What's Really Going On With Your Reflux
Acid reflux is one of those conditions that tends to get managed rather than resolved. The burning sensation behind the breastbone, the bitter taste in the back of the throat, the hoarseness in the mornings: these are symptoms most people know well. And the most common advice is to take a proton pump inhibitor (PPI) to reduce the acid.
But here's what I want to explore: acid reflux often isn't about too much acid. For many people, it's about a weakened lower oesophageal sphincter, the muscular valve between the stomach and oesophagus, that allows even normal amounts of acid to backwash upward. The acid burns because it's where it shouldn't be, not necessarily because there's too much of it.
What Drives Reflux
Several things can cause the lower oesophageal sphincter to weaken or fail to close properly:
SIBO (small intestinal bacterial overgrowth), which creates upward gas pressure
Increased intra-abdominal pressure from pregnancy, excess weight, or constipation
Slow gut motility
A hiatal hernia
Dietary triggers including spicy foods, peppermint (which relaxes the sphincter), alcohol, and smoking
H. pylori infection, which should always be ruled out
The link with SIBO is worth pausing on, because it's frequently overlooked. When bacterial overgrowth in the small intestine produces excess gas, that pressure has to go somewhere. It often travels upward, pushing the sphincter open and causing reflux. Treating the reflux without addressing the SIBO means the underlying driver is still very much in play.
Reflux also has a significant vagal component. The vagus nerve governs the tone of the lower oesophageal sphincter. Chronic stress, shallow breathing, and an overstimulated nervous system all reduce vagal tone, which reduces the sphincter's ability to stay closed. Diaphragmatic breathing is not a vague wellness suggestion here. It has a direct mechanical role in oesophageal function.
The Problem With Long-Term PPIs
PPIs are effective at reducing acid, and there are absolutely situations where they're appropriate and necessary. But the long-term picture is more complicated.
PPIs bind permanently to the proton pump in parietal cells. Once bound, those pumps are inactivated until new ones are synthesised, which is why it takes around five days for PPIs to reach full effect, and why they can't simply be stopped without consequences.
When you take PPIs for an extended period, the body up-regulates gastrin receptors in response to the suppressed acid environment. When you then stop taking them, a wave of new, highly active proton pumps floods back, gastrin drives them hard, and acid production surges. This rebound effect peaks around four weeks after stopping and can last up to three months. This is the main reason so many people conclude they can't come off PPIs, when in reality they just needed a supported taper rather than an abrupt stop.
Long-term PPI use is also associated with reduced absorption of B12, magnesium, calcium, zinc, and iron, because all of these depend to varying degrees on an acidic stomach environment. The irony is that suppressing acid to manage reflux symptoms creates a set of nutritional deficiencies that generate their own cascade of health issues over time.
How to Come Off PPIs Safely
This process takes time and needs to be done gradually. Coming off PPIs without preparation is likely to result in significant rebound reflux that feels worse than the original symptoms.
Phase one (eight weeks before reducing the dose): Focus on healing the gastric mucosa. DGL liquorice root, chewed before meals, is one of the most evidence-supported options here. If H. pylori is suspected, address that first. There's no point tapering off a PPI if the underlying infection is still actively damaging the lining.
Dose reduction: After the mucosa-healing phase, reduce to half the standard dose for four weeks, then every other day, then every third day. The slower the taper, the less severe the rebound.
Supporting sphincter tone and motility: Ginger is a useful prokinetic, meaning it supports forward digestive movement and helps the gut clear content rather than letting it stagnate and push back.
Probiotics: Lactobacillus reuteri specifically has anti-H. pylori activity and supports post-PPI recovery. Saccharomyces boulardii is also useful during the transition period.
Melatonin is often overlooked in reflux protocols and is worth mentioning. Melatonin receptors are distributed throughout the gastrointestinal tract, and there is good evidence for its role in supporting the lower oesophageal sphincter and reducing GERD symptoms.
The mindful eating piece is foundational: chewing thoroughly, eating slowly, not eating under stress, and not lying down within two to three hours of a meal. These aren't general wellness platitudes. They directly affect oesophageal sphincter tone and the rate at which the stomach empties.
If you're on long-term PPIs and looking to reduce your dependency, this is something I work through with clients in detail as part of a full gut health consultation.