Dealing with heartburn through breathing techniques


Although heartburn has long been considered one of the unpleasant symptoms of gastroesophageal reflux disease (GERD), it is not exclusively linked to GERD. There are also functional gastrointestinal disorders that do not show clear structural changes, but nevertheless significantly affect the daily lives of patients.

When it comes to eliminating heartburn, we often hear the same familiar advice: adjust the angle of your bed, avoid certain foods, reduce stress, and so on. But what if these measures aren’t enough?

Research shows that stress can significantly worsen your symptoms by triggering complex physiological and psychological responses that affect the digestive function. It’s therefore important to explore alternatives that can help manage your symptoms and improve the quality of your life.

Find out why conventional approaches and medications often fail to bring relief, and what else you can do.

Heartburn: not only a symptom of GERD, but a possible indicator of other oesophageal disorders

Heartburn is the most common symptom of gastroesophageal reflux disease (GERD), which affects a large percentage of the population and is increasingly prevalent among young people. With GERD, the contents of the stomach flow into the oesophagus, causing unpleasant problems such as heartburn, regurgitation, chronic coughing and hoarseness, and can eventually lead to changes in the oesophageal wall. However, heartburn is not exclusively associated with GERD.

In fact, in approximately 70% of people who suffer from heartburn there are no signs of damage to the oesophagus. Heartburn may therefore also be a symptom of nonerosive reflux disease (NERD), in which an increased amount of reflux occurs without damage to the oesophagus, reflux hypersensitivity or functional heartburn.

Heartburn is thus also associated with functional gastrointestinal disorders. Functional gastrointestinal disorders are chronic problems in the digestive tract which do not indicate structural changes, nor are there any biochemical deviations that could explain the problems that patients are experiencing. Nevertheless, the patient may experience problems such as – in the case of irritable bowel syndrome – abdominal pain, bloating, chronic diarrhoea or constipation.

Functional heartburn manifests itself in burning pain or a sensation behind the sternum similar to that of GERD, but there is no evidence of damage to the oesophageal mucosa and no increased acid reflux, nor is there a correlation between heartburn symptoms and the presence of acid reflux. A diagnosis of functional heartburn is established once GERD and NERD have been excluded.

In any case, functional heartburn as well as GERD and NERD have a significant impact on the patients’ quality of life. They are a cause of constant anxiety, reduced productivity, poor sleep quality, and other negative outcomes.

The diagnosis of functional heartburn should include the following Rome IV criteria:

  • a burning sensation or pain behind the sternum at least twice a week for the last 6 months,
  • no improvement of symptoms following optimal pharmacological therapy (antacids, H2-receptor antagonists, proton pump inhibitors),
  • absence of evidence of gastroesophageal reflux or eosinophilic oesophagitis,
  • absence of major oesophageal motor disorders (absence of peristalsis, diffuse oesophageal spasm, etc.).

The causes of heartburn are multifaceted

Heartburn is extremely widespread in the Western world. Studies show that 21% to 40% of the population is affected. The causes of heartburn are multifaceted and usually lifestyle-related, for example poor eating habits, obesity, smoking and to a large extent stress.

As in other functional gastrointestinal disorders, the exact mechanisms of functional heartburn remain unclear. However, studies suggest a hypersensitivity of the visceral nerves of the oesophagus and changes in the functioning of the gut-brain axis.

Since functional heartburn is not the result of increased acid reflux, one hypothesis is that it is related to increased mucosal permeability. This may allow harmful substances to reach deeper layers of the oesophagus where they can trigger an inflammatory response. This response results in peripheral hypersensitivity of the oesophageal nerves. Another possible cause is central hypersensitivity in the parts of the brain that control pain, which can be activated by cognitive factors such as psychological distress, stress, anxiety, and so on. Oesophageal hypersensitivity can occur when non-painful stimuli become painful or when painful stimuli are intensified.

A woman suffering from heartburn.

Heartburn: why general advice may not be enough and what else to do

The first step in treating heartburn involves lifestyle changes, including dietary adjustments, more exercise, losing weight, quitting smoking, stress management, etc.

We recommend the following general measures against heartburn:

  • sleeping with your head elevated,
  • eating smaller and more frequent meals,
  • eating your last meal at least three hours before going to bed,
  • going for a walk after eating,
  • following a low-fat diet,
  • avoiding chocolate, tomatoes, lemon, peppermint and coffee.

While these tips are widely used and you’ve probably heard them many times, they’re usually not effective enough and do not bring much relief.

On the other hand, the main pharmacological approaches prescribed by doctors, such as antacids, proton pump inhibitors, prokinetics, H2 receptor antagonists, and the like also aren’t effective for functional heartburn. These common pharmacological therapeutic approaches do not address the causes of the problem, do not focus on the mechanisms of reflux and do not strengthen the antireflux barrier or speed up the clearance of oesophageal reflux.

Read on to find out what else you can do.

Understanding the impact of stress on the symptoms of heartburn   

The link between stress and heartburn is complex, involving both psychological and physiological responses that occur during periods of stress. When we are feeling stressed, the body activates the fight-or-flight response, which is a natural evolutionary behaviour designed to protect us from danger and allow us to adapt to our environment. However, chronic and excessive stress can adversely affect the functioning of organ systems, especially the digestive tract. Increased anxiety and stress levels can have several effects on the digestive tract and oesophagus:

  • changes in motility, peristalsis of the digestive tract, leading, for example, to a slowing of stomach emptying, and consequently to increased pressure in the stomach;
  • increased permeability of the mucous membranes of the digestive tract;
  • heightened visceral pain sensitivity of the oesophagus, with studies showing that psychological stress also affects the pain perception of nociceptors, the free endings of pain fibres;
  • impaired capacity for the regeneration and blood supply of the gastrointestinal mucosa;
  • activation of immune cells and enhanced inflammatory processes, which can heighten the sensitivity of pain fibres;
  • restricted or excessive release of gastric acid, with studies showing the increased release of acid due to stress in some individuals, while others experience reduced release during periods of stress;
  • changes in the gut-brain axis and changes in the parts of the brain responsible for pain perception, such as the amygdala and prefrontal cortex.

These changes can result in various disorders and diseases of the oesophagus, such as GERD, reflux hypersensitivity and functional heartburn.

Even in healthy people, excessive stress can produce a physiological response that manifests itself acutely in the form of pain. When it comes to a person with a hypersensitive digestive tract, however, even mild stress often triggers an overreaction in the nerve pathways, which worsens or even restarts symptoms.

Experts believe that functional gastrointestinal disorders are often caused by daily exposure to stress and anxiety. For example, one study found that patients with functional heartburn who had been under constant stress for the past six months experienced more severe heartburn than healthy subjects. Patients with functional heartburn were also more likely to report higher levels of anxiety than patients with GERD. In addition, functional heartburn often occurs together with other gut-brain axis disorders, such as irritable bowel syndrome and functional dyspepsia.

In times of stress, we also tend to switch to unhealthy eating habits, and more often choose fast food and fatty and sugary foods, as well as alcohol and coffee, which can trigger or worsen the symptoms of heartburn.

At first glance this may seem like an unsolvable problem, but the disrupted gut-brain balance can be restored with the right neurological and hormonal signals, which in turn can be activated by lifestyle habits that include a fibre-rich diet, adequate sleep, regular exercise, mindfulness, meditation and calming the nervous system with breathing and relaxation techniques.

The woman is stretching.

Alternative ways to manage stress-related heartburn

Breathing and relaxation techniques: the key to a healthy gastroesophageal barrier

A well-functioning gastroesophageal barrier, which includes a good tone of the lower oesophageal sphincter, crural diaphragm pressure and maintaining a normal acute esophagogastric angle, is key to oesophageal health.

The importance of good lower oesophageal sphincter function

The lower oesophageal sphincter is a muscle that acts as a gate between the stomach and oesophagus. When we eat, this muscle contracts, closing the opening, and when we swallow it relaxes and opens to allow the passage of food and liquids into the stomach. Occasionally there are transient relaxations, unrelated to swallowing, which allow the release of gas bubbles (belching, hiccupping).

If the lower oesophageal sphincter is not sufficiently closed or relaxes at inappropriate times, then the reflux of gastric acid into the oesophagus and throat can occur. The sensation of stomach acid coming into contact with the oesophageal mucosa is heartburn. It has been observed that GERD patients have more frequent transient relaxations of the lower oesophageal sphincter. The tone of this muscle is influenced by diet and hormonal and neural signals. 

While it is known that diet has a significant effect on oesophageal sphincter tone, it is less well known that deep breathing relaxation techniques can also have a beneficial effect on the lower oesophageal sphincter tone.

Diaphragmatic breathing combined with other relaxation techniques can increase diaphragmatic pressure and thus oesophageal sphincter pressure, reducing the incidence of reflux and consequently heartburn.

The diaphragm – an anatomical and functional component of the antireflux barrier

A perhaps overlooked but highly effective way to manage the symptoms of heartburn is to breathe properly. Breathing is something that most people think they have mastered, but in fact the exact is true. Most people are using their main respiratory organ inefficiently. And no, it’s not the lungs, it’s the diaphragm.

The abdominal diaphragm is the flat muscle that separates the thoracic and abdominal cavities and is the main respiratory muscle, performing 80% of the muscular work involved in breathing.

In its relaxed state, the diaphragm is shaped like a dome. The rib part of the diaphragm plays the most important role in breathing, expanding the lower rib arch, while the crural part of the diaphragm does not have such a central respiratory role and does not appreciably change the dimensions of the rib arch. On the other hand, it’s strongly involved in gastroesophageal functions such as swallowing, and acts as an important part of the gastroesophageal reflux barrier.

It’s estimated that 85% of the entire antireflux barrier is attributable to the diaphragm.In other words, the diaphragm acts as a valve, keeping acid in the stomach where it’s needed to digest food.

Optimising diaphragm function is the key to an effective antireflux barrier

Many factors influence the performance of the diaphragm. A taxing lifestyle, which includes unhealthy eating habits that result in excess weight gain, a lack of physical activity, chronic stress and poor posture (stooped posture or overly expanded chest), as well as smoking, which reduces the elasticity of the respiratory tissues – all these can lead to impaired diaphragm function.

The diaphragm needs to function in harmony with the abdominal and thoracic muscles and the fixators of the upper chest to perform its role effectively. In people with GERD, there is an imbalance between these muscles, which causes the chest to be in a position known as open scissors syndrome. This in turn alters the breathing pattern, as the diaphragm becomes less active, reducing the strength of the antireflux barrier and even increasing the risk of hiatal hernia.

In contrast, activities that strengthen the diaphragm, such as abdominal breathing and exercise, increase the tone of the lower oesophageal sphincter and improve oesophageal peristalsis, which is an important component of the antireflux barrier.

The diaphragm is a skeletal muscle over which we have partial voluntary control, and its function can be improved by various respiratory therapy techniques, key among which is training in diaphragmatic breathing.

Appropriate breathing exercises increase diaphragmatic muscle tone, thereby improving chest expansion and the clearance of air passages, as well as strengthening the respiratory muscles. Strengthening the diaphragm can thus improve the function of the antireflux barrier.

 Studies show that both short-term (30 min) or long-term (several weeks for a few minutes a day) diaphragmatic breathing can significantly improve the function of the antireflux barrier. After several months of training, the need for medication is also significantly reduced.

The woman is doing breathing exercises that can help alleviate heartburn.

Other effective oesophageal health interventions

In addition to diaphragmatic breathing, other behavioural interventions for oesophageal disorders that have been more widely researched include cognitive behavioural therapy, hypnotherapy, acupuncture and other relaxation techniques.

Cognitive behavioural therapy

Cognitive behavioural therapy has been used as a treatment for functional gastrointestinal disorders for many years. Patients who have been in regular cognitive behavioural therapy for several years, learning to control their thoughts, behaviour and physiological responses, report substantial improvements in their symptoms and mental health.


Hypnotherapy, which focuses on the oesophagus, aims to create a deep state of relaxation and focused attention that enables the patient to learn how to control their physiological sensations and symptoms. A study of a seven-week hypnotherapy programme demonstrated relief of heartburn and improved quality of life in patients with functional heartburn.

Key article highlights

Heartburn is more than just an unpleasant symptom of gastroesophageal reflux disease (GERD), and in 70% of cases is an indicator of other oesophageal disorders. Even with various treatment approaches such as dietary changes and medication, heartburn may remain difficult to treat, especially if it is stress-related.

Instead of relying on antacids, which are sometimes necessary for immediate relief, it’s sensible to choose a different approach and address the underlying causes, which are most often linked to an unbalanced lifestyle. Although this path may seem longer, it’s much more effective, sustainable and healthier, as it not only relieves the symptoms of heartburn, but also improves overall quality of life.

A healthy diaphragm is the key to preventing acid reflux and heartburn symptoms. By understanding how it functions and the factors that affect it, whether negatively or positively, and by practicing diaphragmatic breathing, reflux problems can be reduced or even prevented.


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