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Carbohydrate Restriction & GERD

iStock-1334047332Patients who suffer from acid reflux are often told to avoid potentially triggering or irritating foods and beverages, such as coffee, tomato sauces, spicy and acidic foods. But what if a different approach were effective—one that didn’t require people to eliminate some of their favorite foods? Interesting research suggests low-carb diets can help prevent reflux, to the point where some people can discontinue antacid medications and remain free of heartburn.

Restricting dietary carbohydrate is increasingly recognized as a go-to intervention for type 2 diabetes, metabolic syndrome, and obesity. But evidence is mounting that a low-carb approach may have perhaps “unexpected” beneficial effects for numerous other issues, including gastroesophageal reflux disease (GERD).

On the surface, it may seem counterintuitive that a low-carb diet could be beneficial for acid reflux. Conventional recommendations for reducing reflux often call for avoiding high-fat or “greasy” foods, such as bacon and other fatty meats. And while coffee concoctions loaded with butter or MCT oil aren’t a required part of a low-carb diet, they’ve become pretty popular, and combining acidic coffee with high-fat items seems to completely contradict the standard advice. But it’s important to know that low-carb or ketogenic diets aren’t about loading up on fats and oils; they’re about keeping the carbs very low. And clinical trials have shown that when people follow this advice, acid reflux improves.

One case series reported on five patients who experienced resolution of GERD after initiating low-carb diets. The results are confounded by the fact that three subjects did eliminate coffee and all five reduced intake of acidic foods. However, the researchers speculated that there may be more going on than the reduction of potentially irritating substances: “…carbohydrates may be a precipitating factor for GERD symptoms and that other classic exacerbating foods such as coffee and fat may be less pertinent when a low-carbohydrate diet is followed.”

Research conducted more recently and with a greater number of subjects corroborates the finding that carbohydrate restriction may be beneficial for GERD. In one such study, a small group of subjects with obesity and GERD had their stomach acidity measured (via 24-hour esophageal pH probe test) at baseline, prior to starting a low-carb diet. In less than a week, the subjects reported striking improvements in heartburn, nausea, stomach gurgling, sour taste in the mouth, pressure or discomfort in the chest, belching, and more. A key factor about these findings is that they go beyond subjects’ self-reported symptoms and include objective measurements in the form of the Johnson-DeMeester score, used to quantify a patient’s acid exposure. At baseline, subjects’ mean score was 34.7—more than double the cutoff point that’s considered “abnormal” (14.7). The mean score dropped to 14.0 after only six days on a low-carb diet. Additionally, the percentage of time subjects experienced with pH less than 4 in the distal esophagus decreased from 5.1% to 2.5%—reduced by half in less than a week.

The most impressive findings related to the effect of a low-carb diet on GERD come from a study of 144 women with obesity and GERD. All medication, both prescription and over-the-counter, was discontinued within only ten weeks. All subjects experienced complete resolution of GERD symptoms, including those who’d suffered symptoms as often as 5 times per week. The study’s conclusion stated:

“Contrary to long-held belief that higher fat intake promotes GERD symptoms; nationally representative data do not show a strong association between dietary fat and GERD. Thus, the present study provides important insights that contribute to the accumulating evidence of a role for dietary simple carbohydrates in GERD pathophysiology. We found that simple carbohydrates, particularly sucrose, contribute to GERD in obese women and the likelihood of having GERD was predicted by simple carbohydrate (total sugars) intake.”

This study is notable because it was not explicitly a ketogenic diet. The study cited earlier called for a “very low-carbohydrate diet,” defined as a daily carb intake of less than 20 grams, and ketosis was verified by urine dipstick testing. Participants were allowed to consume unlimited portions of meat and eggs, plus limited amounts of hard cheeses and select low-carbohydrate vegetables. In the latter study, carbohydrate intake was substantially reduced, but not to levels that likely would have induced nutritional ketosis. Data indicate subjects were still deriving over 20 percent of their daily calories from carbohydrate, with guidance for that to be half complex and half simple carbohydrates. So it seems that a strict ketogenic diet—which may be difficult for some people to adhere to—may not be required to make GERD symptoms a thing of the past, but of course individual patient responses will vary.

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