Functional Approach for the Reversal of Hypochlorhydria: A Case Study
Gastric juices are liquids produced in the stomach, containing several compounds including hydrochloric acid (HCL), pepsin, lipase, mucin, intrinsic factor, peptides, nucleic acids, and electrolytes (Lu et al., 2010). HCl is the most studied, and known to be an imperative factor of digestion and absorption. It is a very strong acid, with a pH of 2-3, produced by the parietal cells in the stomach.
Several biochemical pathways rely on the strong acidity of HCL, including activation of pepsin and absorption of nutrients. Hydrochloric acid serves many functions, although the primary functions are to digest proteins and provide a protective barrier by killing the harmful micro-organisms introduced into the body through our food. (Lu et al., 2010). An acidic environment protects the gastrointestinal system from pathogens. Increases in pH (lower acidity) may result in a bacterial overgrowth in the stomach which serves as initiators in the atrophy-metaplasia-dysplasia- carcinoma pathway (Lu et al., 2010).
Achlorhydria or hypochlorhydria are the formal terms for low stomach acid (content). Patients with low stomach acid commonly present with abdominal bloating, acid reflux, iron deficiency, dysbiosis, excessive gas after meals, undigested food in stool, constipation, halitosis, and abdominal cramping (Fardet & Boirie, 2013). Several factors may influence the production of HCL, including age, acid-neutralizing medications and proton pump inhibitors such as Alka-Seltzer and Prilosec, and bacterial infection with Helicobacter pylori (H. pylori). Furthermore, factors influencing biochemical processes where hydrogen (H) and or/or chloride (Cl) is lost, due to metabolic alkalosis or excessive perspiration which may contribute as limiting factors in HCL production.
While there are many possibilities influencing low acid production, several more problems may arise from hypochlorhydria. Because HCL is required for food digestion, limited levels of HCL inhibit the ability to properly digest foods. Trace elements are unable to be absorbed which contribute to the onset of other diseases such as cancer, neurodegenerative disorders, and heart disease. Lowgastric causes an overgrowth of bacteria, increases the incidence of food poisoning, and the introduction of virulent strains. Pathogenic bacteria living in a hypochloremic stomach can produce nitrite and nitroso compounds, which serve as initiators in the atrophy-metaplasia-dysplasia- carcinoma pathway (Lu et al., 2010). Moreover, dysbiosis has been linked to decreased levels of serotonin and acetylcholine which cause low mood and depression (Nishihara, 2008).
Overproduction of gastric acid exhibits similar symptoms to that of low production. Frequently, individuals experiencing the previously stated symptoms, self-treat with over the counter acid blocking medication, without seeking the cause of the digestive problem. Because the symptoms of elevated levels of HCL and limited HCL are nearly identical, it is imperative we look at all of the associated symptoms to assure improved gastrointestinal function.
History of Present Illness for Patient YA
For several years, YA has experienced frequent gastrointestinal pain, ranging from mild to extreme discomfort. He reported having diarrhea most of the time with a bowel movement frequency of three to four times per day. When he doesn’t have diarrhea, he also experiences constipation which causes reoccurring hemorrhoids, or experiences burning in the anus, with foul smelling, oily stool. He reports taking Alka-Seltzer to control his indigestion, which is experienced as excessive belching, acid reflux, flatulence, and abdominal bloating. Additionally, he takes Prilosec when the discomfort of his symptoms are more severe. The pain has been recurrent for as long as he can recall (at least 25+ years).
YA indicates many times bread will give him extreme indigestion (with the exception of sourdough). However, he didn’t notice the same symptoms while living in Mexico and Spain. He reports to have almost no pain after a meal low in protein, however, will experience extreme discomfort after eating a steak or cheeseburger. YA frequently finds undigested particles of food in his stool. Last, YA experiences extreme hyperhidrosis, characterized by profuse sweating with temperature change, physical activity, and elevated heart rate.
* Eliminated from blog post to protect client privacy
YA likely has multiple factors contributing to his gastrointestinal discomfort. The focus of this case will be to reverse the gastric hypoacidity, control his symptoms of GI distress, and lower the BMI and waist to hip ratio. This involves dietary changes, supplementation, increased physical activity and implementation of mind-body practices.
Yago et al. (2013) implemented a pilot study, evaluating the extent and time frame of gastric reacidification with oral betaineHClin six healthy volunteers. Hypochlorhydria was pharmaceutically induced. After confirming each had a gastric pH greater than four, a dosage of 1,500 mg of betaine HCL was given orally with water and gastric pH was monitored continuously over the course of two hours. The results indicate that betaineHClsignificantly decreased gastric pH levels within 30 minutes after administering the dosage. Furthermore, Yago et al. (2013) report no adverse side effects after taking betaine HCl. Based on these findings, Betaine HCL has the potential to aid in digestion and the absorption of vitamins and minerals.
YA began one capsule of Betaine HCL with Pepsin prior to eating dinner and reported any sensations of burning. He described no notable discomfort and was asked to take two capsules at his next meal. This process continued until a he began to feel slight discomfort with four capsules. The dosage was then set to three capsules of Betaine HCL taken with lunch and dinner, and two taken in the morning with breakfast as needed. Yago et al. (2013) report a natural elevation in HCL production after supplementation with Betaine HCL. It is intended that long-term use not be required, current supplementation will merely stimulate HCL production to a sufficient level. YA will continue to take the supplements with meals until he feels burning and discomfort, at which point he may discontinue use.
Many of YA’s symptoms of discomfort, constipation, mirror those of IBS. Implementing a modified diet, low in some of the fermentable oligo-saccharides, disaccharides, monosaccharides, and polyols (FODMAPs) may benefit some of his present symptoms of irritable bowel syndrome (IBS). Halmos et al. (2014) investigated the comparative effects of a diet low in FODMAPs with that of the typical Australian diet. During a time span of 21 days, they reported a reduction in gastrointestinal discomfort, flatulence, and bloating. Furthermore, participants with IBS reported greater satisfaction with stool consistency. The study concluded that a diet low in FOODMAPs successfully reduced symptoms of gastrointestinal distress, providing supportive evidence for the use of this diet as first-line therapy (Halmos et al., 2014). YA will limit cereal grains, legumes, processed meats, berries, garlic, and onions for a period of six weeks. After which, he will reincorporate one food types each week to establish any intolerances.
Moreover, because of YA’s excessive perspiration, he is experiencing a significant loss of salt (NaCl). Without a sufficient amount of NaCl, the body is unable to carry out the biochemical reactions required to maintain homeostasis, further impeding the production of HCl. Incorporating Celtic sea salt into his diet will help replenish what is lost through perspiration.
YA’s BMI and waist to hip ratio put him at risk for heart disease and diabetes. In addition to implementing a modified low FODMAP diet, he will also reduce his calorie intake by 500. This brings him to an average caloric intake of 2,000-2,500 calories per day. Of the food choices he makes, they must be whole foods or minimally processed organic foods without added sugar.
Functional and medicinal foods
Green leafy vegetables
Celtic Sea Salt
Organic Greek Yogurt with live cultures
Wild caught salmon
Blueberries and strawberries
Organic free-range eggs
YA carries an elevated risk of cardiovascular disease (CVD) and diabetes with his family history and present BMI and waist to hip ratio. Given his indicated perceived stress and need for physical activity, yogic practice is recommended whenever possible, starting with 20-30 minutes 5 times per week, working up to 60 minutes per day. Several studies indicate yogic practice promotes a significant decrease in the modifiable symptoms related to cardiovascular disease (Behr, 2016). Yoga involves an intervention of lifestyle; with a particular focus on increased physical activity and mindfulness (Behr, 2016). The physical activity of yogic practice unquestionably has an effect on overall reduction of BMI, but the heart of the practice is something more than exercise and has a profound influence on the molecular mechanisms involved in the reversal of chronic disease (Behr, 2016). Continued practice has proved beneficial in the reduction of perceived stress and negative feelings while diminishing mental and physical symptoms of disease (Behr, 2016). Additionally, interventions with yoga practice have indicated an overall decline in mental stressors such as anxiety and depression.
Achieving and maintaining gut health offers a new approach to preventive medicine. Much of the current medical research focuses on treating GI diseases rather than preventing the disease. Preventive medicine is finding importance for economic reasons, especially in the field of gastroenterology (Bichoff, 2011). Because of this, it is in our best interest to consider scientific approaches to restore and preventing gut health. While several factors contribute the overall gut health, we have significant evidence that particular lifestyle factors, such as a diet, exercise, chronic stress, and social connectedness all have integral roles in maintaining overall health. Continued research will help determine the underlying biochemical mechanisms so we may continue to influence the pathways of health in a positive way (Bischoff, 2011).
YA had misdiagnosed his hypochlorhydria, and for several years antagonized the condition with over-the-counter medications. Within one week on a modified low FODMAP diet, supplementation with betaine HCL, yogic practice, and dietary changes, YA reported increased energy, decreased GI discomfort, reduced constipation, and improved mood. Three weeks later, he lost 10 pounds, reducing his BMI to 25.3 (down from 27.1). Additionally, his waist to hip ratio was reduced to 0.98 (down from 1.04). Furthermore, YA reports a significant reduction of his GI symptoms. Therefore, it is advised he continue with the recommendations.
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