Naturopathic Protocol for GERD

Gastroesophageal reflux disorder (GERD) commonly presents as heartburn, regurge of food or sour taste in the mouth. Sometimes GERD is asymptomatic or produces non-digestive symptoms like a chronic cough or post-nasal drip. Most evidence suggests that GERD results from inappropriate relaxation of the lower esophageal sphincter (LES), a muscular ring that acts as a door to the stomach. In rare cases, severe GERD can progressive to erosive esophagitis where ulcers form and may require more aggressive treatment. The naturopathic protocol for GERD focuses on protecting the esophagus, stimulating digestion, increasing LES tone, removing food triggers, improving eating habits and healing damage to the esophagus.

1. PROTECT THE ESOPHAGUS

Relieve symptoms of heartburn first, as identifying and treating the underlying cause of the GERD may take time.  It is important to make the patient feel better and prevent further damage. Demulcent herbs relieve heartburn because they insulate the esophagus from corrosive acid.

A. Stimulate Mucous Production

Deglycyrrhizinated Licorice (DGL) helps heal ulcers.^1–3 It stimulates mucous protection to protect the gastrointestinal tract. Patients can take it as needed to improve heartburn symptoms with no significant side-effects.

Caution: Avoid both licorice & DGL during pregnancy because safety concerns exist.^4,5  Both licorice and DGL inhibit the breakdown of prostaglandins (PGE2 and PGF-2α) involved in both mucous production and uterine contractions.^6,7

B. Supplement with Mucilage

Some demulcents herbs, like marshmallow and slippery elm, contain mucilage that forms a slimy, viscous liquid when added to water. Mucilage coats the esophagus to shield it from acid and relieve heartburn.  The Commission E approved the use of marshmallow root for “irritation of the oral and pharyngeal mucosa and associated dry cough, and for mild inflammation of the gastric mucosa.”⁸

Demulcent Tea – I often recommend patients sip the following throughout the day
• 4 parts marshmallow (root)
• 1 part licorice root, powdered
Instructions: Add 1-2 tsp of powder to hot water. Cool and sip throughout the day.

2. Improve Digestion

People with GERD frequently have issues digesting their food. Atonic digestion refers to people with weak digestive function and is associated with reduced stomach acid (hypochlorhydria), decreased enzyme and bile secretion. Many things can suppress digestive function (food sensitivities, drugs, bland diet, stress, eating habits) and these causes should be addressed. In most cases, stimulating digestion with herbs should suffice, but supplementing with digestive juices (acid, enzymes, bile) may be required.

A. STIMULATE DIGESTION

Bitter herbs stimulate the release of saliva, stomach acid, pancreatic enzymes, and bile. Bitter herbs likely increase lower esophageal sphincter (LES) tone to help keep stomach contents from flowing up and increase mucous production as well. I find 5-30 drops of Yellow Gentian 5-10 mins before meals can help prevent most cases of reflux. The German Commission E approved gentian root for “digestive disorders, such as loss of appetite, fullness, and flatulence.”⁸ Different species of gentian have been shown to increase stomach acid, enzymes, and mucus production.⁹

Caution: In rare cases, bitter herbs can aggravate heartburn caused by H. pylori, certain drugs, hiatal hernia, erosive esophagitis, and anatomical issues.  If the patient’s heartburn worsens, discontinue immediately.

B. SUPPLEMENT DIGESTION

If patients refuse to take bitter herbs or they cannot produce sufficient digestive juices, I sometimes recommend digestive enzymes or betaine HCl.  They support digestion and accelerate gastric emptying to reduce GERD.

Caution: Digestive enzymes and betaine HCL can sometimes irritate inflamed mucosa like esophagitis and ulcers.

3. Avoid Triggers

Every person with GERD has a unique set of triggers and therefore there is no definitive list of foods to avoid. Foods may trigger GERD via several mechanisms. Spicy foods relax the LES. IgG food sensitivities may cause inflammation and delay emptying of the stomach. People with a histamine intolerance may develop GERD after consuming histamine-rich foods. High-fat meals delay emptying of the stomach.¹⁰ I’ve compiled a list of common food triggers from various research studies. Begin by removing this list of foods.  If there’s no improvement in symptoms try a thorough elimination diet.

Common Foods That Cause GERD^11–19

• Sugar
• High-fat meals (Fried food)
• Tomato, Asparagus, Lettuce
• Milk
• Eggs
• Yeast (Wine, Beer, Leavened Bread)
• Gluten (Bread, Noodles, Crackers)
• Rice
• Pork
• Coffee
• Chocolate
• Tuna, Sole, Shrimps

4. LIFESTYLE CHANGES

Research supports the following lifestyle changes to reduce GERD:

• Eat to 80% stomach capacity. Overeating stretches the stomach and increases pressure in the stomach and makes the LES work harder.  Also, it delays emptying of the stomach.  Smaller meals reduce the risk of reflux.^20,21
• Eat at regular meal times. Our bodies crave routine so they can optimize processes. Predictable meal times helps prime the digestive tract for food and reduce GERD.²²
• Eat early and no bedtime snack. Eating dinner >4 hours before bedtime reduces the risk of night-time GERD.^22,23
• Raise the head of the bed. Use a 20cm block to raise the head of the bed to prevent night-time reflux.²⁴

5. WEIGHT MANAGEMENT

Being overweight increases intra-abdominal pressure leading to reflux.²⁵ A higher BMI increases the risk of erosive esophagitis, a severe form of GERD. Weight management should be one of the primary treatments in overweight patients.²⁶

6. SUPPLEMENT MELATONIN

The intestinal tract makes 500 times more melatonin than then pineal gland.  This “sleep hormone” plays a vital role in digestive function. Significant research supports the use of melatonin for GERD. Melatonin works by numerous mechanisms including increasing mucous production, decreasing stomach acid and increasing LES tone.^27–29 Supplementing with melatonin is particularly useful for patients suffering from night-time reflux.

7. HEAL THE ESOPHAGUS

Some patients with severe chronic GERD will have significant damage to the esophagus. The following recommendation are not required for occasional mild heartburn. In most cases of GERD, reducing stomach acid is not required. However, in severe cases, like erosive esophagitis, it may be necessary to reduce stomach acid to allow time for the esophagus to heal. Short rounds of powerful acid-blocking drugs may be required, but antacid herbs may suffice.

A. MEADOWSWEET

Herbalists recommend meadowsweet to treat heartburn and stomach ulcers. Research demonstrates it can reduce stomach acid and prevent the formation of gastrointestinal ulcers.^30–32

B. CHAMOMILE

Commission E approved the internal use of chamomile for “gastrointestinal spasms and inflammatory diseases of the gastrointestinal tract.”⁸ Chamomile can reduce stomach acid and help heal ulcers. If required, I would recommend drinking 1-3 cups of chamomile tea on an empty stomach.

Ulcer Tea – I often recommend patients sip the following throughout the day if I suspect significant damage to the mucous membranes:
• 2 parts marshmallow (root)
• 1 part chamomile (flower)
• 1 part meadowsweet
• 1 part licorice (chopped root)
Instructions: Add 1-2 tbsp of mixture to a 1-2 cup of hot water. Drink on empty stomach 2-4 times a day.

Summary of the Naturopathic Protocol for GERD

The naturopathic protocol for GERD offers a rational approach to reflux.  Patients with mild occasional GERD will likely only require identifying and removing food triggers and supplementing with DGL or marshmallow as needed.  People also complaining of digestive issues may benefit from digestive support like bitter herbs or enzyme supplements.  Suffers from nighttime GERD, in addition to changing their diet, should raise the head of their bed, eat smaller and earlier dinners and consider a melatonin supplement.  Severe chronic GERD with extensive damage to the esophagus may need all the above recommendations and antacid, demulcent and vulnerary herbs.