Heartburn. Why acid blockers sometimes make the problem worse, not better.

I have been through it myself. Nights that burn. Pills that quiet the burning, but not the story behind it.

I know this feeling from the inside. You are lying in bed. You ate late, maybe not even that late, and yet something is rising. A burning behind the breastbone. A sour taste. You turn to the side. You get up. You drink water. It does not get better.

I went to my family doctor back then. The answer that many people know came almost word for word. Do not drink coffee. Do not drink alcohol. Do not smoke. Eat healthy. I did not smoke, I rarely drank alcohol, I did not drink coffee. What healthy eating actually meant was left open. So I got a prescription and felt the way many patients feel. Understood as a category. Not understood as a person.

Then I set out on my own path. Read, tested, observed, adjusted. I learned that heartburn is not a single disease but a symptom with many roots. In my case it looked as though my burning came not from too much acid but from too little. I rebuilt my diet, changed the order in which I ate my meals, started working with my breath. For me personally the burning settled along this route. I know that a single course proves nothing, and I cannot derive a rule for you from it. I see similar patterns in practice again and again, but they by no means apply to everyone.

In a ten-minute appointment this mechanism is hard to explain, it branches too widely. That is not a question of ability but of time in the system. This article takes the time that daily practice often does not have, and it wants to complement the work of your family doctor, not replace it. How heartburn can arise. Why the quick pill sometimes continues exactly the thing it is meant to calm. And which levers you, together with your doctor, are allowed to look at first, before a medication becomes a permanent tablet.

Section 1Heartburn is not only a question of acid, but also of the sphincter

The word heartburn sounds like a diagnosis. But it describes a symptom. A symptom that something which should stay in the stomach is reaching the esophagus. The actual actor is not the acid itself, but the door in between. This door is called the lower esophageal sphincter, or LES for short. It is a ring-shaped muscle at the junction of esophagus and stomach. It is reinforced from the outside by your diaphragm, which sits around it like a second outer cuff.

Modern reflux research describes this closure mechanism as a dual system. Inside the LES, outside the diaphragm. When both work together well, the stomach contents stay down. The strength of the acid is only one part of the story. Just as important can be whether this dual system of sphincter and diaphragm closes at the right moment. Reflux research today describes an interplay of acid exposure, esophageal self-cleansing, mucosal protection and sensitivity. There are very brief, involuntary openings of the sphincter. Research calls them transient relaxations or TLESRs. They are considered the most important mechanical trigger for reflux.

What can weaken such a door? Many things. An anatomical hiatal hernia, where part of the stomach slides up through the diaphragmatic opening. A chronically tense or weak diaphragm. Abdominal pressure from excess weight or pregnancy. High gastric filling from large meals or evening snacks. Delayed gastric emptying from too little acid, too little vagal tone, or a sluggish thyroid. Certain medications. And not least, psychological pressure, which puts the stomach in a state where it neither acidifies nor empties well.

Section 2Too much or too little acid? Both can burn

Here it gets interesting. Heartburn can come from real acid excess. It can also come from acid deficiency. The same symptom, two very different stories. Anyone who does not separate them treats next to the mechanism, not at it.

Classical acid excess exists. In acute gastritis, in a fresh ulcer, in the rare condition Zollinger-Ellison syndrome, in pronounced erosive reflux esophagitis. In such cases an acid blocker is often the right tool. These diagnoses belong in gastroenterological hands, not in self-care.

The second hypothesis is examined less often: too little stomach acid. The reasoning behind it goes like this. Protein might then be digested more slowly. The stomach would stay full longer. In the upper abdomen carbohydrates could ferment, pressure gases could form, the pressure upward could increase. The sphincter would open more often. And even a little acid can hurt when it reaches the wrong place. This is an explanatory model from functional medicine. Robust human studies on it are lacking so far. I describe it here explicitly as a hypothesis, one that should be measured and not guessed.

There is an old home experiment: in the morning on an empty stomach, a pinch of baking soda in a glass of water. If you burp quickly and forcefully, that speaks more for enough acid in the stomach. If burping fails to come, that can be a hint toward low acid. The test is not scientifically validated and does not replace diagnostics. If you have heart or kidney problems, take blood pressure medication, have high blood pressure or need to watch your sodium, please leave it out and take the medical route directly. The clean way is medical testing anyway. A gastropanel in the blood that measures pepsinogen I and II, gastrin and Helicobacter antibodies. A Heidelberg pH capsule or a gastroscopy with biopsy are the reliable methods. These steps belong in medical hands.

Section 3Why the idea of alkaline versus acidic leads astray here

Anyone searching online finds two loud camps. One says you should eat alkaline. The other says you should eat acidic. Both have a true core and a thinking error.

The thinking error is confusion. The pH in the blood is very stable and lies between 7.35 and 7.45. The pH in the stomach in healthy state lies between 1 and 3. These two pH worlds are decoupled from each other. What you eat barely shifts your blood pH at all, because your body buffers it precisely. What you eat can however very much influence the conditions in the stomach, because every meal arrives there and reacts.

From this follows an important distinction. A very alkaline-oriented diet, lots of salad, lots of stewed fruit, little protein, can be relieving for a stomach with sufficient acid. But for a stomach with acid deficiency it is often the wrong thing. It provides few stimuli that the acid would need, and it delays gastric emptying. With the hypothesis of acid deficiency, the opposite can make sense. Something bitter or slightly sour before the meal, then protein, then fat, then carbohydrates. This is not a fad, it is a physiological consideration. In reflux it has not been tested so far.

Section 4The vagus nerve. Your forgotten conductor of digestion

When I explain to patients why their heartburn is connected to their breathing, I often see a frown. With the breath? Yes. With your breath. More precisely, with your vagus nerve and with your diaphragm. Together they form the invisible stage on which your stomach either works calmly or nervously closes and opens.

The vagus nerve is your tenth cranial nerve. It runs from the brainstem deep into the abdomen. It controls, via acetylcholine, the acid production of the parietal cells, it controls gastric emptying, it controls the wave that cleans the small intestine between meals. A low vagal tone, measured via heart rate variability, is linked in review articles with disturbed motility and increased sensitivity in the digestive tract (Bonaz et al., Neurogastroenterology & Motility 2016). When your vagus goes quiet because you live in constant alarm, sleep poorly, hurry, scroll and eat standing up, your gastric emptying can slow down. More content stays up longer. Pressure can rise. The sphincter can open more often.

This is where the breath comes in. Your diaphragm is a breathing muscle and at the same time the outer cuff of your lower esophageal sphincter. Whoever breathes shallowly into the chest gives the diaphragm little movement. Whoever breathes into the belly also trains their sphincter helper. Exactly this exercise is measurable.

Section 5The toxin track. What quietly turns your stomach down

There are substances and habits that directly weaken your anti-reflux barrier. Some weaken the sphincter, some irritate the mucosa, some slow the vagus, some promote microbes that do not belong in the stomach.

Alcohol can irritate the gastric mucosa, relax the lower esophageal muscle and impair acid production long term. Even small amounts in the evening can intensify nocturnal reflux in sensitive people. Nicotine is similar. In a large prospective investigation, smoking cessation was one of the few factors that measurably brought reflux back down in normal-weight individuals.

Coffee is not the enemy. But it can briefly relax the sphincter. Sensitive people should not drink coffee on an empty stomach and not directly with the meal, but rather between meals and in moderate amounts. Pain medications from the NSAID group such as ibuprofen or diclofenac can damage the mucosa, especially with frequent use. Certain blood pressure medications like calcium channel blockers and some asthma medications also relax the sphincter. This is not a call to discontinue them. It is a hint that your reflux can have an explainable medical background that is allowed to be discussed with your family doctor.

Helicobacter pylori is a frequently overlooked player. This bacterium can cause both phases of too much and of too little acid. Anyone with chronic heartburn, iron deficiency, fatigue or unclear abdominal symptoms should be tested for it. A stool antigen test or breath test is often enough as a starting point.

And then there is lack of movement. Anyone who sits all day often breathes more shallowly, and that can go along with lower vagal tone, slower gastric emptying and slower bowels. Movement here is not just a lifestyle bonus. Movement is part of digestion.

Section 6What you can change yourself, long before medication is in order

The following levers are studied. They do not replace a diagnosis. They are the stage on which your stomach can resume its work. They often only work in combination.

Relieve weight, where present

Belly fat raises pressure in the abdomen. This pressure pushes the stomach upward and opens the sphincter more often. A structured weight loss program can address this mechanic.

Use sleep as therapy

Lack of sleep can measurably worsen reflux. In one study, just two nights with only four hours of sleep increased acid exposure in the esophagus. Sleeping position also seems to play a role. People sleeping on the left side had less nocturnal reflux in the studies so far than on the back or on the right side. The anatomical explanation is plausible: on the left side, the stomach inlet sits higher than the outlet. The data base for this, however, is still thin.

Close the day differently

Anyone who eats nothing for three hours before sleep gives the stomach time to empty. Anyone who raises the head of the bed by about 15 to 20 centimeters lets gravity do part of the work. Both are documented in studies and cost little.

Movement after eating

A ten- to fifteen-minute walk after eating can support gastric emptying and stabilize blood sugar. It does not have to be sport. A slow walk is enough. Gentle yoga, qigong and quiet breath work can address the ventral vagus and the diaphragm. Strength and endurance training can favorably influence gastric motility long term, but should not happen at high intensity directly after a meal.

Learn to breathe

Three deep breaths before the first bite. Five seconds in, seven seconds out. Sounds small. Can measurably change your heart rate variability and your vagal tone and prepare your stomach for the meal. Anyone who combines this with abdominal breathing training from the Eherer pilot study, about ten to fifteen minutes daily, has a lever in hand that works without a tablet.

Section 7The two nutritional paths. Different for too little acid than for too much

Here the article gets uncomfortable for everyone who wants a single answer. There is none. There are two paths, and you first need clarity on which one you are walking. Without this clarity you make the work hard for yourself. Eating alkaline with acid deficiency could quietly make things worse. Eating acidic with acid excess can make things worse immediately.

When the hypothesis is more likely acid excess

Here a plant-forward, Mediterranean line can help. Lots of vegetables, olive oil, legumes, some fish, little red meat, little ultra-processed food, little sugar. Strongly acidifying foods are reduced, especially tomato sauce, citrus, spicy food, large amounts of coffee, chocolate, peppermint, alcohol, fatty fried things. Meals are kept rather small and early. Movement after eating can support emptying.

When the hypothesis is more likely acid deficiency

Here many things turn around. Something slightly sour or bitter before eating can support this route. Important first: as long as it is not clear whether your esophagus or your stomach is inflamed or sore, sour things do not belong in a self-experiment. They can irritate an already irritated mucosa further. Acidic things also attack tooth enamel, so never neat and never brush your teeth right afterward. Please have this checked medically first. Once that is clear, it can look like a teaspoon of apple cider vinegar in a glass of water, a slice of lemon, a few drops of a bitter tincture or a small salad with vinegar and lemon. Then first protein and fat, that means meat, fish, eggs, tofu, legumes, plus good oil. Only then the carbohydrates, that means bread, rice, pasta, potatoes, sweets.

This order is not a new idea. It has a long tradition in naturopathy and, more recently, studies on blood sugar on its side. For blood sugar it is well studied. In a crossover study of 15 people with prediabetes, the blood sugar peak was over 40 percent lower when protein and vegetables came before the carbohydrates, and the insulin response was clearly flatter. Whether the same order also gets acid production going earlier is a plausible consideration, but it has not been measured so far.

I offer this order to many people in practice. Some get along well with it, others do not. It is not a universal recipe and I never sell it as one. With suspected acid excess it can even worsen things. That is why clarity belongs in the picture first.

Section 8Plants, minerals and anthroposophic helpers

When the stage is right, small plant tools can accompany the process. They do not replace a diagnosis and they do not replace a doctor. Which ones suit you, whether they suit you at all and in what form, depends on the picture of your symptoms, on your hypothesis and on your metabolism.

In this section I deliberately do name names. A text with every name stripped out does not make you safer, it only leaves you more helpless. What you will not find here are dosages. They depend on the preparation, on age, on liver and kidney function and on the whole picture, so they belong in the package leaflet and in the medical conversation. Everything that follows is context. It is not a recommendation for you personally, and every name carries its risk right beside it. That is why the risk is written right beside it.

Bitters before the meal. The classic bitter herbs are gentian, wormwood, yarrow, dandelion and centaury. They can trigger reflexes via the sense of taste that prepare the stomach for the meal, and so set the cephalic phase in motion. In German pharmacies you mostly meet them in two finished preparations. Both are pharmacy-only, neither is prescription-only.

WALA Bitter Elixier contains an extract of gentian root, ginger root, calamus root, pepper fruit and wormwood herb, and it is alcohol-free. According to the package leaflet it must not be used with gastric or intestinal ulcers, not with known hypersensitivity to ginger and pepper, and not in pregnancy and breastfeeding. With gallstone disease only after consulting a doctor. It contains sucrose, which can matter with diabetes and with fructose intolerance.

Weleda Amara-Tropfen contain wormwood, chicory, centaury, gentian, juniper, yarrow, sage and dandelion among others. The alcohol is the point to watch here: according to the leaflet 91 mg of ethanol per 15 drops, which is 27 percent. For that reason the preparation must not be given to people with alcohol dependence, and in pregnancy, breastfeeding, childhood, liver disease or epilepsy the alcohol content has to be taken into account.

For bitters in general: with an active gastric ulcer, an acute inflammation or an obstruction of the bile ducts they do not belong in self-care. Wormwood additionally contains thujone and is not suitable in pregnancy and breastfeeding or with epilepsy. Whether any of them comes into question for you belongs in a medical conversation or at the pharmacy, not in a self-experiment.

Herbal combination preparations. When your stomach works arrhythmically, sometimes too fast, sometimes too slow, one name comes up in Germany almost every time: Iberogast. It is pharmacy-only but not prescription-only, and it has been studied in research on functional dyspepsia. There are two versions, and the difference between them is the actual reason I name the preparation here instead of hiding it.

Iberogast Classic contains nine plant extracts, among them greater celandine. That component has been under suspicion for years of being able to damage the liver. After several reports of liver injury, including one fatal case with liver failure and transplantation, the German regulator BfArM ordered a change of the product information in September 2018 in a formal risk assessment procedure. Since then the contraindication reads: with existing liver disease or liver disease in the medical history, or with concurrent use of medicines with liver-damaging properties, it must not be taken. A contraindication for pregnancy and breastfeeding was added. Signs at which you should stop immediately and seek medical advice are yellowing of skin or eyes, dark urine, discoloured stools, upper abdominal pain, nausea, loss of appetite and fatigue. According to the prescribing information, Classic also contains 31 percent alcohol by volume and is not intended for children under three.

Iberogast Advance arrived in 2020 and contains six extracts, without greater celandine, without angelica root and without milk thistle. And one more detail that matters precisely in reflux and that hardly anyone mentions: both versions contain peppermint. Peppermint can additionally relax the lower esophageal sphincter. With pure dyspepsia that may not matter, with pronounced reflux it may. Which version comes into question for you, and whether either does, is therefore something to clarify medically or at the pharmacy.

Mucilages. Marshmallow root, licorice root in deglycyrrhizinated form (DGL), elm bark. They can lay like a gentle film on irritated mucosa and ease burning, especially in superficial irritations. Important with licorice: only the deglycyrrhizinated form. Licorice that has not been treated this way can raise blood pressure and lower potassium in larger amounts.

Nutrients around the mucosa. Two substances keep coming up here, and I name them so you know what is being talked about.

Zinc-L-carnosine, also called polaprezinc, is a compound of zinc and the dipeptide carnosine. In Japan it is approved as a medicine for gastric ulcers. In Germany it exists only as a food supplement, and that difference matters more than it sounds: a food may not be given a disease-related claim. That is why the package says nothing about the stomach or the mucosa, and why I write down no application for you here either. Review articles describe mucosa-protective and anti-inflammatory properties, while the human data come mostly from small studies and partly from quite different indications. The zinc load is worth thinking about: EFSA gives 25 mg of zinc per day from all sources combined as the tolerable upper intake for adults. Too much zinc over a long period can favour a copper deficiency.

L-glutamine is an amino acid that can serve mucosal cells as fuel. Specifically for reflux the evidence is thin, most of it comes from other areas of gut research. In the prescribing information for glutamine infusion solutions, severe hepatic insufficiency and severe renal insufficiency count as contraindications. That reservation makes sense for oral intake too. Both therefore belong in a medical conversation and not in a self-experiment.

Lemon balm, chamomile, fennel. Gentle teas can calm vegetatively and relax the diaphragm. Peppermint should be enjoyed with caution here, because it can additionally relax the sphincter.

Betaine hydrochloride. An acid preparation that can temporarily lower the pH in the stomach. In a small randomized study in nine healthy volunteers it brought postprandial gastric acid values back down to the lower range faster. It belongs only in medical hands. With active ulcers, fresh inflammations, in pregnancy and breastfeeding or under ongoing acid blocker therapy, it is to be avoided. That is why no dosage here.

Anthroposophic accompaniment. Here too I name names, but a preliminary remark belongs with it, and it matters to me. Anthroposophic medicines are licensed or registered as medicines in Germany. Their fields of application, however, are derived, as the leaflets say word for word, from anthroposophic knowledge of the human being and of nature, and not from randomised trials. Anyone expecting proof of efficacy in the conventional medical sense will not find it there. I write that openly, because you should know it before you engage with them. All of the following are pharmacy-only and not prescription-only.

Hepatodoron by Weleda consists of wild strawberry leaves and grape vine leaves and is used to stimulate liver activity, so on the liver-gallbladder axis. The tablets contain lactose and wheat starch. With lactose intolerance and with wheat allergy that has to be considered.

Calmedoron by Weleda contains oat, passionflower, hops, valerian and potentised coffee and is used for nervousness and difficulty falling asleep, so at the autonomic nervous system of the evening. The liquid form contains a lot of alcohol, 49 percent by volume according to the Rote Liste, which is relevant with alcohol dependence, in pregnancy, while breastfeeding and in children. The globules contain sucrose and therefore do not suit hereditary fructose intolerance.

Antimonite, the potentised mineral antimony sulfide, is used in anthroposophic medicine for digestive disturbances with bloating among other things, mostly as part of combination preparations.

Solidago, goldenrod, is related to elimination via the kidney. There is a hard limit here that you should know: irrigation therapy with goldenrod must not be carried out when there is oedema due to impaired cardiac or renal function.

They complement, they do not replace. Which selection suits you, and whether any suits you at all, belongs in a medical conversation.

Section 9Acid blockers. Tool, trap and everything in between

Acid blockers, in technical terms proton pump inhibitors or PPIs, are among the most prescribed medications of the western world. The active substances are called omeprazole, pantoprazole, esomeprazole, lansoprazole and rabeprazole. I name them because many people have been taking a tablet for years without knowing the name of the substance in it. A look at the package is worth it.

One point that often gets lost: under the German prescription regulation, omeprazole and pantoprazole at the 20 mg strength and in small packs of 7 or 14 are exempt from the prescription requirement. So you can buy them at the pharmacy without a prescription, but expressly only for short-term self-treatment of no more than 14 days. Anything beyond that, so higher strengths, larger packs and above all long-term therapy, is prescription-only and belongs in medical hands. It is exactly at this border that most of it happens in practice: fourteen days of self-treatment quietly turn into four years.

They are brilliant when needed. They are tricky when they run for years without anyone asking whether they still fit. Both is true.

When they are valuable

In acutely bleeding mucosa. In a fresh gastric or duodenal ulcer. In severe erosive reflux esophagitis. In Barrett's esophagus for risk reduction. As gastric protection under certain pain medications, especially in older patients with comorbidities. In the treatment of a Helicobacter infection. Here they can enable healing, prevent bleeding, even save lives.

When they become a trap

When they are prescribed without clear indication. When they are not reduced after symptoms have settled. When no one asks anymore whether the original diagnosis still fits. Several surveys from different countries suggest that a portion of long-term prescriptions no longer formally meets the indication. The figures vary widely by country and survey method.

Which long-term consequences are discussed

The research here is not unambiguous. Much comes from observational studies that show associations but do not prove a cause. The large JAMA review on reflux disease states explicitly that these observations need to be confirmed before they should influence clinical decisions (Maret-Ouda et al., JAMA 2020). A review specifically on the adverse effects of long-term use arrives at a similar picture (Maideen, Chonnam Medical Journal 2023). Still, the data are sufficient that international medical societies recommend restrained, targeted use. What follows is therefore not about proven harms, but about topics where looking together is worthwhile.

The withdrawal phenomenon that drives many into an endless loop

There is an invisible trap, called rebound acid hypersecretion. In anyone taking an acid blocker for a longer time, the level of the hormone gastrin can rise. Under this stimulation, the gastric cells can grow. When the medication is then abruptly stopped, acid production can temporarily overshoot beyond the original level. In studies in healthy individuals without a reflux history, about 40 to 50 percent developed symptoms after stopping that they did not have before. Whoever does not know it thinks they really need the medication. Whoever knows it can shape the withdrawal differently, with medical guidance.

Section 10What else can hide behind heartburn

There are pictures that look like reflux and are not. Briefly naming them is a duty.

Histamine intolerance and mast cell activation can cause burning, pressing symptoms in the upper abdomen and esophagus, often accompanied by hot flushes, headache, skin redness. With shifting symptoms it is worth a look.

Eosinophilic esophagitis is an immune-mediated inflammation of the esophagus. It feels like reflux but often does not respond to acid blockers. It needs gastroscopy with biopsy to diagnose.

Functional dyspepsia and gastroparesis with delayed gastric emptying can cause similar complaints. Here movement, breath and bitters can accompany the process, sometimes specific medications are needed.

Hiatal hernia can mechanically fix reflux. Here both lifestyle and in some cases a surgical option are on the table.

The message is not to differentiate everything yourself. The message is that there are differential diagnoses and that a careful workup is worthwhile before a treatment runs for years.

Section 11Quiet signals I gather in practice

Section 12Three steps you can take starting tomorrow

Section 13And now you know why

Heartburn is not just an annoying burning. It is a message from your body. Sometimes it says you really do have too much acid and the mucosa needs protection. Sometimes it says your acid is too weak and your stomach needs help, not less acid. Sometimes it says your sphincter and your diaphragm are out of rhythm. Sometimes it says your vagus is tired. Almost always it says your lifestyle and your stomach are talking to each other every day.

You are not weak. You are not hypochondriac. You are right that there should be answers that go beyond coffee and alcohol. Those answers take time, and time is scarce in daily practice. If you did not get them in ten minutes, that does not mean they do not exist. It means it is worth asking together about the mechanism, before it is shut down for years.