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Citrus Fruit, Acid Reflux, and The Paleo Diet®

By The Paleo Diet Team
September 9, 2014

A great, nutrient-rich category of seasonal food are citrus fruit. Oranges, grapefruits, lemons, and limes, for example, are all packed with antioxidants and health-promoting flavonoids. Citrus fruit is also a great source to stay hydrated. Our go to association for “hydration” is “8-10 glasses of water per day.” However, many citrus fruits are over 80% water (w/w), so they’re not only a low calorie snack (frequently fewer than 50 calories in a whole fruit), but also a potentially valuable source of hydration.

Whole Fruit > Fruit Juices

It should go without saying, but eating the whole fruit is a much better way to harvest all of the health potential than drinking fruit juices. For starters, most juices include added sugars to make them sweeter, but also lack fibre. And as far as antioxidants go, the antioxidant activity in whole fruits is significantly greater than the individual components. For example, one study showed the whole fruits contained more antioxidant activity than the soluble (juice) and insoluble (fibrous) fractions.1

Citrus Fruit and The Paleo Diet

A low level of chronic inflammation is one of the most pervasive and ubiquitous threats to our health. This is another place where flavonoid-rich citrus fruits shine. In one seminal study, participants were assigned to increase their consumption of either low or high flavonoid fruits.10 The study showed certain biomarkers of inflammation were significantly improved in the high flavonoid group after 6-18 weeks.

But what about citrus acidity and reflux/heartburn? Many of these symptoms are more strongly associated with fruit juices than with whole fruits,4 so this is likely one of those “your mileage may vary” areas where personal experimentation is warranted. Further, one comprehensive review concluded that there is no strong evidence supporting citrus fruit avoidance for people prone to acid reflux.7

Similar to acid reflux, much of the evidence about citrus and dental erosion is specific to fruit juices.9 However, some studies have found an association with citrus fruits themselves, so if you’re predisposed to dental erosion, you may want to consider limiting servings to less than two per day.6, 8

There are numerous examples of citrus fruit consumption in hunter-gatherers, but net acid-load of the Paleo Diet is estimated to be quite low.3, 11 Thus, our hunter-gatherer ancestors would’ve readily consumed these foods, when they were available.

Citrus fruits are proven to be anti-inflammatory, antioxidant, and possibly even bear cancer-protective effects.2 Unless you experience fructose malabsorption,12 intolerances to FODMAPs,5 or some other malady impairing your ability to digest fruits, then there are few reasons to exclude these delicious foods when they’re seasonally available.

William Lagakos, Ph.D.

William Lagakos, Ph.D.

Dr. William Lagakos received a Ph.D. in Nutritional Biochemistry and Physiology from Rutgers University where his research focused on dietary fat assimilation and integrated energy metabolism. His postdoctoral research at the University of California, San Diego, centered on obesity, inflammation, and insulin resistance. Dr. William Lagakos has authored numerous manuscripts which have been published in peer-reviewed journals, as well as a non-fiction book titled The Poor, Misunderstood Calorie which explores the concept of calories and simultaneously explains how hormones and the neuroendocrine response to foods regulate nutrient partitioning. He is presently a nutritional sciences researcher, consultant, and blogger.


1. Alvarez J, Pastoriza S, Alonso-Olalla R, Delgado-Andrade C, Rufian-Henares JA. Nutritional and physicochemical characteristic of commercial Spanish citrus juices. Food Chem. Dec 1 2014;164:396-405.

2. Annuzzi G, Bozzetto L, Costabile G, Giacco R, Mangione A, Anniballi G, . . . Rivellese AA. Diets naturally rich in polyphenols improve fasting and postprandial dyslipidemia and reduce oxidative stress: a randomized controlled trial. Am J Clin Nutr. Mar 2014;99(3):463-471.

3. Eaton SB, Konner MJ, Cordain L. Diet-dependent acid load, Paleolithic [corrected] nutrition, and evolutionary health promotion. Am J Clin Nutr. Feb 2010;91(2):295-297.

4. Feldman M, Barnett C. Relationships between the acidity and osmolality of popular beverages and reported postprandial heartburn. Gastroenterology. Jan 1995;108(1):125-131.

5. Goebel-Stengel M, Monnikes H. [Malabsorption of fermentable oligo-, di-, or monosaccharides and polyols (FODMAP) as a common cause of unclear abdominal discomfort]. Dtsch Med Wochenschr. Jun 2014;139(24):1310-1314.

6. Jarvinen VK, Rytomaa, II, Heinonen OP. Risk factors in dental erosion. J Dent Res. Jun 1991;70(6):942-947.

7. Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med. May 8 2006;166(9):965-971.

8. Linkosalo E, Markkanen H. Dental erosions in relation to lactovegetarian diet. Scand J Dent Res. Oct 1985;93(5):436-441.

9. Lussi A, Jaggi T, Scharer S. The influence of different factors on in vitro enamel erosion. Caries Res. 1993;27(5):387-393.

10. Macready AL, George TW, Chong MF, Alimbetov DS, Jin Y, Vidal A, . . . Group FS. Flavonoid-rich fruit and vegetables improve microvascular reactivity and inflammatory status in men at risk of cardiovascular disease--FLAVURS: a randomized controlled trial. Am J Clin Nutr. Mar 2014;99(3):479-489.

11. Sebastian A, Frassetto LA, Sellmeyer DE, Merriam RL, Morris RC, Jr. Estimation of the net acid load of the diet of ancestral preagricultural Homo sapiens and their hominid ancestors. Am J Clin Nutr. Dec 2002;76(6):1308-1316.

12. Shepherd SJ, Gibson PR. Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management. J Am Diet Assoc. Oct 2006;106(10):1631-1639.

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