Research & Education

Low-Carb Diets & GERD – Counterintuitive or Cutting Edge?

If television commercials for prescription and over-the-counter antacids are any indication, acid reflux has reached epidemic proportions.  Stomach acid has launched an all-out attack on people’s digestion and quality of life, inching its way up into the esophagus and causing the pain and irritation most people know simply as “heartburn.”  For those who suffer from acid reflux, finding a natural remedy would be most welcome, because reflux can turn eating—something that should be one of life’s simple pleasures and joys—into a painful experience they dread.  Evidence indicates that cutting carbs may be a simple strategy to provide quick relief from acid reflux and GERD.

Conventional Advice for GERD & Acid Reflux

Common recommendations provided for those with acid reflux include:

  • Remaining upright after eating: For individuals whose GERD is due to a weakened lower esophageal sphincter (LES), letting gravity do its job may help reduce the likelihood of food traveling up into the esophagus.  This means standing or sitting upright after a meal rather than lying down or reclining.
  • Eating smaller meals: Smaller meals mean less food in the stomach, and therefore, potentially less likelihood for upward pressure on the LES leading to reflux.
  • Avoiding acidic, spicy, and fatty foods: By themselves, these foods may not cause reflux, but when the LES is weakened, acidic and spicy foods may be more irritating to the esophagus, which is not protected by a layer of mucus in the way the stomach is.  Individuals with GERD are typically cautioned to stay away from coffee, carbonated beverages, tomatoes and tomato sauces, lemon and other citrus fruits, hot peppers, garlic, onions, vinegar, and other acidic foods.  Chocolate and peppermint may also exacerbate GERD in some people.
  • Losing weight if overweight or obese: A larger concentration of body mass in the abdominal area may increase pressure on the LES, potentially resulting in acid reflux. 

But what if someone has already tried all the above, to no avail?  Are they destined to take antacid medications for the rest of their life—drugs that, owing to their deliberate impairment of healthy digestion—increase risk for chronic kidney disease, iron deficiency, low magnesium, bone fractures, B12 deficiency, and even dementiaPeople assume these drugs are safe to take for the long term, as they often assume all they’re doing is reducing their stomach acid.  They may have no idea the consequences of extended use can be so dire. 

Low Carb Diets for Acid Reflux & GERD

    It may sound counterintuitive at first that a low carb diet might be beneficial for acid reflux.  Since conventional medical advice recommends avoiding fatty foods, a high-fat diet would be contraindicated for individuals with acid reflux or GERD.  Additionally, some of the foods people frequently enjoy on low carb diets are cautioned against in traditional advice for reflux, such as the aforementioned coffee, dark chocolate, tomato sauces, garlic and onions.  According to this traditional advice, the popular trend of putting butter and coconut oil in a cup of coffee or tea would be the worst thing someone with reflux could do!

On low carb blogs and forums, anecdotes abound from people who report complete resolution of GERD after ditching carbs.  Fortunately for the skeptics, there’s also a solid body of scientific research corroborating these “N of one” experiments.  However mysterious or illogical it may seem, low-carb diets have proven very effective for relieving GERD and acid reflux.

One study reported on five patients who self-initiated low carb diets and had resolution of GERD.  Three of them eliminated coffee, and all of them eliminated acidic foods, but the researchers did not attribute the effects to this.  They noted that “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.”  So maybe coffee and an omelet would be fine for someone with GERD, but that same coffee with a donut or scone could spell esophageal disaster.

Another study added weight to the possibility that carbohydrates are, at least for some people, a trigger for GERD.  In a small cohort of adults with GERD, compared to a liquid meal containing 85 grams of carbohydrate, a liquid meal of the same volume but containing about 180 grams of carbohydrate resulted in greater total time experiencing reflux and a greater number of reflux episodes lasting more than 5 minutes. No knowledgeable nutritionist would recommend a liquid meal of 85 grams of carbs, but this study wasn’t intended to investigate low carb diets.  It was designed to evaluate “the effect of different carbohydrate density on low esophageal acid and reflux symptoms,” and it certainly did just that: the high-carbohydrate meal aggravated GERD more than the lower-carbohydrate meal. 

A more formal study that did evaluate the effects of a low carb diet confirmed the power of carbohydrate restriction: A small group of obese subjects with GERD began a very low carb diet after undergoing a 24-hour esophageal pH probe test to assess the acidity of their stomachs.  Within just six days, subjects had dramatic improvements in GERD. In the Johnson-DeMeester score, used to measure esophageal acid exposure, a score > 14.72 indicates reflux.  At baseline, subjects’ mean score was a whopping 34.7.  This dropped to 14.0 after just six days on the low carb diet, and subjects reported significant improvements in symptoms such as heartburn, pressure or discomfort inside the chest, a sour taste in the mouth, frequent gurgling in the stomach, nausea, a feeling of pressure or a burning sensation in the throat, belching, flatulence, and more.  This study on the effects of a low carb diet on acid reflux is especially telling, because not only did the subjects report subjective improvements in their own symptoms, but the reduced esophageal acidity was confirmed by direct measurement.  They cut carbs, and acid refluxing into the esophagus was reduced by more than half in less than a week.

In the most impressive study performed so far, in a cohort of obese women, after just 10 weeks on a low-carb diet, in all subjects with a confirmed GERD diagnosis, “all GERD symptoms and medication usage had resolved in all women.”  Within just 10 weeks, all subjects with GERD had complete resolution of symptoms, including women who’d experienced symptoms twice daily or as often as 5 times per week.  All medication, both prescription and over-the-counter, was discontinued.

The authors noted, “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.

Ameliorating GERD and acid reflux may have less to do with what patients consume—antacids—and more to do with what they don’t consume: large amounts of sugar and starch.  Those who have followed conventional advice for improving or preventing acid reflux but have failed to experience any relief might do well to trial a low carb diet.  Sure, they might have to give up some of their favorite foods, but that’s a small price to pay for also giving up heartburn, pain, and dependence on potentially harmful antacid medications.

By Amy Berger, MS, CNS