GERD: Treat it with a low- or high-carb diet

GERD, gastroesophageal reflux disease, can be a miserable disorder causing its victims an array of symptoms ranging from the mildly uncomfortable to absolute torture. Also known as acid reflux and heartburn, GERD can make those who have it fear going to bed at night because lying down typically worsens the symptoms, which can be anything from slight chest discomfort to wracking pain and a throat full of acid. It doesn’t stop at just mercilessly tormenting its sufferers; GERD can, and often does, cause cellular damage potentially leading to the virulently malignant esophageal cancer.

GERD: What is it?

GERD is the collection of symptoms occurring when stomach acid gets into the esophagus where it doesn’t belong. The esophagus is the muscular tube through which food travels to the stomach after swallowing. At the lower end of the esophagus there is a muscular one-way valve or sphincter, called, logically enough, the lower-esophageal sphincter (LES). The LES functions to allow food to pass into the stomach, while at the same time preventing the caustic contents of the stomach from backwashing into the esophagus.

LESAlthough the stomach and the esophagus are connected, they are entirely different organs with different cellular linings. The stomach is lined with acid-producing cells (as well as cells releasing other gastric juices) and with cells producing protective mucus to prevent damage to the stomach from its own acid. The esophagus is lined with cells similar to those lining the inside of the mouth. Stomach acid doesn’t hurt the stomach because of the thick mucus present, but a splash of stomach acid in the esophagus is about the same as a splash of strong acid in the mouth. It burns the lining of the esophagus just like it would burn the lining of the mouth. The only difference is the lining of the esophagus doesn’t contain many nerve fibers whereas the lining of the mouth has an abundance. So acid in the mouth would create intense pain while an equivalent amount of acid in the esophagus registers as a dull discomfort. Both, however, cause the same type and amount of cellular damage. Many GERD sufferers reflux enough acid to make it all the way up through their esophaguses and into their throats and mouths. They can attest to how much it burns.

But symptoms aren’t always that bad. In early or mild cases, symptoms of GERD may not even be recognized as such. GERD can present as simply a mild morning cough that fades as the day progresses or as a slight sore throat that goes away once you’re up and about. These minor symptoms are caused by a small amount of stomach acid reaching the throat and causing irritation.

Severe or mild, the symptoms of GERD indicate something is going on that needs to be addressed.

GERD: What causes it?

Strangely enough, no one really knows 100 percent for sure though theories abound. I have my own ideas based on a reasonable interpretation of what I’ve seen over my many years of practice.

Although more and more youngsters are being diagnosed with GERD (see below for why I believe this is happening), the disorder is mainly one of aging. My guess is that the muscles of the LES – like all muscles – become weaker with age. A weaker LES is less able to hold back the pressure of gases coming from the stomach and below, and so allows some of the stomach contents to pass through into the esophagus. But findings from many of my own patients persuaded me that there has to be more going on than a simple age-related laxity of the LES.

Over my many years of using a low-carb diet to treat patients with various disorders, I noticed that almost all who happened to have GERD found their symptoms resolved. I never started out treating GERD with a low-carb diet, but the huge numbers of patients finding relief told me that somehow carb restriction was helping. They would ask why their GERD went away, and I would have to confess that I didn’t really know. I thought and thought about a possible biochemical or physiological mechanism that would explain why a low-carb diet almost always got rid of GERD, but I could never come up with a reasonable explanation. So, I just told patients who had GERD that if they ate low-carb, their GERD would probably go away. But I also told them I didn’t know why.

Then a few years ago I ran into a microbiologist named Norm Robillard who had a theory on the cause of GERD that explained the results I had been seeing and made perfect physiological sense.

The most probable cause of GERD.

As everyone knows, enormous numbers of bacteria grow in the colon. But what many people don’t know is that bacteria also grow in the small bowel as well. The lower end of the small bowel closest to the colon has the most growth, but bacteria are found throughout. Bacteria in the small bowel dine on the contents of the small bowel; the farther the food goes down the bowel during the digestive process, the more bacteria there are to nourish. The types and amounts of bacteria in the small bowel are a function of the foods coming down the pipeline. If fat and protein are the main foods, fewer bacteria grow, and those that do grow don’t produce much gas. Carbohydrates, however, provide food for rapidly multiplying bacteria that actually ferment the carbs, and the fermentation process produces a lot of gas. If there is an overgrowth of the carb-loving bacteria in the small bowel – a condition called small intestinal bacterial overgrowth (SIBO) – then a substantial amount of gas is released into the bowel. As more bacteria multiply and more gas is released, the pressure inside the bowel increases. The increased pressure then can force the gas, along with the acidic stomach contents upstream, through the lax LES and into the esophagus. And then you experience the symptoms of GERD.

Once I understood this process, it all made perfect sense to me. I realized immediately why a low-carb diet got rid of GERD. Few carbs means few bacteria. And few bacteria with little to ferment means minimal gas. The LES can hold firm against what little gas there might be, and so no stomach acid gets into the esophagus. And the symptoms of GERD vanish.

This SIBO mechanism also explains another phenomenon I’ve had described to me by many patients. A patient suffers with GERD, goes on a low-carb diet, and gets complete relief. The patient stays on the low-carb diet for months and has no symptoms of GERD. Then the patient has a carb blow out, but has no GERD. Eats some more carbs, still no GERD. Consumes more carbs, then, wham, the GERD is back. What happened?

It takes a while for carb-loving bacteria to recolonize the small bowel once the carbs enter the diet again and a plentiful bacterial food supply returns. Until the bacteria reach a critical mass, at which point they are producing enough gas to push through the LES, there won’t be symptoms. But once they do, GERD returns in full force.

After I thought about this theory for a bit, it occurred to me that if the bacteria were fermenting the carbs causing the gas that drove GERD, then GERD-wise, complex carbs should be much worse than simple carbs such as sugar. Why? Because simple sugars are absorbed through the wall of the gut rapidly whereas complex carbs take longer to digest, leaving them around to ferment. Complex carbs, especially those with a low glycemic index, digest more slowly and prevent rapid rises in blood sugar, whereas simple sugars do just the opposite. But these same slowly digesting complex carbs would – or so it seemed to me – provide more of a substrate for the growth of bacteria than simple sugars that didn’t hang around long enough.

I brought this up to Dr. Robillard, who thought it sounded reasonable. He set to work analyzing the different types of carbs and their relation to the development of GERD, and, sure enough, it turns out that complex carbs and fibers are actually much more problematic for GERD and even for IBS (Irritable Bowel Syndrome, another gastrointestinal malady, which is also driven by SIBO).

After evaluating countless types of carbohydrate and fibrous foods, Dr. Robillard derived a factor he’s termed the Fermentation Potential (FP), which is a measure of the amount of carb and/or fiber in a given food providing fare for gas-producing bacteria.

Knowing the FP of various foods allows one to avoid those with a higher FP, which should reduce SIBO and symptoms of GERD and/or IBS. But it’s not as straightforward is it might seem. For instance, certain kinds of white rice (Jasmine rice) are quickly absorbed and don’t result in much fermentation, whereas other types of white rice (Uncle Ben’s) do ferment and worsen GERD. Same with potatoes – different types create more or less fermentation. By knowing the FP, you can continue to eat rice, potatoes and many other high-carb foods yet reduce of eliminate the symptoms of GERD. You can find more information about Dr. Robillard’s work on GERD and IBS in his books Fast Tract Digestion: Heartburn and Fast Tract Digestion: IBS, both of which contain pages of tables showing the FP of numerous foods.

Getting rid of most carbs in the diet solves the problem without having to make carb choices, which is why the low-carb diet works so uniformly well. But if you don’t want or don’t need to go on a low-carb diet, yet have GERD and want to get rid of it, following a diet lower in complex carbs, eschewing especially those with the greatest FP, may be your ticket.

So, paradoxically, simple sugars, the villains as far as rapidly increasing blood sugar, insulin resistance and hyperinsulinemia are concerned are actually not particularly problematic as promoters of GERD. But the complex carbs and fiber, considered by most to be much more healthful, are the real culprits in SIBO and consequently GERD and IBS.

Which is probably the reason the incidence of youngsters developing GERD is on the rise.

When I was a kid, we all ate sugar and other highly refined carbs. And although I’m sure we ate them, we had never heard the term complex carbohydrate. Today, though there is still plenty of sugar in most kids’ diets, there is a major push for increased complex carbs and fiber, all of which provide sustenance for gas producing bacteria in the small bowel. And probably a lot of kids with GERD.

Don’t get me wrong. This isn’t a post telling you to eat sugar or prescribing sugar for your kids. I am simply explaining an extremely likely mechanism for the increase in GERD we’re now seeing in all age groups including children.

But, strangely, this post didn’t really start out to be a post about GERD, it just ended up that way. It was intended to be a post about how screwed up mainstream medicine is and why, even though I am a doctor and went through a mainstream medical education, I have real trouble believing my colleagues. It all started with a video I saw about the treatment for GERD, which launched me off on an explanation of GERD.

Since you now know all about GERD, in the next post, I’ll show how screwed up mainstream medicine can be.

Photo of LES: Johns Hopkins

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157 thoughts on “GERD: Treat it with a low- or high-carb diet

  1. WooHoo! So nice to see a blog post from you. It’s been a while.

    I didn’t realize how completely my GERD disappeared on a low carb diet until you wrote that post about Norm Robillard’s book. It is an eye-opener.

    I’m also curious to learn about low carb diets in the realm of nerve diseases such as MS, ALS, etc (so many). I seem to be bumping into more and more people with these diseases and can’t help but think that all the years of ‘low fat everything’ hasn’t given the neuron axons what they need (sat fat) for the myelin sheath. Thoughts?

    • It’s nice to be missed.

      I agree with you about the myelination issues; I just don’t have any hard evidence to support my opinion. That’s not to say there isn’t any evidence out there, I just don’t have it. Maybe others will.

  2. This is brilliant and helps explain why I am more comfortable with sweeter carbs like sweet potato, roots, or even some fruit, whereas very starchy foods like taro or potato aren’t always so great.
    I have an additional theory to suggest; some foods produce more osmotic stress, because they contain more small molecules; sweets, very salty foods, vitamin supplements, some starches, food additives, for example. This irritates the stomach and esophagus; whereas protein and fat have low potential for osmotic stress, but need more stomach acid before they are digested.
    Combine these 2 sorts of food, and high acidity is present at the same time as osmotic stress. Separating carbs from fatty meat (if you do eat much carbs) is a suggestion that seems to work for some people.

    • I had really painful GERD – chest/neck pain and heart palpitations. I found relief only after separating my food as you suggested. If I eat bread, I eat it with veggies only, or meat with veggies only, but never mix the two.

      • Gina, I too had many episodes of terrible pain in my chest, throat and chin at times which were distressing. I know it’s related to carbohydrate intake as my symptoms almost disappeared after considerably reducing carbs in January only to have them return recently after a lasagne meal – cooked by my very special grandson and enjoyed till later when the discomfort returned!
        Until I read your comment I had forgotten that I actually started the low carbs with a separation of carbs (bread if eaten and/or red skinned potatoes which is the only potato I eat now if I have any) from protein. This, I believe helped enormously but over the last two months I realize that separation crept away somewhat which was what brought back the symptoms.
        Thank you for reminding me of how good it was to have no GERD problem for 6-8 months!!! I will be more vigilant in future.
        Michael, this is a great blog – wish there were more of them though!

  3. I think another factor is that the small intestine is
    smart enough to slow the absorption of glucose when
    whole-body glucose disposal is sluggish, so it might not
    be just a matter of complex versus simple carbs, but also
    a matter of insulin sensitivity and glycogen requirement.

  4. This approach is problematic from evolutionary perspective: complex carbs were the rule rather then exception. Sugar which was mostly available as honey (and more regularly probably after invention of fire) and carob AFAIK. It looks like there must be some other mechanisms present.

    I suggest that the missing factor is that complex carbs were coming down with base forming chemicals (greens are rising pH level). Today, due to modern agriculture industrial techniques, the level of minerals is many times lower then in paleolithic times (some estimates being from 2 – 80 times) and many people do not eat them, particularly young. Wild plants also contain numerous toxins which probably served as natural antibiotics thus there was most definitely double effect present: pro-basic stomach environment with natural antibiotics; this would reduce the amount of acid and kill eventual microbes which would have higher possibility to thrive due to the absence of full blown acid barrier.

    Older people are following mainstream dietary advice far more then youngsters and are probably salt cautious so GERD should be offset by shifting the status of stomach acid production to achloridia (one also needs to account PPIs and friends, typically used by such population, and some think that aging influence acid production negatively although AFAIK this has not be sufficiently proved). Because of this and all above said, GERD diagnoses should rise far more in youngsters then in older, in my opinion.

    On the related note, some types of hemorrhoids (external) also depend on the strength of anal sphincter so the similar story should hold in that case (which my personal experience confirms so far).

    • Human and pre-human diets were typically carb-poor until agriculture. The climate (many dry ice ages), isotope studies, and expensive tissue hypothesis all point to this. Even honey, if unprocessed, is rich in protein and fat because of the bee larvae present.

    • majkinetor,

      I’m a bit confused by a couple of things you said. What does your comment “greens are rising pH level” mean? Is it that green, leafy matter is more acidic or more alkaline?

      If more older people than young follow mainstream dietary advice, then why do you expect more GERD diagnoses in youngsters than in the elderly?

    • Or, human beings simply did not eat as much plant matter in prehistoric times as long as they had the ability to follow the herds and didn’t have to settle down. Modern people don’t seem to want to accept this idea–they’re convinced “cavemen” had to be salad-eaters year-round. But we’re going to have to accept that people ate meat then and that, for that matter, plant availability was seasonal. Even in the equatorial region in which we originally evolved, you didn’t have the same plant foods available in the same amounts year-round. All plants have growth stages and life cycles.

      But even when people settled down, how do we know they never suffered from GERD? We know from paleopathology that they suffered more disease than their forager counterparts, and not all of it was infectious. Those of us with any background in herbalism whatsoever also know that one of the traditional uses of certain herbs is to reduce gas. Human beings are a pragmatic bunch, at our best; we wouldn’t have noticed that plants we ate reduced gas if we didn’t have gas to reduce. So… for what it’s worth.

  5. Yes, great to have an update from you – looking forward to your next update about mainstream medicine.

    I have learned a little about GERD – the most important, beside how a low carb diet helps, has been that omeprazole (losec) is addictive. You try to stop taking it but your symptoms get worse so of course you think you need the pills. I finally weaned myself off them by taking Zantac (Ranitidine) as needed. Now, as long as I keep to low carb foods and don’t eat too much heavy cream, I am free from reflux.

    So many people must be caught up in the high carb/losec cycle thinking, as I did, that there was nothing that could be done.

  6. Summed up nicely. I, too, could quit prilosec OTC within days of starting Atkins and the problem only came back with wheat (most rapid agent) and still with others like corn or rice in high-enough quantities. It did seem that not all carbs were equal in this regard, which correlates nicely with Dr. Robilliard’s FP theory.

  7. I eat low carb, but am still troubled by GERD symptoms, Sometimes. I wonder if I’ve eaten too much. Sometimes I notice it after high fat, (cocoanut oil and fermented codliver oil).
    I especially notice it if I’ve gone to water exercise. I think then it’s the water pressure on my body.

  8. Well hello! So nice to hear from you again, you have been sorely missed.
    I took care of my GERD with a combo of very low carb diet (less than 28 gm/day), high fat and protein and daily small amounts of home-made yogurt (which is full fat and tastes a thousand times better than the garbage they sell in the stores). You started me on this over nine years ago and, boy, has it paid dividends.
    Thanks for showing up again!

  9. KarenJ: The sheathing on your nerves is a fatty cholesterol-type substance. MS is fundamentally the loss of this sheathing. “Nerve-dead” areas are a known side effect of cholesterol-lowering drugs, which are among the most-prescribed drugs today. If you ‘lower’ your cholesterol via drugs, what happens to the sheathing on your nerves??

  10. I Said goodbye to GERD after adopting the low carb lifestyle.

    I agree with Jeanne Shepard. I noticed a return after very high fat moment. (I added a very large amount of heavy cream to some berries and experienced indigestion . I viewed it as a “one off” as the portion was really larger than normal.)

    Thanks for the post Mike.

    • In your situation I would try again with another kind of fat, not dairy fat, and see if I got the same result. You could just have a dairy sensitivity. It happens.

  11. Every trace of heartburn vanished when I began the Protein Power diet. The logical conclusion is that heartburn is a sign that one is eating the wrong foods. I met a doctor who, unknown to me, treats GERD. I made the faux pas of suggesting that GERD is not a “real disease” but merely your body telling you that you’re eating wrong. Wow did he get defensive. He flew off the handle and chastised me for my tomfoolery. I really pressed his hot button. I guess I was wrong using the term “real disease” but we know the truth about the cause and the remedy now, don’t we?

  12. Good to see a new post!
    My son had gerd so bad he was sent twice to ER with what he thought was heart attack. Was told by VA doc (!) to read Wheatbelly. Getting off gluten, going low carb cured him. I was so impressed I eliminated the low carb wheat prodcts I was using, like GG crackers, and stopped forty years of horrible migraine headaches. It seemed miraculous!

  13. This sounds similar to the FODMAP diet (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols).

    To the commenters having issues with large amounts of heavy cream, it could be the lactose and/or carageenan gum.

    • There isn’t a lot of lactose in cream, and it’s possible to get cream that doesn’t have any gums in it. I have found a source local to me in central Ohio. (For those who live here and have probably been living under a rock, it’s Snowville brand.)

  14. Funny, I was just thinking yesterday that you never post any more, and hoping you don’t take your website down. You need to post more often just so half the comments aren’t about how happy readers are that you posted something! I’m always ready for a good discussion of mainstream medicine incompetency, so I hope you have part two on its way soon.

    I’ve been plagued with reflux in the throat for a while; in my case it has seemed that a low-carb diet isn’t quite a match to counter all the effects of aging and menopause, even with bio-identical hormone replacement, but I have experienced noticeable improvement since my integrative medicine doctor had me start taking a pro-biotic. I assume it resolved some intestinal flora issues. Just something to consider as an additional support for those suffering from reflux.

  15. Here is more cheers at having you back on the blogging trail. I noticed that your launch of the Sous Vide took much of your time. Now that I have finally acquired that marvelous kitchen magic kettle I hope we may be able to hear from you more often.

    If I have it then most of the world has already beaten a path to your door.

    Thanks for all you do, both of the Eades.

    • Thank you for the kind words. And thanks for the sous vide purchase. Hope you’re enjoying it.

      We’re far from being in every house, though. And the big growth in our company is in Europe, so we’ve been spending a lot of time there.

  16. Welcome back! Your blog is a sight for sore eyes, that’s for sure. Since it’s my home page, I see it every time I start up the computer (which is not every day as I keep it on most of the time), and I was just thinking again the other day how much I miss your posts and hoping you’d post again soon. Voila! You did.

    Nice to have you back. I can’t wait for more posts from you.

  17. It was just within the last few weeks that I was thinking about how my own GERD has disappeared … and I have been eating a “paleo” style diet for several months. I thought that it must have something to do with my diet, had no idea how it could have worked, but felt very glad for it. Now, here comes your blog post. Gas pressure makes sense to me, as my bloating has also disappeared. Thanks so much for this post.

  18. I’ve worked for a beekeeper, in the honey house. Even unprocessed, I wouldn’t call honey “high in protein”. Rather, it’s basically fruit sugar (honey is chemically indistinguishable from corn syrup) with assorted minor contaminants. Mostly dead wasps, dead spiders, and the occasional dead mouse. Dead larvae, occasionally, but brood is not normally raised in the same combs as where honey is stored. Total at best is about 5% animal protein, probably more like 1% in an undamaged hive.

  19. It took me a long time to realize that I … like many of us with Northern European genes … don’t digest fructose well. Sucrose is made of glucose and fructose. Wheat is loaded with fructans, which break down into fructose. But so are some less obvious culprits … onions, artichokes, lentils! I spent a month or two trying to get rid of the fructose/fructans in my diet, and what a difference THAT made!

    Starches and sugars that are pure glucose, don’t bother me at all. Fructose is a simple sugar, BUT, if you don’t have the right enzymes, it just feeds the wrong microbes.

    Konjac (glucomannan) is a polysaccharide, but happens to work really well for people with fructose intolerance. It breaks down into glucose and mannose.

    http://books.google.com/books?id=_MNUShKSyZEC&pg=PA270&lpg=PA270&dq=glucomannan+fructans&source=bl&ots=uz8qcb_3Lj&sig=mtgWcLDNfjSbmW2ksL3NvUbHgro&hl=en&sa=X&ei=KXJCUv6WLsjOrQGTwIHoDA&ved=0CKsBEOgBMBA#v=onepage&q=glucomannan%20fructans&f=false

    http://www.ncbi.nlm.nih.gov/pubmed/2840365

    Definitely solved a mystery for me!

  20. Hi from NZ I am 57 petite and underweight, I have had on going reflux for years I also have a hiatus hernia and emphysema on my left lung, I eat mostly gluten free food but take 20mg Losec am and pm. Wish I didn’t need it but can’t seem to manage without it. i am a small eater and can’t seem to put on weight. Would love help. I’m going through menopause now too

  21. Dear Dr Eades

    For a long time I have suffered with GERD. In recent months I have been on a low carb diet in order to loose weight (and very successful that has been too). I recently commented to my wife that I had not had any GERD attacks for some time and now I know why! Amazing – thank you.

    Michael

  22. Thanks very much for this article! After 30 year of trying to lose weight with a calorie restricted diet, I came across Gary Taubes a year ago. Never looked back, following a LCHF diet. Also read about every book and internet site available. Never found GERD explained related to LCHF. But next to losing 25 pounds, I also got rid of my medication for heartburn. Now I know how that works.

  23. For me, eliminating gluten got rid of all my GERD and this was before I dropped the other carbs. Have not had GERD in 10 years.

    Nice to find you are posting again.

  24. Nice article. I came to the same conclusion (bar the step re. complex carbs being “worse”) after reading an article on SIBO and the mechanisms involved. I have had GERD/heartburn issues for many years and only started looking at alternatives to PPIs after reading the long term side effects they can have, discovering I have a hiatus hernia and getting fed up on the constant “bloated” feeling after my lunch time sandwich!

    One of the obvious effects of ppi’s is lower stomach pH. At first glance the implications, bar relief from GERD symptoms, are perhaps not so obvious:
    – High pH stomach acid kills bacteria and reduces the chance of overpopulation (not sure if this has a knock-on effect on the bacteria in the small bowel/intestinal tract?)
    – Of course food is not broken down and digested as well with the low pH, so not only is you take up of nutrients lower, but presumably more “food” is available for the intestinal/small bowel bacteria to thrive on.
    – When stopping PPI’s, without a low-carb diet change, the resulting GERD is worse than ever due to the SIBO, as described in your article , creating a vicious cycle.

    For many years I had been skeptical of so called “trigger” foods as they very often didn’t apply to me at all. As a result I worked my own “trigger” foods out and guess what they all have in common??? Carbs. Not spicy foods, fatty foods, acidic foods, chocolate (as long as it’s dark high cocoa butter/low sugar) but all sugary foods, BREAD, pasta, pastry potatoes, British beer (stick to wine!)….etc

    One unusual trigger that I think is worth mentioning is very interesting, as it is often promoted as a great “sugar free” alternative sweetener, is Xylitol. Apparently the “normal” gut bacteria cannot metabolize it but the bacteria commonly found in the intestinal tract/small bowel in SIBO love it – result – GERD – very rapidly!!! It would be interesting to see what your Dr. Robillard thinks of Xylitol and what FP it has.

    Thanks again for your posts Michael.

    Best regards,
    Dave.

    • Thanks for the comment. Unfortunately, the list of problems with PPIs is more extensive than the three you mentioned. I’ll be dealing with all that in my next post.

      Did not know about the xylitol. I’m a big fan of it for dental protection, but not in huge amounts.

      • Yes – PPI’s have a raft of issues but I commented on the ones I was aware of that are relevant to the SIBO issue. I look forward to your next post on it. As usual I am sure I will learn a lot.

        I also started with some xylitol mints for the the dental benefits but it wasn’t long before I managed to put 2 & 2 together with relation to my GERD issues returning.

        Thanks,
        Dave.

        • So the xylitol mints made your GERD worse? Are you sure you got pure xylitol mints? The reason I’m asking is that xylitol is expensive relative to other sugar alcohols, say, sorbitol, for instance. And it’s a lot more expensive than sugar. So a lot of manufacturers put a little xylitol in gums and/or mints, then label them as containing xylitol. They do contain a tiny bit of xylitol but most of the sweetening comes from sorbitol or even sugar.

          If they were pure xylitol, do you have any idea how many mints it took to generate the symptoms of GERD?

          • Hi Michael,

            They have no sugar or other sugar alcohols – from these guys :
            http://www.peppersmith.co.uk/ Ingredients (in order) are Xylitol, Gum arabic, calcium stearate, peppermint oil and carnuba wax. Gluten free, calcium stearate from vegetable sources and xylitol from beech trees.

            They are actually very nice imo but obviously not for me!

            As for numbers taken – they are pretty small – 25 mints in a 15g box. I probably had no more than 4 or 5 a day (max) to cause the issue.

            Cheers,
            Dave.

          • Dave, I believe it is the peppermint that is the trigger, not the Xylitol. If you look online, you will find lots of information declaring peppermint a cause of acid reflux.

          • Hi kris,

            I think most generally accepted information about causes of acid reflux is (for me a least) a load of rubbish to put it politely 🙂

            I don’t have any issues with peppermint, spicy food (unless you get silly) etc I have a huge issue with bread – not one you’ll find as a generally accepted cause of acid reflux but it is the number 1 for me (wheat/grain based anything really).

            I just googled xylitol and SIBO and there are quite a few articles referring to xylitol as it is a sugar alcohol that isn’t readily broken down by normal gut bacteria but IS by common SIBO bacteria.

            I guess my point is not that you are wrong, as I am sure many people have issues with peppermint, but that for me peppermint isn’t the problem.

            Cheers,
            Dave.

    • Sorry to be technical, but lower pH would be more acid, higher pH (over 7) is alkaline.
      This runs counter to our perception of acidity as hot, but is just based on what pH is actually measuring.
      (pH is defined as the decimal logarithm of the reciprocal of the hydrogen ion activity, aH+, in a solution, not that I understand what that means)

      • Well now, I don’t understand what that means either 😀
        Don’t know what’s a decimal logarithm, should say the ‘base 10’ logarithm (as opposed to a logarithm in another base, for example, the ‘natural’ logarithm, which is base ‘e’).
        You can also forget ion ‘activity’.
        So : pH is a measure of the molar concentration of hydrogen ions, reported as the negative base 10 logarithm of that concentration.
        It stands for ‘power of hydrogen’ , btw.
        :…if we’re being technical, ya’know 😉

  25. Hey Dr. Mike.

    I know you, like I, have great unfortunate personal experience with GERD. Here’s an excerpt of a comment on my blog (I tweeted the comment link to you) about my own experience vis-a-vis my interest in resistant starch.

    ~~~

    Two outaa-my-ass speculations:

    1) View the trillions of bacteria in your gut as in constant, brutal war. Good vs. bad (to the host—us), to-the-death, winner take all. If RS primarily feeds the “good guys” (they’re amoral, after all), then you’re simply giving aid & comfort to your allies by feeding them. Or, they have such an evolutionary leg up anyway that simply cutting NAofD (Neolithic Agents of Disease) and adding RS helps them keep things in check as they’ve been doing for millions of years or, rectifying adverse situations.

    2) Since it’s well known that bacteria glom onto RS granules and provide safe passage to the colon, why can’t bacteria too numerous in the small intestine “get on the bus” as RS passes through, and get taken to their intended place? I get the sense that those not really digging into the science see bacteria as just taking a bite out of RS, multiplying, etc. So in that context, it make logical sense that RS could actually proliferate small intestine bacteria and make SIBO worse. But that’s not what they do. They glom on, and all the while, stuff is moving through. So, by necessity, they are being moved further and further down the whole poop chute.

    Make any sense?

    For myself, a GERD sufferer since I was a teenager, the following:

    1) Beer and pizza in college was BAD.

    2) Wonderful baguettes and cheese, and that 1-2 aperitif before the noon or evening meal while living in France in the early ’90s was BAD.

    3) I first did Atkins in 1991 (while in France). Cleared up my chronic heartburn like magic in days. Did it a number of times in coming years, same result. But I was never LC for more than a coupla months at a time.

    4) Went on PPIs around 2000, was on them for seven years. They’re a miracle in the sense of virtually eliminating GERG no matter what. If you don’t know better, they become your best friend miracle drug ever because GERD is really fucking debilitating, especially waking up at night choking, because you’ve just aspirated stomach acid. But, this is where I went from just a bit overweight of 10-20 pounds to 70-80 pounds overweight.

    5) 2007 I transitioned into LC Paleo, got of PPIs (there is withdrawal, and you’ll get nuclear heartburn). But, GERD gone and this persisted for a long time. Then it came back, eventually, but slowly, over time, even LC. At a point, everything gave me some measure of heartburn. Only difference was it seemed less intense, unless I indulged in pizza, pasta, beer, etc. Then, nuclear.

    Those are the facts, I can’t say for sure why or by what means, but I have a few ideas.

    1) Alcohol is a definite promoter for me.

    2) A good 30 hour fast (which is also “LC” by definition) seems to reset things. So, if I’m diligent and do at least one 30 hour fast per week, it keeps heartburn well in check.

    3) Supplementing RS (potato starch, tapioca starch, plantain four) over the last few months, 15-30 g/d on average—some days none in supplemental form—SEEMS to be giving me a more long-term corrective solution. I’m fully aware of my own “bright eyed” tendencies, so I am holding out for more experience.

    4) I’ll post about this but always wanting to try something new, I’ve been experimenting with some of the new gluten free products out there, in the form of pasta and bread. They aren’t LC, but guess what? Two things different from the standard wheat varieties (and I must say, they are damn close in taste & texture): a) no heartburn, and b) no coma. Interesting.

    Anyway, in all the anecdotes posted in comments here or in email from those supplementing RS, not one person has said their GERD got worse, or that they developed GERD. Based on the number of people who’ve purchased Bob’s Red Mill Unmodified Potato Starch using my Amazon links, there’s well over 100 and it probably represents less than half of all, since it’s easily obtainable in local markets and many have indicated that’s how they got it.

    ~~~

    So I’m marching onward.

    • Good to hear from you. Haven’t been on Twitter since early this morning so didn’t see your tweet. I’ll take a look.

      Also, I don’t know enough about resistant starch to make an intelligent comment. And I have no experience with it, personal or otherwise, in the sense your talking about. It seems that I may have written a post on resistant starch years ago, but I don’t believe I was thinking about it then in the way it’s thought of today.

  26. Anecdotally, I seem to get GERD symptoms when eating a large meal with a lot of polyunsaturated fats (particularly the sort of stuff that’s widely used in restaurants for frying — soybean oil, canola oil, etc.) On the other hand, on occasion I can fry up a whole bunch of shrimp, sweet potatoes, etc. in the deep fryer at home (where I’m typically using non-hydrogenated palm oil shortening and have no GERD as far as I can tell.

    Now it’s possible that the latter is eaten more slowly (takes a while with a small deep frier) and that’s the relevant factor, but I can’t help but wonder if there’s something going on related to inflammatory effects of ingesting the polyunsaturated fats.

  27. It’s great to see you back!

    It is also great to see you independently say what the Specific Carbohydrate Diet (SCD) and Gut And Psychology Syndrome (GAPS) diet people have been saying about types of carbs vs. gut flora.

    I think it comes down to the fact that, not being true herbivores, we don’t have the intestinal structures and gut flora to deal with huge amounts of what herbivores eat. Primates were originally tree-canopy eaters who got some leaf matter but also a lot of fruit and bugs. (Frugivores have a different nutrient intake than creatures that eat mostly grass and leaves!) And then our particular type of primate has been hunting for a very long time now, which has pushed us into a whole new direction.

    I don’t just have problems with reflux when I eat too many complex carbs. I have problems on the other end too. I feel “stuck” and sluggish, exactly the opposite of the effect these foods are supposed to have on me, if you listen to mainstream medicine.

    The overall effect of eating grains, even non-glutenous grains, is worse for me than eating vegetables, fruit, and nuts. But no matter where it’s from, insoluble fiber and starches seem to cause me trouble. Soluble fiber seems to get along better with me.

    Did you ever notice that back in the 80s they classified both starch and fiber as complex carbohydrates, and now a lot of people only assign that label to fiber? Odd.

    • Yes, it is odd re the switch from starch and fiber to fiber only. The recommended 12-25 g per day (or whatever it is of fiber now) could really give some people a lot of GI and GERD distress.

  28. Dr. Eades, good to read your post as usual.

    The concept of “if you build it they will come” is a reality for bacteria. Feed them, and they will come. I agree with your theory about carbohydrates sustaining fermentation (CO2 production).

    As far as the xylitol comment, it reminds me that bacteria are responsible for many dental cavities.

    What is very interesting is that the bacteria that cause most cavities tend to also be “carbivores.” I can’t find the study now (may have been Michigan Dental school), but in the 1930s it a type of acidophilus was found to colonize root caries. The authors of the study pointed out that the bacterial population declined on a “diabetic diet” which was back then devoid of carbohydrates and sugar (!!!!) and that is what was suggested to lower incidence of caries.

    Regards,
    Alex

    • To bad that information from the 30s was lost on today’s practitioners. Or perhaps it isn’t lost, it’s just that they think they’re making a tradeoff. In their minds, consuming fewer carbohydrates means increasing fat consumption. And since most believe fat consumption drives heart disease, they probably figure they’re making a reasonable trade of of caries for heart attacks.

      • I may be simplifying here, but isn’t poor oral health correlated with poor overall and, especially, poor heart health?

        If that’s the tradeoff they are making, the logic of that theory escapes me.

  29. Great article on my favorite subject! Just one point for your readers. In my review of carbs that drive reflux (and IBS), two simple carbs made the list – lactose and fructose. Over half of the population is fructose intolerant and 80 percent (excepting Northern Europeans) are lactose intolerant. And sucrose is half fructose. That means limiting high lactose dairy, honey and table sugar is a good idea for controlling symptoms.

  30. Love your book, Protein Power, and I have taken nexium, one a day for yrs now and I must say, when read wheat belly I cut back on wheat and did notice heartburn lessened but still I find sometimes a high fat food item may trigger it, but with no wheat, I can probably go off nexium, which makes sense with what you are saying here!! Glad to read a post from you again, always enjoy them.

  31. Also, just thinking about what Dr Davis calls junk carbs, the gluten free breads, desserts etc, since these spike the insulin, assume they’d be simple carbs and so probably wouldn’t cause GERD either?? Not great for the waistline but makes sense that if these are simple carbs, probably would not ferment the way a wheat bread would?

    • I’m not sure. But my guess is they would pretty much act the same re GERD as regular bread. Gluten is a protein, and proteins aren’t really culprits in GERD. So removing something that’s not problematic (re GERD, not talking about other problems with gluten) shouldn’t make any difference. At least I wouldn’t think so.

  32. Somebody mentioned the Sous Vide machine. We have one and use it all the time but, and I only figured this out a couple of months ago, it is also a wonderful yogurt maker. One can almost make 3 quarts of yogurt in it overnight. (I use a full gallon of milk, with some cream, but one quart gets done in the hot tub, unconventional but highly effective).
    Again, WELCOME BACK!

  33. Combinations of foods: I usually go into a yawn with diet books that make a big deal of how foods are combined. But in my experience, combinations really do affect GERD. Alchohol of course. Just relaxing the muscle? I doubt it because the symptoms prior to AR don’t require the valve to open. In my case coffee, but not tea, contributes significantly to AR. George Henderson above refers to combinatorial effects. Deep fried potatoes versus boiled potatos are a frequently mentioned dichotomy. So although the Robillard theory is on the right track, I don’t think it has reached its final destination yet.

  34. On another subject, how do you feel about the movement to eliminate all consumption of grains (particularly wheat)? I had always thought from your writing that limited consumption (under 20 g per day) would be OK unless there was an allergy. Just a bit confused, not trying to stir things up…..

    • If you don’t have any problems with wheat, it should be okay in small doses. If you do, then I would avoid it. Hard to tell if you have a problem or not unless you eliminate it for a bit to see what happens. In my case, I ditched it for a couple of months, then ate a little to see what, if anything, would happen. I didn’t have a problem. But a lot of people do.

  35. What a great post! I recently started having mild heartburn, but it is almost constant. This was very educational, and I will defiantly be putting your tips to use. Thanks for sharing!

  36. One more commenter who suffered mightily from GERD until I went low-carb and, ultimately, gluten-free. This blog, among others, helped show me the way, so thanks, Mike.

    If you are going to write about PPIs, maybe you can comment on the following. I saw a study once somewhere that concluded that the LES valve is sensitive to acid: the more acid it senses, the more tightly it closes. Makes sense. But it also means that PPIs are working against us. They reduce the acidity of the stomach, sure, but they may actually make it more likely that what acidity remains gets through.

  37. I suffer myself of GERD..for many years now…Basically when I eat carbs especially sugars after…6-8 PM….. I feel pain during the night.With a low carb(meat or fat for example) diet nothing of this things happen ..just opposite,My personal theory around causes of GERD is based on observation and involving aging but not in traditional way ……is inspired from the famous Dr Wolfgang Lutz…..article “The colonisation of Europe and our western diseases”..(google it if you want)

    Basically my theory is…… The human ability of eating and digesting starch derived based carbohydrates(cereals) is recent in human evolution, coming on out “food table” along with development on agriculture 10000 year or so(evolution terms ..very recent) and as any other new evolution addition start disappearing first when trouble arisen .when the human body start aging he will also slowly loose the ability…of digesting these specialized carbohydrates and this can cause a lot of problems for the body like GERD when eating them….I’m not a biochemist but I know for each nutrient to be absorbed ….the body pancreas produce lipase for digesting lipids,protease for digesting proteins and amylase for digesting carbohydrates.IMO the body when aging or eat very often these type of carbohydrates(based on starch)the capacity of pancreas to produce amylase in enough quantity or quality decreased also..enough for the body to compensate producing a lot of gastric acid ….with that GERD.
    Of course this is my not proved theory…take it as it is.

  38. I am not really buying into the theory here, doc. Before doing LC, I had a touch of gerd, and I was developing a longer and longer list of things I couldn’t eat in the evening. That included alcohol, 7-layer dip, then anything with sour cream, tomatoes. After LC’ing, it went away, but I can bring it right back with a large meal containing the formerly offending foods along with wheat.
    I probably eat more carbs than many, and plenty of Jerusalem artichokes in the winter. If this theory is correct, I should be getting gerd from them, but I don’t. Discomfort sometimes, yes, but not gerd unless I have eaten wheat within the past day.

    • I think what you mean is that you’re not really buying the theory as it applies to you. Others may have a different outcome. And I’m sure their are multiple causes of GERD. The SIBO theory proposes a way to treat if your particular variety is caused by SIBO.

  39. I suffered from GERD for years due to stress in my job, being forced to take increasing doses of PPIs which solved the problem but lead to maldigestion of protein and gave me some lightheadedness. After becoming a bit more relaxed (some years later) I was able to switch to the less powerful Ranitidin (H2 blocker) and my digestion problems stalled and the acid-reduction was still good enough to prevent my GERD symptoms most of the time.

    Some weeks ago I tried the “whole30”-Paleo-protocol (no grains, no dairy [I “cheated” with pastured butter], no sugar, no bad oils, no processed foods etc.) and I could only keep it up for 14 days due to increasing hunger bouts… But interestingly I was able to stop taking the Ranitidin 4-5 days after starting the Paleo-thing and I never experienced any GERD symptoms. After falling off the wagon it took one week to feel the first acid attack coming back.

    The severity now depends on the amount of “bad foods” I eat. Sugary sweets and white chocolate are quite bad (in every sense, of course…). But plain whole joghurt is not less bad in GERD terms for me. Chicken soup or fricassee are horrible too, but grilled chicken (containing fat) or chicken breasts (no fat) are OK. Quite mysterious.

    I also develop GERD symptoms when brushing or rinsing my teeth with Xylitol – that’s the reason why I wanted to leave a reply here. I use dissolved Xylitol and I am trying not to swallow it. But the very little amounts I cannot avoid to swallow before immediately rinsing with fresh water are sufficient to give me a serious, but short lasting GERD “attack”.

    I am eager to try the paleo thing again, because I am convinced that it is the best way to eat. But hunger and cravings are a big problem for me then. That’s why I want to include some “safe starches” (PHD-style) in the beginning – perhaps I am able to “ease into it” that way. Although I am still sceptical that something like a “safe starch” even exists…

    I saw my mother’s bloodsugar going through the roof after having a meal of “safe” white potatoes with eggs (“Bauernfrühstück” here in Germany), while nothing like this happened after having a low carb meal with meat, vegetables and two small potatoes, following the “LOGI”-method. OK, she is diabetic and even “common wisdom” should say, that potatoes are not the best food for diabetics – but the Jaminets defend their PHD as being suitable even for those patients. I still doubt it – even for people with impaired glucose tolerance that are not yet diabetic.

    Thank you for posting again!! My impression is, that we need “more Eades” in the blogosphere and not necessarily “more Guyenets”… 😉

    Cheers, guzolany

    • Thanks for the vote of confidence. But there is probably enough room in the blogosphere for all of us. Nice – for me, at least – to see how other people view the same problem or question.

  40. Thank you for making sense of how GERD happens. I had thought my symptoms of GERD were nonsensical and inconsistent, but if your theories are correct, then it all actually makes quite a bit of sense…and is quite consistent after all!

  41. Have missed you terribly Dr. Eades, so hate to disagree with you on your first post after such a hiatus.

    My son has had GERD from his early teens. In spite of making me sound like a horrible mother, I’ll admit he never liked vegetables except for fries and tomato sauce on pizza, no fruit unless you count gummy bears, and would never eat fiber in the way of whole grains or whole wheat bread. He always gravitated to fried and processed food. He loves spicy junk foods like Doritos which trigger a severe reaction.

    I think instead of the fiber trend, it might possibly be the processed food trend. Another consideration is the number of kids put on antibiotics from infancy. My son was one of those with the constant ear infections and antibiotic use. Could this trend of frequent antibiotic use be changing the biology of our digestive track?

  42. It’s funny, literally all my life I’ve been bombarded with messages about the horrors of heartburn. And I’ve spent all these years wondering what the hell it was, and do I have it?, and will I get it? Thanks to you, now I know pretty much exactly what it is, that I’ve never had it and I never will have it. A lifetime of advertising fueled worry over nothing haha!

    And oh yeah, Cheers! Good to see you back in action!

    • Umm never say never my friend.
      I always thought I’d never get it even though my dad has complained of it forever!
      Lo and behold last month did I ever get it!
      I thought I was having a heart attack in the middle if the night and then had severe heartburn for the next couple of weeks everytime I ate! I was put on RabZole and now Nexium.
      Boy do I wish I had died that night?!
      The most intense pain I’ve ever felt in my life!
      🙁

  43. Dr. Eades,

    Ray Peat came to the same conclusion as you with regard to SIBO and starches/sugars. His approach to this is rather unique – a daily chopped/shredded carrot with a bit of olive oil and vinegar. Evidently, as carrots evolved, growing in the dark, damp soil, they developed some anti-fungal and anti-microbial compounds which, when ingested by humans, push the SIBO down to the lower end of the small intestine where the fermentation is not as problematic. Seems to have helped a lot of people with SIBO issues.

      • I haven’t tried it with JUST carrots, but thinking about it … the times in my life when I ALWAYS had a salad for lunch … which always included carrots … I had few gut problems. I figured the salad was magical. The vinegar on salads is also very good in a number of ways.

        These days I tend to use konjac powder, which also seems to kill ulcers nicely.

        For GERD, limonene is marvellous. Also easy. Just add a twist of lemon to a cup of tea. I tend to eat the lemon rind after. I use organic lemons, and keep them, sliced, in the freezer so they are handy. Limonene is highly anti-fungal … lemon slices also make tea taste good!

  44. “Interesting. First I’ve ever heard of it. Anyone out there given this a try? If so, let us all know how it worked.”

    Me too, Mike. Actually, back in the strict Paleo days I loved to chew on raw carrots and celery for that very reason in symptomatic terms. Both seemed to settle things. Also, salty sunflower seeds in shell.

    Many of us are speculating that Resistant Starch in the form of things like unmodified potato starch (this is a low processed, starch faction of raw potato, 80% RS by weight), tapioca flour (similar) and plantain flour may do similar things in getting SIBO bacteria to “get on the bus” and take a physical ride father down the poo chute.

  45. Dr. Eades – Resistant Starch is an amazing thing. Both pathogenic and beneficial gut microbes are attracted to it, but only the beneficial microbes can digest it. It is very slow to be digested, therefore, anything that adheres to an RS granule in the small intestine gets flushed to the large intestine before it can be digested slowly by bacteria which can digest RS (almost exclusively the bifido and lacto bacterias). It seems like this would be a good thing, even a cure for, SIBO.

    They have been using this phenomenon it for years to clear up cholera, and are just recently beginning to understand how it works.

    See: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1183348/

    “We hypothesize that during diarrhea, positive effects such as SCFA formation, attributed to the regular consumption of resistant starch, disappear. These well-documented effects are intimately linked to the natural microflora of the gut, which is washed out during the severe fluid loss. Thus, beneficial effects from starch, when incorporated into Oral Rehydration Solutions, are either related to its physical properties and its interaction with the human body or due to the diarrhea-causing-agent interactions with the starch. As starch incorporation seems to be beneficial in a manner related to the causative agent, we claim that the latter prevails. When no interaction exists between the causative agent and the starch, starch incorporation into ORS has no significant effect. In contrast, V. cholerae interacts with starch, resulting in a marked effect on the ORT. In accordance with our findings, we suggest that adhesion to the starch granules might compete with sites in the lumen during colonization. We suggest a model where V. cholerae adheres to the ungelatinized starch granules, which are practically indigestible in the intestine and are secreted from the intestine. It is therefore possible that in this way that the adhering V. cholerae is removed from the intestine…”

    • Ha, Nobody has proved that “resistant starch only feeds the good bacteria”. I am so sick of the rose-colored glasses people automatically assuming it. Resistant starch gives me wierd symptoms NOT reported by most people. Feeding a bad bacteria? Yes, it could be.

  46. Hey Mike.

    I see you have a new post up and it’s like a week ago. OK, right after this.

    Tim is a collaborator or mine, having probably read more of the hundreds of studies on RS done over the last 30 years than any human alive. I have another collaborator who comments regularly on my blog who’s a PhD physical chemist working for a well known institute of science. They collaborated together over months and this is the result, with data and graphs, I just posted:

    http://freetheanimal.com/2013/10/resistant-ingestion-blunting.html

    Bottom line:

    1. RS has zero effect on ketosis (BG or state of ketosis) if taken alone, even like 30 g of it in a bolus.
    2. RS has significant blood glucose blunting effects. The most come from daily RS ingestion (20-30g) along with supplemental RS for a high glycemic meal. But, very astounding “second meal effect” is noted if it’s just daily RS. This likely explains the mechanism behind the ability of beans to not only cause less of a spike, but the effect lasts for hours and even into the next day.
    3. For those in ketosis or who fast regularly, there’s little to no BG blunting as compared to those on a normal diet.
    4. Those in ketogenic or fasting may have a long term effect of 10-20% less spike peak in response to a high glycemic meal.

    Hope that wets your appetite even more, Mike.

    • The list you provided is of bad things RS doesn’t do. If I don’t eat it, I don’t get any of those effects, either. What I’m more interested in is what does it do that’s good? On other words, why should I throw back potato starch other than to just be throwing it back. I’ve got to get some benefit, or it’s not worth the effort.

      • I have a comment on the “2nd meal effect”. Some of the resistant starch can end up being fermented into butyrate. Butyrate IS energy … it’s used mostly by the gut itself. It keeps the gut walls happy. I do think it’s important to get the *right kind* of starches though … wheat is problematic for a lot of people, and degrades into fructose. Most starches in the US have added iron too, and iron feeds the wrong kinds of microbes.

        http://www.sciencedirect.com/science/article/pii/S0924224402001310

        A suggestion put forward is that beneficial effects may be obtained in particular by the consumption of resistant starch (RS) because of the high yield of butyrate and propionate when fermented. These SCFA are the prime substrates for the energy metabolism in the colonocyte and they act as growth factors to the healthy epithelium. In normal cells butyrate has been shown to induce proliferation at the crypt base, enhancing a healthy tissue turnover and maintenance.

        • mreades,
          the effect of RS on the health and integrity of the gut lining, as noted also by HeatherTwist, is one of its main advantages.

          In addition, there’s a laundry list of beneficial effects of RS, due its overall beneficial effects on the health of the gut biome.

          Research on RS has been going on for 30years, but as the importance of the microbiome has been investigated more and more recently, the importance of RS is becoming evident.

          RS feeds and maintains a healthy gut biome, ‘feeding’ primarily the beneficial types of gut bacteria.

          In this way RS is important, for example, to immunity, gut lining integrity and health and improved blood sugar control (the latter likely mediated by the SCFA that the beneficial gut bacteria produce upon fermenting the RS).

          I looked into it primarily because for its effect in colon cancer, having a family member that’s been stricken by that disease.
          The improved Glucose Control (‘blunting’ of postprandial BG spikes) is just a bonus in that case, but it’s something that might be of primary interest to those with Metabolic syndrome or T2 Diabetes.

          If you are interested, there’s a great deal of well-organized references to the literature (including beneficial effects in several pathologies, cancer, IBS, diabetes, etc) on the FTA site. I can’t do it justice, there are too many 🙂

      • When I first came across the notion of potato starch as an RS supplement, it was because of this pig study: http://www.ncbi.nlm.nih.gov/pubmed/17936196 Prior to reading this, RS just meant ‘cold potato salad’.

        From the link:

        “RPS (raw potato starch)-fed pigs had reduced apoptosis in the crypts, lamina propria and lymphoid nodules in the colon, and ileal Peyer’s patches. Fermentation of RPS reduced indices associated with damage to epithelial cells, such as crypt cell proliferation and magnesium excretion, whereas mucin sulfuration was increased, which promotes epithelial protection. The numbers of intraepithelial T cells and of blood leukocytes, neutrophils, and lymphocytes, mainly T-helper lymphocytes, were reduced in RPS pigs.

        CONCLUSION: Long-term intake of RPS induces pronounced changes in the colonic environment, reduces damage to colonocytes, and improves mucosal integrity, reducing colonic and systemic immune reactivity, for which health benefits in inflammatory conditions are likely to be associated.”

        The great thing about potato starch (and RS in general) is that it’s a tool for better gut health. When you start taking it, you can see almost immediate results in improved bowel movements–even if you thought you were fine to start with. You will also notice some changes in your flatulence habits. Infrequent noxious gas is usually replaced with more frequent non-odorous gas. If ingestion of RS causes problems–you are probably in need of some beneficial microbe diversity. But, the takeway here is that when taking RS you SHOULD see some changes to bowel habits…if you saw nothing, you would know this is all hogwash.

        Along with the easily observable changes to bowel patterns, other things are happening as well:

        Almost as immediate are the changes in BG regulation if you look for such things. Many report better sleep right away. A bit more digging should show changes for the better in trigs and cholesterol. The hidden benefits are hard to see, but they are there: better gut microbes mean improved uptake of vitamins and minerals as well as increased production of gut-made vitamins (k2 for one) and neurotransmitters (like serotonin) and chelation/elimination of heavy metals.

        If your main focus is BG control, weight control, or GERD, and you get that with your current diet–you may still be missing a big piece of the health mystery. Intestinal microflora plays a pivotal role in almost every system of our metabolism and even brain function. To starve the microflora of your gut just to meet a BG parameter, calorie target, or get relief from heartburn may be doing more harm than good in the long run.

      • “What I’m more interested in is what does it do that’s good? On other words, why should I throw back potato starch other than to just be throwing it back. I’ve got to get some benefit, or it’s not worth the effort.”

        Sorry that didn’t come across clearly. The benefits noted by most (and there are now well more than 100 folks out there taking it, just from my Amazon Affiliate stats):

        1. FBG lowering, even for those with physiological insulin resistance or “dawn effect.” Happened for many others, myself and my wife too. From low 100s to 80s and 90s with no other changes. My mom was able to further reduce her insulin (T2).

        2. BG spike blunting. There’s 2 things going on. The first is that as shown in the graphs in my linked post, there’s a continual post-prandial “2nd meal effect” for those on a ‘normal’ diet–by which I mean not ketogenic and not regularly fasted–who simply take RS daily. In addition, there is additional blunting if RS is taken supplementally before or with a meal, particularly a starchy one.

        3. Improved TMI.

        4. Improved energy and feelings of warmth. Some, including myself has noted a complete reversal of “cold hands & feet.”

        5. Deep sleep. I was almost afraid to put this one out there, but my dream state has undergone profound changes. Dreams are now long, complex narratives that I can remember the next day. Others have reported it too, and how “freaky” it can be.

        Nobody has reported anything adverse except one thing. It can take a while to wade in, unless you happen to like farting. I dove right in and so for a couple of weeks I’d have bouts of fartage that reached comical levels. I mean so profound you just have to laf. What’s noted most commonly is that the farts are not odorous, and they are hot, i.e., noticeably hot. The little buggers seem to be generating significant heat in what they give off from digesting RS.

        For me that all settled out after a few weeks and most others report similarly. For some, it seems to persist. This is likely a result of the lay of the bacterial land when commencing.

        So, hope that helps. Your point is well taken but in actuality, most of us are taking this because of the benefits of BG regulation and blunting spikes, no more coma after a starchy meal, improved energy, warmth, sleep.

        • Thanks for the info.

          You wrote:

          …most of us are taking this because of the benefits of BG regulation and blunting spikes, no more coma after a starchy meal, improved energy, warmth, sleep.

          I don’t eat starchy meals, so don’t have the coma. I sleep fine and, although I suppose it could be improved, have plenty of energy and warmth. Any other reasons I should try RS?

          I guess what I’m trying to say is that I don’t want to take something just for the sake of taking it. If it will improve my life and health, then I’m all for it. But if I have no symptoms or problems RS will fix, why should I take it and endure some of the side effects you mentioned for no gain.

  47. Hi Mike:

    I applaud your discipline, especially world travelling and all; and I must admit, what we’re seeing with PS supplementation at $5 pound and 4 T per day seems to mimic an LC diet, though without the costs (other than those 5 bucks) associated with that.

    I’m assuming we can agree that all actions have associated costs, even if only in terms of time & trouble whilst one could be yelling at their kids instead?

    So, in terms of what I believe I understand now, one reasons RS doesn’t have the same effects LCers KTs have is because LC is a means of moderating BG in the first place. So, yea, RS is “late to the party.”

    What I’m interested in, however, is the potential ability to mimic the valid results of LC and KT, all while enjoying regular real food, including starchy real food. Even LCers or maybe, especially LCers go head down often enough. What if one might be able to dose 4T of potato starch before Thanksgiving meal and not go all coma and head down? And, if that works, what does it portend for the other 364 days?

    I’m assuming that if that could be the case, you would stand and applaud. You’re welcome to correct me if that’s a false assumption.

      • It’s not really about that at all, Mike. I’m actually a relatively LCer by default, now, not having grain of any sort in the house for years beyond the off baguette for guests.

        But there are starchy foods I love, like taters, properly made corn tortillas and even rice or beans cooked on chicken or beef stock.

        I guess I’ll just say it. I can’t honestly say anymore that carbs per se were ever the problem. I know that makes a lot of people wrong who hate that. But wrong is wrong, On the other hand, it is probably owing to LC that people eventually figured out the real problem, which is what companies do with the most common LC foods.

        I’m not looking for LC to look stupid. I also know that’s hard, because that’s kinda the way things work. People don’t say “that was a great period that helped a lot.”

        There’s very too much, Mike, people thriving in health after adding natural carbs and I see it every single day in my very active blog and its comments.

        • I’m really not trying to be argumentative about this. I’m more than happy to take a look at RS when I have the time.

          My point is that with the lifestyle I’ve settled into, I don’t add stuff to my diet just to be adding it. Whatever it is needs to provide some sort of benefit above and beyond the typical diet I follow. If I were having trouble adhering to a low-carb diet or if I had major carb cravings all the time, then I might be on the lookout for something that would allow me to indulge consequence free. But, I’m happy with the way I eat.

          That’s me. Others may see it differently, and for them, RS may be a Godsend if it acts as everyone reports that it does.

          I guess I’m just saying a) I don’t really know anything about resistant starch, and b) I don’t, myself, consume anything, and I don’t recommend anything, that I haven’t researched pretty thoroughly in the scientific literature. And since I haven’t done (b), I can’t really discuss the subject intelligently.

          • Wowzers Mike.

            I can not ever in my soon 53 years recall reading anything close to such a “we’re cool, here’s me, but we’re cool” email or comment.

            I thank you for your indulgence.

  48. I think this whole debate boils down to whether or not we believe that gut microbes play a role in our health, and how to best support a healthy gut.

    I think RS has been proven beyond a shadow of a doubt to:

    – Selectively feed beneficial bacteria
    – Cleanse the small intestine of certain pathogenic bacteria and out-of-place beneficial bacteria
    – Create a healthier large intestine through tightening of junctions, feeding of colonocytes, butyrate production, and forming biofilms impenetrable by pathogens

    All of these mechanisms I described are at a disadvantage on a low-carb/low fermentable fiber diet. Beneficial microbes need undigested carbs to flourish–they cannot get what they need from fat and protein.

    • Hi Tim,
      Funny meeting you here. I admire your dedication in your studies on the health benefits of RS and you know I appreciate this discussion – we don’t need to be right but science does.

      As I have mentioned before, I support healthy people diving in head first consuming all the RS they want, though perhaps not before a flight. But I believe that people with GERD, IBS or other SIBO-related conditions, should avoid it. I won’t repeat my blog post on why, but in regard to your comments:

      I think RS has been proven beyond a shadow of a doubt to:
      – Selectively feed beneficial bacteria
      * Where is the proof? RS can be fermented by a wide variety of both good and bad gut bacteria, including those species identified in SIBO.

      – Cleanse the small intestine of certain pathogenic bacteria and out-of-place beneficial bacteria.
      *What is the evidence for this? Restricting carbs is the best way to clear SIBO and dysbiosie (see below).

      – Create a healthier large intestine through tightening of junctions, feeding of colonocytes, butyrate production, and forming biofilms impenetrable by pathogens
      *What is the evidence for tight junction improvement?
      *Yes butyrate feeds coloncytes, but on either LC or Low FP diets there is still plenty of fermentable material present. Otherwise people on these diets would not form feces. Gut microbes also ferment sugars that make up mucus that coats the entire intestine. They also ferment protein (we malabsorb between 10-20% of the protein we consume) and they produce butyrate from both of these activities.
      *Biofilm microbes – best adapted at securing binding to the mucosal layer and excluding pathogens – are actually fed by this mucus layer and less dependent on added fermentable material.

      Lastly, please explain the success of LC, Low FP, FODMAP, low fiber and elemental diets in treating GERD, IBS, Crohn’s and Celiac disease and show me one adverse event, cancer, or infection from any of these studies.

      On a personal note one of my reservations to RS is because my own GERD symptoms were driven by high carb foods such as bread and pasta. If RS was not to blame, what was to blame?

      Because this is all ongoing research, its possible that RS is not the worst carb driving gut dysbiosis and SIBO, perhaps being more comparable to the least fermentable fiber type – cellulose, but as a GERD sufferer, I would like to see proof that it doesn’t hurt and it adds health benefit. To date, the many studies I have read (admittedly, not nearly as many as you) on RS, which are almost 100% supported by the RS industry, don’t convince me.

      Norm

      • Hey, Norm — you caught me proselytizing RS again! I hope this all comes out readable.

        1. – RS selectively feed beneficial bacteria
        * Where is the proof? RS can be fermented by a wide variety of both good and bad gut bacteria, including those species identified in SIBO.

        The proof is in the hundreds of studies done, especially the ones from the last few years that show RS is specifically targeted for fermentation by butyrate producing species of bifido bacteria. But actually, this is only half the story…with RS, it takes two to tango. There are some recent studies on RS that show it’s fermentation is a two-step process. I have a great paper (pdf, not linkable) called, “Analyzing the Functionality of the Human Intestinal Microbiota by Stable Isotope Probing” in it, they describe the cross-feeding effect of RS, potato starch is used in their experiments:

        From the paper: “A substantial part of the human diet is represented by the daily intake of dietary carbohydrates, such as resistant starch and other carbohydrates which are not
        digested in the small intestine. Chapter 2 details the application of RNA-based Stable Isotope Probing (SIP) in linking metabolic activity to microbial identity. Here, RNAbased SIP in combination with T-RFLP fingerprinting analysis of samples obtained from the TIM-2 in vitro model of the human colon revealed Ruminococcus bromii as the primary degrader of [13-C]-labeled potato starch. Additionally, molecular and
        metabolic analyses suggested metabolic cross-feeding in the studied system, where populations related to Ruminococcus bromii are the primary starch degraders, while those related to Prevotella spp., Bifidobacterium adolescentis and Eubacterium
        rectale might be further involved in the trophic chain.”

        All of the degraders, primary and secondary, are probiotic species–ones that convey health benefits to the host. The primary degrader of RS, Ruminococcus bromii, has further been classified as a ‘keystone species’ in this full-text study:

        http://www.nature.com/ismej/journal/v6/n8/full/ismej20124a.html

        If r. bromii is not present in the microbiome, the human host will poorly digest RS.

      • Splitting it up for readability….

        2. – Cleanse the small intestine of certain pathogenic bacteria and out-of-place beneficial bacteria.
        *What is the evidence for this? Restricting carbs is the best way to clear SIBO and dysbiosie (see below).

        This is something I have only recently come across. I hope it turns out to be a cure for SIBO, or at least a big help in ridding the SI of some BO.

        Cholera is caused by the microbe Vibrio cholerae who has a life outside humans, where it grows a tail and swims around in polluted waters, and a life inside humans where it loses it’s tail and burrows in the lumen of the small intestine causing severe diarrhea and dehydration. Oral Rehydration Therapy is used when people get cholera to rehydrate the patient until antibiotics can kill the pathogen. However, if you add resistant starch to the Oral Rehydration Solution, the cholera often subsides on it’s own. This has been done historically with rice and corn starch.

        It was surmised that the RS in the solution caused a buildup of butyrate/SCFA/etc… and helped the body rid itself of cholera. However this study: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1183348/ examined the effects and found out that the vibrio cholerae attaches itself to the RS granules as soon as they come in contact, and the this slowly digesting substance takes the vibrio for a ride out of the SI and into the LI where it can be eliminated.

        Apparently, RS has surface structures that appeal to certain pathogens like vibrio cholerae, a. hydrophila, e. coli, and p. aeruginosa. These pathogens cannot utilize RS as a food source, or even begin to ferment it, but yet withing 2 minutes, 98% of the vibrio growing in a petri dish leaves it’s attachment to the agar and binds to the RS.

        As the study concluded:

        “In accordance with our findings, we suggest that adhesion to the starch granules might compete with sites in the lumen during colonization. We suggest a model where V. cholerae adheres to the ungelatinized starch granules, which are practically indigestible in the intestine and are secreted from the intestine.”

        Also noted in the study was that the presence of sugars disrupted this attachment–which I find very interesting!

        I would love for you to read through this study and tell me if I missed anything, but it seems to me this would be a novel cure for SIBO.

      • I hope I’m not coming across like a smart-ass. It’s just that I love talking about this!

        3. – Create a healthier large intestine through tightening of junctions, feeding of colonocytes, butyrate production, and forming biofilms impenetrable by pathogens
        *What is the evidence for tight junction improvement?

        Nearly every study on RS and the colonic environment has something like this in it (from http://www.ncbi.nlm.nih.gov/pubmed/15287679) :

        “RS modifies the lumenal environment, largely through altered fermentation of polysaccharides and proteins. RS also affects epithelial biology in that it increases apoptotic deletion of genetically damaged cells. More work is needed to define what types and combinations of RS, perhaps with probiotics, exert the greatest effects on colonic environment and epithelial biology,”

        Many studies have attempted to define an optimal intake, most conclude it is somewhere around 20-40g per day. The max anyone seems to be able to ferment is 50g per day, above that level, it is excreted in stool. The excretion point means the entire colon is flooded with RS, and, from the above study”

        “To generalize from these studies, RS softens stools and increases stool bulk, decreases pH, increases short-chain fatty acids (SCFAs) including butyrate, reduces products of protein fermentation, and decreases bile salts in fecal water. Such changes seem to be achieved within about 4 weeks of commencing consumption. The greatest effects are seen with the highest doses where increased fecal starch recovery is observed.”

        I haven’t fully digested this study (pun intended), but it seems to be tackling the concept that high protein diets damage the colonic environment and RS restores the environment:

        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3742201/ (full text)

        “Recent data with high protein diets confirm that genetic damage can be increased, consistent with greater CRC risk. However, this damage can be reversed by increasing SCFA supply by feeding fermentable fibre as resistant starch or arabinoxylan. High protein, low carbohydrate diets have been shown to alter the colonic environment with lower butyrate levels and apparently greater mucosal exposure to ammonia, consistent with our hypothesis.”

        I’m thinking that even on an LC diet, RS would be useful in helping one attain an optimal gut.

      • 4. *Yes butyrate feeds coloncytes, but on either LC or Low FP diets there is still plenty of fermentable material present. Otherwise people on these diets would not form feces. Gut microbes also ferment sugars that make up mucus that coats the entire intestine. They also ferment protein (we malabsorb between 10-20% of the protein we consume) and they produce butyrate from both of these activities.
        *Biofilm microbes – best adapted at securing binding to the mucosal layer and excluding pathogens – are actually fed by this mucus layer and less dependent on added fermentable material.

        I’m not an expert here, won’t even pretend! I do, however, love this study, called “Chemostat Enrichments of Human Feces with Resistant Starch Are Selective for Adherent Butyrate-Producing Clostridia at High Dilution Rates” found at http://aem.asm.org/content/66/10/4212.full :

        In this study, they took human fecal matter and applied RS to it and watched what happened. The results were astounding–within minutes, it was colonized by butyrate producing microbes in ways they had never imagined. Certain species formed rosette like structures and biofilms around the RS granules.

        A blurb from the study:

        “Since SCFA production is directly related to the supply of nutrients to the colon, shifts occur in the metabolism of microbial populations in response to changes in the diet (15). In vitro studies show that compared to the fermentation of non-starch polysaccharides (dietary fiber) by gut microorganisms, butyrate formation mainly occurs during starch breakdown (10, 11, 25). The physiology of butyrate metabolism in the large intestine has been extensively studied (16, 24, 37). Apart from being an important respiratory fuel for the colonocyte (5), this SCFA regulates gene expression and cell growth, and reversibly alters the in vitro properties of human colon cancer cell lines by prolonging doubling times (39). Low concentrations also reduce DNA synthesis and suppress proliferation in a variety of cell types (16). ”

        What this tells me, is that the undigested proteins, fats, and plant matter that reach the large intestine are indeed digested, just not in a way that benefits the host. The definition of ‘Probiotic’ is ‘A microbe that protects its host and prevents disease.’ The microbes that digest protein, fat, and most FODMAPs are not probiotic. The microbes that digest RS are.

      • 5. “Lastly, please explain the success of LC, Low FP, FODMAP, low fiber and elemental diets in treating GERD, IBS, Crohn’s and Celiac disease and show me one adverse event, cancer, or infection from any of these studies.

        On a personal note one of my reservations to RS is because my own GERD symptoms were driven by high carb foods such as bread and pasta. If RS was not to blame, what was to blame?”

        I think these diets are effective because they remove the real culprits, whatever they are, but it is not the RS component. The real culprit may be rapidly digestible starch, sugar, oligosaccharides, plant proteins, vegetable oils, polyols, or many other usual suspects–but I’d bet not the RS. I saw a paper the other day that suggested they were starting to add RS to elemental diets for coma patients because their gut flora was so messed up from the standard elemental diet. A standard feeding tube solution is usually composed of amino acids, fats, sugars, vitamins, and minerals–no prebiotics whatsoever.

        • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2806551/

          RS in elemental diets to prevent c. diff infections.

          “A further common, but less recognized, etiological factor is the prolonged use of elemental diets. Such diets are totally absorbed within the small intestine and therefore deprive the colonic microbiota of their source of nutrition, namely dietary fiber, fructose oligosaccharides, and resistant starch. The resultant suppression of colonic fermentation leads to suppression of the “good” bacteria, such as butyrate-producers (butyrate being essential for colonic mucosal health), and bifidobacteria and the creation of a “permissive” environment for C. difficile colonization and subsequent infection.”

          “So what can we do to reduce the incidence of C. difficile infection and its progression to colitis? Survival in the ICU is commonly dependent on the protracted use of broad-spectrum antibiotics, and so withholding their use is not an option. However, prophylactic antibiotics post-operatively and in conditions, such as severe pancreatitis where they are of unproven benefit, should be avoided[22]. Secondly, PPIs are grossly overprescribed in the ICU usually with the intent of preventing stress ulceration, but there is poor correlation between this and gastric acidity. One study looking at the association between C. difficile associated colitis and PPIs, showed that 63% of patients had no valid indication for acid suppression[23]. Not only would restriction of PPI use likely decrease the incidence of C. difficile associated colitis but it would also have enormous heath care savings worldwide. PPIs now account for 10% of the annual prescribing costs in the UK; more judicious use would save the National Health Service at least £100 million/year[24]. Finally, the use of non-residue tube feeds should be restricted to those critically-ill patients with ileus and borderline gut function and since, in practice, ileus usually resolves and function returns with the slow progression of tube feeding over three or 4 d[13], even in these patients a change can often be made to a fiber or “prebiotic” containing formula after the first week.”

      • 6. “Because this is all ongoing research, its possible that RS is not the worst carb driving gut dysbiosis and SIBO, perhaps being more comparable to the least fermentable fiber type – cellulose, but as a GERD sufferer, I would like to see proof that it doesn’t hurt and it adds health benefit.”

        The only thing I have to convince you is the standard test for SIBO, the hydrogen breath test. Numerous studies gave hydrogen breath tests to people after RS consumption. It took 4 hours to begin fermentation. I don’t think that RS stays in the small intestine long enough to cause SIBO. I think it actually grabs pathogens and probiotics alike and takes them to the large intestine.

        If you could prove this, you could probably make millions. Seems like it would be easy to test: Take a fasted SIBO person, feed them 40g of RS in water 2 or three times a day, along with a zero fiber, low carb diet, and redo the hydrogen breath test.

        Here are a couple RS hydrogen breath test papers:

        http://www.ncbi.nlm.nih.gov/pubmed/7835324

        http://journals.lww.com/jpgn/Fulltext/1999/09000/13C_and_H2_Breath_Tests_to_Study_Extent_and_Site.16.aspx

      • 7. To date, the many studies I have read (admittedly, not nearly as many as you) on RS, which are almost 100% supported by the RS industry, don’t convince me.

        I have gone waaaay out of my way to choose studies that were NOT supported by the starch industry. Yes, they have spent billions to further RS. Mostly, this RS comes from GMO corn that needs a new home since the fall of HFCS,

        Many, many, many independent studies and papers show that plain old potato starch, tapioca starch, mung bean starch and even just eating beans and rice are just as effective as the franken-food Hi-Maize Corn Starch. Many show they are even more effective–potato starch particularly, due to the size of the starch granules.

        I almost gave up on RS when I saw how invested Ingredion and National Starch were in furtheringRS as a functional ingredient. I have ‘insider’ papers that show the extents they are going to get corn starch redesignated as a functional fiber and how they can work the system just to get a high fiber rating on muffins and biscuits by using a tiny smidgeon of Hi-Maize–it’s criminal, really!

        Anyway, I hope you take this in the spirit of “we don’t need to be right but science does.”

        Nice talking with you, Norm.
        Tim

  49. Can someone tell me what is wrong with the fibre in green leafy vegetables, and in other low-carb veges like gourd family and such?
    Leaving aside a few cruciferii that contain FODMAPs, I’d have to say, not much. Green leafy veges are the fibrous foods that epidemiology likes to single out as beneficial. Animals that eat them generate plenty of butyrate. It seems to me that people who eat want to eat LC can get benefits from greens, and people who eat more carbs are probably well-advised to make those high-RS carbs, and then everybody’s happy.
    Different folks will have different microbes even if everyone eats the same, so maybe we all end up, if we’re lucky, on the diet that suits best our potential for hosting beneficial microbes.

      • Thanks for that. I love your writeup … most of the people I talk to either believe “fiber is bad” or “fiber is good”, but there is little talk about what KIND of fiber we are talking about. I’ve been doing really well lately on my “Asian diet” which is high in rice and some root vegies, but it took some time to realize that when it didn’t work was when I was eating the FODMAPS. Who ever thinks of onions as a problem?

        I hope you don’t mind, but I coalesced your comments into one thread, so I could send them to someone who has SIBO.

        http://eatingoffthefoodgrid.blogspot.com/2013/10/resistant-starch-and-sibo.html

        I think you are exactly right about RS fighting bacterial overgrowth. Konjac is a sort of super-concentrated RS I think, and it works really well.

      • Not only is RS not on the list, neither is fiber. They advocate adding more RS and fiber as well. To me it’s like throwing oak logs on a fire. Takes time to get going, but once it’s going it burns hot. Also, recall, the Fast Tract Diet does not eliminate RS or fiber, but limits overall fermentable carbs to 40 grams per day until your symptoms abate. I agree with part of what Gary said – “Green leafy veges are the fibrous foods that epidemiology likes to single out as beneficial. Animals that eat them generate plenty of butyrate.”

        • I wanted to clarify a point that I may have muddled. When I am speaking RS, I am speaking of it in an isolated fashion, like raw potato starch. I think that in your approach to minimizing GERD, etc… you would be wise to avoid RS-rich foods as per your fermentation potential formula. RS in real food is always accompanied by low GI fibers and slowly digestible starches.
          Thanks

  50. Hi Tim,
    Thanks for your personal efforts along with Richard Nicoley, to educate us on the merits of RS. I have to admit that your work is raising some fascinating possibilities. I am particularly impressed with some of the data on blunting second meal blood sugar spikes.

    I also want to take a moment to appreciate the fact that we are talking about the fine points on how to modulate diet to treat digestive disorders – as opposed to grabbing for a pill bottle. Dr. Eades helped me enter this area many years ago and I have never looked back. What we are all involved with is an epic change in how these challenging conditions are treated. Let’s work together to really move this area forward.

    Now, when it comes to using RS to treat people with SIBO/dysbiosis, I am open to your ideas, but you really have your work cut out for you. This will be my final response (you can have the last word as I need to get back to some actual work : )).

    The debate we are having essentially mirrors “Gibsons Conundrum”
    Q. Manyan Fung and Andrew Szilagyi. Carbohydrate Elimination or Adaptation Diet for Symptoms of Intestinal Discomfort in IBD: Rationales for “Gibsons’ Conundrum”. International Journal of Inflammation Volume 2012, Article ID 493717

    The paper is more focused on FODMAPs and Inflammatory Bowel Disease but also includes significant review of IBS which is linked to GERD. The paper seems to be slanted towards prebiotics which is surprising because “removing” fermentable carbs was successful in virtually every study, yet the largest double blind randomized controlled study for prebiotics cited concluded: ”An adequately powered placebo-controlled trial of FOS showed no clinical benefit in patients with active Crohn’s disease.” and at least one other report referenced on success with prebiotic / probiotic blends for Crohn’s was later found not to be effective at preventing relapses. Nonetheless, the review is worth reading and makes some excellent points and frames the discussion well. And Tim, I realize the study mentioned above used FOS not RS. You dodged a bullet on that one.

    1. – RS selectively feed beneficial bacteria
    * Where is the proof? RS can be fermented by a wide variety of both good and bad gut bacteria, including those species identified in SIBO.
    The proof is in the hundreds of studies done, especially the ones from the last few years that show RS is specifically targeted for fermentation by butyrate producing species of bifido bacteria. But actually, this is only half the story…with RS, it takes two to tango. There are some recent studies on RS that show its fermentation is a two-step process. I have a great paper (pdf, not linkable) called, “Analyzing the Functionality of the Human Intestinal Microbiota by Stable Isotope Probing” in it, they describe the cross-feeding effect of RS, potato starch is used in their experiments:
    Hundreds of studies show RS is specifically targeted for fermentation by butyrate producing species of bifido bacteria

    [NR: As I mentioned, many different types of gut microbes make butyrate from numerous carb sources as well as protein. And many different types of bacteria (good and bad) can ferment RS. Here is one example of a bad bacterium (Klebsiella pneumonia) who’s overgrowth is definitively linked to the autoimmune disease ankylosing spondylitis that specifically ferments RS (http://www.ncbi.nlm.nih.gov/pubmed/8835506). Reducing RS improves the outcome of the disease. Alan Ebringer has decades of work on Klebsiella, AS and low starch diet. Lastly, LC and Fast Tract do include significant amounts of fermentable carbs and protein (just fewer carbs that SAD diet). More on this below.]

    2. – Cleanse the small intestine of certain pathogenic bacteria and out-of-place beneficial bacteria.
    *What is the evidence for this? Restricting carbs is the best way to clear SIBO and dysbiosis (see below).

    This is something I have only recently come across. I hope it turns out to be a cure for SIBO, or at least a big help in ridding the SI of some BO.
    However, if you add resistant starch to the Oral Rehydration Solution, the cholera often subsides on its own. This has been done historically with rice and corn starch.
    It was surmised that the RS in the solution caused a buildup of butyrate/SCFA/etc… and helped the body rid itself of cholera. However this study: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1183348/ examined the effects and found out that the vibrio cholerae attaches itself to the RS granules as soon as they come in contact, and the this slowly digesting substance takes the vibrio for a ride out of the SI and into the LI where it can be eliminated.
    This study found out that the vibrio cholerae attaches itself to the RS granules as soon as they come in contact, and the this slowly digesting substance takes the vibrio for a ride out of the SI and into the LI where it can be eliminated.

    [NR: This speculative in vitro study showing that Vibrio cholera attaches to starch granules is interesting and many other bacterial types likely adhere to starch as well, but does it mean bad bacteria (only) will be carried away from the small intestine under all conditions in vivo? The paper you cite does not show the evidence for actual efficacy in people with Cholera (might exist, but you don’t cite it) Also, they likely adhere as they are preparing to ferment it. People with fuctional gut problems often have slowed motility. Given the extra time you could postulate that fermentation might occur before arriving in the large intestine contributing to symptoms. All I’m saying is this observation with one pathogen does not convince me that RS will have a positive effect on people with SIBO where the culprit is not a single pathogen, but an overgrowth of normal gut bacteria migrating from the large to small intestine.]

    3. – Create a healthier large intestine through tightening of junctions, feeding of colonocytes, butyrate production, and forming biofilms impenetrable by pathogens
    *What is the evidence for tight junction improvement?

    Nearly every study on RS and the colonic environment has something like this in it (from http://www.ncbi.nlm.nih.gov/pubmed/15287679) :

    [NR: I don’t see any evidence presented in this review that RS improves tight junctions. Did I miss it?]

    Many studies have attempted to define an optimal intake, most conclude it is somewhere around 20-40g per day. The max anyone seems to be able to ferment is 50g per day, above that level, it is excreted in stool. The excretion point means the entire colon is flooded with RS, and, from the above study”

    [NR: In Bird, et.al.’s paper Starches, Resistant Starches, the Gut Microflora and Human Health. Curr. Issues Intest. Microbiol. (2000) 1(1): 25-37., they estimate fermentable substrate in the Western diet to be between 29 and 94 g/day (including endogenous secretions). Note the differences described below between chemical and physiological measurements could double that amount raising fermentable substrate 58 – 188 g / day. Using my FP formula, I arrive at approximately 150 g/day for SAD diet plus the 6-9 g/da from endogenous secretions noted below the table. The fast tract diet limits fermentable substrate to 30 – 40 g/day plus endogenous secretions of 6-9 g/day. Interesting that you are recommending 20-40 g fermentable material in the form of RS while I am recommending up to 49 g fermentable material per day – all source.
    Except from above referenced paper:

    Table 1. Potential Bacterial Substrates of Dietary Origin Reaching the
    Colon in Adult Humans Consuming a Westernized Diet

    Substrate Amount (g/day)
    Resistant Starch 8-40
    Non Starch Polysaccharides 8-18
    Oligosaccharides 2-8
    Simple Sugars 2-10
    Proteins 3-9

    From Cummings and Macfarlane, 1991; Baghurst et al., 1996.
    Note that endogenous secretions (6-9 g/day) and sloughed intestinal cells
    (unquantified) also contribute substrates for the colonic microflora.

    “These personal influences have led to the description of RS as “physiological” and “chemical” RS (Annison and Topping, 1994). The former term embraces RS as it occurs in the body and the latter the values obtained by chemical analysis. The differences between physiological and chemical RS may be considerable for specific foods. For example, baked beans or brown rice contain low amounts of RS when analyzed by standard procedures (Cheng and Yu 1997; Parchure and Kulkarni 1997). However, in animals the contribution of starch escaping into the large bowel is enough to double the effective “ fibre” content of these foods (measured as digesta mass or SCFA)”]

    “Recent data with high protein diets confirm that genetic damage can be increased, consistent with greater CRC risk. However, this damage can be reversed by increasing SCFA supply by feeding fermentable fibre as resistant starch or arabinoxylan. High protein, low carbohydrate diets have been shown to alter the colonic environment with lower butyrate levels and apparently greater mucosal exposure to ammonia, consistent with our hypothesis.”
    I’m thinking that even on an LC diet, RS would be useful in helping one attain an optimal gut.

    [NR: I support you in making your case, but you need to show that LC diet is unhealthy in the first place and there is a need for more fermentable carbohydrate than is already contained in LC diets.]

    4. *Yes butyrate feeds coloncytes, but on either LC or Low FP diets there is still plenty of fermentable material present. Otherwise people on these diets would not form feces. Gut microbes also ferment sugars that make up mucus that coats the entire intestine. They also ferment protein (we malabsorb between 10-20% of the protein we consume) and they produce butyrate from both of these activities.
    *Biofilm microbes – best adapted at securing binding to the mucosal layer and excluding pathogens – are actually fed by this mucus layer and less dependent on added fermentable material.

    I’m not an expert here, won’t even pretend! I do, however, love this study, called “Chemostat Enrichments of Human Feces with Resistant Starch Are Selective for Adherent Butyrate-Producing Clostridia at High Dilution Rates” found at http://aem.asm.org/content/66/10/4212.full :

    [NR: Interesting, but how does this play out in actual health outcomes for people with SIBO/dysbiosis.]

    5. “Lastly, please explain the success of LC, Low FP, FODMAP, low fiber and elemental diets in treating GERD, IBS, Crohn’s and Celiac disease and show me one adverse event, cancer, or infection from any of these studies.

    On a personal note one of my reservations to RS is because my own GERD symptoms were driven by high carb foods such as bread and pasta. If RS was not to blame, what was to blame?”

    I think these diets are effective because they remove the real culprits, whatever they are, but it is not the RS component. The real culprit may be rapidly digestible starch [NR: Not likely as most non-resistant starch is rapidly digested / absorbed], sugar, oligosaccharides, plant proteins, vegetable oils, polyols, or many other usual suspects–but I’d bet not the RS. I saw a paper the other day that suggested they were starting to add RS to elemental diets for coma patients because their gut flora was so messed up from the standard elemental diet. A standard feeding tube solution is usually composed of amino acids, fats, sugars, vitamins, and minerals–no prebiotics whatsoever.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2806551/
    RS in elemental diets to prevent c. diff infections.

    [NR: Sorry Tim. This is an opinion article, not a test of the idea in patients.]

    6. “Because this is all ongoing research, it’s possible that RS is not the worst carb driving gut dysbiosis and SIBO, perhaps being more comparable to the least fermentable fiber type – cellulose, but as a GERD sufferer, I would like to see proof that it doesn’t hurt and it adds health benefit.”

    The only thing I have to convince you is the standard test for SIBO, the hydrogen breath test. Numerous studies gave hydrogen breath tests to people after RS consumption. It took 4 hours to begin fermentation.

    [NR: You need to prove that it takes 4 hrs in people with SIBO as you allude to below]

    If you could prove this, you could probably make millions. Seems like it would be easy to test: Take a fasted SIBO person, feed them 40g of RS in water 2 or three times a day, along with a zero fiber, low carb diet, and redo the hydrogen breath test.

    [NR: Great idea Tim! If you really believe in your idea for people with SIBO, it’s a long bumpy road, but you can make it happen. You have my support. ]

    7. To date, the many studies I have read (admittedly, not nearly as many as you) on RS, which are almost 100% supported by the RS industry, don’t convince me.
    I have gone waaaay out of my way to choose studies that were NOT supported by the starch industry. Yes, they have spent billions to further RS. Mostly, this RS comes from GMO corn that needs a new home since the fall of HFCS,
    Many, many, many independent studies and papers show that plain old potato starch, tapioca starch, mung bean starch and even just eating beans and rice are just as effective as the franken-food Hi-Maize Corn Starch. Many show they are even more effective–potato starch particularly, due to the size of the starch granules.
    I almost gave up on RS when I saw how invested Ingredion and National Starch were in furthering RS as a functional ingredient. I have ‘insider’ papers that show the extents they are going to get corn starch redesignated as a functional fiber and how they can work the system just to get a high fiber rating on muffins and biscuits by using a tiny smidgeon of Hi-Maize–it’s criminal, really!
    Anyway, I hope you take this in the spirit of “we don’t need to be right but science does.”
    Nice talking with you, Norm.
    Tim

    [NR: As always, you too Tim. Keep up your fascinating research on RS]

    • Thank you for this immense undertaking and giving it a hard look. I won’t dispute anything you said as I think it gives good balance and anyone who comes across this in the future can look up all the references we’ve given and research it however they please.

      I was a bit surprised that you invoked one of my favorite papers, (Bird, et.al. Starches, Resistant Starches, the Gut Microflora and Human Health. Curr. Issues Intest. Microbiol. (2000) 1(1): 25-37)
      as a case against more RS, the entire paper is basically high-praise for more RS, and it has a large section on the ankylosing spondylitis connection you mentioned:

      “A diet low in starch has been shown to lower circulating IgA in these patients leading to the suggestion that the presence of potentially pathogenic organisms in the faecal microflora may be a trigger for these conditions (Ebringer and Wilson, 1996). If this were to occur, it could be a serious contraindication for greater RS consumption. However, further study has not supported a primary role for K. pneumoniae in spondylitis (Smith et al., 1997) or this organism, Escherichia coli or Listeria monocytogenes in IBD (Walmsley et al., 1998). Indeed, it appears that these responses may be a consequence of active disease rather than causative. Removal of RS from the diet induces temporary remission through bowel rest as does a low fibre diet (Klurfeld, 1999). ”

      The full-text of this paper may be found here and is a must-read for anyone studying RS.

      http://www.open-access-biology.com/probiotics/bird/

      • Won’t be the first time there were conflicting findings. Here is a new review and some convincing evidence for the connection between AS and Kleb P.

        Taha Rashid, Clyde Wilson, and Alan Ebringer. The Link between Ankylosing Spondylitis, Crohn’s Disease, Klebsiella, and Starch Consumption. Volume 2013 (2013), Article ID 872632, 9 pages

        • One possible explanation for the results in the smith paper. Have a look at their material and methods. They tested the control samples within 3 hr of receipt but the patient samples were send by mail from “wide geographical areas” and tested within 24-48 hr. Any standard micro lab invalidates samples or test results if the samples are received after 24 hr. They also noted that fewer species over all were recovered from patient samples than controls, the sample storage temperatures were different and the samples of 8 patients showed no growth at all on the selective media. These study results are not valid.

        • That’s some pretty heady reading!

          “Hence, increased consumption of starch-containing foods by genetically susceptible individuals such as those possessing HLA-B27 genes could result in the initiation and development of AS or spondylitis-associated CD. Dietary manipulation in the form of low starch diet intake can be included in the management of patients with AS or CD, especially when used in conjunction with the current medical therapeutic measures.”

          And here is the link if anyone’s interested: http://www.hindawi.com/journals/cdi/2013/872632/

          • Tim, The science daily report doesn’t give the details and I believe it’s a preliminary report from a meeting. Alcohol was also long thought to trigger GERD, a SIBO-related disorder. But a large Swedish study showed alcohol was not linked to GERD. Also, GERD symptoms were not improved in people who stopped drinking alcohol (http://www.ncbi.nlm.nih.gov/pubmed/16682569/). So what’s going on?

            What would trigger SIBO is fructose and sucrose found in sweetened mixed drinks, sweeter wines, RS in non light beer, etc. Non the less, the Fast Tract Diet limits recommends light beer, dry red and white wines or distilled spirits straight up, on the rocks or with sugar-free beverages.

            As for cirrhosis, that’s a different matter. The liver is very much involved in digestion.

  51. Dear Dr. Eades,

    Thank you for your two blogs about heartburn! I ordered the book (using the link here so you get credit) & it is helping a lot! I have been searching for this solution for a very long time. There are so many conflicting theories about this problem & you have hit the nail on the head! I am off my PPI. (Stepped down to Zantac & then off that entirely). I am telling my friends with heartburn about my success (& about this blog).

    For others with posture problems due to extreme heartburn pain I would recommend “8 Steps to a Pain Free Back” by Esther Gokhale. I have been hunched over for years & need to fix my posture. It is work, but well worth it. Her program is excellent.

    Thanks for your life-saving article! I was well on the way to throat cancer despite being on a PPI. It was not working very well.

    Allegra

  52. Outstanding.

    Thank you for this.

    I have been suffering a lot of GERD in the last year or so – but it has got unbearable in the last month.

    I do not want to go back to a PPIs after the things I’ve read. I’ve tried DGL liquorice, ACV – even kinesiology.

    I’m an endurance athelete and a committed bike racer. I tried significantly reducing carbs 72 hours ago – and am researching high fat low carb diets for athletes.

    My symptoms have literally disappeared. I’m fairly convinced that high carbs and the imbalance in my gut has been a major factor – and am now looking at teaching my body to burn fat over carbs – at least until the racing season.

    Thanks for the information.

    • Very interesting to see that response. As an addendum to the post above, I have also looked extensively at Norm Robillard’s GERD work (see his book on Amazon). The reduced starch/fibre and monitoring of certain foods also works for me. I have since been able to inform the relevant Doctor with regard to my symptoms and the potential cure.

      There is (to me anyway) clear progress being made here.

  53. Low carb diet includes: meat, eggs, nuts and non-starchy vegetables like leafy greens, broccoli, cauliflower, cabbage and green beans.

    Eating these foods would definitely reduce acid reflux issues.

  54. Hi, I had never heard of GERD until last week when I went to the ER with pressure under my ribs.I’ve never experienced reflux before but I’ve had 2 weeks of burning, burping, reflux and poor sleep. I’ve been given PPIs and antiacids, but a week later and I’m still struggling to eat without feeling very uncomfortable and having reflux. I came across your blog doing research into what I should eat as the doctors don’t seem to be very helpful.
    I am keen to try anything that takes away the symptoms, but I’m vegetarian. Does the protein diet have to contain a lot of meat? I’m living in China, so I would rather avoid meat until I get back home. If I start eating meat again after 7 years could that make the symptoms worse?

    • I doubt starting to eat meat again would make the symptoms worse (as long as carbs were reduced), but you won’t know till you try. I would go on a very low-carb diet to see if that helps. It shouldn’t take more than strict adherence to such a diet for a day or two to see a huge difference.

  55. I found it most intresting in what You written. But how many who has this problem have got medication to take down the acid. I`ve read some articles about one medication, Omeprazol/Losec, in whitch they point to the fact that when you give this, ph starts to go up, and then they get problems with many more bacteries that enjoy they knew enviroment.
    This is articles from Sweden. I don´t know whats written in Your country!
    Best regards
    Birgit

  56. I got cured permanently by leaving Gluten out of my diet after suffering 6 years of Acid reflux. I tested several home remedies, but none of them really helped. Here is the full story of my struggle http://www.gerdcured4good.com

    I hope I can help others to get rid of the GERD too, without any medication or additional products! 🙂

    Medication won’t help. You need to remove the root cause of your problem!