Please note that this post contains affiliate links. As an Amazon Associate, I earn from qualifying purchases.
What is Gastroesophageal Reflux Disease (GERD)?
GERD is defined as symptoms or complications that result from the abnormal reflux of stomach contents into the esophagus, oral cavity, and/or lungs (1).
It is characterized by two main symptoms: heartburn (reflux) and regurgitation (the movement of stomach contents back up into the mouth) (2).
What are the different types of GERD?
Based on the presence or absence of damage to the esophagus, GERD is classified into one of the three following subtypes (5):
1. Non-erosive reflux disease
Patients with non-erosive reflux disease (NERD) experience typical GERD symptoms but have no visible signs of injury to the lining of the esophagus during upper endoscopy (6).
This is the most prevalent type of GERD, affecting 60-70% of patients (5).
2. Erosive esophagitis
In contrast to NERD, patients with erosive esophagitis show signs of injury (or erosion) in the lining of the esophagus in addition to reflux symptoms (7).
This is caused by inflammation that occurs when stomach acid, bile salts, and pepsin enter the esophagus (2).
Approximately 30% of patients with GERD have erosive esophagitis (5)
3. Barrett’s esophagus
Some patients develop a condition known as “Barrett’s esophagus,” which occurs when long-term acid reflux causes severe damage to the mucosa of the esophagus (8).
What is the difference between acid reflux, heartburn, and GERD?
Although used interchangeably, these terms have different meanings.
Acid reflux occurs when acid travels from the stomach, past the lower esophageal sphincter (a ring of muscle that acts as a valve), and up into the esophagus (10).
Heartburn is the term used to describe a burning sensation in the chest caused by acid reflux in the esophagus (near the heart) (10).
How common is GERD?
Approximately 20% of the United States population experiences GERD symptoms at least once per week (12).
What are the signs and symptoms?
- Chronic cough
- Difficulty swallowing
- Epigastric (upper abdomen) pain
- Hoarse voice
What causes GERD?
The following factors may contribute to the development of GERD:
1. Lower esophageal sphincter dysfunction
The role of the lower esophageal sphincter (LES) is to protect the esophagus from highly acidic stomach contents (5).
Between meals, the LES contracts to create a barrier between the stomach and the esophagus, which prevents reflux (5).
During swallowing, the LES relaxes, allowing food to pass through the esophagus and into the stomach (5).
The LES also relaxes during “transient LES relaxations” (TLESRs), short periods of time (10-45 seconds) that allow the stomach to vent gases during belching (2).
TLESRs can also be increased by certain factors, many of which are known to be triggers for GERD symptoms, including alcohol, smoking, and caffeine (5).
2. Enhanced postprandial gastric acid pocket
After a meal, there is an area below the LES (at the top of the stomach) where highly acidic stomach contents can accumulate, referred to as the postprandial gastric acid pocket (PPGAP) (2).
The PPGAP can push up through the LES and cause symptoms, especially in people with hiatal hernia (2).
3. Delayed gastric emptying
Approximately 26% of patients with GERD have delayed gastric emptying, in which the stomach doesn’t empty food as quickly as it should (16).
This allows the acidic mixture of partially digested food to linger in the stomach for too long, increasing the opportunity for reflux (16).
4. Impaired esophageal peristalsis
Normally, any stomach acid that reaches the esophagus is cleared by esophageal peristalsis (a series of coordinated muscle contractions) (5).
What are some potential complications of GERD?
The following health complications may occur in people with GERD:
1. Esophageal stricture
In some patients, esophageal stricture (a narrowing of the esophagus) can develop due to inflammation and damage caused by GERD (2).
Stricture can cause difficulty swallowing, painful swallowing, chest pain, and food impaction (when food gets stuck in the esophagus) (2).
2. Esophageal adenocarcinoma
Between 5% and 15% of patients with erosive esophagitis will eventually progress to Barrett’s esophagus, a condition that increases the risk for esophageal cancer (2).
In Barrett’s esophagus, long-term inflammation due to acid reflux causes the normal, healthy cells lining the esophagus to be destroyed (2).
These healthy cells are replaced with cells that are typically found in the intestines and are more likely to become cancerous (2).
Approximately 0.4-0.5% of people with Barrett’s esophagus go on to develop esophageal adenocarcinoma (2).
3. Dental erosion
According to one study, dental erosion (or loss of tooth enamel) was present in about 88% of patients with GERD, compared to 32% in the control group (19).
This occurs because acid reflux sometimes reaches the mouth and begins to eat away at the minerals that make up the teeth (19).
The following conditions have been linked to GERD:
1. Hiatal hernia
A hiatal hernia occurs when the upper part of the stomach bulges through an opening (the hiatus) in the diaphragm and into the chest cavity (20).
This can increase the risk for GERD, because it impairs LES functioning and allows for acid reflux (5).
Patients with hiatal hernia tend to have episodes of reflux that are more frequent and more severe (2).
This is most likely caused by increases in the hormone progesterone, which causes the LES to relax (2).
3. Excess abdominal fat?
Having a higher BMI is linked with an increased risk for GERD and a higher likelihood of having symptoms that are more severe (22).
It is thought that excess abdominal fat increases pressure on the stomach and contributes to the development of reflux (2).
Studies suggest that 30-65% of patients with asthma also have GERD (23).
5. Irritable bowel syndrome
A 2012 meta-analysis found that 42% of patients with IBS also experienced symptoms of GERD (25).
More research is needed to understand the reason for this link (26).
Research suggests that anxiety may promote acid reflux by lowering LES pressure, altering esophageal peristalsis, and increasing acid secretion (27).
How is GERD diagnosed?
GERD may be diagnosed by a physician in the following ways:
1. PPI trial
In patients with classic symptoms, such as heartburn and regurgitation, doctors often choose to begin treatment with proton pump inhibitors (PPIs) even without an official diagnosis (5).
A diagnosis of GERD can be confirmed If symptoms are reduced in response to PPI therapy (5).
2. Barium swallow
Some doctors may order a barium swallow, a procedure in which the patient’s esophagus is x-rayed after drinking a contrast solution (30)
This test can rule out structural problems, like esophageal stricture or hiatal hernia, but it’s generally not the best option for diagnosing GERD (1).
3. Upper endoscopy
Patients with certain symptoms, such as difficulty swallowing or chest pain, are often evaluated by upper endoscopy (also called esophagogastroduodenoscopy) (1).
During this procedure, an endoscope (a flexible tube with a camera at the end) is inserted down the throat and used to examine the lining of the esophagus (31).
This helps identify signs of damage and can aid in diagnosing erosive esophagitis and Barrett’s esophagus (1).
4. Ambulatory reflux monitoring
If a diagnosis of GERD can’t be made via a PPI trial or upper endoscopy, doctors may choose to order ambulatory reflux monitoring (also called esophageal pH monitoring) (1).
During this test, a probe is guided through the nose and down into the esophagus near the LES or a disposable wireless capsule may be placed in the esophagus via an endoscope (32).
For a 24-hour period, the probe records the pH of any reflux that enters the esophagus, while the patient is given a device that can be used to track any symptoms that occur (32).
Afterward, the probe is removed and the results are analyzed (32).
How do doctors typically treat GERD?
Conventional physicians may treat GERD in the following ways:
Signs and symptoms of hypercalcemia include nausea, vomiting, fatigue, bone pain, kidney stones, and constipation (40).
2. H2 blockers
After a meal, gastrin (a hormone produced by the stomach) stimulates the release of histamine, which binds to H2 receptors on parietal cells and promotes acid secretion (41).
H2 receptor antagonists (also called H2 blockers) lower stomach acid by blocking H2 receptors on parietal cells, which prevents histamine from binding (41).
These drugs provide temporary relief from GERD symptoms and are intended for short-term use (1-2 weeks) (35).
Common H2 blockers include famotidine (Pepcid), cimetidine (Tagamet), and ranitidine (Zantac), all of which are available over-the-counter (OTC) (41).
In April 2020, the FDA requested the removal of all ranitidine products from the market, because they were found to contain high levels of N-nitrosodimethylamine (NDMA) (42).
3. Proton pump inhibitors
Proton pump inhibitors (PPIs) are some of the most commonly prescribed drugs (also available OTC) in the United States (45).
PPIs work to decrease stomach acid by blocking the hydrogen/potassium ATPase enzyme (found in parietal cells), which is responsible for pumping acid into the stomach (45).
Common PPIs include esomeprazole (Nexium), omeprazole (Prilosec), lansoprazole (Prevacid), and pantoprazole (Protonix) (45).
In patients with chronic GERD, surgery may be considered, especially for those with erosive esophagitis or Barrett’s esophagus (35).
Laparoscopic fundoplication is a procedure in which the fundus (upper part) of the stomach is wrapped around the esophagus to restore the function of the LES and prevent reflux (35).
This is considered the gold standard for surgical treatment of severe GERD (50).
How effective is the standard treatment?
They provide symptom relief in 57-80% of patients with erosive esophagitis and about 50% of patients with NERD (53).
However, these drugs are more like a bandaid, because they don’t address the root cause and can ultimately make symptoms worse when discontinued (46).
Surgery has about an 80% success rate, but is typically only considered in very severe cases that haven’t responded to other treatments (54).
The following nutrient deficiencies have been linked to acid-lowering medications:
1. Vitamin B12
People who take acid-lowering medication for more than 10 months are at a higher risk of developing vitamin B12 deficiency (55).
When stomach acid is low (due to acid-lowering medications or other causes), vitamin B12 deficiency can develop (58).
Additionally, having low stomach acid can lead to small intestinal bacterial overgrowth (SIBO), which also increases the risk for B12 deficiency (48).
In SIBO, large numbers of bacteria in the small intestine utilize vitamin B12 for themselves, leaving little to be absorbed by the body (59).
2. Vitamin C
Some studies have found that PPIs reduce the concentration of vitamin C in gastric juices, as well as the proportion of vitamin C found in its antioxidant form, ascorbic acid (60).
However, it is unclear whether this would affect systemic levels (60).
Acid lowering medications also interfere with calcium absorption, which requires a low pH in order for calcium ions to disassociate from their inorganic salts and become absorbable (61).
This may explain the link between long term PPI use (>1 year) and increased risk of bone fractures (62).
Vegetarians on acid-lowering medications may also be at higher risk of iron deficiency since non-heme iron requires the presence of stomach acid to be properly absorbed (60).
These drugs may also reduce the effectiveness of iron supplements (63).
One study found that long-term PPI users had a 28% lower plasma zinc level than healthy controls (64).
Long-term PPI use has also been associated with low magnesium levels, but the mechanism is not understood (67).
Limited research suggests that PPIs may inhibit the absorption of beta-carotene (an antioxidant found in plants that converts to vitamin A) (68).
Can acid-lowering drugs eventually be discontinued?
For patients who have been using PPIs for longer periods of time, discontinuation can actually result in stomach acid levels that are higher than before treatment (known as rebound hyperacidity) (45).
Stopping these medications abruptly increases the risk of rebound hyperacidity, so patients must be gradually weaned under the guidance of a physician (45).
What diets are recommended for GERD?
Dietitians may recommend the following diets for GERD:
1. Low-carbohydrate diet
Fermentable carbohydrates (such as fructooligosaccharides) have been shown to increase GERD symptoms in some individuals, possibly by increasing the rate of TLESRs and the number of acid reflux episodes (71).
In one study, participants with BMIs classified in the obese range who followed a very low-carbohydrate diet (<20 g/day) had significantly reduced symptoms after just 6 days (75).
Foods to Avoid with GERD
Avoiding the following foods may help reduce GERD symptoms:
A recent meta-analysis found that alcohol consumption was significantly associated with a higher risk of GERD, especially in those who drank more than 3-5 times per week (77).
In the past, it was thought that regular coffee (but not decaf) increased GERD symptoms due to its caffeine content (79).
However, a 2014 meta-analysis showed no significant association between coffee intake and self-reported symptoms of GERD (80).
Yet, in those who were diagnosed based on endoscopy (rather than symptoms alone), coffee intake was associated with greater acid damage in the esophagus (80).
However, a 2019 meta-analysis of 30 studies showed that drinking tea was NOT significantly associated with an increased risk for GERD, except in East Asia (81).
Further research is needed before any firm conclusions can be made.
5. Carbonated beverages?
Many patients report carbonated beverages (soda, sparkling water, etc.) as a trigger for heartburn (87).
6. High-fat foods?
Patients with GERD are often advised to reduce their intake of fried, greasy, or high-fat foods (84).
A large study from 1999 found that having a high fat intake was not associated with increased risk of hospitalization due to GERD symptoms (93).
More research is needed.
7. Spicy foods?
Interestingly, long-term consumption of these foods is associated with a decrease in GERD symptoms (94).
8. Raw onion?
In an older study, participants experienced significantly greater heartburn symptoms when given a burger with a slice of raw onion, compared to a burger with no onion (95).
An older study found that spearmint had no effect on LES pressure or acid reflux, but it did increase symptoms when given in high doses (500 mg) (99).
The authors suggested that spearmint may irritate the lining of the stomach and esophagus, causing symptoms that mimic heartburn (99).
The following foods are frequently reported to cause symptoms of GERD, but haven’t been evaluated in any studies that we are aware of (98):
- Citrus fruits
What lifestyle changes are recommended?
The following lifestyle changes may help reduce GERD symptoms:
1. Weight loss?
Weight loss is often recommended for GERD patients who are classified as overweight or have had significant recent weight gain (1).
In one prospective study, 81% of individuals with a BMI in the overweight or obesity range who lost 5-10% body weight or reduced their waist circumference by 5-10cm reduced their symptoms, and 65% experienced a complete resolution of GERD, however, the study was not blinded and lacked a control group (100).
Other smaller studies have not found an association between weight loss and GERD symptoms (158, 159, 160). More research is needed to determine whether weight loss or waist circumference has a direct impact on GERD symptoms, for which populations, and the mechanisms of action.
2. Smoking cessation
Smoking tobacco reduces LES pressure and causes impaired clearance of acid reflux from the esophagus (101).
3. Mealtime habits
- Avoid eating before exercise (2).
- Eat smaller meals (2).
- Drink fluids between meals (not during) (2).
- Chew gum for 30-60 minutes after meals to improve the clearance of reflux from the esophagus (103, 104).
- Take a walk after dinner to increase gastric emptying (104, 105).
4. Bedtime tips
- Avoid eating 2-3 hours before bedtime to give the stomach time to empty its contents into the small intestine (2).
- Lie on your left side in order to position your stomach below the esophagus, reducing the opportunity for reflux (2).
- If you lie on your back, elevate the head of the bed at least 20 centimeters (about 8 inches) (2, 106).
5. Stress reduction
Are elimination diets helpful for GERD?
In children, cow’s milk allergy can mimic or aggravate symptoms of GERD (113).
A 2014 trial showed a 50% decrease in symptoms when participants followed personalized elimination diets that excluded their food sensitivities for several months (114).
Participants in the control group, who were told to avoid random foods but continued to eat foods they were sensitive to, had a 27% decrease in symptoms.
This suggests that roughly half of the symptom reduction seen in the test group was due to the placebo effect.
After the initial test period, the control group was told to avoid new foods (the ones they were actually sensitive to) and matched the symptom improvement seen in the test group.
Are any supplements beneficial?
The following supplements may be beneficial for GERD:
1. Sodium alginate
A 2017 meta-analysis found that alginate-based therapies are more effective than antacids for treating GERD symptoms (121).
Alginate supplements (in the form of sodium alginate) are widely available in addition to Gaviscon, a popular OTC alginate-based medication (121).
A recent review of 13 studies found that probiotic supplementation could reduce regurgitation and heartburn in patients with gastroesophageal reflux disease (GERD) (125).
Lactobacillus gasseri LG21 and Bifidobacterium bifidum YIT 10347 were two of the most commonly used strains (125).
Further research is needed.
3. Deglycyrrhizinated licorice root
Unfortunately, licorice is known to cause increases in blood pressure because it contains a compound called glycyrrhizin (129).
In order to avoid this negative side effect, glycyrrhizin is removed to create a supplement known as deglycyrrhizinated licorice (DGL) (129).
A 2011 trial showed a significant decrease in heartburn and other symptoms, in patients with functional dyspepsia who received DGL (75 mg/day) for one month (130).
Further studies are needed, specifically in patients with GERD.
DGL Plus by Pure Encapsulations is a popular DGL supplement that also includes aloe vera, slippery elm, and marshmallow root.
Iberogast (also known as STW-5) is a liquid supplement containing 9 herbal extracts (bitter candy tuft, lemon balm leaf, chamomile flower, caraway fruit, peppermint leaf, licorice root, angelica root, milk thistle fruit, and greater celandine herb).
Although there is no research specifically in subjects with GERD, several studies suggest that treatment with Iberogast (20 drops, 3 times/day) reduces acid reflux and heartburn in patients with functional dyspepsia (131, 132, 133).
It has been suggested that Iberogast works by improving gastric emptying time, but studies haven’t confirmed this theory (133).
Iberogast can be purchased here.
Melatonin is a sleep-promoting hormone produced by the pineal gland (in the brain) in response to darkness (134).
A small 2010 study found that patients who received melatonin supplements (3 mg/day) for 4 weeks experienced significantly fewer GERD symptoms (137).
More studies are needed to confirm these results.
It is commonly used as a flavoring agent in fruit juices, soft drinks, baked goods, ice cream, and pudding (138).
In several small, unpublished studies, 86-89% of patients with chronic heartburn or GERD experienced complete resolution of symptoms after receiving d-limonene supplements (1000 mg per day or every other day) for 2 weeks (140).
Higher quality research is needed to confirm these results and determine the mechanism responsible for limonene’s effects.
Although it’s best known for its sedative effects, chamomile may also help soothe the stomach and relax the muscles of the gut (141)
Chamomile is high in terpenoids (such as α-bisabolol, chamazulene, etc.) and flavonoids (including apigenin and quercetin), which may be responsible for these medicinal properties (141).
One study in 149 patients found that chamomile, as part of a multi-herb supplement known as Gastritol (available in Germany), reduced heartburn in patients with mild GI disorders (142).
However, there was no control group, and it’s unclear whether chamomile alone was responsible for the results (142).
8. Slippery elm?
Ulmus rubra, also known as slippery elm, is a native tree in North America that was traditionally used to aid digestion and soothe inflammation (143).
Controlled trials are needed to confirm these results.
9. Marshmallow root?
Althaea officinalis (also known as marshmallow) is an herb found in Asia and Europe that is known for its cough suppressant effects (150).
Human trials are needed to evaluate its effects on symptoms of GERD.
Are there any other alternative treatments?
The following alternative treatments have some promise for GERD:
In one study, acupuncture (once every other day for 8 weeks) was actually more effective than PPI therapy (omeprazole) (157).
Amy is a registered dietitian nutritionist and experienced nutrition editor. She received her Masters in Nutrition Diagnostics from Cox College and her Bachelors in Dietetics from Missouri State University. She currently works as a nutrition editor for Healthline and Greatist. Her passion is finding ways to communicate nutrition research in an interesting and easy-to-understand way.