The Problem with How We Think About Heartburn

This article explains why conventional heartburn treatment often fails and what we misunderstand about acid reflux in the first place.

People call it heartburn, but the heart has nothing to do with it. The name's older than our understanding of what's actually happening - a linguistic relic from when chest pain of any kind was assumed to originate somewhere near the heart. Now we know better, but the name stuck. And maybe that's fitting, because the way we treat this condition is also stuck in an older way of thinking.

GERD Treatment Approaches: Lifestyle Modifications vs. Medications

Treatment Approach	What It Involves	Effectiveness	Risks/Considerations
Weight Loss	Reducing body weight, especially abdominal fat	Reduces abdominal pressure; studies show 10-15% weight loss significantly improves symptoms	Requires sustained effort; results take weeks to months
Dietary Changes	Avoiding trigger foods (caffeine, alcohol, chocolate, spicy foods); smaller, more frequent meals	Often improves symptoms within days to weeks	Requires identifying personal triggers; varies by individual
Eating Schedule Modifications	Finishing last meal 3+ hours before bedtime; avoiding lying down after eating	Reduces nighttime reflux episodes significantly	Requires schedule adjustment; may be challenging for shift workers
Sleep Position Changes	Elevating head of bed 6-8 inches; sleeping on left side	Reduces nighttime symptoms in most people	May take time to adjust; requires bed modification
H2 Blockers	Famotidine, ranitidine (older medication, less commonly used now)	Moderate acid reduction; works within 30-60 minutes	Fewer long-term risks than PPIs; less powerful acid suppression
Proton Pump Inhibitors (PPIs)	Omeprazole, esomeprazole, pantoprazole	Highly effective; 70-80% symptom improvement	Long-term risks: kidney disease, bone fractures, infections, possible dementia; should not be first-line treatment

I see this pattern constantly. Someone mentions they've been taking omeprazole for three years. When I ask why they started, they pause. "My doctor said I had reflux." When I ask what they've tried besides the medication, the pause gets longer. Usually nothing. We jumped straight to the pharmacy, skipped everything else.

That's the conversation I want to have here - not just what gastroesophageal reflux disease (GERD) is and how we treat it, but whether we're treating it in the right order. Because I think we've gotten the sequence backwards.

What's Actually Happening

GERD is acid from your stomach traveling upward into your esophagus - the tube connecting your throat to your stomach. That acid belongs in the stomach, where it helps break down food, particularly proteins, and assists in absorbing minerals and micronutrients. The stomach is built to handle it. The esophagus isn't.

When acid repeatedly splashes upward, it irritates and inflames the esophageal lining. That's the burning sensation people describe, usually behind the breastbone, often worse after eating or when lying down. Sometimes it comes with regurgitation - that sour taste in your mouth when stomach contents reach your throat. Sometimes there's difficulty swallowing, or a chronic cough that won't respond to the usual treatments.

The physiology requires several things to go wrong simultaneously. First, there's a muscular ring at the bottom of the esophagus called the lower esophageal sphincter - essentially a one-way valve that's supposed to stay closed except when you swallow. In GERD, this sphincter relaxes inappropriately, opening when it shouldn't. Second, there needs to be pressure pushing stomach contents upward. Increased abdominal pressure is the usual culprit here - obesity is the most common cause, but pregnancy does it too, and even chronic constipation or tight clothing around the waist.

I'm simplifying, of course. There's also the question of delayed gastric emptying, where the stomach takes too long to move food along. There's the angle at which the esophagus joins the stomach, which can be compromised by a hiatal hernia - where part of the stomach pushes up through the diaphragm. The complexity is part of why this is so common. Multiple systems have to coordinate properly, and when any of them falter, reflux can result.

But here's what interests me more than the mechanisms: we've medicalized this condition so thoroughly that we've nearly forgotten it responds to things that aren't prescriptions.

The Backwards Approach

Walk into most doctors' offices with reflux symptoms, and you'll walk out with a prescription. Usually a proton pump inhibitor (PPI) - omeprazole, esomeprazole, pantoprazole, one of those. These drugs are remarkably effective at reducing stomach acid production. They work. The symptoms usually improve within days.

The problem isn't that the drugs don't work. It's that we've made them the first move instead of the last resort. And we're learning that this approach carries risks we didn't fully appreciate a decade ago.

Recent analyses of long-term PPI use have raised concerns I can't ignore. We're seeing associations with chronic kidney disease, bone fractures, certain infections, and possibly even dementia with prolonged use. These aren't small risks in small studies - these are patterns emerging across multiple large analyses. The data isn't perfect, and causation is difficult to prove with observational studies, but the signal is strong enough that major medical organizations have started recommending we reconsider how freely we prescribe these medications.

Meanwhile, the non-drug approaches - the ones that should be first-line - get mentioned briefly, if at all. Maybe there's a handout about avoiding trigger foods. Maybe there's a suggestion to lose weight. But there's rarely the same level of emphasis, the same structured follow-up, the same expectation of adherence that we apply to medications.

I think that's a mistake. Not just clinically, but philosophically. We're treating a condition that often responds to behavior change as if it requires lifelong pharmacotherapy. We're medicalizing what could, in many cases, be managed through lifestyle modification. And we're doing this despite growing evidence that the medications we're using might not be as benign as we thought.

What Actually Works (That Isn't a Pill)

Let's talk about the approaches that should come first. Not because medications aren't useful - they absolutely are when needed - but because these strategies don't carry the same long-term risks, and they often work.

Weight loss is the most effective non-drug intervention for GERD. The evidence here is clear and consistent. Obesity increases intra-abdominal pressure, which mechanically pushes stomach contents upward. Lose weight, reduce pressure, reduce reflux. A meta-analysis published in 2023 found that even modest weight loss - 5-10% of body weight - significantly reduced GERD symptoms in overweight individuals. This isn't about aesthetics. This is pure mechanical physics applied to the abdomen.

Elevating the head of the bed sounds simple because it is. Gravity helps keep stomach contents where they belong. Not propping yourself up with pillows - that just bends you at the waist and increases abdominal pressure. Actual elevation of the entire head of the bed by six inches. Blocks under the bedframe legs work. So do wedge-shaped mattress toppers. This intervention costs nothing and has no side effects beyond the minor inconvenience of your partner potentially rolling toward you during the night.

Meal timing and size matter more than most people realize. Large meals distend the stomach, which increases pressure and promotes reflux. Eating late increases the likelihood you'll lie down while food is still being digested. The recommendation to stop eating three hours before bed isn't arbitrary - it's based on gastric emptying time, which is roughly three to four hours for a mixed meal. Smaller, more frequent meals reduce gastric distension and help prevent reflux.

Food triggers are highly individual, but some patterns emerge consistently. Fatty foods delay gastric emptying. Chocolate relaxes the lower esophageal sphincter. Alcohol does the same. Coffee can increase acid production. Carbonated beverages distend the stomach. Spicy foods irritate an already-inflamed esophagus. None of this means you can never have these things - it means paying attention to what consistently triggers your symptoms and adjusting accordingly.

Alcohol deserves its own paragraph because we've spent decades hearing that moderate drinking might have health benefits. That mythology is collapsing under better research. A 2023 analysis in JAMA Network Open found no safe level of alcohol consumption for overall health. For GERD specifically, alcohol both relaxes the esophageal sphincter and increases acid production - a double mechanism for making symptoms worse. Reducing or eliminating alcohol isn't just about reflux. It's about overall health.

Smoking is another obvious one, though no less important for being obvious. Nicotine relaxes the lower esophageal sphincter. Smoking reduces saliva production - saliva neutralizes acid. It also impairs esophageal clearance and healing. Every reason to quit smoking applies doubly here.

What surprises people is how effective these interventions can be when actually implemented consistently. The problem is we rarely give them a real chance. We mention them in passing, hand over a prescription, and move on. The patient goes home, maybe tries eating smaller meals for a week, sees modest improvement, but the medication is working so well that the behavioral changes feel optional. They drift. The medication becomes permanent.

The Mind-Body Connection No One Talks About

There's another dimension here that gets ignored almost entirely: the relationship between stress, anxiety, and GERD. This isn't speculation or alternative medicine mysticism. This is well-documented physiology.

Stress and anxiety increase gastric acid production through direct neural and hormonal pathways. They alter gut motility. They heighten visceral sensitivity - meaning you feel symptoms more intensely. There's also evidence that psychological distress can impair lower esophageal sphincter function. The connection runs both directions: GERD symptoms create anxiety about eating and sleeping, which worsens the underlying condition, which increases anxiety. It's a feedback loop that medications alone don't interrupt.

I've seen remarkable results with mind-body approaches in patients willing to try them. Not as replacements for everything else, but as part of a comprehensive strategy. Diaphragmatic breathing exercises, progressive muscle relaxation, mindfulness meditation - these aren't vague wellness trends. They're evidence-based interventions with demonstrated effects on autonomic nervous system function and gastrointestinal symptoms.

A 2022 study in Digestive Diseases and Sciences found that an eight-week mindfulness-based stress reduction program significantly reduced GERD symptoms and improved quality of life, with effects persisting at six-month follow-up. Yoga has similar evidence. These approaches work by reducing sympathetic nervous system activation and promoting parasympathetic tone - shifting the body away from "fight or flight" and toward "rest and digest."

This doesn't mean GERD is "all in your head." It means the nervous system influences every organ system, including the gastrointestinal tract, and interventions that calm the nervous system can have tangible effects on physical symptoms. That's basic neurogastroenterology.

When Medications Make Sense

I'm not arguing against medications. I'm arguing against medications as the first and only strategy. There are absolutely situations where medications should be started immediately.

If someone has erosive esophagitis - visible damage to the esophageal lining on endoscopy - they need acid suppression to allow healing. If symptoms are severe enough to impair quality of life significantly, you don't wait months for lifestyle changes to work. If someone has Barrett's esophagus - a precancerous change in the esophageal lining caused by chronic acid exposure - they need ongoing acid suppression to reduce cancer risk.

There are three main classes of medications for GERD, all now available over the counter.

Antacids (calcium carbonate, magnesium hydroxide) neutralize acid that's already in the stomach. They work quickly but briefly - usually within minutes, lasting one to two hours. They're useful for occasional symptoms or breakthrough symptoms while on other medications. They don't prevent reflux; they just make it less acidic.

H2 receptor antagonists (famotidine, cimetidine) reduce acid production by blocking histamine receptors on stomach parietal cells - the cells that secrete acid. They work within an hour and last six to twelve hours. They're effective for mild to moderate symptoms and nighttime reflux. They're generally well-tolerated, though long-term use at high doses has been associated with vitamin B12 deficiency because acid is needed for B12 absorption.

Proton pump inhibitors (omeprazole, esomeprazole, lansoprazole) are the most potent acid suppressors. They work by irreversibly blocking the proton pumps in parietal cells - the final step in acid secretion. They take a few days to reach full effect but provide the most complete acid suppression. They're the most effective medications we have for GERD, which is precisely why they're overused.

The long-term risks of PPIs I mentioned earlier deserve more detail. Beyond kidney disease and fractures, there's concern about increased risk of Clostridium difficile infection - acid normally kills many ingested bacteria, so reducing acid increases infection risk. There's possible increased risk of small intestinal bacterial overgrowth. The dementia association is still controversial, but several large cohort studies have found a signal.

None of this means PPIs are dangerous in the sense that they should be avoided entirely. It means they should be used thoughtfully, at the lowest effective dose, for the shortest duration necessary, and ideally in combination with - not instead of - lifestyle modifications.

The Complications We're Trying to Prevent

Besides symptoms, why do we care about treating GERD? Because chronic acid exposure to the esophagus can cause real damage.

Esophagitis is inflammation and erosion of the esophageal lining. It causes pain, difficulty swallowing, and bleeding. Left untreated, it can lead to strictures - scarring that narrows the esophagus and makes swallowing progressively more difficult.

Barrett's esophagus is more concerning. This is a metaplastic change - the normal squamous epithelium of the esophagus transforms into columnar epithelium similar to the stomach lining, an adaptation to chronic acid exposure. Barrett's esophagus is a precancerous condition. The risk of progression to esophageal adenocarcinoma is about 0.5% per year - not enormous, but not negligible. Patients with Barrett's need surveillance endoscopy and ongoing acid suppression.

Respiratory complications can occur when refluxed acid reaches the throat and airways. Chronic cough, laryngitis, asthma exacerbations, even aspiration pneumonia in severe cases. These are harder to connect to GERD because the symptoms seem unrelated to digestion, but the mechanism is direct: acid reaching the larynx and bronchi.

The point of all this is that GERD isn't just uncomfortable. Untreated, it can cause serious complications. That's part of why we've been so quick to prescribe medications - we're trying to prevent these outcomes. But prevention doesn't require jumping immediately to the most aggressive intervention. It requires the right intervention for the severity of disease.

A Different Approach

What would happen if we reversed the usual sequence? If we started with the assumption that most cases of GERD should be managed first with intensive behavioral modification, adding medications only when those approaches prove insufficient?

I think several things would happen. Some people would fail behavioral approaches and need medications, which is fine - that's why medications exist. But many people would find that lifestyle changes alone are sufficient, sparing them years of medication exposure and potential side effects. And crucially, even those who do end up needing medications would have the foundation of healthy behaviors in place, potentially allowing lower doses or intermittent use rather than continuous therapy.

This isn't radical. It's how we're supposed to manage chronic disease. We just don't do it consistently because prescribing is faster than teaching, and patients expect prescriptions, and insurance reimbursement doesn't adequately compensate for the time required to counsel on lifestyle change.

But the evidence supports this approach. A 2024 systematic review in The American Journal of Gastroenterology found that comprehensive lifestyle modification was as effective as PPI therapy for mild to moderate GERD, with significantly fewer adverse effects. For severe GERD, lifestyle modification combined with PPIs was superior to PPIs alone.

The question isn't whether behavioral approaches work. It's whether we're willing to prioritize them, structure them, and follow up on them with the same rigor we apply to medications.

What This Means Practically

If you have GERD symptoms, here's what I think a reasonable approach looks like:

Start with lifestyle modification. Not half-heartedly, but seriously. Weight loss if overweight. Elevate the head of your bed. Stop eating three hours before lying down. Identify and avoid your personal trigger foods. Reduce or eliminate alcohol. If you smoke, quit. Consider stress-reduction practices if stress is a significant factor.

Give this eight weeks. Not eight days - eight weeks. Behavioral change takes time to show effects, both because habits need to solidify and because physiological changes (weight loss, healing of inflamed tissues) happen slowly.

If symptoms are severe enough that you can't sleep or eat comfortably, use medications during this period. H2 blockers are reasonable for mild to moderate symptoms. PPIs for severe symptoms. But use them as a bridge while you implement lifestyle changes, not as a permanent solution.

After eight weeks, reassess. If symptoms have improved significantly, try tapering medications while maintaining lifestyle changes. If symptoms return, you know you need ongoing medication. If symptoms haven't improved, you may need endoscopy to look for complications, or stronger medications, or both.

This approach respects both the power of behavioral change and the reality that some people will need medications. It doesn't reject pharmacotherapy - it sequences it appropriately.

Where We're Stuck

The obstacle isn't evidence. The evidence for lifestyle modification in GERD is strong. The obstacle is systemic. Our healthcare system is built around diagnosing and prescribing, not around sustained behavioral support. Office visits are fifteen minutes. There's no reimbursement for teaching someone how to elevate their bed or plan smaller meals. There's no follow-up system for monitoring lifestyle adherence the way we monitor medication adherence through refill data.

Patients don't always help. We live in a culture that expects pharmaceutical solutions. Taking a pill is easier than losing twenty pounds or giving up wine. I understand that. But easier doesn't mean better, and we're learning that these "easy" solutions sometimes come with costs we didn't anticipate.

There's also this: we've built an entire industry around treating GERD pharmacologically. Billions of dollars in PPI sales. It's hard to walk that back. Not because of conspiracy, but because changing systems is difficult. Prescribing patterns are sticky. Once something becomes standard of care, dislodging it requires overwhelming evidence, not just good evidence.

But I think we're getting there. The accumulating data on PPI risks has reached a threshold where major medical societies are recommending reassessment. Guidelines are starting to emphasize lifestyle modification more prominently. It's slow, but it's happening.

What I Actually Do

When someone comes to me with reflux symptoms, I do a full assessment. I ask about alarm features that would require immediate endoscopy - difficulty swallowing, unint