Keto And Hiatal Hernia: A Safe Combination?

The ketogenic diet is a low-carbohydrate method of eating that is said to help with diabetes, epilepsy, autoimmune disorders, acid reflux, inflammation, hormonal imbalances, and other issues. However, the question of whether it is suitable for those with a hiatal hernia is more complex. A hiatal hernia involves a part of the stomach pushing through an opening in the diaphragm, and the main symptom is acid reflux, which can lead to gastroesophageal reflux disease (GERD). While some people with GERD and hiatal hernias have reported improvements on a keto diet, others have found that fatty foods—which are included in the keto diet—trigger their symptoms. Therefore, it is important to consult a healthcare professional before starting any new diet, especially if you have a pre-existing condition such as a hiatal hernia.

Keto and its impact on acid reflux

The keto diet is characterised by a reduction in carbohydrates and a relative increase in the consumption of proteins and fats. While the diet has been demonstrated to help with certain disorders such as epilepsy, it may not be for everyone.

The keto diet may spell trouble for those with acid reflux. Fatty foods can cause the lower esophageal sphincter (LES) to relax, allowing more stomach acid to back up. Fat also takes longer to leave the stomach, which could increase acid reflux symptoms. Obesity plays a key role in increased acid reflux symptoms, and most nutritionists agree that losing weight involves consistently choosing real, unprocessed foods and avoiding those that are high in fat and sugar.

However, a study published in the journal of Digestive Diseases and Sciences in 2006 demonstrated that a very low-carbohydrate diet in obese patients with GERD significantly reduces distal oesophageal acid exposure. All patients reported improvements in heartburn, chest pressure, excessive burping, and other GERD-related symptoms. The study is too small to draw any major conclusions, but the results do suggest decreased acid reflux in obese patients on a low-carbohydrate diet.

A very low-carbohydrate and high-fat diet, like the ketogenic diet, may be of great benefit to obese GERD patients, especially those who are overweight and insulin-resistant. However, GERD is a multifactorial problem, and patients with advanced GERD are less likely to benefit from just diet and lifestyle changes. Advanced GERD is associated with abnormal anatomy (hiatal hernia), esophageal dysmotility, and significant gastric emptying issues.

The link between keto and GERD

The Ketogenic Diet is a low-carbohydrate, high-fat method of eating. While keto is known to help with several health issues, it is not always the best option for everyone. For instance, individuals with a hiatal hernia are often advised to eat low-fat foods. However, keto's high-fat content may be beneficial in reducing heartburn for overweight and insulin-resistant individuals, who make up the majority of the adult US population.

The relationship between diet and GERD

GERD, or gastroesophageal reflux disease, is a multifactorial problem that affects the gastroduodenal motility, causing a reflux of gastric content into the oesophagus. While the relationship between diet and GERD is well-recognised, it is not well-studied. Spicy food, alcohol, and chocolate are known to exacerbate acid reflux, but the underlying mechanism is not known.

A heavy meal rich in fat is more likely to cause heartburn than a light meal consisting of lean meat and fresh vegetables. Fat, like smoking, alcohol, chocolate, and mint, is believed to decrease the lower oesophageal sphincter pressure, favouring acid reflux. Ingested food alters gastrointestinal motility in several ways that are not yet fully understood. In the case of GERD, certain ingested foods alter gastric motility in a way that favours reflux.

The impact of keto on GERD

A very low-carbohydrate and high-fat diet, like the ketogenic diet, may be of great benefit to obese GERD patients. Several individuals with GERD have reported an improvement in their acid reflux symptoms after adopting the keto diet. However, this is not the case for everyone, as some have also reported an increase in their GERD symptoms while on keto.

Managing GERD symptoms

To reduce the chance of acid reflux, some recommended tips include:

• Cooking with healthy fats like avocado, coconut, and olive oils
• Eating whole foods instead of processed foods
• Eating small meals every few hours instead of three large meals a day
• Adding probiotic foods to your diet, such as cultured vegetables, yogurt, kefir, and kombucha
• Drinking plain water—drinking eight glasses of water per day may help
• Walking after eating and avoiding lying down shortly after a meal
• Elevating the head of your bed so your chest is slightly higher than your legs
• Sleeping on your left side
• Managing your weight
• Stopping tobacco use if you smoke
• Skipping tight-fitting clothes, which can make heartburn worse
• Taking probiotics and digestive enzymes
• Eating meals in a calm and relaxing place
• Eating slowly and chewing well
• Avoiding standing up while eating

Foods to avoid with a hiatal hernia

A hiatal hernia occurs when part of the stomach enters the chest cavity through a hole in the diaphragm. This can cause acid reflux and heartburn, which may lead to gastroesophageal reflux disease (GERD). Dietary changes can help manage and prevent symptoms.

• Spicy or highly seasoned foods
• Certain vegetables, such as garlic, onion, and peppers
• Smoked or salted fish
• Pickles, vinegar, or mustard
• Strongly flavoured meats and sausages
• Dried nuts and fruit
• Strong tea or coffee
• Acidic foods, such as citrus fruits
• Fatty and fried foods, such as fried chicken and fatty cuts of meat
• Peppermint and spearmint
• Tomato-based foods, such as spaghetti sauce, pizza, and salsa
• Carbonated beverages
• Alcohol
• Dairy products, such as whole milk, ice cream, and creamed foods

It is important to note that everyone's tolerance to food is different, and some of the foods listed above may not cause discomfort for people with hiatal hernias. Keeping a food diary can help identify specific triggers.

Foods to eat with a hiatal hernia

A hiatal hernia can cause heartburn and acid indigestion, and certain foods can make these symptoms worse. A hiatal hernia occurs when part of the stomach enters the chest cavity through a hole in the diaphragm. Dietary changes can help manage and prevent symptoms. Here are some foods that can be included in the diet to help with the symptoms:

• Lean meats, such as skinless chicken, turkey, meat with little visible fat, ground turkey instead of ground beef, and fish. Lean beef cuts include round, chuck, sirloin, or loin. Lean pork cuts include tenderloin or loin chop.
• Non-citrus fruits, such as apples and bananas.
• Green beans, peas, carrots, and broccoli
• Grains, like cereals (bran and oatmeal), bread, rice, pasta, and crackers
• Low-fat or skim milk and low-fat yogurt
• Fat-free cheeses, cream cheese, and fat-free sour cream
• Fermented or cultured foods that are rich in probiotics. Popular fermented foods include yoghurt, kimchi, sauerkraut, kefir, and miso.
• Pretzels, graham crackers, rice cakes, and baked potato chips
• Low-fat sweets (no chocolate or mint)

It is important to note that everyone tolerates food differently, and some people may find that certain foods listed above may cause discomfort while others do not. To determine the best diet, it is recommended to keep a food diary and avoid anything that triggers symptoms.

Lifestyle changes to help manage a hiatal hernia

A hiatal hernia occurs when a section of the stomach pushes through the diaphragm and into the chest cavity. While it is not always symptomatic, it can cause heartburn and acid reflux. There are two types of hiatal hernia: sliding and paraesophageal (or rolling). Sliding hernias are the most common, constituting more than 80% of cases, while rolling hernias account for about 5–15% of cases.

Dietary Changes

• Eat non- or low-acidic foods: Opt for non-acidic, minimally processed, and high-fibre foods. Examples include lean meats (turkey, chicken), rice, pasta, bread, non-citrus fruits (apples, bananas), crackers, and pretzels.
• Fermented or cultured foods: Include foods rich in probiotics, such as fermented foods, but avoid probiotic-fortified ice creams, juices, yogurts, sweetened protein powders, and gummies.
• Follow a Mediterranean-style diet: This diet is high in fruits, vegetables, and whole grains and has been shown to reduce symptoms of GERD and hiatal hernias.
• Limit or avoid certain foods: Reduce your intake of acidic, rich, oily, or preserved foods. Spicy or highly seasoned foods, certain vegetables (garlic, onion, peppers), smoked or salted fish, pickles, vinegar, mustard, strongly flavoured meats, sausages, dried nuts and fruits, and strong tea or coffee may trigger symptoms.
• Eat smaller, more frequent meals: Instead of three large meals, try eating several smaller meals throughout the day.
• Drink fluids after meals: Avoid drinking fluids during meals, and opt to drink them after you've eaten.
• Avoid eating or drinking late at night: Refrain from consuming food or beverages 2 to 3 hours before bedtime or lying down to prevent acid reflux.
• Eat slowly and chew food well: Take your time while eating and chew your food thoroughly.
• Avoid very hot or very cold foods: Consuming extremely hot or cold foods and beverages may trigger symptoms.

Weight Management

Maintain a moderate weight: Losing weight, if needed, can help reduce gastric acid secretion and lower the chances of experiencing a hiatal hernia.

Smoking Cessation

Quit smoking: Smoking can irritate the digestive system and worsen symptoms.

Sleep Position

Elevate your head while sleeping: Raise the head of your bed by about 8 inches to keep your head elevated while sleeping, which can help reduce acid reflux.

Clothing

Wear loose clothing: Avoid tight clothing that can increase pressure on your abdomen, such as tight belts, control top hosiery, or body shapers.

Bowel Habits

Promote healthy bowel movements: Stay hydrated, eat enough fibre, and avoid straining during bowel movements to reduce abdominal strain.

Exercise

• Avoid strenuous activities: Refrain from heavy lifting or strenuous exercises that strain the abdominal muscles.
• Opt for low-impact exercises: Swimming and walking are suitable exercises for people with hiatal hernias as they do not strain the stomach.

Stress Management

Manage stress: Engage in stress-reducing activities such as walking, spending time in nature, mindfulness, meditation, or yoga to help alleviate symptoms.

It is important to note that while these lifestyle changes can help manage a hiatal hernia, severe or persistent cases may require medical attention, prescription medication, or, in some instances, surgery. Always consult with a healthcare professional before making significant dietary or lifestyle changes or if symptoms persist or worsen.

Frequently asked questions