Brijen J. Shah, MD
Brijen J. Shah, MD, a professor of medicine and gastroenterology at the Icahn School of Medicine at Mt. Sinai in New York and a Fellow of the American Gastroenterolgical Association.
It goes by many names—heartburn, acid reflux, gastroesophageal reflux disease (GERD) and agita—but whatever you call it, it’s just no fun to have it. Bottom Line asked gastro specialist Brijen J. Shah, MD, what causes heartburn and, more importantly, how to get rid of it.
Heartburn is the result of stomach acid rising up into the esophagus and mouth. That acid can cause an unpleasant burning sensation in the chest, which is why it’s often called heartburn even though it has nothing to do with the heart. It’s a feeling that millions of Americans know well—nearly one in three US adults experience heartburn at least once a week, according to a 2019 study by researchers at Cedars-Sinai Medical Center in Los Angeles. But while the burn of acid in the chest is the classic symptom of heartburn, it’s far from the only symptom, and some other symptoms are easy to misinterpret.
In addition to the unpleasant sensation of acid irritating the esophageal lining in the chest, symptoms of heartburn could potentially include…
Nausea and/or regurgitation. Heartburn doesn’t always stop at the chest—stomach acids and other stomach contents can travel up the esophagus all the way to the throat and into the mouth, potentially causing the urge to vomit.
Bitter or sour taste in the mouth. Some people experience a metallic taste.
Tightness in the chest. The chest discomfort produced by heartburn doesn’t always feel like burning—instead there might be a sense of tightness or pressure typically just below the ribcage. It can be severe enough to wake you up and is troublingly similar to one of the classic symptoms of a cardiac event. But the pressure and chest tightness from a cardiac event will be greater, and taking an antacid will not improve symptoms.
Tooth erosion. If stomach acid reaches your mouth frequently, it can over time eat away at your tooth enamel. That enamel loss could lead to tooth sensitivity, discoloration and increased risk for cavities, among other potential dental consequences.
Sore throat, difficulty swallowing and/or hoarseness. Irritation to the esophagus and larynx caused by stomach acid often are assumed to be the result of viral infection.
Chronic dry cough. Like the sore throat cited above, this cough is caused by irritation to the esophagus but is less common.
Take note of when your symptoms occur. If heartburn truly is the cause of chest discomfort, nausea and/or an unpleasant taste in the mouth, symptoms generally will appear 30 to 60 minutes after eating and when you lie down, bend forward or exercise.
A band of muscle called the lower esophageal sphincter is supposed to serve as a gatekeeper between the esophagus and the stomach, opening only to allow food you’ve consumed down into your stomach, and occasionally to allow gas from your stomach up through the esophagus when you burp. Heartburn results when this sphincter doesn’t close tightly, allowing stomach contents including acid to pass through and enter the esophagus.
What you eat and drink can affect your lower esophageal sphincter’s ability to function properly—certain foods and beverages relax this sphincter, hindering its ability to shut tightly and increasing the odds of heartburn. These include alcohol, caffeinated beverages, chocolate, garlic, onions and mint, including peppermint. Use of nicotine products also can relax the sphincter.
Other foods that increase the amount of acid in the stomach can exacerbate heartburn. These include foods that are themselves acidic, such as citrus fruit, tomatoes and juices and sauces made from them. Fatty, fried and high-protein foods can increase stomach acid levels as well—they are difficult to digest and cause the stomach to produce lots of acid. And many heartburn sufferers find that spicy foods cause problems for them, too—spices can irritate the esophagus.
Certain health conditions also increase the odds of experiencing heartburn, including obesity, pregnancy and having a hiatal hernia—a type of hernia where a portion of the stomach pushes above the diaphragm and into the chest. Obesity also increases risk for heartburn. In fact, the link between obesity and heartburn likely explains why heartburn rates are rising in the US—an increasing percentage of Americans are obese. Living with chronic stress is associated with increased rates of heartburn, too, according to several studies, including one by researchers at UCLA.
What doesn’t cause heartburn: There is no known genetic predisposition to heartburn. While it does tend to run in families, that’s most likely because families tend to share similar diets. A predisposition to obesity can be genetic, however, and obesity does increase the odds of developing heartburn.
It’s often possible to control heartburn without taking drugs. Start by reducing your consumption of the potentially problematic foods and beverages cited above, especially those that have triggered your heartburn in the past. Also…
Eat four to six small meals per day rather than two or three large ones. The odds of acid escaping up into the esophagus is reduced if the stomach is never full.
Stop eating at least two to three hours before bedtime, and don’t nap after meals—gravity helps prevent stomach contents, including acid, from rising up into the esophagus, but it can’t do that if you’re lying down.
Try sleeping with your upper body elevated at a 20% to 30% incline if you experience heartburn while lying in bed. There are adjustable beds that tilt to this angle at the touch of a button…or wedge body pillows or bed risers can serve a similar function for a fraction of the cost. Bed risers are small stands that can be positioned under the legs of the head of the bed.
Seek treatment if you have sleep apnea. Sleep apnea is linked to a long list of undesirable health consequences, but one that’s rarely mentioned is that it increases the odds of developing a heartburn problem, according to several studies, including one by researchers at Marshall University.
Schedule your exercise sessions for times of day when you have not eaten for the prior two to three hours if you experience heartburn when you exercise. Don’t exercise when your stomach is in the process of digestion. But don’t give up exercising entirely because of heartburn—not only is exercise good for your overall health, it can reduce your heartburn by helping to control your weight.
Avoid clothes that are very tight around your midsection. This tightness can interfere with digestion and potentially even with the function of the lower esophageal sphincter.
Live a healthy life. Obesity, nicotine use and chronic stress all have been shown to increase the odds of heartburn, so anything you can do to reduce these is likely to reduce your heartburn.
If the diet and lifestyle changes described above don’t solve your heartburn, there are a range of safe and effective medications that probably can…
For mild and only occasional heartburn, an over-the-counter (OTC) antacid such as Tums or Rolaids should do the trick.
For moderately intense heartburn that occurs about once or twice a week, an OTC H2 blocker, taken 30 to 60 minutes before a meal, should provide six to 10 hours of relief. H2 blockers include famotidine, ranitidine, cimetidine and nizatidine. Brand names include Pepcid and Zantac.
If your heartburn is severe and frequent, take a course of an OTC proton pump inhibitor (PPI). PPIs include lansoprazole, omeprazole and esomeprazole. Brand names include Nexium and Prilosec. Caution: There is some evidence that taking high doses of PPIs for a decade or longer could increase risk for osteoporosis and bone fractures.
All of these drugs are safe to use, though as with any drug, it’s worth confirming with your doctor or pharmacist that they won’t interact with other drugs you’re taking.
If the strategies and drugs mentioned above don’t solve your heartburn problem, discuss your options with your doctor. He/she can prescribe a stronger PPI than is available over the counter and confirm that what seems to be persistent heartburn isn’t actually a symptom of something more serious.
