Functional Nutrition for H. Pylori

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What is H. pylori?

Helicobacter pylori (H. pylori) is a gram-negative, spiral-shaped bacterium that grows mainly in the digestive tract (1).

The bacteria’s unique shape allows it to burrow into the gastric mucosa (the mucous layer of the stomach), where it can survive due to the higher pH (2).


How common is H. pylori infection?

It is estimated that roughly 50% of the population worldwide is infected with H. pylori, with developing countries having the highest prevalence (up to 88%) (3).

About 10-15% of individuals infected with H. pylori will develop further complications (4).

In the United States, the reinfection rate after successful eradication of H. pylori is very low (about 1%) (5).


Is H. pylori contagious?

Yes, it is transmitted orally via vomit, saliva, feces, or contaminated food and water (6).

After colonizing the gastric mucosa, H. pylori typically remains in the stomach for a person’s lifetime unless it is successfully treated (7).


What are the risk factors?

Risk factors that increase susceptibility to H. pylori infection include (8):

  • Alcohol consumption
  • Having an infected family member
  • Low intake of fruits and vegetables
  • Low socioeconomic status
  • Poor hygiene
  • Smoking

What conditions are linked with H. pylori infection?

The following conditions are associated with H. pylori infection:

1. Gastritis

Up to 95% of individuals infected with H. pylori will develop gastritis (inflammation of the stomach), which increases the risk for ulcers (9).

Symptoms of gastritis include stomach pain, feeling full, heartburn, nausea, belching, and bloating (10).

2. Peptic ulcer disease

A peptic ulcer is an open sore in either the gastric or duodenal mucosa (11).

H. pylori infection and non-steroidal anti-inflammatory drugs (NSAIDs) are the two most common causes of peptic ulcer disease (PUD) (12).

Symptoms of peptic ulcer disease vary but may include abdominal pain, bloating, nausea, vomiting, weight loss or gain, and black, tarry stool caused by gastrointestinal bleeding (12).

3. Gastric cancer

H. pylori is recognized as the leading cause of gastric cancer, which approximately 1% of infected individuals will eventually develop (413).

The bacteria sets the stage for cancer by causing inflammation and directly altering the genetic make-up of gastric epithelial cells (14).

However, whether or not cancer will eventually develop also depends on an individual’s genetics and lifestyle factors (14).

Fortunately, successful eradication of H. pylori lowers the risk of developing gastric cancer by 44% (15). 

4. Nutrient deficiencies 

H. pylori can cause nutrient deficiencies by impairing absorption, reducing appetite, and increasing the metabolic requirement for certain nutrients (1617).

The following nutrients may be reduced by H. pylori (1618):

  • Folic acid
  • Iron
  • Nickel
  • Vitamin A
  • Vitamin B12
  • Vitamin C
  • Vitamin E
  • Zinc

Eradication of H. pylori has been shown to improve serum levels of iron and vitamin B12 (18).

5. Migraines

Studies have found that individuals with migraines have higher rates of H. pylori infection than healthy individuals (19202122).

A 2012 clinical trial actually found that patients being treated for migraines had a significant reduction in migraine-related symptoms after achieving successful eradication of H. pylori (23).

It has been suggested that the body’s inflammatory response to H. pylori may be involved in triggering migraines (21).

6. Parkinson’s disease

A recent meta-analysis found a higher prevalence of H. pylori infection in patients with Parkinson’s disease (24).

Interestingly, non-infected patients with Parkinson’s had a lower disease severity score than infected Parkinson’s patients.

However, this is only a correlation and more research is needed.

7. Metabolic disorders

H. pylori infection has been linked with an increased risk for metabolic disorders, such as insulin resistance, metabolic syndrome, and diabetes (252627).

Some experts have suggested that H. pylori induces insulin resistance by promoting the release of large amounts of inflammatory mediators (cytokines, prostaglandins, etc.), which are involved in the pathogenesis (28).

8. Rosacea 

Rosacea is a chronic inflammatory skin disorder that causes redness, visible blood vessels, and acne-like bumps on the face (29).

There is some evidence to suggest that H. pylori infection may play a role in the development of rosacea, possibly due to an increase in inflammation (30).

However, more research is needed (293031).


Does H. pylori have any beneficial effects?

Possibly.

Some studies have found a lower prevalence of autoimmune diseases, such as multiple sclerosis, in individuals infected with H. pylori (323334).

However, this may be due to the “hygiene hypothesis,” which suggests that early childhood exposure to certain microorganisms (including H. pylori) helps to strengthen the immune system (33).


What are the symptoms of H. pylori infection?

These are some of the most common symptoms (113536):

  • Abdominal pain that gets worse on an empty stomach
  • Bloating
  • Belching
  • Burning sensation in the stomach
  • Feeling very full after meals
  • Flatulence
  • Halitosis (bad breath)
  • Heartburn
  • Lack of appetite
  • Nausea
  • Unexplained weight loss
  • Vomiting

However, most people who are infected with H. pylori never develop symptoms (9).


Who should be tested for H. pylori?

Generally, testing is recommended for people who meet any of the following criteria (37):

  • Dyspepsia (indigestion)
  • Gastric mucosa-associated lymphoid tissue (MALT) lymphoma
  • Gastric cancer
  • Idiopathic thrombocytopenic purpura (ITP)
  • Long-term NSAID (including low-dose aspirin) use
  • Peptic ulcer disease (PUD)
  • Unexplained iron deficiency anemia

Testing should also be repeated at least 4 weeks after completing treatment to confirm that H. pylori has been eradicated.


How is H. pylori diagnosed?

Doctors typically diagnose H. pylori in one of the following ways:

1. Urea breath test

H. pylori produces an enzyme, urease, which converts urea (found in gastric juice) into ammonia and carbon dioxide, allowing it to neutralize stomach acid (3839).

During a urea breath test, the person swallows a tablet containing urea, and the amount of exhaled carbon dioxide is measured (40).

This method is highly accurate for diagnosing H. pylori, with a sensitivity of 96% and a specificity of 93% (41).

This test can be ordered through companies like LabCorp and Walk-In Lab.

Before urea breath testing, a doctor should be consulted if the client is taking interfering medications or supplements. For example, antibiotics and bismuth should be avoided for at least four weeks before testing, and PPIs for at least 2 weeks (40). 

These medications can cause false-negative results because they decrease the urease activity of H. pylori (40).

Any changes in medication should be discussed with and approved by a doctor first.

2. Stool DNA test

In a stool DNA test, DNA is extracted from stool samples and amplified by polymerase chain reaction (PCR), which makes it possible to identify and measure bacteria that may be present in the gut (42).

A popular test that uses this method is GI-MAP by Diagnostic Solutions Lab.

Stool DNA tests aren’t used as frequently by conventional doctors, but research shows it has a high rate of sensitivity (93.8%) for detecting H. pylori (42).

GI-MAP also tests for H. pylori’s most common virulence factors, which are molecules produced by the bacteria in order to colonize and invade the host’s tissues (4344).

The presence of certain virulence factors indicates increased risk for H. pylori-induced pathologies, such as gastric cancer and peptic ulcers (454647).

This information can be used by the clinician to determine whether H. pylori treatment is necessary.

3. Fecal antigen test

For a fecal antigen test, patients must provide a stool sample.

The presence of certain antigens (substances capable of stimulating an immune response) in the feces can indicate the presence of H. pylori (48).

This test is less expensive but also slightly less accurate (91% sensitivity and 93% specificity) than a urea breath test (4049).

4. Biopsy-based testing

When a doctor suspects that a patient might have a peptic ulcer, they might recommend a procedure called endoscopy, which involves inserting a tube with a camera attached to it into the digestive tract (37).

During the procedure, a biopsy of the gastric mucosa can be collected to help diagnose H. pylori infection.

However, this method is less common, because it is the most invasive and expensive option.


How do doctors typically treat H. pylori?

Standard treatment typically involves taking both of the following medications for 10-14 days (37):

1. Antibiotics

A combination of at least two different antibiotics are used to kill the bacteria.

The potential for antibiotic resistance (based on past antibiotic use and geographic location) influences which antibiotics are prescribed.

Unfortunately, antibiotic resistance is on the rise, making it increasingly difficult to successfully eradicate H. pylori (50).

2. Acid reducers

The suppression of stomach acid is an essential component to treatment, because it enhances the effectiveness of antibiotics (5152).

Proton pump inhibitors (PPIs), such as omeprazole or pantoprazole, and/or bismuth subcitrate or subsalicylate (Pepto-Bismol) are typically prescribed (37).


How effective is the standard treatment?

Treatment success depends on the type of drug regimen used, the patient’s adherence to the regimen, and the sensitivity of the H. pylori strain to the antibiotics used (37).

The overall success rate for patients given the standard treatment for H. pylori is about 85% (5354).

Unfortunately, success rates are declining as antibiotic resistance increases (37).

Another downside of using antibiotics is that they usually kill off the beneficial gut bacteria and can cause some nasty side effects like diarrhea, nausea, and vomiting (55).


Are there any additional treatment options?

The following may also be used to help eradicate H. pylori:

1. Probiotics

There is strong evidence that probiotics can inhibit H. pylori through several mechanisms, including stabilizing the gastric mucosal barrier and producing antimicrobials that inhibit urease activity (5657585960).

When combined with the standard antibiotic treatment, probiotics significantly increase H. pylori eradication rates and decrease negative side effects, mainly diarrhea (58).

The most common bacterial species used for H. pylori treatment include Lactobacillus, Bifidobacterium, and Saccharomyces (58).

A 2019 meta-analysis found that probiotics containing multiple strains of Lactobacillus were the most effective for treating H. pylori (60).

Use of probiotics alone, however, is not recommended for the treatment of H. pylori, because it results in a much lower eradication rate (14%) (59).

Further studies are needed to determine optimal dosing and which specific probiotic strains are most beneficial.

2. Deglycyrrhizinated licorice root

Evidence from in vitro and animal studies shows that glycyrrhiza glabra (licorice) root extract reduces H. pylori growth by inhibiting its ability to adhere to stomach cells (61626364).

Unfortunately, licorice is known to cause increases in blood pressure due to a compound called glycyrrhizin (65).

In order to avoid this negative side effect, glycyrrhizin is removed to create a supplement known as deglycyrrhizinated licorice (DGL) (65).

Clinical trials have found that supplementation with either reduced-glycyrrhiza licorice (380 mg twice daily) or DGL (150 mg/day) for 60 days significantly increases H. pylori eradication rates (6667).

3. Bismuth

Bismuth is a naturally-occuring metal that is sometimes included in medications, such as Pepto-Bismol.

Strong evidence shows that bismuth increases the effectiveness of antibiotic therapy for H. pylori, especially for antibiotic-resistant strains (6869).

It works by inhibiting urease activity and preventing H. pylori from adhering to the gastric mucosa (70).

However, no studies have evaluated the effects of bismuth separately from antibiotic treatment.

4. Zinc carnosine

Zinc carnosine (also known as polaprezinc) is a compound in which zinc is bound to L-carnosine, an amino acid found in muscle and brain tissue (7172).

There is some evidence that zinc carnosine may promote healing and inhibit gastric inflammation caused by H. pylori (73).

A 2017 trial found that polaprezinc supplementation (75-150 mg twice daily) significantly increased the rate of eradication (77% vs. 59%) in patients receiving antibiotic treatment for H. pylori (74).

5. Berberine

Berberine is a chemical found in several herbs, including goldenseal, that has been used to treat gastrointestinal diseases (7576).

There is evidence that berberine supplementation (500 mg/day) improves eradication rates and reduces adverse effects, such as diarrhea and vomiting, in patients receiving antibiotic treatment for H. pylori (7778).

It is thought that berberine works by suppressing the growth of H. pylori and reducing gastric inflammation (7980).

6. Black seed

Nigella sativa (black seed or black cumin) is an herb known for its antimicrobial effects (8182).

A 2010 study found that nigella sativa seed supplementation (1-3 g/day) resulted in 48-66% H. pylori eradication rates when combined with omeprazole, a proton pump inhibitor (83).

However, the control group, which received antibiotic therapy alone, still achieved a higher eradication rate (83%). 

7. Vitamin C?

Evidence from in vitro and animal studies suggests that vitamin C inhibits the growth of H. pylori (84)

Clinical trials have shown significant increases in H. pylori eradication rates in patients who supplemented vitamin C (0.5-5 g/day) in addition to standard treatment (858687).

However, a recent meta-analysis found that vitamin C has no significant effects on H. pylori eradication rates, noting that the quality of research was low (88).

Some experts have suggested that vitamin C may play a role in the prevention rather than treatment of H. pylori (89). 

8. Curcumin?

Curcumin, the main polyphenol found in turmeric, has been shown to inhibit the growth of H. pylori in rodent studies (909192).

Evidence from one trial suggests that curcumin supplementation (500 mg/day) in addition to antibiotic treatment increases the eradication rate for H. pylori compared to antibiotic treatment alone (93).

However, another study found no difference in eradication rates between the two treatments despite better resolution of dyspepsia symptoms in the group receiving curcumin (94).

9. Mastic gum?

Mastic gum is a resin collected from an evergreen tree (PIstacia lentiscus) that grows on the Greek Island of Chios (95).

Evidence from in vitro studies suggests that mastic gum has antibacterial activity toward H. pylori (9697).

However, trials evaluating the effects of mastic gum supplementation (1-4 g/day) in patients with H. pylori infection have failed to produce significant results (98).

One study from 1984 found that patients with ulcers who received mastic gum (1 g/day) for 2 weeks had significant symptom relief and evidence of healing (99).

More research is needed to clarify these results.

10. Other supplements

There are also several supplements for which there is VERY limited evidence of an effect on H. pylori, including aloe vera, grapefruit leaf extract, lion’s mane mushroom, oregano, propolis, and red ginseng (100101102103104105).


Recommended supplements for H. pylori

The following supplements contain some of the ingredients previously mentioned and are commonly used by dietitians to promote gut health in patients with H. pylori infection:

  • Gastromend HP
    • 500 mg vitamin C, 1 g mastic gum, 200 mg methylmethionine sulfonium chloride (“Vitamin U”), 150 mg DGL, 75 mg zinc carnosine per 4 capsules
    • Inactive ingredients: dicalcium phosphate, cellulose (capsule), tricalcium phosphate, vegetable stearate, silicon dioxide
  • Thorne Pepti-Guard
    • 400 mg DGL, 240 bismuth citrate, 200 mg aloe vera, 200 mg berberine HCL per 2 capsules
    • Inactive ingredients: hypromellose (derived from cellulose) capsule, leucine, silicon dioxide
  • Gastric repair complex
    • 500 mg DGL root extract, 100 mg mastic gum, 100 mg aloe vera gel, 100 mg bismuth citrate, 100 mg sodium bicarbonate, 100 mg potassium bicarbonate per 2 capsules
    • Inactive ingredients: vegetable cellulose capsule, maltodextrin, ascorbyl palmitate, silica, cellulose
  • DGL Plus
    • 300 mg DGL root extract, 50 mg aloe vera extract, 100 mg slippery elm bark powder, 200 mg marshmallow root extract per capsule
    • Inactive ingredients: vegetarian capsule (cellulose, water), ascorbyl palmitate

Foods that may help reduce the risk of H. pylori infection

The following foods may be beneficial for people with H. pylori:

1. Yogurt

Regular yogurt consumption (at least one serving per week) is linked with a decreased risk for H. pylori infection (106).

There is strong evidence that consumption of probiotic-containing yogurt (at least 1 cup/day) for 4 weeks improves eradication rates by up to 5-15% (107108109).

Strains of bacteria used in the yogurt in these studies included L. gasseri, L. acidophilus, L. bulgaricus, B. lactis, and S. thermophilus (107108).

2. Broccoli sprouts

Sulforaphane, a phytochemical found in broccoli sprouts and other cruciferous vegetables, has been shown to kill H. pylori and protect the gastrointestinal mucosa from oxidative stress (110111112).

Evidence from human trials suggests that consumption of broccoli sprouts (70 g/day) for 8 weeks decreases H. pylori levels (110113).

However, studies using broccoli sprouts powder (6 g/day) or broccoli sprout extract (500 mg/day) have failed to show any significant effects on H. pylori (114115).

3. Cranberry juice

Evidence from clinical trials shows that cranberry juice (1-2 cups/day) for 3 weeks to 3 months significantly increases eradication rates for H. pylori (116117

It is suggested that the polyphenols present in cranberries are responsible for inhibiting H. pylori’s growth (118).

4. Ginger

There is evidence that ginger inhibits the growth of H. pylori and reduces inflammation (119120).

A recent study found that ginger powder (3 g/day) for 4 weeks in patients with H. pylori-positive functional dyspepsia resulted in an eradication rate of 53.3% (121).

However, more research is needed to confirm these effects.

5. Garlic

A 2015 clinical trial found that patients who consumed raw garlic (2 medium-sized cloves twice/day with meals) for 3 days had significantly lower urea breath test results (122).

An antibacterial compound that is produced when garlic is crushed or chopped is thought to be responsible for these effects (123124).

If garlic is heated, its inhibitory effect on H. pylori decreases (125).

6. Olive oil

A 2012 study found that consumption of virgin olive oil (2 tablespoons/day) for 14 days resulted in eradication of H. pylori in 27-40% of patients (126).

The antibacterial effects of olive oil are thought to be related to its polyphenols, which can remain stable in gastric juice for hours after consumption (127).

7. Kefir

A 2011 trial found kefir consumption (250 mL/day) significantly improved eradication rates (78.2% compared to 50%) and decreased side effects, in patients receiving antibiotic therapy for H. pylori (128).

More research is needed to determine whether kefir is effective with other forms of treatment as well.

8. Cinnamon?

Evidence from in vitro studies suggests that cinnamaldehyde, the compound that gives cinnamon its flavor and odor, inhibits the growth of H. pylori (129130).

However, a small clinical trial found that alcoholic cinnamon extract (80 mg/day) was ineffective at eradicating H. pylori (131).

More research is needed to determine if other forms and doses of cinnamon might be effective.

9. Green tea?

Evidence from in vitro and animal studies have shown that green tea inhibits the growth of H. pylori and reduces its negative effects on the gastric mucosa (132133134135).

There have been no human trials, but green tea consumption has been linked with a lower risk of H. pylori infection (136).

10. Honey?

Numerous in vitro studies have shown that honey inhibits the growth of H. pylori by reducing the activity of urease (137138139140).

However, research in humans is needed.

11. Apples?

Evidence from in vitro studies suggests that the polyphenols found in apple peels may inhibit H. pylori growth and decrease the damage caused to the gastric mucosa (141142).

Research in humans is needed to confirm these effects.

12. Berries?

A 2004 in vitro study found that berry extracts (strawberry, raspberry, cranberry, elderberry, blueberry, bilberry) significantly inhibited H. pylori and increased the susceptibility of H. pylori to antibiotics (143). 

More research is needed to evaluate these effects in humans.

13. Cabbage juice?

A compound found in cabbage called methylmethionine sulfonium chloride (also known as “Vitamin U”) is thought to lower inflammation and aid in the healing of peptic ulcers (144145).

Several clinical trials from 1949-1956 found that patients with peptic ulcers who consumed fresh cabbage juice (4 cups/day) healed more quickly (145146147)

However, we need newer, higher-quality research to determine whether these results are due to the inhibition of H. pylori.

14. Red wine?

Evidence from in vitro and animal studies shows that resveratrol, a component of red wine, has antibacterial activity against H. pylori (148149150151152).

However, there haven’t been any human trials, and there may actually be a link between alcohol consumption and H. pylori infection (153).


Foods to avoid with H. pylori

People with H. pylori infections may want to avoid the following foods:

1. Excessive salt

Studies have linked high salt diets to increased risk for H. pylori infection (154).

Increased dietary sodium has also been shown to increase the carcinogenic effects of certain virulence factors (cagA(+)) (155156).

It is thought that increased salt concentration alters the growth, survival, and virulence factor expression of H. pylori (157).

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