Although the balance of epidemiologic data supports a relationship between obesity and gastroesophageal reflux disease (GERD), it is difficult to establish true cause and effect. However, results of several studies show that the frequency and severity of GERD symptoms and complications may be higher in obese patients, including an increase in the presence of hiatal hernia. Additionally, findings of a recent meta-analysis demonstrate a statistically significant increase in the risk for GERD symptoms, erosive esophagitis, and esophageal adenocarcinoma in obese patients. No definitive study is available, however, to suggest deviating from standard GERD screening or treatment guidelines for the obese patient. Physicians should approach obese patients with GERD as they do those with reflux disease and ideal body weight. The recommendation of weight loss for the obese patient with GERD is reasonable to improve GERD physiology and symptoms. Lifestyle modifications and medical therapy with a proton pump inhibitor (PPI) once daily before breakfast for 4 to 8 weeks should be initiated. Antireflux surgery is always an option for patients with GERD who have a symptomatic response to PPIs. Prospective studies directed at the obese patient are needed to determine if different approaches are required.