If H. pylori and SIBO have been ruled out, but there’s still acid reflux worsened by carbs, but not protein, would you still recommend trying the betaine HCl-and-pepsin combo?

Chris Kresser:  Yes. Low stomach acid is still possible even without those two conditions.

“Could a hiatal hernia be a cause of acid reflux?” Yes, it could be in that situation.

“What is your recommendation for hiatal hernia?” You still need to treat the patient functionally as much as possible, but in some cases, the functional treatment may not be enough to resolve all of the problems. I usually do see significant improvement from functional treatment because even though the condition is structural in that it’s affecting the actual structure, it’s still the case that addressing the functional aspect of it can lead to a meaningful improvement in most cases. But in other cases, surgery may be required and the surgery is getting less invasive than it had been previously over the past couple of decades, so it might be worth considering in some situations.