Ep. 109: Heartburn Isn't Always A Stomach Acid Problem (Here's What It Actually Is)

Reflux is one of the most common symptoms we see… and also one of the most misunderstood. Most people are told it’s either too much stomach acid or not enough, but many still feel stuck even after trying both approaches. In this episode, we take a step back and look at reflux through a more complete lens. While its easy to assume reflux means "too much" or "too little" acid, its more nuanced than that. It often involves how your body is handling it, including factors like pressure, motility, and how well that “lid” between your stomach and esophagus is functioning. 

In this episode, Dr. Heather covers:

•  What reflux, heartburn, and GERD actually are 
•  Where low stomach acid fits in  
•  Why betaine HCl can sometimes make symptoms worse 
•  How pressure, bloating, and motility influence reflux 
•  The difference between typical reflux and upper reflux (LPR) 
•  Hidden triggers like hiatal hernias, stress, and constipation 
•  Simple, practical strategies to start reducing symptoms

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Transcript

Dr. Heather Finley 0:03

Welcome to the Love Your Gut Podcast. I'm your host, Dr. Heather Finley, registered dietitian and gut health specialist. I understand the frustration of dealing with GI issues because I've been there and I spent over two decades searching for answers for my own gut issues of constipation, bloating, and stomach pain. I've dedicated my life to understanding and solving my own gut issues. And now I'm here to guide you. On this podcast, I'll help you identify the true root causes of your discomfort. So you can finally ditch your symptoms for good. My goal is to empower you with the knowledge and tools you need so that you can love your gut and it will love you right back. So if you're ready to learn a lot, gain a deeper understanding of your gut and find lasting relief. You are in the right place. Welcome to the love your gut podcast.

0:55

Have you ever tried to keep water inside of a container? But the catch is that the container has a broken lid. No matter how clean the water is, no matter how much or how little you pour in, it's still going to leak. And I think that that is one of the simplest ways that you can understand reflux. Now, if you have dealt with heartburn or reflux, you've probably come across the idea. Of either too much stomach acid or too low stomach acid. And to be clear, sometimes those things can be part of the picture, but not always. We have had so many clients come to us after trying to support reflux, either because they've been told they have too much stomach acid or too little stomach acid, and they're really stuck. Um, maybe they were taking battan with meals or taking stomach acid support because they were told that reflux meant that they didn't have enough acid. And instead of improving symptoms are getting worse, more burning, more throat irritation. That regurgitation feeling that you can get and you feel really stuck because you think you're doing the right thing. But then when you look at the full picture. It's not that supporting stomach acid is wrong, it's maybe just not the right starting point. Going back to the container example, yes, what's inside the container matters, but so does the lid, the pressure. How full the container was, how well it empties and reflux is a lot like that where there's just a lot of other pieces. And so this is where today I want to give you a more complex and complete framework because while stomach acid. Either low or high can be part of the puzzle. It can also be driven by your lower esophageal sphincter, sphincter or the LES, how that is functioning pressure in your abdomen. So bloating can be a big trigger. Pregnancy, uh, how quickly your stomach empties, your nervous system and your diaphragm, and then even things like structural changes, hernias, et cetera. So we can't just simplify reflux by, do you have enough stomach acid or do you have too little stomach acid? The better question that we wanna ask for reflux is what's actually allowing acid to move where it shouldn't. And this is why we wanna be thoughtful about how we approach reflux on both ends of the spectrum. Because, yes, sometimes supporting stomach acid is helpful, but jumping straight into something like Betain, HCL. Without understanding the full picture can sometimes make symptoms worse. And then on the flip side. Medications like PPIs can absolutely reduce symptoms and can be helpful from that standpoint, especially short term or in more severe cases, but they don't really address why the reflux is happening and weren't meant to be a long-term solution. In fact, did you know that? PPIs were actually only developed to be a short term six to eight week intervention when in the reality is we have clients that come to us that have been on PPIs for years, and they've tried to wean 'em or been told you don't need to wean it, but when they wean, they have horrible rebound reflux, which is probably an episode for another time. So my goal in this episode isn't to tell you. What to do with one cause or one solution, but to understand the full picture so that you just have a little bit more context and can make some more informed decisions and hopefully make some more sense to your reflux. So I wanna walk through where stomach acid fits in for reflux. The other drivers, how to recognize patterns in your symptoms, what you might look for in testing. And then simple things that you can start doing to actually support your body, because again, reflux isn't always just about acid. It matters so much what your body is actually doing with it. So let's first start with what reflux actually is, because once you understand this, everything else really starts to make a lot more sense. You can think of your stomach like a mason jar. Inside of that jar is acid. That acid is normal, it's necessary. It's. Part of how you break down food, absorb nutrients, protect against bacteria. Your stomach should be very acidic. There's a mucus layer of your stomach that protects your stomach lining from that acid. Now at the top of that jar is a lid. That lid is your lower esophageal sphincter or LES. Its job is really simple. It opens to let food in. It closes to keep everything where it belongs, and so reflux happens when that lid is not sealing the way that it should. So instead of content staying in the stomach, they start moving upwards into the esophagus. And that's what creates that burning feeling, that regurgitation, that throat irritation. And this is where we wanna shift a little bit, how we think about reflux. Reflux is not always a production problem, it is a containment problem, meaning that it's not just about how much acid you're making. It's also about how much your body and what your body is doing with that acid. So I wanna chat through just a few of the main things that would influence whether that lid stays closed or not. So first is something called the transient lower esophageal sphincter relaxations. This is actually the most common mechanism behind reflux. These are brief, uh, relaxations of the lid that aren't necessarily related to swallowing. They're often triggered by stomach distension. So when the stomach stretches after a meal, especially a larger meal, that can signal the lid to relax when it shouldn't. So you now have a full jar, a loosened lid, and contents are moving upwards. Uh, the second is pressure. Anything that increases pressure. Inside the abdomen can push stomach contents upwards. So this could be stuff like bloating, gas, constipation, large meals, tight clothing, even pregnancy. Pregnancy is a great example because you can have both increased pressure from the growing uterus. And hormonal changes that relax smooth muscle, including the LES. So again, it's not necessarily in this case about too much, too little acid. It's just the environment that's allowing that acid to move. The third is motility and clearance. Your stomach isn't just meant to hold food. It's meant to process it and break it down and move it to the next part of digestion. Your stomach actually needs to produce enough acid to properly break down food and empty at an appropriate rate. When your stomach fills with acid, it empties, and that's what influences bowel motility. So if motility is slow, food and acid will sit in the stomach together longer, so that can increase pressure, it can increase distension, and it can increase the likelihood that reflux will happen. On top of that, your esophagus has its own mechanisms for clearing things. So when reflux happens, your body is designed to clear that acid back down. But if that clearance isn't working, that acid will stay in the esophagus longer, which will cause more irritation and likely more symptoms. So when you zoom out, you can see that reflux is really influenced by multiple factors. It's the lid. It's the pressure. It's how full the jar is, it's how efficiently things are moving. I think of this like sourdough. If you've ever had a sourdough starter and maybe you overfed the starter and it starts growing and bubbling up, what does it do? It overflows out of that mason jar, and that is kind of what's happening with the stomach and the lower esophageal sphincter. If that lid is not on tight. That sourdough is then gonna push that lid off, um, because of that fermentation, that gas, that bloating. Now, you're not gonna be able to make sourdough without thinking about that, but this is why you can have significant burning, reflux discomfort, even if your stomach acid levels are quote unquote normal. Because the issue isn't always acid. It's what's happening after that acid is produced, and this is where, this is where we start to see limitations of certain approaches, for example. Medications like PPIs or even just over the counter medications, Pepcid, et cetera, they can reduce the acidity of what's coming up, which can absolutely help reduce that burning sensation. But they're not necessarily addressing why the lid isn't sealing properly or why that pressure is building in the first place. So if we focus on changing the acid without looking at the full system, we can miss the bigger picture of what's actually driving that reflux. Now let's talk about stomach acid, because this is where there's just a lot of chitchat online. Low stomach acid is real. We see this with lots of our clients, and it can contribute to symptoms like bloating, gas, feeling overly full, that like brick and stomach feeling. And then even recurrent issues like SIBO or candida. This is a really common. Root cause. So stomach acid will play a big role in breaking down food, in signaling, digestion, downstream, helping protect against overgrowth of bacteria and yeast. So it's not something that we just want to ignore or dismiss. And it's also top of the chain when it comes to digestion. So if stomach acid is not signaling in the pancreas, the liver, the gallbladder, then the rest of digestion can be sluggish. Where things go sideways is when low stomach acid becomes the default explanation for everyone, especially those that have reflux. Because while it can be part of the picture, it's not always the primary driver and in many cases, it's not the best place to start. There are certain groups where low stomach acid is more likely. This would include people with chronic h pylori infections. We know that h pylori, lower stomach acid, long-term PPI use older adults where just acid production naturally declines. Individuals who have had stomach surgery and then people who are significantly mineral depleted minerals like sodium chloride, zinc, are actually required. To produce stomach acid, so if those are low acid production will be impaired. So yes, low stomach acid can exist and it can definitely contribute to symptoms, but we have to zoom out and ask a better question, is this actually an acid problem or is this something else affecting how acid is being handled? So, an analogy that I can use here is low stomach acid is like having a weak flame on your stove. Your food isn't breaking down well, things feel slow. You might get more fermentation, more gas, more bloating. Reflux, on the other hand is more like food boiling over because the lid isn't on correctly. These are two completely different problems. One is about not having enough heat. The other is about what's happening when things start to build pressure. And that's where we wanna be careful, because if something is already boiling over turning up, the flame doesn't fix the problem, and in a lot of cases it can make it worse. These are the clients that come to us that we hear, oh yeah, my provider told me to just keep increasing the batay until my stomach burned. Not a great option. So the goal isn't to automatically increase stomach acid or automatically decrease it either. The goal is to understand what your body needs. Because it can be helpful to support stomach acid, but other times the priority is supporting that lid. So reducing pressure, improving motility, helping your body manage what's already there. You don't necessarily fix something that's spilling over by just turning up the flame. That's usually gonna make it worse. You fix the reason that it's spilling in the first place, and this is why taking a more complete individualized approach matters so much when it comes to reflux. Now let's talk about Battan, HCL, because this is one of the most common things that people try when they've seen more functional providers. And again, I'm not saying that this is necessarily bad. This can be helpful and. It's where context really matters. It's also one of the last things that we typically would recommend, especially if reflux is present. Because if reflux is being driven more by a containment issue, meaning that that lid or LES isn't sealing well, pressure is building that, that sourdough is, is fermenting and building. Motility is slow. Adding more acid isn't fixing that. It's just changing what's coming up. So in instead of addressing why the reflux is happening, you're just increasing the acidity of what's already there, and that can lead to lots more irritation, lots more discomfort. You can think of this like putting more water into a cup that's already overflowing. The issue isn't the cup. The issue is that it's spilling over. So we have to address that. That's why some people that try betain feel worse. Not because their body can't tolerate it be, it just wasn't the right tool for what was going on. Now, on the flip side, there are people who do benefit from supporting stomach acid, and in those cases we just wanna be thoughtful about how we do it. Instead of jumping straight into Batan HCL, you might use a more gentle, more appropriate starting point. Just getting that natural digestive process to start looking like maybe. Deep breathing before meals, meal hygiene, chewing thoroughly, digestive bitters, bitter foods. Uh, these strategies can help your body stimulate its own acid production in a much more regulated way. Another important piece here is just understanding what might be going on in the background. So for example, if someone has something like h pylori, adding battam without addressing this first can increase the irritation of the stomach lining. So for not looking at the full picture, we can definitely unintentionally make things worse. And that's really just the problem that comes with blanket recommendations. So we need to make sure that we're looking at it through the light right lens. So the takeaway here is not that betain is good or bad, it's just that it's a tool. And just like any tool, it works really well in the right situation and not so well in the wrong one. So instead of just jumping straight in and everybody doing the same thing, we wanna ask the body what it actually needs for support first. So I wanna make this really practical. One of the most helpful things that you can start to do is look at patterns. Not just what you feel, but when you feel it. Because when you have symptoms, tells us a lot more about the symptoms themselves. Your body can give you clues all day long. We just have to know how to read them. So let's walk through a couple patterns that might be helpful. First one is if your reflux is worse after large meals, this often can be a pressure issue. Going back to that mason jar, if you fill it all the way up, that pressure's gonna build. And if the lid isn't sealed. It's much easier for things to come up. This doesn't necessarily mean that anything is wrong with your acid. It may just be simply too much volume for your system to handle at once if your symptoms are worse when you lie down. This brings gravity and clearance into the conversation. So when you're upright, gravity helps keep your stomach contents where they belong. But when you lie flat. Especially after eating, it becomes easier for contents to move upward if that lid isn't fully closed. This is also why some people notice symptoms at night or when they wake up. If you notice symptoms, your symptoms improve after burping, or you feel a lot of pressure building in your abdomen or chest. This can point more towards gas distension. The pressure has to go somewhere. So in some cases, this can overlap with things like a hiatal hernia. Where part of the stomach is being pushed upward, making it harder for that lid to function properly. So again, we're thinking about pressure and structure here, not just acid. If you feel more burning in your throat or irritation higher up rather than like deep in your chest, this can point more towards that upper reflux and if you're dealing with things like a chronic cough, a frequent throat clearing, or just that like lump in the throat, like you just have like a big ball in your throat, this can be more consistent with LPR and you might not actually have burning with this sensation. This is where reflux is affecting the upper airway, not just the esophagus. Now if your main symptoms are constant fullness, bloating, or just feeling like food sits in your stomach, this definitely points more towards digestion and motility. So food is not being broken down well or moving forward efficiently. It's gonna sit, ferment, create gas, increased pressure. And then that pressure can contribute to reflux. So when you zoom out, you can start to see how these patterns connect. It's not just, do you have reflux? What is actually driving it? Pressure, positioning motility, structure. And then once you start answering those questions, you can move out of guessing and actually understanding what the solution is. Let's touch on pregnancy really quick because this is a really common question I get, and time for reflux to show up. I know I've never had reflux a day in my life. It's like the one GI symptom I never had until I was pregnant and I was like, oh my goodness, this is actually horrid. So all of you that have reflux, I feel for you because it was. Actually awful. So during pregnancy, progesterone increases and one of progesterone's amazing effects is relaxing smooth muscle. So that can include that lower esophageal sphincter, that lid that we've been talking about. So it naturally becomes a little bit more relaxed, which can make it easier for contents to move upwards. And at the same time as the baby grows, there's just more physical pressure on the stomach. So now you have increased pressure from the outside in a lid that's a little looser. On top of that, motility tends to slow down during pregnancy as well, partially due to progesterone. And so things are just sitting longer, which can add to that pressure. A simple way to think about this is like squeezing that mason jar from the outside while loosening the lid. If the mason jar were in fact not glass. And this is why women who normally have, okay, digestion can experience reflux during pregnancy. It's not necessarily something you're doing wrong. It's just the environment that your body is in during that time. Now let's talk about testing because this is another question that I get and possibly can connect the dots. So testing doesn't diagnose reflux, the testing that we do, but it does show the environment that allows it to happen. So instead of looking for a single answer, you would be looking on like a stool test for patterns that explain why reflux is occurring. So starting with a stool test, like a GI map, one of the biggest things that we can look for is dysbiosis or imbalances in the gut that can lead to gas production, and gas creates pressure. We've also talked about pressure is a major driver of reflux. You can also look for things like h pylori. This can impact the stomach function, digestion, the integrity of the stomach lining. For some people, it can contribute to symptoms directly or even indirectly. And then we're also looking at markers of digestion. Are you actually breaking down food? Is there evidence that you have poor digestion? Inflammation is another piece. So markers of inflammation or irritation can give us insight into how the system is functioning overall. And sometimes we'll see things like elevated eosinophil activation, protein. This can actually indicate tissue irritation or tissue damage or immune activation. So it doesn't always mean that the issue is directly in the stomach or esophagus, but it tells us that there's something going on that could be contributing. Now, when it comes to minerals or HTMA minerals can play a role in muscle function. That includes the lower esophageal sphincter. So if someone's really low in sodium or potassium. And that can impact muscle tone and how well that lid is able to stay closed. Same thing with magnesium. We also wanna look at stress patterns. Chronic stress can impact the vagus nerve, which plays a huge role in digestion and motility, and just the coordination of the entire system. And then thyroid function ties in here as well. So if thyroid function is sluggish, motility can slow down, which again leads to more pressure and more opportunity for reflux. So. Then there are pieces that maybe don't always show up on testing, but are just as important. Things like motility issues, bile flow, meal hygiene, how fast somebody's eating, when they're eating in a stressed state, when they're rushing. All of that will impact how well digestion actually starts and how smoothly things move through. So when we zoom out, testing can give us those clues. It helps us to understand the environment. But it's really the combination of those patterns along with symptoms and habits that really tell us the full story of reflux. Now let's get into some less obvious triggers for reflux. This is the part where a lot of people have that moment of realizing maybe why what they've done hasn't worked. Because it's not always just about the stomach. It's not always just what's in the jar, but what's pushing on it from the outside. One of the big ones is hiatal hernias. This is where a part of the stomach pushes up through the diaphragm, which can affect how well. That LES functions. So even if everything else is working relatively well, that structural change can make it much easier for reflux to occur. Another factor is chronic bloating, which I mentioned earlier, but if you are frequently bloated, maybe you have SIBO or just chronic bloat, that's constant pressure inside the abdomen and that pressure is pushing upward. Same thing with chronic constipation, so even if your acid levels are normal. Even if your digestion is decent, that pressure alone can contribute to reflux symptoms. This is why people will say they feel worse as the day goes on, especially if they're bloating bills throughout the day. Your diaphragm also plays a huge role and bigger role than most people realize. If you're breathing shallowly or holding a lot of tension in your upper abdomen, that can affect how the diaphragm and the LES coordinate together, so that diaphragm helps that lid function. So if it's tight or not moving well, reflux will become more likely. Constipation is another big one. If things aren't moving down and out, that pressure will build, that upward pressure can contribute. So sometimes addressing bowel movements can actually improve reflux symptoms. And then of course, eating habits matter. So overeating, eating too quickly, eating in a stress state, all of those things can increase pressure and reduce how effectively digestion is happening. When you rush through meals, you're not giving your body that. Signal it needs to properly break down and move food, and then everything downstream becomes more likely to contribute to reflux. And then finally, the last thing that everybody wants to hear. But chronic stress. So stress impacts that vagus nerve, which plays a huge role in digestion, coordination. When your nervous system is dysregulated, digestion will become less efficient, and when you zoom out, reflux is rarely caused by just one thing. It's often a combination of factors that are increasing pressure, maybe affecting the structure or disrupting coordination. And when you start addressing those pieces, that's really when things start to shift. So let's bring this together and talk about the three buckets that we can work on. Number one, support the lid. Number two, reduce the pressure. And number three, improve movement. When you approach reflux this way, it will make a lot more sense and things will start to work. So start with your nervous system and your diaphragm. Your diaphragm and your LES work together. So work on deep breathing. Work on making sure that you're eating in a slow. Relaxed state. This is where things like diaphragmatic breathing can make a huge difference. Slow down at your meals. Take a few deep breaths. Vagus nerve support, things like humming gargling. Next is meal habits. This is simple, but also hard, so sometimes you might need to do smaller, more spaced meals. Chew your food. This gives your body a headstart on digestion. Also, avoid lying down right after eating to give your body some time. And then some physical strategies. So walking after meals is one of the easiest ways that you can support digestion and reduce pressure. Even just 10 minutes can help stimulate movement. Heel drops are another tool. You stand up on your toes and then you drop your heels down firmly. This can help encourage the stomach to move downward, especially in cases where you have a hernia. Also soothing support, so things that help calm and protect the lining of the esophagus. Throat coat tea is a great example. Any dnce, these are are herbs that create that soothing protective layer. Things like slippery elm, marshmallow root will fall into this category. They can be soothing to the tissue and help reduce irritation while you're working on the bigger picture. And then we have digestion and motility support when appropriate. W this is where possibly bitters can be helpful depending on the person they stimulate your natural digestive process. This is where motility support can be helpful if constipation is present. So again, we're not just throwing random supplements, we're supporting the system and making sure that you don't get stuck and we're not just trying to fix the acid. We're fixing that containment, that pressure, that movement. You can't supplement your way of a mechanical problem, so. If the lid isn't working well and that pressure is constantly building, if things aren't moving the right way, then it's not fully gonna resolve. So that's where knowing exactly what's going on with you, having an exact plan matters looking at your specific patterns, your symptoms, your testing to understand exactly what your body needs. This is exactly what we do inside gut. Together we are really going to understand all the pieces of the puzzle. We use testing, so you're not trying random strategies. We're identifying those root causes, building a plan that actually supports your body long term. So we're not just supporting too much or too little acid, because as you've learned, there's more to the story. So I hope that this episode was helpful. Would love to know if you have any questions about this. I know I haven't done a ton of episodes on reflux specifically, but I was running a reflux training for my practitioners and gut practitioner last week, and I thought this would be a great episode for you as well. So. I hope you enjoyed. Let me know if you did and I'll see you next week on the next episode.