This blog is about the intersection between evolutionary biology and food. But also about practical applications, sustainable agriculture, and general tasty things.
Now and then I get an email asking about using Betaine HCL to heal from GERD. I first heard about this supplement through Robb Wolf's podcast. By the time I heard of it, I already did not have GERD. I bought a bottle to use as a digestive enzyme after large meals like Thanksgiving, but it didn't do very much for me and I kind of forgot about it.
The use of acidic products to treat GERD is a common folk remedy. Back when I had GERD, I based my own treatment on both preliminary scientific research such as these studies on supplements and low-carb. But I also drew on some internet folk remedies that utilized harmless foods. At the time that was all that was out there, and the side effects of the Nexium I was on were so intolerable that I felt I didn't have much to lose. At the time one of the top Google results for heartburn remedies was this site advocating apple cider vinegar tonics. I started taking them after every meal. It was initially uncomfortable, but eventually I found relief. And a weird permanent craving from acidic foods that remains to this day and seems to drive my love for kombucha and sour beer.
There aren't any studies at all on acid supplementation and GERD. The folk remedy sites had two theories about it:
1. That GERD was actually caused by LOW stomach acid (I hear this a lot in the alternative health community and there are no studies that show this- consistently studies of people with GERD show high acidity, buts it seems to be more a disease of acidity at inappropriate times, inflammation, and of esophageal sphincter dysfunction). Taking acidic thing X is supposed to fix that somehow.
2. That introducing acidic things into the stomach causes a buffering action and lowers acidity after a meal.
In the instance of apple cider vinegar, because it is a cultured food, there are all kinds of confounders like the phytochemicals from apples and the live bacteria and associated byproducts. Same thing goes for kombucha. There is some evidence that fermented foods can increase gastric acid secretion in the form of a nice glass of wine. Beer may have similar effects, and also stimulates GI motility. But sorry- not whiskey and other distilled beverages. Other things that are known to increase acidity include high-protein meals.
Maybe HCL does something similar? I don't know. I just know that some bloggers like Robb Wolf and SCDlifestyle promote a test for taking it which was to pop the capsules until you feel a warming sensation in the stomach. I've seen it lead to some pretty sad people taking dozens and dozens of these capsules with no effect and thinking they have low stomach acid because of it. It is even possible they are doing real harm to their stomach lining with these pseudoscientific tests- the burning/warming senasation might indicate irritation of the stomach lining, which means that the integrity of that lining is an issue, not necessarily the acidity of the stomach.
- Start with one 400 mg capsule of AdaptaGest Flex in the early part of each meal. You should begin to feel better digestive response following meals.
- After two or three days, increase the dose to two capsules at the beginning of meals. Then after another two days increase to three capsules. Increase the dose gradually in this stepwise fashion until you feel a mild warming sensation.
- When you feel this sensation, reduce the dosage to the previous number of capsules you were taking before you experienced it and stay at that dosage. This is your maintenance dose. You should notice significant improvement in digestion: less gas and bloating, better absorption, more regular and better-formed stools.
- If you start feel a warming sensation at that dose, reduce again. Over time you may find that you can continue to reduce the dosage, or you may also find that you may need to increase the dosage.
- After 90 days on your maintenance dose, try to gradually reduce the dose to zero. For some people, this will be possible. Others may need to take HCL indefinitely (this is especially true if you have a history of PPI or other acid-suppressing drug use).
I guess we'll have to take their word for it. Dr. Art Ayers, a laboratory scientist who sadly hasn't blogged in ages, has questioned Betaine-HCL:
The HCl in betaine-HCl, just means that HCl was used to neutralize the betaine. There is no HCl in betaine-HCl. Using betaine as a supplement will buffer your stomach and have no impact other than perhaps lowering acidity. Betaine is very bizarre stuff, so it may incidentally increase the production of stomach acid, but I know nothing about that.
In most cases, stomach acidity is not the problem. Typically the problem is with gut bacteria...
The confusion comes from the fact that betaine has two ionizable groups, like amino acids in water. The N, bonded to four carbons has a positive charge and the carboxylic acid loses its proton to have a negative charge. When HCl is added, the H+ reprotonates the carboxyl group and the Cl- forms an ionic bond with the positively charged quaternary amine to yield a salt.
There is no HCl in NaCl and no HCl in ammonium chloride and no HCl in betaine-HCl. All of those are salts.
Betaine-HCl cannot be claimed to increase stomach acid in over the counter medications, because there is no evidence to support the claim.
Thanks for the questions.
Whose word to take though? I'm going with Art because at the end of the day there simply is "no evidence to support the claim." Furthermore, think about his explanation- if you looked at the label of Zantac, which is an ANTI-ACID I used to take, it says Ranitidine-HCL.
Now regardless of whether it works, why would someone who is transitioning to a "paleo" diet need something like this? My own impression is that many such diets are excessively high in added fats and this is often a very sudden change for people, not giving their digestive system time to adjust to them. Very high fat meals may also lead to slowed gastric emptying for people who are not used to such foods (this might not be a bad thing always as it increases satiation, but you might feel bloated and have reflux if it's too pronounced). I remember low-carb coconut milk (common additives like guar gum might play a role here)-based meals that felt like they were a brick in my stomach. I wonder a bit if the Dr. Kruse fever that briefly swept "paleos" was a product of his suggestion that people eat a nice high-protein breakfast, which may have stimulated a more favorable gastric environment than the mostly fat breakfasts I often see, though it also included a lot of added fat and some people on forums noted they were bloated or had to force themselves to finish it.
But honestly when you are doing a bunch of different things, it's hard to tell what is responsible for making you better. That's why when people say that Expert X knows that Something works because of "clinical experience," I don't take much stock in that. Few clinicians are recommending just one thing. And the placebo effect is a powerful thing.
Also a lot of Betaine HCL formulations are gelatin capsules- people might benefit from the gelatin rather than the stuff inside the capsule. I did not have any luck with betaine HCL, but I've added a lot of gelatin to my diet with great results. Also the betaine itself, though it's hard to comment on that because there doesn't seem to be much information on the type in the supplement, but studies on betaine have shown it can possibly affect digestion and gut integrity (mostly animal studies), as well as homocysteine metabolism. Like Ayers said, it's weird stuff. That GERD supplementation study I mentioned up thread used betaine (not betaine HCL, but if Ayers is right is should be about the same thing although this supplement publication suggests it will not work as well as betaine, but this livestock publication suggests they should work identically), melatonin, tryptophan, methionine, B12, B6, and folic acid. Most betaine-HCL is also bundled with the enzyme pepsin, which could also improve digestion though there are not many studies out there on supplementing it. So maybe it does work, but for not the reasons people think it does.
Overall though I think the most promising approach to issues like GERD is a
This has worked for me, members of my family, and people who have corresponded with me. Maybe this surprises people because it's quite obvious I eat a higher-carbohydrate diet now, but I've always said low-carb diets can be therapeutic, I just never bought into the idea that you should eat them forever or that they were the optimal human diet.
I would not recommend the "test" of acid levels that involves taking more and more Betaine-HCL, I suspect people getting "acid damage" from that just are upsetting their stomachs.
What do you think? Have you had any interesting experiences with supplements for improving digestion?
woman will be happy when I spend all day gathering 1000 tiny seeds to make tahini with instead of clubbing a deer
While nuts are well-accepted as paleolithic foods, seeds are little more contentious. Technically nuts ARE seeds, but botanics aside, what we think of as nuts are big enough that gathering a decent amount of calories from them in the wild is feasible. The same can't be said for seeds- most are tiny and it can take a long time to harvest enough to make anything out of. I learned this harvesting pigweed seeds. I was hoping to get enough of this amaranth relative to make porridge with, but I ended up with only enough to garnish a piece of fish.
What about their place in a modern paleo diet? After all, we eat plenty of things that would have been tough to gather. For me, the problem with seeds is that if you eat large amounts of them you will be eating nutrients in ratios and amounts that are not appropriate for us evolutionarily. Furthermore, the polyunsaturated fats in them go rancid easily. While some might find hemp useful, I think it's a bad food, at least in the US because you cannot buy it whole and how long has that hemp powder been sitting on the shelf? Probably long enough to render some of those nice omega-3 fatty acids rotten. Flax is a popular ingredient in "paleo" baked goods, but ground and shoved in the oven, the fats can't be good.
Furthermore, if you eat lots of seeds with the exception of flax, the ratio of omega-6 fatty acids to omega-3 fatty acids is likely to tip towards the latter, which is probably not a good thing.
Several sources of information suggest that human beings evolved on a diet with a ratio of omega-6 to omega-3 essential fatty acids (EFA) of approximately 1 whereas in Western diets the ratio is 15/1-16.7/1. Western diets are deficient in omega-3 fatty acids, and have excessive amounts of omega-6 fatty acids compared with the diet on which human beings evolved and their genetic patterns were established. Excessive amounts of omega-6 polyunsaturated fatty acids (PUFA) and a very high omega-6/omega-3 ratio, as is found in today's Western diets, promote the pathogenesis of many diseases, including cardiovascular disease, cancer, and inflammatory and autoimmune disease
Furthermore, the conversion of any omega-3 from plants in your diet is hampered. The omega-3 fatty acids present in plants, alpha linolenic acid, is not immediately usable in the body. In order to be used, it must be converted to Docosahexaenoic acid. The enzymes that do this conversion are called Holman's enzymes. Unfortunately, they are also responsible for converting omega-6 fatty acids (mostly linoleic acid) to arachidonic acid. Lots of omega-6 means that there is not enough of Holman's enzymes to do the job. This is discussed in Susan Allport's book The Queen of Fats
Data for the US indicate that Americans consume between 11 and 16 grams of linoleic acid per day during the years 1989 and 91 and about 1 to 2 grams of alpha linolenic acid. At that ratio, only about 15 percent of the alpha linolenic acid is converted to DHA and eicosapentaenoic acid. At lower ratios, the conservation rate is much higher. The best conversion occurs at a ratio of 2.3:1
For paleo dieters who eat seafood, this shouldn't be a huge problem, but if not, it can be an issue.
Let's also talk about phytic acid, an anti-nutrient present in many seeds, can reduce mineral absorption. There are a couple of other issues, like some estrogenic compounds in flax.
So that's why, in the Paleo Foods section of the site, I classify seeds as Not Paleo, but give the pros and cons. Some tahini sauce on your kale probably isn't as bad as some whole bran bread, but I would recommend keeping their consumption low. Use them as if you had to gather them yourself.