Root Cause of Common Digestive Complaints

Common digestive issues such as heartburn/acid reflux, bloating, gas, indigestion, and nutrient-specific deficiencies occur if digestion is somehow altered or otherwise impaired. Many believe this is related to high levels or excessive production of stomach acid, or hyperchlorhydria, and take over-the-counter antacids or prescription Proton Pump Inhibitors (PPIs) to suppress the acid and alleviate some of these signs and symptoms.¹

When this normally acidic environment is suppressed, or buffered, to a higher pH, gaseous acid bubbles are formed, creating the feeling of gas pressure, bloating, upset stomach, or the need to belch. Furthermore, if these bubbles come in contact with the esophagus, it may be experienced as acid reflux and/or heartburn. Rather than an over-production of stomach acid, these signs and symptoms are indicative of insufficient stomach acid, or hypochlorhydria.²

Hypochlorhydria: Insufficient Stomach Acid

Hypochlorhydria has been linked to chronic inflammation of the stomach, chronic stress, H. Pylori infection, gastritis, pancreatitis, obesity, gastric-bypass surgery, as well as different autoimmune diseases, alcoholism, cirrhosis, hypertension, chronic over-use of antacids or PPIs, and aging.^2,3 Regardless of the etiology, the resulting effect is the same – the stomach-acid producing and secreting cells atrophy and die off.^1,2

With excessive suppression of the stomach acid, the resiliency and functionality of the stomach, digestive system, and immune system are compromised. For example, when stomach acid is suppressed, the first line of defense against stealth pathogens is disrupted and the stomach becomes more susceptible to infectious bacteria like H. Pylori. This often snowballs and leads to chronic inflammation of the stomach, or gastritis, as well as stomach ulcers, SIBO, and other bacterial overgrowths.⁴

Additionally, studies show the stomach operates at an optimal pH range of 1.0-2.0, while hypochlorhydria would present with a resting pH of >3.0, and regular use of antacids and PPIs have demonstrated a resting stomach pH 5.0-7.0.⁴ Therefore, the stomach requires more acid to lower the pH into optimal operating range so to better facilitate digestion, nutrient absorption, and general immune health.^4,5

Digestion of Protein

As digestion is the physical and chemical alteration of ingested food into smaller, more soluble particles, it is required to facilitate proper nutrient absorption. The stomach in particular is responsible for the digestion of protein such as eggs, meat, dairy, legumes, nuts, and seeds. When protein reaches the stomach, specific cells- called parietal cells, secrete stomach acid, or HCl, to support digestion.

With optimal levels of stomach acid, the lowered pH denatures or unfolds the complex 3D structure of protein into a single, long protein chain, allowing for easier cleavage into short protein chains called polypeptides or single protein building blocks- amino acids.^1,4,6 This happens optimally at a pH around 1.8-3.5, is especially useful for the digestion of muscle tissue and other collagen containing meat components, and is rendered inert at a higher, more alkaline pH.⁷ Without proper acidic conditions and without proper denaturation of the proteins, the protein molecules may not be small enough to be absorbed by the intestines, which in turn may contribute to food allergies, protein deficiency, impaired protein and DNA synthesis, and micronutrient deficiencies – specifically  iron, zinc, and B12, which are largely obtained from animal sources.⁴

Protein-Specific Digestive Enzymes

The acidic conditions are also needed to activate the protein-specific digestive enzymes such as pepsin, which is responsible for a majority of the protein cleaving action.⁴ Additionally, stomach acid and other gastric secretions further facilitate the solubility, and absorption, of additional micronutrients such as vitamin C, E, B6, B12, folic acid, iron, calcium, magnesium, zinc, and copper through various, often complex, mechanisms.^1,8,9

As an acidic environment is necessary for the absorption of such micronutrients, the occurrence of nutrient deficiencies is highly correlated with the occurrence of hypochlorhydria and may present as poor skin/hair/nails and slow wound healing, waning of the eyes, heart, or memory, chronic fatigue, chronic inflammation, muscle cramps/spasms, tingling in limbs, high blood pressure, and a high risk of bone fracture.^1,2,4,8,9  Furthermore, if food isn’t properly digested, this may lead to, or further exacerbate, lower GI and/or elimination issues.^2,10  

Testing for Hypochlorhydria

As the signs and symptoms of hypochlorhydria are similar to hyperchlorhydria, the best way to tell if additional stomach acid is needed is to test for it. While there are a handful of specialized tests that a Gastroenterologist can order to test pH, secretion levels, etc, there is a quick at-home test as well. Per the Cleveland Clinic:

The baking soda will combine with the resting level of stomach acid and produce carbon dioxide, or gas bubbles. The gas bubbles will induce burping, if a burp surfaces within 3-5 minutes, then the stomach is sufficiently acidic. If it takes longer than 5 minutes, stomach acid is low and likely requires reacidification support.² More sophisticated testing would be appropriate if there are any suspected nutrient deficiencies, food allergies, or other bacterial overgrowths. 

Digestive Remedies and Interventions to Aid in Stomach Reacidification

Additionally, if stomach acid is determined to be low, there are simple interventions that would help support stomach reacidification and digestion, these include:

• Sucking on or eating something sour before meals
• Eating protein components of the meal first
  • Again, the arrival of protein in the stomach naturally triggers the secretion of stomach acid
• Chewing thoroughly
  • This creates more surface area and further supports protein unfoldment
• Eating fermented foods
  • That support a comprehensive and healthy microbial environment
• Drinking fluids later in the meal
  • This allows time for the acid to work without being buffered or diluted
• Acid replacement therapy or supplementation with betaine HCl

Supplementation with Betaine HCl

Studies have shown betaine HCl to have a relatively immediate effect on stomach reacidification, within 10 minutes of ingestion. The effect has been demonstrated to last around 75 minutes, which provides ample time for specific micronutrients and pH-dependent drugs to become more soluble for absorption.⁵ Additionally, studies have also shown that the body’s natural response to certain physiological cues decrease with age, so the elderly population may benefit from taking betaine HCl before a meal to preemptively acidify the stomach where the body’s natural response system may be slow to action and limit digestion.⁴

Pepsin Supplementation

To further facilitate the digestion of protein, additional supplementation of the stomach-specific enzyme pepsin, which is activated by acidic conditions, may also be warranted as it contributes to specific peptide cleavage, where these cleaved amino acids trigger other essential digestive activities, and further promotes nutrient absorption.^2,11 In fact, the signaling activities of pepsin are thought to be more critical to digestion than its protein cleaving action as it triggers other digestive secretions, hormone signaling, and proper gastric emptying. Furthermore, pepsin itself has been shown to alleviate dyspeptic, or stomach acid, imbalances and is widely used  in combination with betaine HCl to correct hypochlorhydria.¹¹ However, a strong acidic environment and other beneficial stomach enzymes are still not enough to completely digest protein or the shorter polypeptide chains. As protein accounts for around 10% of our caloric intake and is needed for wound repair, tissue healing, growth and development, energy, and DNA synthesis, our body needs additional support to be able to absorb these protein-specific nutrients and amino acids in totality.⁷

Digestive Enzymes Secreted by the Pancreas

After the contents are released from the stomach into the first part of the small intestine, or the duodenum, the pancreas first secretes bicarbonate to buffer the acidified stomach contents. The pancreas then secretes additional digestive enzymes, which are only effective in a more buffered, or basic, solution. Of the digestive enzymes secreted, 80% are proteases, or enzymes such as pancreatin that will specifically assist the digestion of protein. The additional 20% of the pancreatic digestive enzymes support the digestion of the other macronutrients – carbohydrates and fat. ^7,12  

Pancreatin

Pancreatin, in particular, finishes the hydrolysis process by fully transforming the bulky protein molecule, or peptide chain, into single amino acids and further promotes total macronutrient absorption .⁷ Without this major component of enzymes, protein goes largely undigested, the other macronutrients go unabsorbed, tissue growth and repair is inhibited, and nutrient deficiencies are common.¹² Therefore, additional digestive enzyme supplementation may also be supportive if signs and symptoms, such as fatigue, slow wound healing, nerve/muscle pain, frailty and/or other bone-related concerns, are present independently or in combination with other GI concerns.

Clinical Takeaways

• Digestive concerns, such as acid reflux, heartburn, gas, bloating, and belching, are synonymous with dyspepsia and assessing stomach acid levels may be worthwhile to better facilitate and improve (protein) digestion, and ultimately, absorption.
• If testing confirms hypochlorhydria, supplementing with betaine HCl would be beneficial to promote stomach reacidification and digestion.
• Digestive remedies such as betaine HCl, further fortified with pepsin and pancreatin, would then support a highly acidic environment, appropriate and healthy digestive signaling, nutrient absorption, and immune health, while addressing and alleviating other common digestive symptoms, malabsorption, and nutrient deficiencies.