stomach maintain an acidic pH of between 1.5 to 3.5, thus preventing the overgrowth of bacteria and yeast within the stomach as well as other parts of the gastrointestinal tract (Banoo & Nusrat, 2016). Research associates the beneficial antimicrobial properties of gastric acid with healthier balance of intestinal bacteria, reduced incidence of Candida albicans (thrush) overgrowth, as well as reduced risk of Helicobacter pylori (H. pylori) infections which are commonly implicated in peptic ulcer disease (Daley, 2012).

Stomach Acid, Agni, and Ayurveda

Fresh spices and herbs are wonderful for kindling Agni. Choose gentle warming varieties such as fresh ginger, cardamom, cumin and black pepper, and avoid excessively stimulating ones such as chilli and Cayenne pepper.

In Ayurveda, stomach acid shares a close relationship with the digestive fire Agni, which oversees all physiological processes governing digestion and metabolism (Agrawal, Yadav & Meena, 2010). When Agni is strong and lustrous, it aids in the creation of ojas (life force) and supports improved physical vitality, immunity against infection and disease, mental clarity, and a radiant, glowing complexion (Agrawal et al., 2010). All ingested food is broken down, absorbed and assimilated by Agni, after which time the metabolic by-products of digestion are converted into energy to sustain life and proffer immunity on a cellular level (Gond, Kumar, Byadgi & Singh, 2015).

Rather than being concentrated solely in the stomach, Agni exists in 12 different forms and exerts its influence both within the gastrointestinal tract as well as throughout other body systems. Jatharagni, a form of Agni which resides within the stomach and shares the closest relationship with gastric acid, is regarded as the most important form of Agni (Gond et al., 2015) Any disturbance in jatharagni's function upsets metabolic equilibrium maintained by its 11 other counterparts, leading to inflammation, infection and disease (Agrawa et al., 2010). Diet is an important consideration in Jatharagni preservation, and is supported by consumption of warming spices such as cinnamon, ginger, cardamom and cumin; regular mealtimes; and warm rather than cold food and drinks.

Acid Reflux: A Traditional Chinese Medicine Perspective

Though a bowl of chili may seem like comfort food to some, TCM advises against excessive consumption of 'heaty' food such as chillies and tomatoes due to their stimulating effect on liver fire which triggers disruption in stomach qi.

Gastroesophageal reflux disease (GERD/ acid reflux) is one of the most common manifestations of disturbed stomach acid production. While allopathic medicine views GERD as stemming from a surplus of stomach acid, naturopathic traditions perceive acid reflux as arising from a deficit of stomach acid (Daley, 2012). GERD, bloating, gas and general digestive discomfort are believed to stem from liver-stomach disharmony, wherein any disruption in liver qi is thought to affect stomach qi (Zhao, Wang, Dong, Chen & Li, 2018). Because the liver is tasked with maintaining proper energy flow between both organs, stagnant or hyperactive liver qi disrupts the downward movement of energy from the stomach to the small intestine, instead causing qi to rise back into the oesophagus from the stomach (Zhao et al., 2018).

Due to the close relationship between the liver and stomach systems, TCM advocates consumption of sour and bitter foods to nourish liver qi, and to prevent possible liver imbalance from disrupting stomach qi. Excess intake of spicy and 'heaty' foods are discouraged due to their stimulating effect on liver fire, which worsens reflux symptoms and increases the risk of 'fiery' emotion and behaviour. This is attributed to the liver's governance of mood and temperament, as long-term imbalance of liver qi is associated with increased risk of irritability and anger alongside gastrointestinal symptoms such as abdominal discomfort, bloating, belching, and food intolerances (Zhen et al., 2018).

Constipation is also associated with liver-stomach disharmony due to misdirection of liver qi to other organs, resulting in disruption of stomach qi as well as spleen qi. In TCM, the spleen is regarded as the main digestive organ, and supports peristalsis and muscle contraction within the gut to facilitate regular bowel movements - a lack of which causes reduced gut motility and impaired faecal elimination (Chung, Chen & Ko, 2016).

Therapeutically, lemons are considered one of the best foods for harmonising liver-stomach function due to their sour and slightly astringent effect on the body which tones the digestive organs and improves free-flow of qi. In fact, a combination of lemon juice and warm water is a popular remedy used across myriad healing traditions as well as in TCM to stimulate the liver and prime stomach acid production. A glass of lemon-water is the perfect ritual to kick-start the day, as lemons' sour taste stimulates a sluggish liver and prompts the gallbladder to release stagnant bile, thereby kindling appetite and stoking digestive fire in time for breakfast.

Causes of Low Stomach Acid

Hypochlorhydria stems from multiple factors, and most people affected by deficient gastric acid production often suffer from a combination of factors. Common causes of impaired gastric acidity include:

1. Irregular eating habits

Regular meal-times are important for optimising gastric acid production, as the stomach anticipates the ingestion of food and primes itself by maximising HCl output at specific times of the day.

Humans are creatures of habit, and our bodies are able to function like well-oiled machines when we have a regular routine for eating, sleeping and working. Ayurveda cites irregular eating patterns as one of the dominant causes of deranged Agni, which if left uncorrected over time, results in gradual depletion or overstimulation of Agni. Hyperactive Agni provokes symptoms characteristic of GERD, and typically manifests as acid reflux, heart burn, and a bitter or sour taste in the mouth. Correspondingly, diminished Agni is also associated with symptoms common to low gastric acidity such as poor appetite, constipation, bloating and food intolerances.

2. Age

All bodily functions progressively decline with age, and stomach acid production is no exception. Approximately one-third of the world's population over the age of 60 suffers from atrophic gastritis, a condition characterised by little to no stomach acid production at all (Pizzorno, Murray & Joiner-Bey, 2016). Due to the close relationship between H. pylori infection and hypochlorhydria, research estimates 50 percent of all individuals aged 50 years and older to be at a risk due to naturally declining stomach acid production, and should therefore be routinely tested for possible H. pylori infection (Pizzorno et al., 2016).

3. Helicobacter pylori infection

Much like a chicken-and-an-egg situation, H.pylori has been shown to cause hypochlorhydria as well as be caused by it (Murray, 2013). H.pylori colonisation shifts the stomach's acidic balance to a more alkaline state due to enzymatic urease released by the bacteria (Uotani & Graham, 2015). Without therapeutic intervention, this reduction in gastric acidity sets the stage for more progressive digestive damage, including chronic gastritis, peptic ulcer disease and gastric cancer (Kalali, Formichella & Gerhard, 2015).

4. Excess water with meals

Though plain water is not recommended immediately before meals, a teaspoon of apple cider vinegar diluted in a glass of warm water and consumed 20 minutes before food is a time-honoured folk remedy for healthy HCl production.

Strong Agni and good digestion go hand-in-hand, and pursuant to this line of thinking, Ayurveda recommends avoiding avoid water with meals to prevent dampening of digestive fire. Most naturopathic practitioners advocate drinking water 20 to 30 minutes prior to a meal, and to wait at least 45 minutes after eating before consuming water to prevent the dilution of digestive juices. Other naturopathic remedies include apple cider vinegar or bitter herbal tonics consumed prior to a meal as a way of priming gastric acid production, as both sour and bitter flavours help increase HCl output.

5. Antacid/ Non-steroidal anti-inflammatory drug use

Certain classes of medication such as antacids and non-steroidal anti-inflammatory drugs (NSAIDs) inhibit gastric acid release by the stomach's parietal cells and trigger a hypochlorhydric state following long-term (ab)use (Nusrat & Banoo, 2016). Excessive use is associated with metabolic alkalosis, which is characterised by high amounts of bicarbonate in the blood, thereby skewing the stomach's pH to a more alkaline state (Nusrat & Banoo, 2016).

6. Proton pump inhibitor use

Considered a first-line conventional treatment for H.pylori infection and acid reflux, proton pump inhibitors (PPIs) are a class of drugs that inhibit gastric acid production, and while effective for controlling GERD symptoms in the short-term, are associated with gastrointestinal complications in the long-run. Research suggests that chronic use of PPIs may reduce vitamin and mineral absorption, and cause intestinal dysbiosis and rebound hypersecretion of stomach acid which provokes an increase in GERD-like symptoms (Kines & Krupczak, 2016).

7. A salt-deficient diet

If you're concerned about increasing your salt intake, switch regular table salt for Himalayan salt instead which is lower in sodium but higher in minerals such as chloride, calcium, iron, magnesium and phosphorus.

While too much salt is associated with a barrage of health complications such as hypertension and cardiovascular disease, too little salt triggers electrolyte imbalances and disrupts stomach acid production. Salt is made up of elemental sodium and chloride, and chloride (Cl⁻) forms an important component of hydrochloric acid (H⁺ and Cl⁻), making sensible salt intake an essential consideration in safeguarding stomach acid production.

8. Stress

It's not uncommon to experience digestive disturbances such as acid reflux, bloating, nausea and constipation when you're rushing to meet deadlines, and here's why: Stress is regulated by the body's sympathetic nervous system while digestion is mediated by the parasympathetic nervous system. Both are antagonistic to each other: parasympathetic functions are disrupted when the sympathetic nervous system is activated, and vice versa. Because the sympathetic nervous system is concerned with immediate survival, blood is diverted away from the digestive tract and channelled instead to the muscles and brain to aid the fight-or-flight response. This decrease in parasympathetic activity halts the production and release of all digestive processes...including HCl output.

The Betaine HCl Challenge

Betaine contained in beetroot is the main component of supplemental Betaine HCl. Eating beetroot and monitoring urine colour is an easy way to gauge stomach acid levels as pink urine suggests possible HCl deficiency.

In addition to supporting gastric acid production using functional foods that enhance Agni and nourish both liver and stomach qi, taking supplemental betaine has also been shown to be effective in boosting HCl. Betaine HCL is comprised of 76 percent betaine and 24 percent HCl, and is administered on a dose-responsive basis. Patients begin with taking a single capsule per day with a protein-based meal of their choice. Lunch is often the best time for administering betaine HCl given that digestive fire is typically strongest during the hours of 11 am to 1pm.

Patients take 1 capsule on the first day of the challenge, two capsules on the second day, three capsules on the third, and so on until a tolerance level is reached. Higher doses are associated with increased levels of gastric acid deficiency, and lower doses indicate gastric acid production that may only be slightly impaired. A warm sensation in the upper abdominal area is common once your tolerance level is reached, as is abdominal discomfort, heartburn and reflux in cases involving excess intake. Upon reaching your designated tolerance level, simply minus the dose by one capsule and continue supplementing daily in this manner until a new tolerance level is achieved. Adjust your dose accordingly until gastric acid production normalises and you can wean yourself off supplementing with betaine HCL altogether.

In individuals with normal stomach acid production, a single capsule is often enough to stimulate heartburn. The betaine HCL challenge is not recommended for individuals with acute or chronic gastritis, peptic ulcer disease, and those on antacid medications.

Hypochlorhydria typically stems from multiple factors, all of which require a personalised approach to optimise therapeutic outcomes. Book a consultation with me to find out more about the Betaine HCl challenge, as well as the best ways for supporting optimal gastric acid production to maximise digestive health and general wellbeing.

References

Agrawal, A. K., Yadav, C. R., & Meena, M. S. (2010). Physiological aspects of Agni. Ayu, 31(3), 395-398. doi:10.4103/0974-8520.77159

Banoo, H., & Nusrat, N. (2016). Implications of low stomach acid: An update. RAMA University Journal of Medical Science, 2(2), 16-26. Retrieved from http://www.ramauniversityjournal.com/medical/pdf_june/16-26.pdf

Chung, Y. K., Chen, J., & Ko, K. M. (2016). Spleen function and anxiety in Chinese medicine: A Western medicine perspective. Chinese Medicine, 7, 110-123. doi:10.4236/cm.2016.73012. doi:10.4236/cm.2016.73012

Daley, J. (2012). The gastrointestinal system. In L. Hechtman (Ed.), Clinical Naturopathic Medicine, pp. 152-209. St Louis, MI: Mosby Elsevier.

Gond, P., Kumar, J., Byadgi, P. S., & Singh, L. (2015). Importance of Agni and its impact on the human body. International Journal of Pharmaceutical and Medicinal Research, 3(1), 186-190. Retrieved from www.ijpmr.org

Kalali, B., Formichella, L., & Gerhard, M. (2015). Diagnosis of Helicobacter pylori: Changes towards the future. Diseases, 3, 122-135. doi:10.3390/diseases3030122

Kines, K. & Krupczak, T. (2016). Nutritional interventions for gastroesophageal reflux, irritable bowel syndrome, and hypochlorhydria. Integrative Medicine, 15(4), 49-53.

Murray, M. T. (2013). Maldigestion. In J. E. Pizzorno & M. T. Murray (Eds.), Textbook of Natural Medicine (4th ed.), pp. 528-531. St Louis, MI: Elsevier.

Uotani, T., & Graham, D. Y. (2015). Diagnosis of Helicobacter pylori using the rapid urease test. Annals of Translational Medicine, 3(1), 9. doi:10.3978/j.issn.2305-5839.2014.12.04

Zhao, L., Wang, T., Dong, J., Chen, A. & Li, G. (2018). Liver-stomach disharmony pattern: Theoretical basis, identification and treatment. Journal of Traditional Chinese Medical Sciences, 5, 53-57. doi:10.1016/j.jtcms.2018.01.001