Most people describe heartburn as burning behind the breastbone, often after a large meal, often worse lying down. Some also get an acidic or bitter taste at the back of the throat, a persistent dry cough, hoarseness in the morning, or the sensation of a lump in the throat.
The common assumption is that the stomach is producing too much acid. Usually it is not. The acid is in the right amount and the wrong place — and the difference matters, because it changes which remedies make sense.
The valve, not the acid
At the junction of the oesophagus and stomach is a ring of muscle called the lower oesophageal sphincter. Its job is to open to let food down and stay closed the rest of the time.
The stomach is built to handle acid. Its lining is protected. The oesophagus is not. When the sphincter relaxes at the wrong moment, or when pressure inside the abdomen pushes stomach contents past it, acid contacts unprotected tissue. That is the burn.
Anything that either weakens that valve or raises pressure below it will produce reflux:
- Large meals, which physically distend the stomach
- Lying down within a few hours of eating, which removes gravity from the equation
- Excess abdominal weight, which raises pressure below the valve
- Pregnancy, for the same mechanical reason plus hormonal relaxation of smooth muscle
- Tight waistbands and belts
- Smoking, which relaxes the sphincter
- A hiatus hernia, where part of the stomach slides up through the diaphragm, weakening the barrier structurally
- Alcohol, which relaxes the sphincter and irritates the lining
Note how many of these are mechanical rather than dietary. That is the central point.
Foods: less decisive than you think
Certain foods are commonly reported to trigger symptoms: coffee, chocolate, alcohol, mint, fatty and fried foods, citrus, tomato, onion, garlic, and spicy dishes. Some of these relax the sphincter; others irritate an already inflamed oesophagus; fatty meals slow stomach emptying and keep the stomach fuller for longer.
But the evidence for blanket dietary elimination is weaker than the internet suggests. Trigger foods are highly individual, and studies removing them wholesale have shown modest effects compared with the behavioural and positional measures below.
The practical approach is to identify your own two or three genuine triggers with a short diary rather than eliminating a long list of foods indefinitely.
What actually works, in rough order of effect
Eat smaller meals, and stop eating three hours before lying down
This is the highest-yield change for most people. A full stomach plus a horizontal body is the core mechanism of night-time reflux. Late dinners are the most common cause of morning hoarseness and unexplained cough.
Raise the head of the bed
Not extra pillows, which bend you at the waist and can increase abdominal pressure. Raise the entire head end of the bed by 15 to 20 centimetres using blocks under the legs, or use a wedge under the mattress. Gravity does the work all night. This has good supporting evidence and costs almost nothing.
Sleep on your left side
Anatomy favours it: on the left, the junction between oesophagus and stomach sits above the level of the stomach contents. On the right, it does not. The difference is measurable in reflux studies.
Lose excess abdominal weight, if applicable
Among the most consistently effective interventions in the research, because it directly reduces the pressure driving the mechanism.
Stop smoking
Nicotine relaxes the sphincter, and smoking reduces saliva, which normally helps neutralise and clear acid.
Loosen the waistband
Unglamorous, occasionally transformative.
Chew gum after meals
Increases saliva, which is mildly alkaline and helps clear the oesophagus. Avoid mint flavours, which can relax the sphincter.
The medications, and what they actually do
Antacids neutralise acid already present. Fast, short-acting, useful for occasional symptoms. They do not heal anything.
Alginates form a raft that floats on the stomach contents and physically blocks reflux. Often underused, and genuinely useful taken after meals and before bed.
H2 blockers reduce acid production, work within about an hour, and last several hours. Useful for predictable evening symptoms.
Proton pump inhibitors are the strongest acid suppressors and the standard treatment for frequent reflux and for healing oesophagitis. Important practical points: they take several days to reach full effect, so they are poor rescue medication; they work best taken 30 to 60 minutes before a meal; and stopping abruptly after long use can cause a temporary rebound in acid production, which people often misread as the condition returning worse than before. Tapering avoids this.
PPIs are effective and, for most people, safe. They are also frequently taken for years without review. If you have been on one continuously for a long time, that is worth revisiting with a doctor — not because they are dangerous, but because the reason for taking them should be reassessed periodically.
Warning signs that need prompt assessment
Reflux is usually benign. These are not:
- Difficulty swallowing, or food sticking
- Painful swallowing
- Unintentional weight loss
- Vomiting blood, or black tarry stools
- Persistent vomiting
- New symptoms starting after age 50
- Symptoms that do not respond to treatment
- Anaemia
One further point that matters. Heart attacks are sometimes mistaken for indigestion, particularly in women and older adults. Chest discomfort accompanied by breathlessness, sweating, nausea, or pain radiating to the arm, neck, or jaw should be treated as a cardiac emergency until proven otherwise. Do not sit at home taking antacids.
Why chronic reflux is worth treating properly
Long-standing untreated reflux can cause inflammation, narrowing of the oesophagus, and in a minority of people a cellular change called Barrett's oesophagus, which carries a small increased cancer risk and warrants monitoring. This is not a reason for alarm about occasional heartburn. It is a reason not to spend a decade quietly self-medicating symptoms that occur several times a week without ever having them assessed.
The short version
Heartburn is a mechanical problem — a valve that opens when it should not, plus pressure pushing contents upward — more than an acid-production problem. The highest-value changes are eating earlier and smaller, raising the head of the bed, sleeping on your left side, reducing abdominal weight, and quitting smoking. Medications help and are appropriate, but they manage the consequence rather than the mechanism.
If symptoms occur more than a couple of times a week, or any of the warning signs above appear, see a doctor rather than escalating the dose on your own.
This article is general information, not medical advice.
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