We Need to Talk About Reflux
Reflux affects around one in five adults in the UK each week.
For some, it’s an occasional discomfort; for others, it’s a daily struggle that interferes with eating, sleep, and overall quality of life.
This rise has coincided with another — the widespread use of proton pump inhibitors (PPIs), a class of drugs designed to suppress stomach acid production. NHS figures between 2022 and 2023 show that more than 73 million PPI prescriptions were issued in England alone. While these medications have their place, they’re now prescribed more frequently — and for longer — than ever before.
And this trend didn’t appear out of nowhere.
During the 2020 pandemic, the UK — along with several other countries — experienced an international shortage of Gaviscon.
Everyone was stuck at home, baking banana bread (or sourdough), drinking more alcohol, and feeling anxious while watching Dr. Van-Tam on the telly each evening.
As stress and digestive symptoms rose, many people turned to Nexium (esomeprazole) as an easy over-the-counter alternative — using it as though it were Gaviscon.
But while the two seem similar, they work very differently. That widespread substitution marked the beginning of an exponential rise in PPI use, a pattern that’s continued ever since.
PPI education is important for everyone — whether you’re taking them, considering them, or supporting those who do. Awareness helps people make informed decisions, and it highlights the impact of both medication and lifestyle in managing reflux.
But to really understand reflux — and how we can begin to manage it — we need to go back to the start of the story: how digestion is meant to work when everything is in sync.
How Digestion Is Meant to Work
Digestion is a beautifully coordinated process that starts long before food even reaches the stomach.
It begins with the cephalic phase — that moment when you see, smell, or even think about food and your brain signals, “Get ready, something’s coming.”
This anticipatory phase kickstarts your digestive system before the first bite ever touches your tongue. Saliva starts to flow, stomach acid begins to build, and your entire digestive tract gears up for what’s next.
In the mouth, the mechanical process of chewing begins breaking down food into smaller, more manageable pieces — making it accessible to the enzymes that follow. As simple as it sounds, chewing your food properly can-do wonders for healthy digestion. It’s not just a mechanical step; it’s communication between your mouth, brain, and stomach, signalling that it’s time to release the right digestive juices.
The chemical side of digestion also begins here, with the release of salivary amylase, the enzyme that starts breaking down carbohydrates. This means that digestion isn’t something that happens after eating — it’s happening right from the first bite.
In the stomach, hydrochloric acid (HCl) and the enzyme pepsin get to work on proteins. HCl also helps kill unwanted bacteria and provides the acidic environment needed for optimal enzyme function. The stomach muscles contract rhythmically, churning the food into a semi-liquid mixture called chyme, preparing it for its next destination.
In the small intestine, bile from the liver and gallbladder emulsifies fats, while enzymes from the pancreas complete the breakdown of carbohydrates, fats, and proteins into smaller molecules that can be absorbed through the intestinal lining. This is where most of the magic of nutrient absorption happens — vitamins, minerals, amino acids, and fatty acids are absorbed and transported into the bloodstream to nourish every cell in the body.
When everything is in sync, digestion feels effortless. But when any part of this finely tuned process is disrupted — too little acid, poor enzyme output, sluggish bile flow, or impaired motility — the knock-on effects can show up as bloating, discomfort, or reflux creeping in after meals.
What Exactly Is Reflux — and Why It Happens
Reflux occurs when stomach contents — acid, bile, or partially digested food — travel back up into the oesophagus, irritating the delicate lining. The term reflux is often used interchangeably with heartburn, but technically, heartburn is a symptom, while reflux is the process.
It’s commonly blamed on too much stomach acid — yet, in many cases, the problem is actually the opposite. Low stomach acid (a state known as hypochlorhydria) slows the entire digestive cascade (see Common causes).
When there isn’t enough acid to trigger the next steps — such as the release of bile and pancreatic enzymes — food can linger in the stomach for longer. The resulting delay increases intra-abdominal pressure, which can push contents back up through the lower oesophageal sphincter (LES).
But this process isn’t just about what you eat — it’s also about how your brain, hormones, and stress levels communicate with your digestive system. When that signalling is weak or interrupted, your digestive organs simply don’t “get the memo” to prepare, and the whole system is compromised before the first bite.
Common Causes of Reflux
While reflux can sometimes appear out of nowhere, it’s rarely random.
In clinic, I often see a handful of recurring patterns that quietly set the stage for digestive discomfort.
Understanding your personal triggers is the first step to breaking the cycle.
1. Low stomach acid (hypochlorhydria)
Contrary to popular belief, too little acid — not too much — is often the issue.
When acid levels are low, food isn’t fully broken down, bacterial overgrowth can occur (hello H.Pylori), and the stomach empties more slowly. This creates pressure that pushes contents back up into the oesophagus.
NB. Stomach acid production generally decreases with age.
2. Food sensitivities and intolerances
Certain foods can irritate or inflame the digestive lining, triggering an immune or histamine response that increases acid activity or weakens the lower oesophageal sphincter (LES). For some, identifying and removing key sensitivities can make a noticeable difference. A reliable, comprehensive IgG food intolerance test can helps identify the hidden culprits (see my Functional testing offerings).
3. Slow gut motility
When food lingers in the stomach for too long, the extended fullness can strain the LES.
Poor motility can stem from low stomach acid, inadequate enzyme output, or stress (remember the gut-brain connection when it comes to digestion?)— all of which reduce the gentle, wave-like contractions that move food efficiently through the gut.
4. Chronic stress
Stress diverts the body away from its “rest-and-digest” mode into “fight-or-flight.”
In this state, the brain sends fewer signals to the stomach to release acid and enzymes, digestion slows, and reflux becomes more likely. Ongoing stress also weakens the vagal tone that coordinates the digestive process.
5. Small intestinal bacterial overgrowth (SIBO)
When bacteria from the colon migrate into the small intestine, they ferment food that should already be digested. This fermentation produces gas and pressure, pushing stomach contents upward. Interestingly, SIBO is common in people who’ve used proton-pump inhibitors (PPIs) long-term — highlighting how medication can sometimes worsen the underlying imbalance.
Each of these factors may contribute on its own, but most often, they overlap — a little stress, a little low acid, a few trigger foods, and reflux begins to build.
The goal isn’t to eliminate everything, but to identify which of these mechanisms might be driving your symptoms and address them at the source.
When It Comes to Women, Hormones Matter Too
While reflux can affect anyone, certain hormonal patterns make women — particularly in midlife — more susceptible.
Throughout the reproductive years, oestrogen and progesterone continuously influence how the digestive system behaves. When either shifts, so does the way food moves, bile flows, and the lower oesophageal sphincter (LES) holds its tone.
During the luteal phase of the cycle and again in perimenopause, rising progesterone naturally relaxes smooth muscle — including the LES — which makes acid and bile more likely to travel upwards. At the same time, declining oestrogen can slow gut motility and reduce bile flow, so meals feel heavier and take longer to digest.
In pregnancy, the effect is amplified: progesterone-driven relaxation combines with the physical pressure of a growing uterus. It’s why up to half of pregnant women experience reflux, especially in the third trimester.
As women move into perimenopause and menopause, oestrogen’s decline affects more than temperature and mood. It also reduces vagal tone, bile secretion, and smooth-muscle coordination — subtle changes that can lead to slower digestion, bloating, and an increased tendency toward reflux.
Layer on midlife stress and disturbed sleep, and the picture becomes clearer. Stress weakens the gut–brain communication that controls digestive secretions, while sleep loss heightens sensitivity to discomfort. The result is a body that’s less prepared to “rest and digest” when it needs to.
Taken together, these hormonal and nervous-system shifts show that reflux in women isn’t just about rich food or festive fizz — it’s a reflection of how hormonal balance, stress, and digestion intertwine across the lifespan.
The Different Faces of Reflux
Reflux isn’t one-size-fits-all. Understanding the type can be key to addressing it properly:
Acid reflux (GORD): The classic burning sensation behind the chest bone, usually after eating or when lying down.
Bile reflux: Less common but often more severe — caused by bile from the small intestine backing up into the stomach and oesophagus. It can cause nausea, abdominal discomfort, and a bitter taste in the mouth.
Silent reflux (LPR): Often missed because it doesn’t cause heartburn. Instead, it presents as throat irritation, a persistent cough, hoarseness, or the feeling of a lump in the throat.
When digestion runs smoothly, food moves through each stage like a well-rehearsed sequence — acid activates enzymes, bile breaks down fats, and nutrients are absorbed with ease.
But when any part of this chain falters — whether from low acid, sluggish bile flow, or disrupted gut–brain signalling — reflux can begin to creep in.
Occasional reflux is normal, but when it becomes persistent, it’s a signal that the system needs attention. Left unchecked, chronic reflux can interfere with how well you absorb nutrients such as vitamin B12, iron, magnesium, and zinc — the very elements that support energy, immunity, and hormone balance.
Looking Ahead In Part 2, we’ll explore the simple, evidence-based steps that can help restore digestive function naturally — without relying solely on acid suppression.
References
11 Stomach-Soothing Steps For Heartburn. Harvard Health. 2020. https://www.health.harvard.edu/staying-healthy/11-stomach-soothing-steps-for-heartburn.
Antunes, C., Aleem, A. and Curtis, S.A., 2023. Gastroesophageal reflux disease. In StatPearls [Internet]. StatPearls Publishing.
Freedberg, D.E., Lebwohl, B. and Abrams, J.A., 2014. The impact of proton pump inhibitors on the human gastrointestinal microbiome. Clinics in laboratory medicine, 34(4), p.771.
Heidelbaugh, J.J., 2013. Proton pump inhibitors and risk of vitamin and mineral deficiency: evidence and clinical implications. Therapeutic advances in drug safety, 4(3), pp.125-133.
Mayer, E.A., 2000. The neurobiology of stress and gastrointestinal disease. Gut, 47(6), pp.861-869.
