supplements

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. 

The test is now on the page of Wolf and Kresser's new brand of "Paleo" supplements that is supposed to help people adjust to "paleo" diets:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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

• low-carbohydrate high-quality (good grass-fed ruminant meats and fish) low-omega 6 fairly high protein diet (particularly low in fermentable carbohydrates likes starches, I actually found things that were not fermentable carbohydrates like honey in my tea did not have an impact)- you might need to restrict added-fats/mostly fat foods like butter, coconut oil, coconut milk, etc. until your body adjusts or at least not eat large amounts in one sitting. Naturally fatty cuts like grass-fed lamb shank never bothered me personally, it was things like coconut milk soups that were a problem. You could also try supplementing lipase. Some types of meat also seem to be more likely to trigger reflux such as smoked or cured meats- sometimes aged meats can be an issue as well. 
• fixing sleep issues- sleeping 8 hours a night in a dark room
• perhaps with some acidic fermented drinks like kombucha or wine with meals, and some supplements based on symptoms. Some ones I've played with based on preliminary research and had good results with include sea buckthorn (possibly helps heal stomach lining, mastic might also work too and I also just really like the flavors of these foods, but I think other similar berries that are more common in the US might have similar properties), gelatin (or from bone broths), bromelain, and probiotics. My general opinion of supplements is to avoid bundles because you are going to get a lot of stuff you don't probably need and you also won't be able to adjust dosages and ratios as easily.
• Stop taking NSAIDs like aspirin and ibuprofen. 
• Screen for H. Pylori and SIBO (small intestinal bacterial overgrowth), perhaps try a scientifically validated test like the Heidelberg test to see what your stomach acidity is like

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?