Written by Eric Suni, Staff Writer , Sleep Foundation https://www.sleepfoundation.org/
Acid reflux, also known as gastroesophageal reflux, describes a backflow of acid from the stomach into the esophagus. Occasional episodes of reflux are normal, but when they occur regularly, they can have serious consequences and are known as gastroesophageal reflux disease (GERD).
GERD is estimated to affect 20% of adults1 in the United States. Most patients with GERD experience an increase in the severity of symptoms, including heartburn, while sleeping or attempting to sleep. Beyond just heartburn, if stomach acid backs up as far as the throat and larynx, a sleeper may wake up coughing and choking or with major chest pain.
In addition to having troubling immediate symptoms, GERD can over time cause significant damage to the esophagus and raise a person’s risk of esophageal cancer.
Understanding GERD, including its symptoms, causes, and treatments can help people with this condition manage it more effectively. Because many people find GERD to be worse around bedtime, focusing on how to sleep with GERD may help reduce symptoms and improve sleep.
What Is GERD?
GERD is a condition marked by repeated episodes of reflux that affect quality of life.
Acid reflux, also known as acid indigestion, happens when stomach acid moves up from the stomach2 and into the esophagus. Under normal circumstances, muscles at the bottom of the esophagus — known as the lower esophageal sphincter (LES) — act as a barrier to prevent this from happening, but if those muscles are weak or relaxed3 and don’t close all the way, then reflux can occur.
Virtually everyone experiences reflux4 from time to time, but for most people, it is mild, infrequent, and goes away quickly on its own.
For people with GERD, on the other hand, acid reflux typically happens at least once per week and often involves more severe and bothersome symptoms. While it is usually thought of as affecting adults, it can occur in infants and children5 as well.
What Are the Symptoms of GERD?
Heartburn, which involves a painful burning sensation in the chest, is the most common symptom6 of GERD, but not all cases of GERD involve heartburn.
Another common symptom of GERD is regurgitation, which means a small amount of stomach acid and sometimes bits of food come up into the mouth or back of the throat.
When leaks of stomach acid rise to the mouth and throat, it can cause coughing and a feeling of choking. It may cause a sore throat, including a hoarse voice. Some patients experience difficulty swallowing, known as dysphagia, or the feeling of something blocking their throat.
On top of the discomfort from heartburn, GERD can cause radiating chest pain7 that can affect the neck, back, jaw, or arms and last for minutes to hours. This symptom is frequently associated with nighttime awakenings for people with GERD.
Why is GERD Worse After Going to Bed?
There are several explanations8 for why GERD is commonly worse at night after going to bed:
When lying down, gravity no longer helps keep stomach acid down, making it easier for reflux to occur.
Decreased swallowing during sleep reduces an important force that pushes stomach acid downward.
Saliva can help neutralize stomach acid, but production of saliva is reduced during deeper stages of sleep.
A combination of these effects can facilitate the leakage of stomach acid into the esophagus and allow the acid to remain in place for longer, potentially causing more severe GERD symptoms9, including those that can disturb sleep. The problem may be even greater if a person goes to bed soon after eating and/or eats foods that trigger GERD.
What Are the Health Consequences of GERD?
Chronic reflux and GERD can cause serious complications. These include inflammation and ulcers of the esophagus, scar tissue that narrows the esophagus, spasms affecting the airway, chronic cough, damage to teeth, and exacerbated asthma symptoms.
In about 10-20% of cases10 of GERD, damage to the esophagus from stomach acid becomes a condition called Barrett esophagus11. Barrett esophagus is considered to be the primary risk factor for esophageal cancer12 although not everyone with the condition develops cancer.
What Causes GERD?
The immediate cause of GERD is the inability of the muscles at the bottom of the esophagus to block reflux of stomach acid, but other underlying elements have been found to make that condition more likely.
These risk factors13 contribute to the chances of developing GERD. However, not everyone with these risk factors will develop GERD, and not everyone with GERD has these risk factors.
Obesity: GERD occurs at a higher rate in people who are overweight or obese although the exact explanation for why this occurs is uncertain.
Smoking Cigarettes: Smoking has been found to affect the pressure near the lower esophageal sphincter and may slow the clearance of stomach acid.
Drinking Alcohol: Alcohol impacts the processes for emptying the esophagus and stomach in ways that can facilitate acid indigestion.
Using Certain Medications: A number of medications, including many anti-asthma, blood pressure, antidepressant, and sedatives medications can increase the risk of reflux.
Hiatal Hernia14: In this condition, the stomach moves upward inside the body, above the diaphragm and into a position that makes reflux more common.
Dietary Choices: Certain foods and beverages are often reported to induce heartburn or reflux. Examples include chocolate, tomatoes, spicy food, vinegar, citrus, fatty foods, carbonated beverages, coffee, and mint.
Pregnancy: Pregnant women often experience GERD, but their symptoms usually cease shortly after giving birth.
How Are GERD and Sleep Related?
GERD is often cited as a cause of sleeping problems15, including in the National Sleep Foundation’s 2001 Sleep in America Poll. In a more recent survey of people with frequent heartburn, nearly 60% said it affected their sleep16, and more than 30% said it hurt their daytime functioning.
Flare ups of GERD symptoms after lying down can make it hard to fall asleep and can cause nighttime interruptions from heartburn, chest pain, and coughing. Studies in sleep clinics of people with GERD have found that these symptoms are correlated with lower sleep quality17.
GERD and Obstructive Sleep Apnea
Research has also identified a link between GERD and obstructive sleep apnea (OSA), a sleep disorder that involves blockage of the airway that incites pauses in breathing during sleep. Debate exists among experts about whether GERD causes OSA, OSA causes GERD, or if they simply share similar risk factors.
It is possible that GERD affects the airway and ability to breathe normally, causing more apneas during the night. At the same time, people with OSA wake up frequently at night and may then detect GERD symptoms. Lack of sleep from OSA may make the esophagus more susceptible to reflux.
In addition, factors like alcohol consumption, smoking, and obesity can increase risk for both GERD and OSA, so the correlation between the conditions may be a result of these factors.
While the exact relationship between GERD and OSA is subject to further research, it is clear that the conditions can occur together and create significant complications for a person’s sleep, comfort, and overall health.
How Can People With GERD Get Better Sleep?
It’s natural for people with GERD to want to know how they can reduce their symptoms and get better sleep. Although there’s no single solution that works for everyone, there are meaningful steps to get relief from heartburn and GERD and get longer, more restorative sleep.
Work With a Doctor
It is important to see a doctor if you have chronic or severe symptoms of GERD and/or frequent problems with sleep or daytime drowsiness. Because these are complex medical issues, a doctor can best examine the situation, determine the potential cause, order necessary tests, and recommend treatment.
A doctor’s focus may be on addressing GERD directly or on treating an underlying condition, such as obstructive sleep apnea, with the goal of reducing nighttime awakenings.
Treatment options can include both medical and non-medical approaches. The following sections describe some of those treatments, but a doctor is best suited to discussing the pros and cons in any patient’s particular case.
Lifestyle changes to reduce potential GERD triggers are a common aspect of managing the condition. Examples include reducing consumption of spicy and acidic foods, maintaining a healthy weight, and not smoking.
Since many GERD problems flare up at night, some lifestyle changes focus on tips for how to sleep with GERD.
Avoid eating late. Finishing meals at least three hours before lying down can give your stomach time to digest and reduce the chances of reflux.
Sleep on your left side. Multiple research studies have found that being on your left side is the best sleeping position for people with GERD18. Sleeping with your left side down reduces reflux episodes19 and exposure of the esophagus to stomach acid. Sleeping in other positions, including on your back, can make reflux more likely20.
Raise the head of the bed: Propping up the top of the bed (and not just the pillows under your head21) by at least six inches can cut down on reflux when lying down. Using an adjustable bed frame and finding the best mattress to use with the frame is one easy way to incorporate this change.
Medications can be used to treat GERD and may be necessary because lifestyle changes don’t always resolve symptoms.
Over-the-counter medications like antacids can bring temporary relief but may be of limited effectiveness in many people. Other drugs, known as proton pump inhibitors (PPIs) and H2 blockers, try to reduce acid produced in the stomach. These drugs may be available over-the-counter or with a prescription, but because they can have side effects, it’s best to talk with a doctor before taking them.
In rare cases when neither lifestyle changes nor medications have been effective, certain types of surgery may be considered to address GERD.
Improve Sleep Hygiene
People with GERD who want to sleep better may be helped by considering their sleep hygiene, which includes all of the elements that shape their sleep environment and sleep-related habits.
A high level of sleep hygiene can cut down on sleep interruptions and create more consistency in your nightly rest. Many tips for healthy sleep overlap with lifestyle changes for GERD such as avoiding excess caffeine and alcohol. A stable sleep schedule, a relaxing pre-bed routine, and a quiet and comfortable bedroom are other central components of sleep hygiene.