What Actually Causes GERD and Acid Reflux? Why Long-Term PPI Use Often Makes It Worse — What the framework approach to GERD looks like

A treatment approach that addresses the upstream mechanisms of GERD looks different from standard care. The PPI may continue where it is clearly necessary, but at the lowest effective dose, and with simultaneous work on the underlying mechanisms. The sequence: First, identify what is driving the LES dysfunction in the specific patient. Is there SIBO contributing to pressure from below? Is there gastroparesis? Is there hiatal hernia? Is there bioenergetic compromise from chronic illness? Is there vagal dysfunction? Most patients have multiple contributors; one or two are usually dominant. Second, address the pressure-from-below contributors. If SIBO is present, treat per the recurrent SIBO framework. If gastroparesis is contributing, address motility (often through addressing the same vagal and bioenergetic factors). If chronic constipation is contributing, address it with attention to magnesium, hydration, fiber from appropriate sources, and the broader gut framework. Weight optimization if relevant. Third, support LES function directly. Magnesium glycinate (300-600 mg daily) for smooth muscle function and bioenergetic support. Address any zinc, B-vitamin, or other cofactor deficiencies. Slow-paced diaphragmatic breathing for vagal tone and for the diaphragmatic component of LES support. Postural and lifestyle interventions (head of bed elevation, meal timing 3+ hours before ly