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Extinguishing the Flames: Putting Out the Fire of Occasional Heartburn

TABLE OF CONTENTS

1. Introduction: The Upper Digestive Tract and Symptoms of Occasional Heartburn

2. Lifestyle Factors Contributing to Occasional Heartburn

  • 2.1. Stress and Mood Concerns
  • 2.2. Medications
  • 2.3. Excess Weight
  • 2.4. Smoking
  • 2.5. Diet

3. Underlying Causes of Occasional Heartburn

  • 3.1. Low Stomach Acid
  • 3.2. Altered Motility
  • 3.3. Food Sensitivities
  • 3.4. Balance of the Gut Microbiome
  • 3.5. Mast Cell Activation
  • 3.6. H. pylori
  • 3.7. Hiatal Hernia

4. Assessments for Occasional Heartburn

  • 4.1. Betaine HCl Challenge
  • 4.2. Esophagogastroduodenoscopy (EGD)
  • 4.3. Esophageal pH Monitoring
  • 4.4. IgG Food Sensitivity Testing
  • 4.5. Elimination Diet
  • 4.6. 3-Hour Breath Test
  • 4.7. Biopsies with CD117 Staining
  • 4.8. H. pylori Stool Testing
  • 4.9. Barium Swallow

5. Exploring Nutrients to Support Occasional Heartburn‡

  • 5.1. Betaine HCl and Digestive Enzymes
  • 5.2. Deglycyrrhizinated Licorice (DGL), Marshmallow Root & Slippery Elm
  • 5.3. Microbial Balance
  • 5.4. Probiotics
  • 5.5. Ginger Root Extract
  • 5.6. Zinc Carnosine

6. Key Takeaways

  • 6.1. Lifestyle Factors
    • 6.1a. Stress Management
    • 6.1b. Maintaining a Healthy Weight
    • 6.1c. Smoking Cessation
  • 6.2. Diet & Nutrition
    • 6.2a. Avoiding Trigger Foods
    • 6.2b. Low FODMAP
    • 6.2c. Fiber

7. Pure Encapsulations® Nutrient Solutions

  • 7.1. Betaine HCl
  • 7.2. Heartburn Essentials‡
  • 7.3. Digestive Enzymes Ultra
  • 7.4. MicroDefense w/ Oregano
  • 7.5. DGL Plus®
  • 7.6. Probiotic G.I.
  • 7.7. Peptic-Care‡
  • 7.8. MotilPro

8. Conclusion

9. Resources

INTRODUCTION: THE UPPER DIGESTIVE TRACT AND SYMPTOMS OF OCCASIONAL HEARTBURN

The regular movement of food through the digestive tract begins with food traveling from the mouth to the stomach via peristalsis through the esophagus. At the distal end of the esophagus, the lower esophageal sphincter (LES) serves as the anatomical gatekeeper between the esophagus and the fundi, or upper stomach. The LES relaxes after swallowing to allow food to pass into the stomach and then contracts and remains contracted between meals. This way, it prevents food and acid from backing up into the esophagus.

Transient LES relaxation can cause brief episodes of stomach contents refluxing back into the esophagus, which is normal and may resolve without symptoms. LES relaxation, however, can expose the esophagus to gastric acid, digestive enzymes and bile salts, leading to irritation of the esophagus and more bothersome symptoms like occasional heartburn.

Most people are affected by occasional heartburn and can be supported by maintaining a healthy gastrointestinal tract.1

While a burning sensation in the chest and reflux of food and gastric acid into the esophagus are the cardinal symptoms associated with occasional heartburn, patients may also describe accompanying GI and extraintestinal complications, including:

  • Regurgitation
  • Sour stomach
  • Chest tightness
  • Bloating
  • Sensitivity to certain foods and beverages
  • Trouble sleeping
  • Nausea
  • Fullness after eating
  • Hoarseness
  • Cough

Conventional interventions of occasional heartburn involve pharmacological options to suppress, neutralize or buffer stomach acid. Since up to half of patients experience inadequate relief with these options, optimizing lifestyle factors that contribute to occasional heartburn and other underlying causes can be important in improving patient outcomes.2, 3

LIFESTYLE FACTORS CONTRIBUTING TO OCCASIONAL HEARTBURN

STRESS AND MOOD CONCERNS

Patients with occasional heartburn commonly note stress.4, 5 A 2022 meta-analysis of nine observational studies with over one million participants examined the co-occurrence of occasional heartburn and occasional nervous tension or low mood. In studies that used heartburn and accompanying symptoms as outcomes, individuals with occasional nervous tension or low mood had a greater than two-fold increase in occasional heartburn and associated reflux symptoms than healthy controls. What’s more, occasional nervous tension or low mood as outcomes, individuals with heartburn and associated reflux symptoms had a 3.43-fold (95% CI) greater risk of occasional nervous tension and a 2.6-fold (95% CI) greater risk of low mood than healthy controls.6

MEDICATIONS

Certain medications can contribute to or worsen occasional heartburn and accompanying symptoms by irritating the esophagus, lowering LES pressure or delaying gastric emptying,1, 7 including:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Calcium channel blockers
  • Benzodiazepines
  • Asthma medications
  • Tricyclic anti-depressants
  • Anticholinergics
  • Estrogen

EXCESS WEIGHT

Being overweight has been shown to increase the risk of occasional heartburn and accompanying symptoms up to 3-fold3, with a dose-dependent relationship between increasing BMI and frequency of symptoms. 8

SMOKING

Smoking is an independent risk factor for occasional heartburn.9 People who smoke may experience reduced LES pressure, prolonged acid clearance and decreased bicarbonate in their saliva compared to non-smokers.9

DIET

Alcohol: Several observational studies have found a significant association between alcohol consumption and the risk of occasional heartburn,10 observing a dose-response relationship between alcohol consumption and occasional heartburn risk. Individuals who drank more than 3-5 times or days per week had a greater risk of occasional heartburn and associated symptoms. These studies also propose that the hyperosmotic properties of alcohol may contribute to esophageal sensitivity by disrupting the integrity of tight junctions in the esophageal epithelial layer, allowing penetration of gastric acid and stimulation of sensory nerves.10

Food Triggers: Patients experiencing occasional heartburn may describe dietary triggers,1, 7 including:

  • High-fat foods
  • Acidic foods like tomatoes and citrus
  • Chocolate
  • Mint
  • Coffee and caffeine
  • Spicy foods
  • Carbonated beverages

UNDERLYING CAUSES OF OCCASIONAL HEARTBURN

The National Institutes of Health have reports that occasional heartburn and its accompanying symptoms are the most frequent digestive concerns seen at ambulatory care visits.12 Causes of occasional heartburn can be multifactorial and can include existing health conditions as well as contributors like low stomach acid, altered motility, diet and an altered microbiome.

LOW STOMACH ACID

Insufficient stomach acid can inhibit proper digestion and absorption. This can lead to altered motility, altered microbial balance, fermentation by microbes, symptoms of gastric distension and occasional discomfort accompanying occasional heartburn.13, 14 Gastric distension can stimulate LES relaxation and cause stomach contents to wash back into the esophagus.15

ALTERED MOTILITY

Delayed gastric emptying increases the time acidic food remains in the stomach and raises intragastric pressure. Increased intragastric pressure causes a relaxation of the LES, allowing the regurgitation of stomach contents back into the esophagus and contributing to occasional heartburn symptoms. Some patients may also experience altered esophageal motility, resulting in impacted esophageal peristalsis.16

FOOD SENSITIVITIES

IgG-mediated food sensitivities can have a role in Functional GI concerns and trigger occasional heartburn and accompanying symptoms.17 Patients often report that dietary factors bring on their symptoms. Aside from the apparent trigger foods known to promote occasional heartburn, patients may have difficulty isolating other offending foods related to IgG-mediated sensitivity.

BALANCE OF THE GUT MICROBIOME

The gut microbiota and its metabolites can impact the integrity of the intestinal barrier and its secretions, affect the gut-brain axis and contribute to altered motility, promoting the development of occasional heartburn and accompanying symptoms.18 The fermentation of carbohydrates by gut microbiota can produce various gases like hydrogen and methane, contributing to abdominal distension and bloating. the effect of changes in intragastric pressure on the LES, overlapping symptoms seen between those that may accompany occasional heartburn, altered microbial balance and Functional GI concerns should be considered.

MAST CELL ACTIVATION

Mast cells (MCs) are found throughout the gastrointestinal tract and are associated with other Functional GI concerns where altered motility is a factor. Mast cells generate histamine and serotonin, which promote enteric smooth muscle contraction.19 Activation of mast cells and their mediators can lead to irritation of the gastric lining and altered motility, causing symptoms like abdominal pain, upset stomach, bloating and change in bowel habits and occasional heartburn.18

H. PYLORI

Heliobactor pylori is a bacteria that can survive stomach acid and lead to chronic irritation of the gastric lining. However, the discussion on the role of H. pylori in occasional heartburn symptoms is not without controversy. It has been argued that the presence of H. pylori may be protective against occasional heartburn and that its eradication may increase the risk of occasional heartburn and accompanying symptoms.21, 22 Conversely, it has also been argued that treating H. pylori has a beneficial effect on occasional heartburn.23 Although there is no unified consensus on the role of H. pylori and occasional heartburn, a patient’s history, individual response to pharmacological agents used during treatment and the level of irritation in the stomach lining require consideration in a personalized treatment plan.21

HIATAL HERNIA

A hiatal hernia can be present in up to 43% of patients experiencing occasional heartburn, and a linear relationship exists between the size of a hiatal hernia and the severity of a patient’s symptoms.15 The protrusion of the upper stomach into the esophageal hiatus can displace the crural diaphragm from the LES and increase the frequency of transient relaxation of the LES. The size and location of the hiatal hernia may also cause it to act as a basin, trapping gastric acid and impeding esophageal clearance.15

ASSESSMENTS FOR OCCASIONAL HEARTBURN

BETAINE HCl CHALLENGE

Long-term use of acid-suppressing agents and poor diet can lead to reduced hydrochloric acid production. Challenge with Betaine HCl, dosed to tolerance with meals containing protein, can be used when hypochlorhydria is a concern. This assessment method is contraindicated in patients with irritated esophagus, stomach lining or duodenum.

ESOPHAGOGASTRODUODENOSCOPY

An esophagogastroduodenoscopy (EGD), or upper endoscopy, is used to observe the lining of the esophagus, stomach and duodenum to investigate and assess concerns related to occasional heartburn. Biopsies of the esophageal tissue may also be performed.1

ESOPHAGEAL pH MONITORING

Esophageal pH monitoring detects stomach acid in the esophagus. Stomach acid can be detected by a catheter inserted through the nose and into the esophagus or with a capsule placed in the esophagus lining. Patients also wear a monitor that receives information from the catheter or capsule about their diet, sleep and symptoms. Esophageal pH monitoring may also be used to assess the effectiveness of treatment.

IgG FOOD SENSITIVITY TESTING

Because food sensitivities may trigger symptoms that overlap with occasional heartburn and other symptoms associated with Functional GI concerns, IgG Food Sensitivity Testing can assist with making personalized dietary recommendations for patients.

ELIMINATION DIET

In multiple clinical trials where food exclusion diets were implemented based on foods identified as having IgG antibodies with ELISA testing, patients found significant improvement in symptoms that often lead to or accompany occasional heartburn, including abdominal distension, bowel regularity and stress.24, 25, 26

3-HOUR BREATH TEST

Breath tests involving ingestion of a lactulose solution are a noninvasive way to measure exhaled hydrogen and methane gases and are used to determine altered microbiota, which may be an underlying cause for heartburn and related GI symptoms.

The 3-hour profile is a useful tool for those patients who also experience occasional constipation and for pinpointing the possible presence of hydrogen sulfide gas, indicated by a flat line at the 3-hour mark.

BIOPSIES WITH CD117 STAINING

Patients with occasional heartburn may also have dyspeptic symptoms induced by mast cells and their mediators. A jejunal biopsy with CD117 staining can be utilized to determine mast cell numbers and activity in the mucosa of the proximal small intestine.34

H. PYLORI STOOL TESTING

Two different stool tests exist as a noninvasive way to assess the presence of H. pylori. The Stool Antigen Test (SAT) detects proteins related to H. pylori. The PCR test, although more expensive, can detect H. pylori and identify other factors that could impact methods of intervention.

BARIUM SWALLOW

The Barium Swallow is a contrast-enhanced x-ray used to examine aberrations in the esophagus and stomach. It can identify strictures, perforations and motility concerns of the esophagus and identify the presence of a hiatal hernia. These physiological factors and assessments may be indicative of or identify a more serious issue than occasional heartburn alone. Such diagnoses should come from a qualified healthcare professional.

EXPLORING NUTRIENTS TO SUPPORT OCCASIONAL HEARTBURN‡

Betaine HCL & Digestive Enzymes: In addition to being an underlying contributor to occasional heartburn, hypochlorhydria or achlorhydria and reduced digestive enzyme production can lead to malabsorption of nutrients, inadequate digestion, increased risk of food hypersensitivity, bacterial overgrowth and digestive discomfort and bloating.13, 275 In patients where either of these are suspected, Betaine HCl may be used at mealtime to support optimal gastric pH and enhance digestion of protein and other nutrients to support daily wellness and neurotransmitter synthesis.28, 29 The use of digestive enzymes can also support the digestion and absorption of proteins, carbohydrates, fats and fibers not acted upon by the gastric environment.‡

Deglycyrrhizinated Licorice (DGL), Marshmallow Root & Slippery Elm: Deglycyrrhizinated licorice (DGL), marshmallow root and slippery elm bark are demulcent herbs that are traditionally recognized for their value in soothing the gastrointestinal tract and maintaining the integrity of the mucosal lining.30, 31, 32‡

Microbial Balance: With the commonality of symptoms that exist between heartburn and microbiota imbalance in the GI tract, employing strategies to mitigate growth of non-beneficial bacteria may be warranted in some patients. Botanicals like artemisia, olive leaf extract, oregano, clove and berberine sulfate can help promote healthy microbial balance33, 34, 35, 36, 37‡

Probiotics: Probiotics are believed to support healthy gut-associated lymphoid tissue (GALT) composition and support barrier function, G.I. epithelial cell health and T cell function within the G.I. tract.38 Some probiotic strains may also modulate local production of cytokines and other immune mediators in the G.I. epithelium.39‡

Ginger Root Extract: Ginger helps to stimulate digestive enzymes and the production and secretion of bile from the liver and gallbladder.40 More recent evidence shows that ginger’s volatile oil components (gingerols and shogaols) modulate intestinal serotonin receptors that regulate motility and secretions.41 Ginger also maintains healthy eicosanoid balance in the GI tract, joints and the cardiovascular system.42, 43‡

Zinc Carnosine: Zinc and carnosine provide synergistic antioxidant protection, support the stomach’s mucosal defenses, buffer gastric acid and maintain healthy cytokine release.44 Studies suggest that this combination is more effective in maintaining the integrity of the gastric lining than either ingredient alone.45‡

KEY TAKEAWAYS

LIFESTYLE FACTORS

Stress Management: Stress is the most common lifestyle factor described by patients with occasional heartburn.4, 46 In a post-hoc analysis of over 12,000 patients from the LEGEND study, addressing lifestyle factors that contributed to stress had a significant effect on patient’s heartburn and accompanying symptoms.4 Patients who receive advice on stress management techniques have reported improvement in GI symptoms and quality of life.47

Maintaining a Healthy Weight: Excess weight, particularly in the midsection, increases the gastroesophageal pressure gradient.48 The higher intragastric pressure correlates to lower LES pressure and increased frequency of transient relaxation of the LES.14 Encouraging patients to make lifestyle changes to initiate weight loss of 10-15 lbs. can be a successful strategy to reduce occasional heartburn.8

Smoking Cessation: A prospective study by Kohata et al. examined the long-term effects of smoking cessation on heartburn and accompanying symptoms and health-related quality of life in 191 patients. Those patients who successfully achieved smoking cessation (n=141) experienced a significant (43.9%) improvement in symptoms compared to those who were unsuccessful at quitting smoking (n=50, 18.2%). Significant improvement in health-related quality of life was only seen in the success group.9

DIET & NUTRITION

There are multiple dietary approaches that can be explored for individuals with occasional heartburn. In addition to providing education about foods that can relax the LES, the practitioner should also consider a patient’s possible food sensitivities and dietary patterns, as some patients may benefit from trial elimination of difficult-to-digest carbohydrates.

Avoiding Trigger Foods: First-line treatment of occasional heartburn often involves avoidance of foods that commonly trigger occasional heartburn. Advising patients to eat smaller meals and to avoid eating too close to bedtime may also be supportive.

Low FODMAP Diet: FODMAP stands for Fermentable, Oligo-Di and Mono-saccharides and Polyhydric Alcohols. FODMAPS encompass foods that can interact with gut microbiota, and through fermentation can provoke symptoms of GI discomfort often seen with occasional heartburn.
In a small, randomized crossover study, patients with occasional heartburn and Functional GI concerns were provided either a high FODMAP meal or a low FODMAP meal for breakfast and lunch to evaluate the effects of each meal on postprandial transient relaxation of the LES, intestinal gas production and occasional heartburn and accompanying GI symptoms. The results indicated that the high FODMAP meal induced a higher frequency of transient LES relaxation, greater heartburn and higher upper GI symptom scores than the low FODMAP meals.49

Fiber: Contrary to a Low FODMAP diet, a cross-sectional study of nearly 4000 adults found that those individuals with the highest intake of fruits and vegetables had a 33% lower risk of occasional heartburn.50
Low dietary fiber intake has been associated with altered motility, delayed gastric emptying and increased intragastric pressure.51 In some patients, a fiber-rich diet may support an increase in LES pressure and decrease frequency of occasional heartburn.50
Just as multiple mechanisms can contribute to heartburn and accompanying GI symptoms, multiple factors can contribute to an individual’s response to different foods, illuminating the merits of individualized dietary advice and nutrient support for patients.

PURE ENCAPSULATIONS® NUTRIENT SOLUTIONS

While there is some value in pharmacological agents to counter acid production, patients can develop a reliance on them, leaving underlying causes of occasional heartburn unaddressed. Long-term acid suppression can also affect a patient’s absorption of multiple micronutrients including B12, calcium, iron and magnesium.52

Pure Encapsulations has products to help you provide individualized dietary supplement recommendations to attend to your patients’ nutrient needs and extinguish the flames of occasional heartburn, by supporting their gastric function, promoting motility and microbial balance, maintaining the mucosa, and soothing irritation.‡

Certain medications may be appropriate and should be used under the recommendation of healthcare professional for managing chronic, long-term, and/or more serious cases of acid reflux and heartburn. Dietary supplements are not intended to replace the use of such medications.

However, if looking for a way to potentially manage occasional and/or minor heartburn, the following supplement recommendations may be appropriate for you, along with other dietary and lifestyle changes.

DIGESTION/DIGESTIVE ENZYME SUPPORT

  • Betaine HClcontains betaine HCl and pepsin to supports healthy gastric function and promote absorption of protein, vitamin B12, and calcium.‡ Suggested use: 1 capsule, 3 times daily, with each meal.
  • Digestive Enzymes Ultra contains an extensive profile of vegetarian digestive enzymes to support protein, carbohydrate, fat, fiber, and dairy digestion and promote enhanced nutrient bioavailability and absorption.‡ Suggested use: 2 capsules with each meal.

MUCOSAL SUPPORT

  • Heartburn Essentials‡ contains a unique blend of Gamma oryzanol, deglycyrrhizinated licorice extract, marshmallow root extract, slippery elm extract, artichoke extract, turmeric extract along with amylase, lipase and cellulase to support comfort and relief from occasional heartburn, and occasional gas and bloating, promote healthy gastric secretion and support the integrity of the mucosal lining.‡ Suggested use: 1 capsule at the start of each meal.
  • DGL Plus® contains a synergistic combination of deglycyrrhizinated licorice extract, aloe vera extract, slippery elm and marshmallow root extract to help stimulate the quality and production of stomach mucus, provide nutritional support to the gastrointestinal tract and support the body’s natural defense mechanisms.‡ Suggested use: 1 capsule daily before a meal.
  • Peptic-Care‡ contains a patented 1:1 chelate of zinc and l-carnosine provides synergistic G.I. mucosal protection, and supports the stomach’s mucosal defenses, buffers gastric acid, maintains healthy cytokine release and provides antioxidant support for the GI tract.‡ Suggested use: 1 capsule, 1-2 times daily, with meals.

MICROBIAL BALANCE

  • MicroDefense w/ Oregano is comprised of a combination of olive leaf, artemisia and clove extracts to promotes healthy gastrointestinal tract function and microbial balance‡ and supports immune function and respiratory tract balance.‡ Suggested use: 1 capsule, 1-3 times daily, just before a meal, with 6-8 oz water for 2-3 months.

PROBIOTICS/PREBIOTICS

  • Probiotic G.I. provides 10 billion CFU per capsule of the beneficial bacteria Lactobacillus acidophilus, Lactobacillus salivarius, Lactobacillus casei, Bifidobacterium bifidum, Bifidobacterium lactis and Streptococcus thermophilus to promote healthy immune balance within the G.I. tract and help maintain the integrity of the intestinal mucosa.‡ Suggested use: 1 capsule, 1-2 times daily, with or between meals.

MOTILITY

  • MotilPro contains ginger extract, 5 hydroxytryptophan, pyridoxal-5 phosphate, and acetyl-l carnitine that provide support for gastrointestinal motility, GI comfort and stimulation of gut-signaling neurons.‡ Suggested use: 2 capsules, 1-2 times daily, between meals.

CONCLUSION

Diet and lifestyle play significant roles in gastrointestinal health. Addressing occasional heartburn requires a comprehensive approach to not just alleviate symptoms but to also investigate underlying causes, assess the patient’s nutrient needs and support their digestive function.

With Pure Encapsulations, you have the promise of premium-sourced ingredients backed by verifiable science, so you can be confident you are recommending products with quality, purity and potency to meet your patients’ needs.

RESOURCES

Heartburn Support Protocol: This protocol offers focused interventions to support gastrointestinal health in patients with occasional heartburn.

Drug-Nutrient Interactions Checker: Offers scientifically supported, clinically relevant information that’s easy to understand with product suggestions based on verifiable science.

You can also explore Pure Encapsulations® to find On-Demand Learning, Clinical Protocols and other resources developed with our medical and scientific advisors.

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