As far as nicotinic acid vs niacinamide; I have experienced extreme nausea and vomiting from niacinamide (non time-released) while I experience no nausea from much larger amounts of straight nicotinic acid. There is an enlightening discussion on niacin here http://healthcorrelator.blogspot.com/2010/06/niacin-turbocharges-growth-hormone.html that leads me to believe that taking it throughout the day is the issue as far as liver damage, particularly taking it away from mealtimes. Starting today I'm trying 3g with my one daily meal, and tomorrow I'll add ribose.

I've been doing much better digestion-wise with the niacin alone, it is exciting to hear of the radical difference you feel with the ribose!

Here is another informative webpage about NAD therapy:
"An induced state of NED is reversible and temporary in nature. The cellular NAD pool can be lowered sufficiently to bring about a NED through:
* Excessive alcohol consumption
* Excessive exercise
* Drug abuse and misuse
* Severe Malnutrition"

I actually previously had Irritable Bowel Syndome (which is apparently more common with those with CFS), and slight chronic fatigue (but not Chronic Fatigue Syndrome) and slight hairloss for years. But I got severe chronic fatigue syndrome (CFS) in 2008, after the worst flu of my life (mononucleosis), after which my IBS worsened by about a factor 2. A preceding period of excessive exercise, poor diet, alcohol use (I normally never drink alcohol), an erratic sleep schedule, and stress probably were also contributing factors that triggered the CFS. After about a year of worsening health, I decided to start zero-carbing in 2009 after reading some testimonials. (I started same age as the Bear and as Danny, if I am not mistaken.)

I had tried lots of different supplements for CFS, as recommended by various people. For example, Dr. Sarah Myhill recommends a supplement protocol for treating CFS, which she nicked from cardiologist Dr. Stephen Sinatra, which includes Co-enzyme Q10, L-carnitine, niacinamide, D-ribose and magnesium. (Sarah Myhill writes: "acetyl L-carnitine [is] also available through eating red meat, especially mutton, lamb, beef and pork - but to get 2 grams you need to eat about a pound of meat a day!" Who would be so crazy as to a eat a pound of meat per day?! Har har har!) With every supplement I used the question "Does this occur naturally in meat?" as a rule of thumb to determine whether I needed a supplement, because I disagreed with some of supplements people recommended, such as megadoses of vitamin C, which are not natural in a carnivorous diet. As carnitine, Q10, and niacin (also from tryptophane, and in beef liver) are all found in large amounts in an all-meat diet, I had started using Q10, L-carnitine, and a B-complex from Puritans Pride, among other things. Because ribose does not occur in meat (except in trace amounts), and because it is a carbohydrate, I avoided it.

My chronic fatigue syndrome somehow got better after a few months of zero-carb, but strangely, the maldigestion problems got worse and worse by order of magnitude (I don't have an explanation for this). Zero-carb didn't help me in this regard at all. After months of physical torture, the maldigestion thread on ZIOH finally helped me to figure out I needed HCl.

After a while I figured out that I could take as much as 70 betaine HCl capsules per meal without problems; 80 to 100 caused stronger burning sensations of varying degrees of strength. The most I ever took was 144 (don't ask...). I could swallow 20 capsules on an empty stomach without feeling anything. Recall that the pH scale is logarithmic (with base 10): multiplying the concentration of HCl decreases the pH by 1 point. A 5% solution of betaine HCl is approximately 8 tablets of 648 mg dissolved in 100 ml water. If it is the case that a "5% solution of Betaine HCl has a pH of 1", then 80 capsules have a pH of 0. As a reference point, the pH of an empty stomach is about 1, like a car battery, and food buffers the acidity by about 2-3 pH points upward.

But what is truly more insane is that the gastroenterologist literaly said "I don't believe you have hypochlorhydria"! Both gastroneterologists I visited I visited did not even know what hypochlorhydria was, and didn't test for it; So much for specialists! I could not believe it, but it was just like Dr. Jonathan Wright describes in his excelent book: stomach pH testing and supplemental HCl has fallen in disrepute among doctors apparently because pharmaceutical companies make millions of profit from stomach acid inhibitors.

In the past months, I have been reading all the books and web sites on hypochlorhydria I could get my hands on. As I almost died from malnutrition before I figured out what was going on, hypochlorhydria has (unfortunately) become of the utmost importance to me (as you can imagine). I became way too fatigued to participate in any forum discussions but I was avidly reading everything. That's when I stumbled upon these series of articles by Dr. Jonathan Prousky (1, 2, 3).

These articles implicate mitochondrial dysfunction as the cause of hypochlorhydria. Since my stomach problems really worsened after I got CFS, and mitochondrial dysfunction is suspected to be the cause of CFS, I (belatedly) decided to resume the ENTIRE recommended supplement protocol for CFS, this time including megadoses of nicotonic acid AND ribose (plus a good B-100 complex): I started using 3 g of nicotinic acid spread throughout the day as well 20 g of ribose spread throughout the day.

BOOOOOOOOOOOOOOOOOM!

Within about 2 weeks I could drop the needed HCl from about 70 capsules to almost zero!

I tried quitting the ribose for a week to see if helped. Within a week my stomach symptoms (eructation, slimy greasy feces, red eyes after eating, etc.) retured. When I added back the ribose again, the symptoms disappeared within a week again. Amazing!

However, by this time it was discovered that I had highly elevated liver enzymes, so I quit the nicotinic acid entirely, while still continuing the ribose. This time, my symptoms slowly returned after two weeks. I felt a burn at 50 capsules instead of 70, so maybe the ribose was helping somewhat. I then decided I would start using niacinamide 3 g per day instead of nicotinic acid, as several sources claim pure niacinamide is not harmful to the liver (1, 2, 3). I will need to retest in a few weeks. (I also added an NAD supplement, but this is too expensive to use long term.)

I just started this week with the niacinamide and my eructation has ceased again, but I still need HCl so it is to early to tell. I am keeping my fingers crossed, as I don't know what will happen.

I now believe the root cause of hypochlorhydria is the same as the root cause of CFS: mitochondrial dysfunction.

(See also Chronic fatigue syndrome and mitochondrial dysfunction and Lack of Stomach Acid - Hypochlorhydria - Can Cause Lots of Problems)

I would recommend following the entire supplement protocol recommended by Sarah Myhill, but personally, niacin and ribose were the only things that helped me, so it was due to NAD deficiency. Niacin alone did not help me, and ribose alone did not help me, but the combination did. I read that the body also requires ribose for the synthesis of NAD, so that might be the reason. Normally the body manufactures ribose itself from glucose, but somehow this mechanism is malfunctioning in me.

(I believe the fellow named "moises" from the forums has the same problem I do, as he also has eructation as his main symptom. I have found that the the pyloric sphincter thightens when it is in contact with acid (just like the lower esophageal sphincter tightens when it is in contact with acid, which is why Dr. Wright recommends HCl for GERD). Taking HCl on an empty stomach immediately makes my eructaton stop, making the lower half of my belly (the intestines) inflate without the gas flowing from the intestines to the stomach. Moises used 8 HCl tablets but did not feel anything, but didn't increase the dosage. I recommend taking HCl to tolerance (until it burns); don't worry about causing permanent damage: I have no ulcer).

I do not believe hormones are a cause of hypochlorhydria at all, but out of curiosity I might check it out further. I also do not believe bacterial overgrowth is a cause of hypochlodhydria (except for H. Pylori -- which I did not have, according to two different stomach biopsies). Bacterial overgrowth might be a consequence, not a cause of low stomach acid. Supplementing with salt did not help me. Supplementing with zinc did not do help me either. Pemmican didn't help me either. Magnesium, CoQ10, Carnitine and a low-niacin B-complex did not help me either. As I later figured out the B-complex contained too little niacin compared to the other B-vitamins (only 23% of the RDA). Other stuff -- glutamine, omega-3, you name it -- didn't help me either. All the meat I was eating was literally rotting in my intestines for days or even weeks causing HUGE amounts of PAINFUL eructation, 24 hours a day, as well as severe malabsorption, so believe me when I say that rotting meat and 'friendly bacteria' did not help me either. Indeed I believe the stomach and intestines should ideally be as sterile as possible.

Mitochondrial failure can apparently manifest itself in different ways; in any case my CFS mostly cleared up, but I still have hypochlorhydria (either that, or CFS has another additional cause which cleared up). It was during this period that I also got hundreds of horrible tiny hyperpigmentation spots (nevi) all over my body. Apparently, mitochondrial failure can also manifest as skin hypergpigmentation, as niacinamide is effective in reversing skin pigmentation. I will be watching to see if my skin improves, and keeping my fingers crossed. I damn well hope so, because I feel like I have aged a decade in one year, and am very depressed. I feel trapped in a body that is falling apart. :-(

P.S. Support Sarah Myhill!

I apologize if I came off as combative. I'm suggesting that nutrient deficiencies follow metabolic conditions.

It appears that the whole hypo/achlorhydria issue is self-perpetuating, with carbs feeding the overgrowth of the wrong microbes and protein passing through to the intestines to ferment anaerobically and feed the microbes as well. Only fat passes without issue (apart from likely poor absorption.) Here we see how pemmican helps tremendously, apparently mostly digesting prior to passing into the contaminated bowels- though even pemmican probably requires at least a mildly acidic stomach to fully absorb the nutrients.

I really wish you would qualify your "better question" with some experience regarding niacin or zinc before dismissing the possibility so briskly; of the many individuals struggling with ZC, this appears to be an unexplored avenue.

The only other idea I have currently as far as resolving achlorhydria is replacement of the stomach/intestinal flora with competing "friendly" bacteria, i.e. the high-meat approach. Aajonus claims this is all that is needed, though there are several high-meat eaters on the raw paleo forum who still struggle with ZC. This may simply be a matter of consuming large enough amounts of the 'good' microbes to totally eradicate the bad. Unfortunately my current lifestyle makes rotting huge amounts of meat impossible, but I hope to give it a shot down the road.

The better question is, what condition is causing low zinc/niacin, leading to low stomach acid.

I used Green Pasture's HVCLO. Use sparingly, a little goes a long way!

Great input Tom.

As usual you always have well thought out, valuable responses. We'll see were this new road takes me.