Acid Reflux, GERD, and Thyroid Health
Published May 9 2016
Gastroesophageal reflux disease (GERD) is a common condition, and although it’s not directly related to thyroid health, it is a condition commonly seen in people with thyroid and autoimmune thyroid conditions. I more commonly see it in those with hypothyroidism and Hashimoto’s Thyroiditis, but it can be present in people with hyperthyroid conditions as well. 15 to 20% of the general population experience symptoms of GERD such as heartburn, regurgitation, and/or retrosternal pain (1). In this article I’m going to discuss some of the different causes of GERD, along with some natural treatment options.
I’d like to start off by talking about what happens when someone has GERD. The lower esophageal sphincter (LES) plays a crucial role in maintaining the mechanical barrier necessary for the prevention of gastric reflux (2). And GERD involves lower esophageal sphincter relaxation, which in turn causes a reflux of the gastric contents into the esophagus. Why does the lower esophageal sphincter become impaired in some people?
First of all, keep in mind that transient relaxations of LES is normal, but with GERD these are prolonged and more frequent. Some of the factors that decrease LES tone include hormones such as cholecystokinin and progesterone ( in pregnancy), certain medications (nitrates, calcium channel blockers, etc.), specific foods like high-fat meals and chocolate, as well as smoking, caffeine and alcohol (3). Some other risk factors for developing GERD include obesity, poor diet, lack of physical activity, and respiratory diseases (4).
In addition to problems with the lower esophageal sphincter, some of the other potential causes or contributing factors of GERD include impaired esophageal acid clearance and delayed gastric emptying, a hiatal hernia, visceral hypersensitivity, and impaired mucosal resistance (5). This doesn’t mean that everyone with GERD will have these other conditions, but if they do have any of these then of course they should be addressed.
Symptoms of Gastroesophageal Reflux Disease
Although I mentioned a few of the more common symptoms of GERD in the opening paragraph, I’d like to include a more complete list below (6). Not all of these symptoms are present in everyone, and the symptoms of GERD are more common after meals, and are also more common in a reclining or resting position.
Epigastric pain (pain in the upper abdomen below the ribs)
How To Diagnose GERD
High digestive endoscopy and esophageal pH testing seem to be the most sensitive methods of diagnosing GERD (7). An endoscopy can also help to diagnose or rule out some other conditions such as a peptic ulcer, esophageal moniliasis, gastric cancer and eosinophilic esophagitis, all of which present with dyspepsia symptoms (7). GERD can be classified as non-erosive reflux disease (NERD) or erosive reflux disease (ERD) based on the presence or absence of esophageal mucosal damage seen on endoscopy (8). People with NERD frequently will have a negative endoscopy (9). Unlike those with erosive reflux disease, studies show that most NERD patients will not progress over time to erosive esophagitis or Barrett’s esophagus (9). Many people with NERD don’t respond to proton pump inhibitors.
Esophageal Spasms and GERD
Some people with GERD experience esophageal spasms, which are abnormal contractions of the muscles of the esophagus. The symptoms can include problems swallowing, pain or tightness of the throat, and pain in the chest or upper abdomen (10). Sometimes the pain can spread to the neck, jaw, or arms (10), which can make some people think that they are having a heart attack.
As for what causes esophageal spasms, one of the main causes is thought to be the surge of gastric acid into the esophagus. There are actually two main types of esophageal spasms associated with GERD:
Diffuse esophageal spasm. Distal esophageal spasm (DES) is associated with difficulty in swallowing and/or chest pain (11). The contractions might be due to a nitric oxide deficiency (12), and while medications that block nitric oxide degradation such as Sildenafil might help (11), natural treatments to help increase nitric oxide might also be beneficial, as I discussed in an article entitled “Nitric Oxide and Thyroid Health“.
Nutcracker esophagus. Nutcracker esophagus is commonly seen in patients with noncardiac chest pain, and they demonstrate a hypersensitive and stiff esophagus (13). Increasing nitric oxide might also help with this, although you might need to incorporate the natural treatment methods suggested towards the end of this article.
Hiatal Hernias, Acid Pockets, and Barrett’s esophagus
The hiatus is an opening in the diaphragm, which is the muscular wall that separates the chest cavity from the abdomen. The esophagus is located in this hiatus, as it attaches to the stomach. A hiatal hernia involves a small part of your stomach that bulges through the diaphragm and into this hiatus. The cause of this is frequently unknown, but increased pressure from being overweight, pregnant, or even coughing or straining when having a bowel movement can cause a hiatal hernia.
Although not everyone with a hiatal hernia experiences symptoms, in some people this hiatal hernia can cause acid reflux and lead to the development of GERD. As for how a hiatal hernia is diagnosed, a barium swallow is commonly used, although an endoscopy is another option. If there are no symptoms then this usually isn’t treated, although sometimes dietary and lifestyle changes (i.e. losing weight) will be recommended. If it results in severe symptoms then surgery might be an option.
An “acid pocket” is an area of unbuffered gastric acid that accumulates in the proximal stomach after meals and serves as the reservoir for acid reflux in healthy individuals and gastroesophageal reflux disease (GERD) patients (14). This acid pocket actually occurs in all individuals, but in patients with GERD the gastric acid refluxes back from this pocket into the esophagus much more frequently than in those who are healthy (15).
Barrett’s esophagus is a metaplastic alteration of the normal esophageal tissue, and it is present in 10 to 20% of patients with GERD (16). The main concern with Barrett’s esophagus is that people with this condition have a greater risk of developing an esophageal adenocarcinoma, which carries a high mortality rate (16). This condition is thought to be caused by acid-induced injury to the cells of the esophagus. Additional factors that appear to be risk factors for the presence of Barrett’s esophagus include obesity, the presence of a hiatal hernia, and the absence of Heliobacter pylori infection (16). The reason why H. Pylori can prevent the development of Barrett’s esophagus is because it can decrease gastric acidity, which normally isn’t a good thing, but can be beneficial in someone with GERD. So in order to prevent Barrett’s esophagus one wants to do things to treat GERD, which is typically accomplished with acid suppressing drugs, although I’ll shortly talk about some things you can do naturally for this condition.
Is There A Relationship Between GERD and Thyroid Health?
There is some evidence that a hiatal hernia and GERD are early signs of Hashimoto’s Thyroiditis (17). And there is also evidence that Hashimoto’s may be associated with an esophageal motility disorder presenting as dysphagia or heartburn (18). In addition, those with Hashmoto’s Thyroiditis have a greater likelihood of being overweight or obese, and this is a risk factor for GERD. On the contrary, most people with hyperthyroidism and Graves’ Disease aren’t overweight (although there are exceptions), and this is one reason why there is a decreased incidence of GERD in those with hyperthyroid conditions.
Conventional Treatment Methods For GERD
Many medical doctors will recommend lifestyle and dietary changes to their patients with GERD. This may include a recommendation to lose weight, along with avoiding common triggers such as caffeine, alcohol, spicy foods, and chocolate. However, medication is commonly recommended and can include antacids, histamine-receptor antagonists, or proton-pump inhibitors (19). GABA agonists are also used in some cases (20) (21), and the reason for this is because they can have a strong inhibitory effect on the transient LES relaxations. While these can provide relief, they of course don’t do anything to address the cause of the condition. Anti-reflux surgery is recommended in some situations.
Can Too Little Stomach Acid Cause GERD?
As crazy as it might sound, GERD can also be caused by a low levels of gastric acid. This isn’t to suggest that the symptoms someone experiences isn’t due to stomach acid refluxing into the esophagus. But usually the problem isn’t due to too much gastric acid, but instead is caused by problems with the LES as I mentioned earlier. In addition, bacterial overgrowth can be an issue, as this is common when someone has low levels of gastric acid.
In fact, some people actually feel better when supplementing with betaine HCL. This of course doesn’t describe everyone, and I can understand being concerned about taking something such as betaine HCL when most medical doctors advise you to take acid-blocking medication. But of course these drugs don’t do anything to address the cause of the problem, and blocking stomach acid affects the absorption of nutrients, and as I just mentioned, can lead to bacterial overgrowth.
Natural Treatment Options For GERD
So what natural options are there for GERD? Let’s go ahead and look at some of them:
Diet. Eating a healthy diet consisting of healthy whole foods while avoiding the refined foods and sugars will help with most chronic health conditions. In addition, avoiding those foods which act as triggers is also important. Some of the foods which can worsen the symptoms of GERD include spicy foods, citrus fruits and juices, tomatoes and tomato juice, peppermint, fatty meals, sweets, alcohol, breads, carbonated drinks, and caffeinated drinks (22) (23). Keep in mind that this doesn’t mean that all of these foods will worsen the symptoms of everyone with GERD.
Physical activity. Although moderate exercise can exacerbate GERD (24), since it’s common for people with GERD to be overweight, being active is very important. So while you might not be able to engage in moderate cardiovascular exercise, doing some light walking on a daily basis is a good idea, and if you work behind a desk all day then you will want to take frequent breaks.
Yoga and breathing exercises. One study showed that actively training the diaphragm through breathing exercises can improve GERD (25). This was a small study involving only 19 patients with GERD, and so while larger studies need to be conducted, it makes sense to try to do things to improve the health of the diaphragm and LES. Practicing yoga might also help to alleviate GERD by impacting the autonomic nervous system which limits the ability of the gastrointestinal tract to continue peristaltic contractions and prevents appropriate fluid and secretion shifts needed for digestion (26).
Melatonin. Numerous studies show that melatonin can benefit people with GERD by providing protection against GI ulcerations, treating functional dyspepsia, and it has been shown to protect against esophageal injury from acid-pepsin and acid-pepsin-bile exposure (27) (28) (29).
D-Limonene. This is a major constituent in several citrus oils, and because of its ability to neutralize gastric acid and support peristalsis, D-limonene has been used for the relief of heartburn and GERD (30).
Licorice (Glycyrrhiza), Slippery Elm and Zinc Carnosine. Licorice has numerous benefits, and is known for its anti-ulcer properties (31) (32) (33). While it won’t do anything to address the cause of GERD, it can act as a demulcent by protecting the mucosa. Slippery elm also acts as a demulcent and might be beneficial for those with GERD, although I couldn’t find anything in the research that shows this. Zinc carnosine has anti-ulcer properties and may offer mucosal protection and help to repair the gut (34) (35).
Take agents that can increase GABA levels. Since GABA agonists can help with the transient LES relaxation, it might be worth taking some things that can increase GABA levels. L-theanine and valerian root can increase GABA levels (36) (37), or taking a form of GABA such as beta-phenyl-GABA (Phenibut) might also help.
Consider supplementing with betaine HCL. Yes, I admit that this is controversial, but many people actually feel better when taking betaine HCL with meals. However, before doing this it might be a good idea to work with a natural healthcare professional to give you some guidance, help you with the dosing, etc.
Address bacterial overgrowth. If small intestinal bacterial overgrowth (SIBO) is an issue, then this needs to be addressed. I discussed this in an article I wrote entitled “SIBO and Thyroid Health“.
Acupuncture. There is some evidence that acupuncture can help with GERD by inhibiting the intraesophageal acid and bile reflux, which in turn can help with alleviation of the patient’s symptoms (38) (39) (40). So it’s not necessarily addressing the cause of the problem, but it’s still a way of helping to improve the symptoms of GERD without taking medication.
Visceral manipulation. Having a chiropractor or osteopath perform visceral manipulation can help with mild to moderate hiatal hernias, which in turn can help with the symptoms of GERD.
In summary, Gastroesophageal reflux disease (GERD) is common in many people, including those with thyroid and autoimmune thyroid conditions. This involves relaxations of the lower esophageal sphincter that are prolonged and frequent, and certain factors which can affect this include endogenous hormones, medications, and foods. Obesity, poor diet, lack of physical activity, and respiratory diseases can cause the development of GERD. Some of the symptoms associated with this include heartburn, regurgitation, epigastric pain, indigestion, nausea, esophageal spasms, chronic cough, laryngitis, and dental erosions. Eating a healthy diet, being active, and doing mind-body-medicine can benefit people with GERD, and some supplements which may help include melatonin, D-limonene, licorice, and zinc carnosine. Acupuncture and visceral manipulation might also offer some benefits.