- The Silent Reflux Diet
- Laryngopharyngeal Reflux (LPR): Management and Treatment
- The Supreme Guide to LPR Causes & Treatment
- LPR Treatment: Common Causes and their Fixes
- 2. A Common Mistake: Acid
- 3. Why Pepsin Plays a Crucial Role in Curing LPR
- 4. Can Low Stomach Acid Cause LPR?
- 5. Small Intestinal Bacterial Overgrowth
- Treatment Options are Plentiful
- Silent Reflux: A Preventable Epidemic, Pt 2 (4:14)
- What’s the Structure of the Books?
- The Actual Diet (Dr Jamie Koufman Diet)
- Koufman Diet / Dropping Acid Diet Review Conclusion
- Mayo Clinic Q and A: Lifestyle changes may ease laryngopharyngeal reflux
The LPR Cure: Everything I’ve Learned
- What is LPR and why does it happen?
- Why am I writing about LPR?
- Start here: the low-acid diet
- Here’s how the low-acid diet works
- What about medication? PPIs, H2-antagonists and antacids (amongst others)
- What else? More good ideas.
- “Natural” supplements which may or may not help
- A bonus tip
- The bottom line
- Recommended further reading
- Acid Reflux Food To Avoid For Your Reflux Baby
- Fruits – Acid Reflux Food to Avoid
- Meats – Acid Reflux Food To Avoid
The Silent Reflux Diet
The silent reflux diet eliminates foods that can aggravate reflux symptoms and relax muscles in your lower esophagus. These muscles, also known as the esophageal sphincter, are the gateway between your esophagus and stomach that prevents stomach acid and food from traveling backward. When it’s relaxed, the esophageal sphincter can’t close properly and causes reflux symptoms.
Paired with medication, dietary changes help prevent reflux symptoms and identify the trigger foods that can worsen your condition.
Foods to avoid
If you decide to pursue the silent reflux diet, doctors recommend eliminating high-fat foods, sweets, and acidic beverages.
Some foods to avoid include:
- whole-fat dairy products
- fried foods
- fatty cuts of meat
- tomatoes and tomato-based foods
It’s also important to avoid chocolate, mints, and spicy foods because they’re known to weaken the esophageal sphincter.
However, each trigger food can affect people differently. Pay close attention to what foods cause you more discomfort or worsen your upper endoscopy results.
Foods to eat
The silent reflux diet is similar to other balanced diets that are usually high in fiber, lean proteins, and vegetables. A 2004 study showed that increasing fiber and limiting salt in your diet can protect against reflux symptoms.
Some of these foods include:
- lean meats
- whole grains
- caffeine-free beverages
- leafy green vegetables
Laryngopharyngeal Reflux (LPR): Management and Treatment
How is laryngopharyngeal reflux treated?
Most cases of LPR do not need medical care and can be managed with lifestyle changes, including the following:
- Follow a bland diet (low acid levels, low in fat, not spicy).
- Eat frequent, small meals.
- Lose weight.
- Avoid the use of alcohol, tobacco and caffeine.
- Do not eat food less than 2 hours before bedtime.
- Raise the head of your bed before sleeping. Place a strong, solid object (like a board) under the top portion of the mattress. This will help prop up your head and the upper portion of your body, which will help keep stomach acid from backing up into your throat.
- Avoid clearing your throat.
- Take over-the-counter medications, including antacids, such as Tums®, Maalox®, or Mylanta; stomach acid reducers, such as ranitidine (Tagamet® or Zantac®); or proton pump inhibitors, such as omeprazole (Prilosec®), pantoprazole (Protonix®), and esomeprazole (Nexium®). Be sure to take all medications as directed.
In very severe cases of LPR, surgery may be recommended as treatment.
What can happen if laryngopharyngeal reflux is not treated?
If it is not treated, LPR can lead to:
- Sore throat
- Chronic cough
- Swelling of the vocal folds
- Ulcers (open sores) on the vocal folds
- Formation of granulomas (masses) in the throat
- Worsening of asthma, emphysema, and bronchitis
Untreated LPR also may play a role in the development of cancer of the voice box.
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The Supreme Guide to LPR Causes & Treatment
There are many causes of LPR.
Which is why there are many potential solutions as well.
Many physicians treat generically – each patient receives the same treatment. If the patient is lucky, that treatment tackles the root cause. If not, the LPR symptoms will persist or come back.
For a permanent cure, you need the right solution for your individual problem.
Let’s have a look at 5 groups of LPR contributors and their respective treatment:
LPR Treatment: Common Causes and their Fixes
The key contributor to laryngopharyngeal reflux (LPR) are malfunctioning sphincters.
Sphincters are valves that keep food in the right organ of your digestive system until it’s ready to be passed on.
Whenever one or more of those sphincters do not work as they should, problems start to happen – often in the form of reflux.
These are the three sphincters that play a role in LPR:
A) Lower Esophageal Sphincter (LES):
The LES is the first anti-reflux barrier and the best-understood sphincter. It sits directly above the stomach.
The LES has a complicated task. It needs to open at exactly the right moment. Only then is it possible to swallow food, yet still prevent reflux the rest of the time. For reasons not yet completely understood, the LES relaxes regularly. Those events are called transient lower esophageal sphincter relaxations. Maybe it is a way to relieve pressure in the stomach.
Everybody has these relaxations which is why everybody also has reflux. The point is: People with reflux symptoms have those relaxations more often. Your body can tolerate some reflux. Only when it becomes too much, you start to feel the symptoms.
The lower esophageal sphincter is a muscle. However, it works differently than most muscles in our body. It does not get stronger if we use it a lot – it gets weaker! It is a little bit like when you have back pain from sitting too long in one position. You are overusing some muscles. But instead of becoming stronger they become tense and painful. They stop fulfilling their function as they should.
The lower esophageal sphincter reacts in the same way if it is being put under unnatural stress for long periods of time. It becomes unable to fulfill its function as a barrier against reflux.
After years of overeating and late night eating, the lower esophageal sphincter can get weaker and reflux can increase. Most people do not even realize that they are eating unnaturally – as pretty much everybody these days is doing it. We grow up with it.
How to Treat a Malfunctioning LES
It will have a high impact if you start eating smaller meals. That will put less stress on your LES.
Even more important is to stop late night eating. As long as you are in an upright position, gravity is on your side. When you lie down, the contents of your stomach are pressing on the LES. On top of that, digestion is slower when you sleep. While most people with LPR reflux during the day, the worst cases are due to nighttime reflux. At night, all of your anti-reflux defenses slow down, which is why reflux causes more damage.
There are some foods that impair the function of the lower esophageal sphincter. Some relax the sphincter-like chocolate, caffeine (coffee, tea, etc.) & alcohol. Others produce gas which presses open the sphincter, like onions. I will talk more about diet later in this article.
If diet alone is not enough, there are also surgeries available:
A very established surgery is the Nissen Fundoplication in which a part of the stomach is wrapped around the LES to tighten it up.
The Fundoplication is proven to work for most LPR patients. However, side effects like bloating are common and can be severe. Also, it is a permanent option. You can redo it if the wrap loosens up. You can have it loosened to relieve side effects. But you are going to be stuck with a fundoplication for life.
A newer solution is the LINX device. It is a band of magnetic beads which is implanted around the lower esophageal sphincter. The upside of the LINX is that it can be removed if it causes problems. However, there is very little data on how well it works for LPR patients. Most experts recommend the Nissen Fundoplication over the LINX.
I think another surgery will be the first line of defense against LPR in the future: the Stretta Procedure.
The procedure is fairly new, a bit more than 10 years old. It takes longer for standard medical treatment guidelines to change. While Stretta is less effective in fighting reflux than other procedures, it is low-invasive and rarely has long-term side effects.
When you do a Stretta, the muscles of your LES are stimulated with electricity. This causes them to grow and reduces the amount of relaxations. The downside is that it takes a few months after the treatment to feel the results. That is how long it takes the body to build more and stronger muscle.
The good thing with Stretta is, if you do not get better, you can still do any other kind of surgery. The Stretta does not cause conflict with other procedures as it only grows muscle and improves its behavior.
There is medication which can increase the pressure of the sphincter, for example so-called prokinetic agents. Another agent is Baclofen which reduces the frequency of sphincter relaxations. The problem is that all those agents can have significant side effects – psychological, neurological and on the motoric function – which is why they are rarely used.
Medication can be great to assist with the healing process in the short term. Patients who need them long term are usually better off with surgery. The risk/benefit ratio is simply better.
It is important that your LES can resist the pressure in your stomach. The lower esophageal sphincter is the first line of defense against laryngopharyngeal reflux.
The more reflux gets through, the more the next barrier, the upper esophageal sphincter, has to fight.
B) Upper Esophageal Sphincter (UES):
The UES is the final barrier before reflux reaches your airways.
If your UES malfunctions, you will develop LPR symptoms.
The airways have minimal resistance to reflux. They can be damaged by amounts of reflux that the esophagus would not blink an eye about. That is why many people have LPR but no heartburn.
Despite the UES’ importance in LPR, there has been little research done on it. That is because up until recent years LPR did not get much research attention.
How to Treat a Malfunctioning UES
The UES often recovers through a better diet alone.
LPR is a vicious circle.
The tissue that lines the UES becomes inflamed which reduces the sphincter’s ability to function. This creates even more reflux. Reducing the reflux with a proper anti-reflux diet can break the vicious circle.
C) Pyloric Sphincter
The pyloric sphincter sits in between the stomach and the intestines. It’s job is to keep food in your stomach until it is digested enough to travel forward.
Problems start if your pyloric sphincter is stronger than the LES above your stomach. For digestion to work, your stomach needs to contract and press food out into the intestines. If the LES is weaker, it will open up instead of your pyloric sphincter.
Imagine it like a tube of toothpaste. Usually, when you press the tube, the paste should come out of the opening in front. Now imagine you cut a big whole into the back of the tube. When you press, the paste suddenly comes out both openings. The same happens in reflux. If the LES does not hold tight, there will be two openings for food to leave the stomach.
One reason for a malfunctioning pyloric sphincter is that the supplying vagus nerve is damaged. It is not that uncommon.
The result can be delayed gastric emptying (gastroparesis) with symptoms like bloating. Your stomach can not empty itself properly as parts of the gastric content are pushed into the esophagus instead of the intestines. According to Dr. Mark Noar, up to 40% of people with reflux have this problem.
A malfunctioning pyloric sphincter can be diagnosed by doing an electrogastrogram (EGG). The test senses electrical signals that are coming from the muscles of the stomach. It is a similar test to an EKG that is used to evaluate the function of the heart.
How to Treat a Malfunctioning Pyloric Sphincter
It is possible to dilate the pyloric sphincter while doing an endoscopy of the stomach.
However, it is a procedure that is still rarely done for reflux patients. Probably because the knowledge about pyloric sphincter malfunction and its treatment is still rather new and not widespread.
2. A Common Mistake: Acid
Acid causes reflux. Or maybe not?
Well, “normal” reflux is caused mostly by acid, yes. With normal reflux, I mean symptoms in your esophagus like heartburn.
However, with LPR, acid is only a part of the equation. Much more important is to understand the role of pepsin:
3. Why Pepsin Plays a Crucial Role in Curing LPR
LPR is caused by a combination of acid and the stomach enzyme pepsin.
The job of pepsin is to digest proteins in the stomach. If you have LPR, pepsin gets up into your throat and airways. There it goes on with its job: digesting. It’s just that pepsin now digests the cells of your airways. That does not sound good, does it?
Pepsin is highly influenced by the presence of acid.
The acidity is expressed by the pH. A pH of 1-2 is about the level of the empty stomach and is very acidic. A pH of 7 is neutral. Everything above is alkaline.
Usually, the pH in the throat is about neutral. Pepsin becomes inactive in such an environment. However, each time pepsin comes in contact with acidity, it becomes reactivated.
The lower the pH is, the higher the damage potential of pepsin:
Once refluxed, pepsin can stay in your airways for days or weeks.
What You Can Do About Pepsin
It is crucial to avoid drops in acidity in the throat and airways. Otherwise, the damage potential of pepsin will be increased massively.
One way to do that is to avoid reflux in the first place. For example, by fixing your sphincters which we already talked about above. Each acidic reflux will not only transport new pepsin into the throat, but on top of that, the acidity will reactivate the pepsin that is already there.
Other treatments target pepsin more directly:
Avoid Acidic Drinks & Foods
Each time you consume acidic drinks or foods your throat is bathed in acidity. It will reactivate pepsin and promote LPR symptoms over time.
Dr. Jamie Koufman is a pioneer in low acid diets to treat the symptoms of laryngopharyngeal reflux disease. She wrote a whole book on how you can control LPR with diet, especially by removing acidic foods and drinks.
According to her, anything under pH 5 should be banished from the diet, at least until the symptoms have disappeared. After that, a cautious reintroduction of slightly acidic foods up to pH 4 is possible.
Almost all fruits are more acid than pH 5 and therefore not a good choice for LPR sufferers.
Sodas like cola and Fanta are even more acidic than most fruits. Sodas are about as acidic as lemons. Their pH is between pH 2.5 and pH 3. The sugar in soda is covering up the acidic taste. Without the sugar, sodas would be inedible.
Melons are an exception. They have an about neutral pH and can, therefore, be eaten.
You have to be careful when you are looking up the acidity of foods on the internet.
In LPR, it is relevant which pH food has when it passes through the throat. This is the moment when acids can reactivate the pepsin and cause them to destroy the mucus membranes. However, many sources on the internet refer to whether acids or bases (alkaline substances) are formed during the metabolism – meaning inside your body. Pepsin does not care about what happens after digestion. However, it is of relevancy in some diseases like arthritis which react negatively to acidity in the body. Much data on the Internet references those values AFTER digestion.
I know this is confusing. If in doubt, you can test the pH of foods with pH strips. I also have an extensive list of the acidity of foods and drinks in my online course.
While acidity reactivates pepsin, alkalinity above pH 8.8 permanently deactivates pepsin. That means afterward, even acidity can not make the pepsin work again.
Drinking or gargling with alkaline water is helpful for “washing” the pepsin out of your throat. This is not a miracle cure. You will only be able to hit pepsin in your mouth and throat. Some of the water will also spill through the entrance of your larynx.
Alkaline water can be one step in the direction of symptom resolution. Just keep in mind that alkaline water cannot do anything against you refluxing new pepsin. You still need to fix the reflux itself.
Some people show improvement by drinking or gargling alkaline water while others show no improvement at all. You have to try it out.
There are multiple ways to get or make alkaline water:
Bottled: Some brands like Evamor are naturally alkaline. It is the healthiest solution – but also the most expensive.
Baking Soda: You simply mix it with water. You can get baking soda everywhere that sells baking supplies. The chemical name is sodium bicarbonate. It a substance which is natural in your throat. It is excreted by the mucosa to neutralize acid. That makes it part of your natural reflux defenses.
Baking soda is very cheap and easy to transport.
The problem with this solution is that you will consume loads of sodium which is not good if you have problems with high blood pressure. It can also lead to side effects like water retention & edema when you overdo it.
On the other hand, some people say that you specifically need sodium bicarbonate to permanently deactivate pepsin. Baking soda is pure sodium bicarbonate.
pH Drops: There are bottles that contain concentrated alkaline minerals which you can use to make any water alkaline. Often they are sold under names like “pH boosters”. You just place a few drops in a glass of water. While they definitely increase the pH I am not sure if they make a difference with LPR. It has been suggested by me by Dr. Mark Noar that it might actually be a chemical reaction caused by the bicarbonate that deactivates pepsin – not just any high pH level. Those pH drops contain different minerals (usually not bicarb) and might not help at all. They also become expensive very quickly with regular use.
Other Solutions: There are different machines and water filters that promise to create alkaline water. Those machines can be a very expensive investment. On the other hand, they might come out cheaper than the other solutions if you use them for years. I have never tested any of those machines so I cannot tell which ones are good.
If you make your own alkaline water, you will need pH test strips (like the ones I mentioned above) to make sure your solution has the right pH. I recommend targeting pH 9. Producing your own alkaline water is never completely exact. If the water is in the range between pH 8.8 and 10 it should be fine. Do not go higher as it will lead to new problems like high sodium levels or neutralizing the acid in the stomach which you need for digestion.
I gargle with alkaline water in the morning (my reflux is nocturnal) and drink a few sips. That way I harness the upsides of alkaline water while minimizing the downsides.
Why PPIs are a Usually a Poor Treatment Choice
Many physicians ignore the role of pepsin in LPR and only treat the acidic component. That is why acid-reducing medication does not work well against LPR.
The most commonly prescribed medication to reduce acid production is a group of drugs that are called proton-pump inhibitors (PPIs). They are very effective at reducing the acid output of your stomach.
Here are the brand names of the available PPIs and in brackets their generic names:
Studies Show: PPIs do not Work for LPR
Proton-pump inhibitors are prescribed like crazy for LPR. That is insane, considering that numerous studies have shown they do not work for this type of reflux.
You might ask, why do PPIs not work? After all, we already established that acidity causes pepsin to be more active. Wouldn’t that mean that PPIs should help as they reduce the acidity in the reflux?
Most studies only show the average improvement of all patients in a study. A theoretical example: If half of the people get 30% better and the other half gets 30% worse, the study will show that the medication did not change anything – on average. Improvement and damage nullify each other.
From feedback of patients and physicians, I assume that some people indeed get better on PPIs while others get worse. Why people can get better on PPIs is easy to understand: less acid in the reflux means pepsin is less active & harmful.
However, the side effects of PPIs include numerous negative gastrointestinal symptoms. Anything that puts the digestive process out of balance might also lead to more reflux.
Additionally, the acid usually dilutes the pepsin in the gastric content. If you block acid production, it means that the concentration of pepsin in the reflux is higher.
An additional theory sees gas-producing bacteria as a cause of reflux. The bacteria consume incompletely digested food and emit gas. PPIs might lead to more incompletely digested food and therefore more gas. We will talk more about that below.
All of those (potential) negative effects of PPIs might cancel out the benefit of taking acid blockers and therefore explain why studies fail to show benefits of PPIs against LPR.
However, this also means that when we look at single individuals, PPIs might be beneficial. Experts that I trust recommend them in combination with diet changes – but only in selected patients and only for a few weeks or maximum months. PPIs – especially in long term usage – can create new gastrointestinal disorders which kick you into a vicious circle.
Be Careful of Overly Eager PPI Prescribers
What I hear from most of my readers is that their physicians prescribe completely contrary to that. They prescribe PPIs to LPR patients like tic tac’s.
It is a bit perverse that many medical recommendations for physicians say that if PPIs do not work for a patient after one month, they simply should be prescribed for 3 months – and then for 6 months if that still fails. Instead of changing the approach, something that did not work in the first place is simply tried again and longer.
I guess the pharmaceutical companies who produce proton-pump inhibitors had a strong influence in creating those recommendations.
PPIs are earning billions of dollars for the pharmaceutical industry every year.
It plays into the hand of big pharma that most physicians are unaware of the latest research about the role of pepsin in LPR. Those physicians think that blocking the acid production will work for LPR as it does for reflux into the esophagus (GERD). It is not correct but an understandable assumption.
In the past, I used to do market research for pharmaceutical companies by interviewing physicians and pharmacists to analyze their knowledge.
I learned that not all, but many companies will use a lack of education about a disease to their advantage where they can – in this case, to push more PPIs against LPR onto the market. That is why I got into the education of people instead of doing market research.
Rebound Effect – Increased Reflux Symptoms after PPIs
If physicians do not specialize in LPR, I strongly recommend to question when they try to put you on PPIs – especially as it is tough to get off them. The longer you take PPIs, the stronger the reflux symptoms become once you stop taking them.
This phenomenon is called the rebound effect. Not only reflux sufferers have worsened symptoms when stopping PPIs usage. Even about half of healthy people will get heartburn symptoms if they have taken PPIs for one month and then stop taking them.
The longer you have taken PPIs, the longer it will take for your acid production to go back to normal.
Taking PPIs for just 2 weeks would be not a big deal. But for LPR most physicians prescribe PPIs for much longer.
I get emails nearly daily from readers who have been prescribed PPIs for 4-6 months. Many of those patients do not get any improvement on the PPIs. However, they struggle to stop taking them as they get worsened LPR symptoms or heartburn.
I do not want to tell you that you should not take PPIs at all. What you should understand is that PPIs are prescribed like tic tac’s – – without a good understanding of their limited potential to treat LPR.
There are also H2-Inhibitors, also called H2-Blockers as a type of acid reducing medicine. Examples are Zantac (ranitidine), Pepcid (famotidine) and Tagamet (cimetidine). They are less effective in reducing acid production than PPIs, at least on an empty stomach.
H2-Inhibitors have limited use in LPR for the same reason as PPIs. They have fewer side effects than PPIs. The reason is that H2-Inhibitors are weaker than PPIs and do not reduce acid production as much. Compared to PPIs, they do not produce rebound effects – or only light ones.
If your stomach is empty, H2-Blockers work better than PPI which is why they are often prescribed for during the night.
Gaviscon Advance is a pharmaceutical product from the UK. It contains an algae extract. After swallowing, it creates a foam on the surface of the gastric content.
This foam acts as a barrier which keeps the stomach content where it belongs. Additionally, the algae extract filters the reflux by binding pepsin. That means less pepsin will make it into the airways. The effect of the filter will be strongest shortly after taking Gaviscon Advance and wear out over a few hours.
Gaviscon Advance won’t stop all your reflux or pepsin from coming up. But it makes an observable difference in many patients. Studies have shown that Gaviscon reduces LPR symptoms much better than placebo.
Attention: Gaviscon Advance is not available in the U.S. The Gaviscon product there is a simple antacid that does not work against LPR.
The U.S. Gaviscon contains no alginates and therefore has neither barrier effect nor filters pepsin.
While you cannot buy Gaviscon Advance in the U.S., you can buy it from importers on Amazon.
4. Can Low Stomach Acid Cause LPR?
The internet is an amazing tool to find information on improving your health.
The downside is that there is information which sounds very accurate, but is actually incorrect. The reason is that many websites are financed by advertising. Most forms of online advertising only pay a few cents per reader. To make the business model work, publishers hammer out a huge mass of articles – often on multiple websites. The quality of those articles is secondary.
Of course, there are sources of high-quality information out there.
However, it can be difficult to decide which advice is legit and which not.
I get emails all the time asking me why I do not write more about the “true” cause of reflux: low stomach acid.
Many people in online forums, less well-researched health blogs, and the social media are raving about how you supposedly can heal reflux by supplementing with artificial stomach acid to boost your digestion. Most people I know who tried that only got a painful stomach (gastritis) and sometimes worsened reflux symptoms.
All this buzz around low stomach acid started with Jonathan Wright’s book about “Why Stomach Acid Is Good for You”. The book describes exhaustively how acid and digestive enzymes are the basis for healthy digestion – which is correct.
An assumption of the book is that low stomach acid is the root cause of many diseases, also of reflux. Wright makes it sound like he can heal nearly any refluxer by boosting stomach acid.
The author is right that stomach acid is crucial for long-term digestive health. A very small percentage might even get reflux from it.
However, there is no data that shows this being the case for most people. If low stomach acid is so common in reflux patients, it would be easy to back this up with studies. Most studies are expensive because you try to show how a treatment is working better than a placebo. But showing that most people with reflux have low stomach acid? That would not be a big deal. The low stomach acid theory also contradicts the experience of other experts in the field, like Dr. Jamie Koufman who writes about the low acidity myth in one of her books.
By the way: I tried to get Dr. Wright for an interview to discuss his book, but he declined.
The book has great reviews. However, if you read through his books reviews on Amazon, you will realize: most people reviewed after they read the book but before they tried the treatment. People just found the book a very interesting read. Few wrote which benefits they got from the recommendations.
In his defense: the book is actually not about reflux. Dr. Wright also does not claim to be a reflux expert. Instead, he tries to explain how the digestive tract works and how you can improve digestion with different natural remedies. In that regard, his book is very interesting. He makes a case against long term usage of acid-reducing medication.
However, what people remember is that he can supposedly cure pretty much everybody of reflux by supplementing with stomach acid and digestive enzymes. Reflux is a complex disease. I can absolutely believe that this works for a small percentage of people, but not even close to everybody.
Dr. Wright claims that boosting acid and digestive enzymes works for most of his patients. I do not want to say he is a liar. Maybe people who are proven to have low stomach acid are simply actively looking for his help. What might work for this sub-group of people will not work for the general population.
If low stomach acid were the cause for reflux, then the rebound effect from PPI usage would not exist. We discussed the rebound effect above – increased reflux symptoms after stopping acid blockers. The rebound effect is caused because your acid production is higher than normal for a while. The effect is the same as supplementing with acid. If the claims of the book were true, increased acid production from stopping PPIs should heal reflux for a while – not worsen it.
You only need to remember one thing from the last few paragraphs. If someone claims that supplementing stomach acid can cure reflux in everybody: do not believe that statement easily. It might be true for a small percentage of people, but not for most.
5. Small Intestinal Bacterial Overgrowth
There is another topic which got a lot of buzz in recent years: small intestinal bacterial overgrowth (SIBO).
SIBO means that harmful bacteria have spread into and overgrown the small intestines. In simpler terms: the gut flora is out of balance.
These bacteria digest parts of our food and at the same time produce gas. This can reduce the effectiveness and general health of your digestive system.
In his book “The Fast Track Diet”, Norm Robillard describes why he sees SIBO as an important cause of reflux. The bacteria produce gas which then pressurizes or leaks into the stomach. This increase in pressure causes reflux.
Robillard recommends avoiding foods that nourish the bad type of bacteria in the intestines. Those bacteria thrive on fermentable carbohydrates like sugar, grains, fiber & fructose. Most legumes like beans and peas are also highly fermentable and worsen SIBO.
SIBO has once been described as “quack” or pseudo-science. But LPR research started the same way. Today more and more diseases are being linked to SIBO, and it is becoming an accepted concept in the medical community.
Whether SIBO is related to LPR is still a polarizing question. It is worth testing whether an anti-SIBO diet helps you. Note that many SIBO diets tend do be overly complicated and confusing. The book linked above is the only one I can recommend at this point.
Foods with a low fermentation potential from the book can be combined with a low acid diet. It avoids reactivation of pepsin. Most acidic fruits contain fermentable sugars anyway.
One word of caution: only for a small percentage of people, SIBO is the cause of their reflux. It was a tough decision whether I should even recommend the above book. What raised a huge red flag for me is that the author praises his method as being the ultimate cure against any kind of reflux (and many other diseases). He turns down widely and scientifically proven causes of reflux as lies without backing that up in any way.
It is a classic approach for selling treatments that are based on the placebo effect. The more you make people believe in a method, the stronger the placebo effect is. Still, a small number of people will profit from an anti-SIBO diet.
However, do not take all of the information in the book as absolutely true. I also do not recommend an anti-SIBO diet as a primary treatment, only as something to try out if you do not get relief from other strategies.
Treatment Options are Plentiful
There are many possible causes for LPR and therefore at least as many potential solutions.
Are you confused where to start? . In the course, multiple proven experts will tell you how to fix your symptoms. It will speed up your recovery. You will avoid making treatment mistakes that only make your symptoms worse.
Most LPR patients are treated completely wrong. Many physicians put their patients on PPIs, give some basic diet advice, and that’s it. Most people still have LPR symptoms afterward. They are told by their physicians that there is nothing else to do. No wonder many become frustrated or even depressed.
You shouldn’t be. In the doctor’s office, there is rarely more time than to prescribe a pill.
There are many possible treatments for LPR out there.
Become the advocate of your own health, and you will cure your LPR.
Silent Reflux: A Preventable Epidemic, Pt 2 (4:14)
3-Step Prevention Plan
The good news is that making simple changes to your diet can allow you to get your silent reflux symptoms in check. Here is a 3-step prevention plan to stop silent reflux before it starts.
Step 1: Deacidify the Foods in Your Diet
By eliminating foods that create acid in your stomach, or have a high acid content as they pass through your throat, you’ll reduce the chance of those stomach enzymes irritating your throat. Cut out acid-causing foods like chocolate, deep-fried foods, mints, and even certain healthy foods like tomatoes and onions. Instead, replace them with alkaline foods that actually reduce the amount of acid your stomach creates like green vegetables, bananas, almond milk, and oatmeal. In just two weeks, the majority of your reflux symptoms should be reduced significantly.
Step 2: Eliminate the 4 C’s
Caffeine, citrus, carbonated beverages (including seltzer), and cocktails all stir up acid in the stomach. And if you’re wondering what’s so bad about seltzer, stomach acid can essentially latch onto the carbonation bubbles, traveling up to your throat like a hot air balloon to activate the damaging pepsin enzyme!
Step 3: Send Canned and Processed Foods to the Trash
Cancer of the esophagus is up 850% since the 1970s, much of which can be attributed to changes in the American diet. So much of what we eat today undergoes a chemical acidification process in order to be preserved in cans or packages with ingredients like citric acid and ascorbic acid. When we eat those foods, we expose our throats to those additional acids, which of course can then activate the enzymes that eat away at our esophageal lining. Avoid canned and processed foods as much as possible, opting instead for fresh, delicious organic or all-natural foods. Your taste buds, and your esophagus, will thank you!
A Vegetarian Thanksgiving
Delicious no-meat recipes for your holiday table.
- A Heartburn-Free Thanksgiving
- A Vegan Holiday Kitchen
- Home Cooking With Jean-Georges
- See All the Recipes
Stomach acid has long been blamed for acid reflux, heartburn and other ills. But now some experts are starting to think that the problems may lie not just in the acid coming up from the stomach but in the food going down.
The idea has been getting a lot of attention lately, notably in popular books like “Crazy Sexy Diet” and “The Acid Alkaline Food Guide” — which claim that readers can improve their health by focusing on the balance of acid and alkaline in the diet, mostly by eating more vegetables and certain fruits and fewer meats and processed foods.
While the science behind such claims is not definitive, some research does suggest a benefit to low-acid eating. A handful of recent studies have shown a link between bone health and a low-acid diet, while some reports suggest that the acidity of the Western diet increases the risk of diabetes and heart disease.
This year, a small study found that restricting dietary acid could relieve reflux symptoms like coughing and hoarseness in patients who had not been helped by drug therapy, according to the journal Annals of Otology, Rhinology & Laryngology.
In the study, 12 men and 8 women with reflux symptoms who hadn’t responded to medication were put on a low-acid diet for two weeks, eliminating all foods and beverages with a pH lower than 5. The lower the pH, the higher the acidity; highly acidic foods and beverages include diet sodas (2.9 to 3.7), strawberries (3.5) and barbecue sauce (3.7). According to the study, 19 out of 20 patients improved on the low-acid diet, and 3 became completely asymptomatic.
The author, Dr. Jamie Koufman, who specializes in voice disorders and laryngopharyngeal reflux (the kind associated with hoarseness), advocates a low-acid diet in her new book, “Dropping Acid: The Reflux Diet Cookbook & Cure.” (You can see some of the recipes in Well’s Vegetarian Thanksgiving.)
Reflux drugs focus on neutralizing or reducing acid produced in the stomach. But while stomach acid is a factor, Dr. Koufman says, the real culprit for many patients is pepsin, a digestive enzyme that can exist in the esophagus. In these patients, she says, it’s not enough to quell the acid sloshing up from the stomach.
“Once you have pepsin in the tissue, acid from above is equally damaging,” she said. “When you drink a soda and you have chest pain, sometimes it may be because acid came from below or sometimes because acid came from above.”
Low-acid eating rebalances the diet: fewer high-acid foods and more high-alkaline ones. The pH scale runs from 0 to 14; distilled water has a pH of about 7 and is considered neutral, and acidity increases by 10 times with each decrease in a whole pH number. A food with a pH of 4 is 10 times as acidic as one with a pH of 5. (The pH of stomach acid is 1 to 4.)
Processed and bottled foods are particularly acidic because of federal rules requiring high acidity as a preservative, Dr. Koufman says. And she notes that the rise in consumption of such foods coincides with a staggering increase in esophageal cancer caused by chronic acid reflux.
To relieve heartburn and reflux symptoms, Dr. Koufman suggests a strict two-week “induction” diet with nothing below pH 5 — no fruit except melons and bananas, no tomatoes or onions but plenty of other vegetables, whole grains, and fish or skinless poultry. High-alkaline foods include bananas (5.6), broccoli (6.2) and oatmeal (7.2).
Some foods must be eliminated for reasons other than acidity. Regardless of pH levels, high-fat meats, dairy products, caffeine, chocolate, carbonated beverages, fried foods, alcohol and mints are known to aggravate reflux symptoms. Certain other foods, including garlic, nuts, cucumbers and highly spiced dishes, may also touch off reflux in some patients.
For people who don’t have severe reflux, Dr. Koufman suggests a “maintenance” diet of foods with a pH no lower than 4, which allows items like apples, raspberries and yogurt.
She notes that the diet is hardly radical, and is consistent with recommendations from various medical groups to eat a diet rich in vegetables and whole grains and to cut back on meats and fatty foods. Still, many people with a relatively healthy diet may be eating too many high-acid foods, like diet soda or citrus juice. She says that once people learn the basics of low-acid eating as well as their own trigger foods, it’s a relatively simple diet to follow.
“This is a trial-and-error process,” Dr. Koufman said. “Grains are good, and almost all the vegetables. It also means nothing from a bottle or can except water. And close the kitchen at 8 p.m.”
If you didn’t already know Dr Jamie Koufman MD has released not 1 but 2 books. One is the Dropping Acid Diet and the other is called Dr Koufman’s Acid Reflux Diet. The dropping acid book was released in 2010 with the 2nd being released in 2015. Both books cover a lot of the same material though the newer option is more refined and updated than the older option and I would recommend just getting the newer version if you aren’t sure which to choose.
Dr Koufman is somewhat seen as an authority in the area of reflux and LPR (Laryngopharyngeal Reflux) mainly because of her knowledge and treatment over the past years which has been gained somewhat from these books.
What’s the Structure of the Books?
As I recommend the newer version of the book I will focus more on its structure and content. The book first talks about everything you need to know about reflux and how said reflux can bring on LPR symptoms on top of or instead of the typical acid reflux symptoms. She talks about how reflux is caused and the strategy that can heal and eventually cure your reflux and LPR (sometimes called silent reflux).
She also talks about why her alkaline diet is effective at treating the problem along with advice for medication and surgery etc.
Basically, once everything has been explained thoroughly and you understand the logic and the reasoning behind her diet strategy then you move forward into the first phase of the diet also known as the healing phase.
The Actual Diet (Dr Jamie Koufman Diet)
As I mentioned the first part of the diet is the healing phase. This part of the diet is more restrictive, but this is to get a faster effect to induce healing and recovery more quickly. To give you an idea of this part of the diet she recommends eliminating foods with a pH of 5 or lower, this is because of the effect it can have when reactivating pepsin in your throat and giving you LPR symptoms. You can read more about the pepsin effect in my complete LPR guide. Along with giving you all the foods that fit the bill she clearly emphasizes the foods that must be avoided and the ones that are the best for healing also. The clear emphasis on the diet is lowering more acidic foods and drinks.
The second element of the healing phase is drinking alkaline water which you can buy or make yourself. Alkaline water helps deactivate the pepsin in the throat due to its alkalinity and this directly will help with LPR issues and general acidity throughout the digestive tract.
For the healing phase of the diet she recommends following it for 2 weeks though that can be extended if needed. Once you fell you have finished the healing phase you can move onto the maintenance phase, the difference being more food options open up for to you to eat when compared to the healing phase. The key point that she emphasizes is the trigger foods, everyone is different and will react differently to different foods. She points out this process during the maintenance phase by slowly reintroducing foods and if you get reflux then you know exactly what food caused it(the trigger food) and then you can avoid that food from then on. She also gives the most common trigger foods that you should be aware of.
As far as drinks for the diet its alkaline water only the whole time with one exception of allowing chamomile tea.
Once all the core parts are explained and all the food you are allowed and not allowed are out in the open the rest of the book gives recipes that follow both stages of the diet.
Koufman Diet / Dropping Acid Diet Review Conclusion
I personally really like how the book is structured and written. There is little to no filler or useless information. In this book it felt that everything had a good reason to be in the book and was informative and helpful. The great thing about this is you can easily read the descriptive part of the book in about 1-2 days. This means you can get started on the diet quite quickly which is great. About one third of the book is the core information and the other 2 thirds is the recipes. As for the recipes they are descriptive with the exact information about portions and how exactly you want to cook and prepare the food which is good. The book has more of a focus on people with LPR but the diet itself is the perfect diet for people with typical reflux symptoms like heartburn.
As for following this diet as an LPR sufferer, I personally did get some benefit though as I later learnt there are some small things about the diet that aren’t quite in line with following foods above a pH of 5, this is because a select few of the foods can be lower than 5 pH and this will trigger the pepsin in your throat and give you LPR symptoms. At this point I am nit-picking the book but I wanted to point it out.
Finally, I would recommend the book for someone who suffers for common reflux symptoms like heartburn or someone who has GERD (Gastroesophageal Reflux Disease) – this diet for them should be very effective. As for someone with LPR this diet is very close to being perfect though there are a couple of foods that it recommends in the “healing phase” which may irritate LPR symptoms slightly. As an example, honey is allowed in the healing phase though it can have a pH as low as 4 which would reactivate pepsin about 60%. If you want more information about these foods leave me a comment below or contact me.
As far as acid reflux diet books this is in the running to be the best low acid cookbook and one of the better books with silent acid reflux treatment in primarily in mind. My final rating of the book is 8/10. You can buy it on Amazon here.
For more information on treating LPR check out my complete LPR guide here.
For people considering an acid reflux diet plan check out my article on LPR Diet & also LPR Foods to Avoid.
For a LPR diet book (guide) that is targeted for people with silent reflux check out my Wipeout Diet plan here.
Mayo Clinic Q and A: Lifestyle changes may ease laryngopharyngeal reflux
DEAR MAYO CLINIC: My husband had a cough for months and eventually was diagnosed with laryngopharyngeal reflux. What is the best option for treatment? He is still constantly coughing and clearing his throat despite regularly taking omeprazole and antacids.
ANSWER: The medications you mention are standard treatment options often recommended for adults who have laryngopharyngeal reflux, or LPR. But, along with taking medications, if he hasn’t already done so, your husband also should consider making diet and lifestyle changes to ease his laryngopharyngeal reflux symptoms. Several complementary therapies may help, too.
Laryngopharyngeal reflux is a form of gastroesophageal reflux disease (GERD). Laryngopharyngeal reflux happens when stomach acid and other contents of the stomach flow all the way up the esophagus, into the back of the throat and, in some cases, into the back of the nasal passages. Frequent coughing and throat clearing are common symptoms. People with laryngopharyngeal reflux may feel as if they have something stuck in their throat. Laryngopharyngeal reflux can cause hoarseness and other voice problems, too.
Medications usually can reduce the symptoms of laryngopharyngeal reflux significantly. A class of drugs called proton pump inhibitors are typically the most effective. They work by decreasing the amount of acid the stomach produces. Omeprazole is a type of proton pump inhibitor.
Antacids and medications called histamine antagonists — which also decrease stomach acid — can be used to treat laryngopharyngeal reflux, as well. Medications that increase the movements or contractions of the stomach and bowels, sometimes called pro-motility drugs, may be recommended for people with laryngopharyngeal reflux.
Along with using medication, there are other steps your husband can take to help control laryngopharyngeal reflux. One of the most important is eating a diet that is low in acid. Research has shown that this type of diet often can reduce laryngopharyngeal reflux symptoms.
Examples of low-acid foods are melons, green leafy vegetables, celery and bananas. Foods that people with laryngopharyngeal reflux should avoid include spicy, fried and fatty foods; citrus fruits; tomatoes; chocolate; peppermint; cheese; and garlic. Foods that contain caffeine, carbonated beverages and alcohol also can worsen symptoms.
For people with laryngopharyngeal reflux, it helps to eat the largest meal of the day at midday or in the morning, rather than in the evening, and to avoid eating within three hours of bedtime. Don’t rush through meals. Take time to eat slowly, without distractions.
Other lifestyle changes that can make a difference for someone with laryngopharyngeal reflux include not smoking, maintaining a healthy weight, and reducing and managing stress in healthy ways.
Several complementary therapies also may be useful in managing laryngopharyngeal reflux. For example, some studies suggest that acupuncture — a therapy that involves inserting extremely thin needles through the skin at strategic points on the body — can reduce symptoms.
Taking a probiotic dietary supplement that contains good bacteria similar to bacteria already in your body may ease some symptoms, too. But they aren’t for everyone, and different supplements contain different types of probiotics. Before your husband takes a probiotic, he should ask his health care provider about the kind and amount that’s right for him.
Finally, voice therapy can be used to treat the effects of laryngopharyngeal reflux. Research has shown that people who take a proton pump inhibitor and participate in voice therapy show faster symptom improvement than people who only take medication.
Encourage your husband to talk to his health care provider about his persistent laryngopharyngeal reflux symptoms. They can discuss additional treatment options and lifestyle changes. In many cases, laryngopharyngeal reflux can be managed successfully. — Dr. Amy Rutt, Otorhinolaryngology, Mayo Clinic, Jacksonville, Florida
The LPR Cure: Everything I’ve Learned
Do you remember the volcanoes at your elementary school science fair? Maybe you even presented one yourself. Acidic vinegar is mixed with alkaline baking soda and BOOM, you have an explosive mess that any third grader can be proud of.
Acid can do some cool stuff. The acid in your stomach does great work in digesting the food which nourishes life. Unfortunately, when this acid doesn’t stay in your stomach, bad things result.
What is LPR and why does it happen?
LPR is Laryngopharyngeal Reflux, an often chronic and unpleasant condition which affected me for nearly a year before I decided to get serious about it. Left untreated, LPR may worsen or even cause other life-threatening diseases, including asthma, COPD, pulmonary fibrosis and cancers of the throat and esophagus; scary stuff.
For me — as for many people — LPR began as a minor nuisance but eventually snowballed into something which significantly affected my quality of life. Note that LPR often differs from GERD (gastroesophageal reflux disease), in that GERD is often charactered by esophageal symptoms (i.e. heartburn) and LPR by symptoms above or outside the esophagus. (I rarely have heartburn.)
Some of the more common symptoms of LPR include:
- Excessive throat clearing
- Sensation of lump in throat which doesn’t go away
- Frequent loss of voice, frequent hoarseness
- Trouble breathing (a lot of “asthma” may actually be misdiagnosed airway reflux)
- Chronic cough
So why does LPR happen? The very basic version is this:
Situated between our stomach and our esophagus, we have a lower esophageal sphincter, or LES. In a healthy person, this muscle opens to allow food to pass into our stomach but otherwise generally remains closed (except to burp or vomit, of course).
Some reflux is actually completely normal; in healthy people, the esophagus quickly (and usually silently) clears the refluxate back into the stomach. Reflux becomes a disease when the body’s various anti-reflux mechanisms stop working, but it isn’t always clear why this occurs. In some, there are underlying physiological abnormalities (e.g. a hiatal hernia or pregnancy) or pathology (e.g. a bacterial infection or fungal overgrowth); some medications can also cause or exacerbate it.
Notably, LPR often occurs in young, active and otherwise healthy people; whereas symptoms of GERD are strongly correlated with inactivity and obesity and often respond favorably to weight loss.
Why am I writing about LPR?
I hesitated to write this post for two reasons. First and foremost, this is a blog about things which anyone can do to live a better life; I didn’t want to subtract from that focus by speaking about a condition which affects only a minority of people.
Second, reflux is a complex condition; there is some disagreement even amongst medical professionals who have been treating the disease for decades. I’m not a doctor and I can only share my personal experience and to a lesser extent, the experiences of friends I’ve talked with. (Obviously, please work with your qualified healthcare professional in developing your personalized treatment approach.)
Ultimately, I decided to share my experience because I’ve been frustrated by the lack of clear answers in my own fight against reflux. After many dead ends, I’ve found some things which have helped me to get better and I hope that this knowledge may help my fellow refluxers as well.
I firmly believe that we are responsible to advocate for our own health. We should trust our doctors but also ask questions and work with them as an active participant in our healthcare, learning as much as possible. Don’t be afraid to get a second opinion or even a third if you have doubts.
As mentioned earlier, when I was first diagnosed, my LPR was basically a nuisance and not a big deal. It felt like there was always something stuck in my throat and I visited an ENT to rule out cancer (yes, when you suffer from anxiety, every new malady screams cancer.) I was given a list of foods to avoid and told to take a PPI like Nexium, but at the time I was just relieved that it was “only” reflux and so basically forgot about it for 6-9 months.
Unfortunately, things progressed and I eventually became short of breath and frequently hoarse. When I did get serious about treating it, I tried a daily dose of progressively stronger PPI medications and got absolutely nowhere; I even cut out coffee (my one true vice) to no avail. Increasingly desperate, I turned to Google, M.D. for answers and finally found an approach which has made a lasting difference.
I’m still healing (severe reflux often requires weeks or even months to achieve meaningful improvement) and I can’t say that I’m fully in the clear yet. However, since starting down this path a few years ago, my throat has returned to normal, I breathe more freely and as a bonus, I just feel better since losing weight and reducing sugar, alcohol and other junk from my diet.
Here’s what I know today.
Start here: the low-acid diet
There are at least two prominent ENTs (more on them shortly) who prescribe a low-acid diet as the cornerstone of successful treatment.
A quick word about diets; I’ve never been a fan. Like, ever. But I read about the low-acid diet, it made sense and eventually I decided that a little deprivation was preferable to spending the rest of my life sick and in pain.
An added benefit of this diet, which is generally quite healthy in its own right, is weight loss in those of us who could afford to lose a few pounds. I wasn’t grossly overweight, but I lost nearly twenty pounds in about six weeks and hope to drop another 15-20 more.
Perhaps not surprisingly, I feel much more energetic and even throughout the day now that I’ve adopted a healthier diet. Generally, feeling much better now outweighs my desire to start binging on junk food again.
Returning now to the low-acid diet; Dr. Jamie Koufman, M.D., F.A.C.S. actually coined the term “LPR” and has treated thousands of patients in nearly thirty years. Her book, Dr. Koufman’s Acid Reflux Diet, offers a comprehensive look at LPR, its causes and an overview of her treatment plan (which she customizes to each individual patient).
Unfortunately, Dr. Koufman lives in New York and I live in Ohio, but her book itself is very insightful. It also offers lots of recipes that I have been mostly too lazy to cook, but the explanation of LPR is worth the price of admission alone; if you read just one resource, make it this one. I’ll refer to her work throughout this post as one of the most credible experts I’ve encountered.
Dr. Jonathan Aviv, M.D., F.A.C.S. has also written a book called Killing Me Softly from the Inside. The two books agree on most counts but there are minor differences. Both Dr. Kaufman and Dr. Aviv claim to have treated the majority of their patients successfully — many of them presenting initially with severe reflux — without need for invasive surgery.
Here’s how the low-acid diet works
The basic premise is this: reflux starts small, maybe as simply as eating too much right before bed or even due to systemic inflammation from the flu. (Also, it’s generally agreed upon that the LES weakens with age.) Over time, reflux progressively overwhelms the body’s natural anti-reflux defenses, inflaming the relevant mechanisms until they no longer function at all, leading to constant, chronic reflux. Truly, a vicious cycle.
Reflux includes both stomach acid and the digestive enzyme pepsin; in the presence of acid, pepsin will digest anything, including your throat and esophageal tissues. This pepsin actually sticks to your esophagus and throat and is re-activated during subsequent reflux events and with every swallow of acidic food or beverage, potentially for days or even weeks (!) after the original reflux event.
The problem is that aside from acid reflux, virtually our entire food supply is heavily acidified. Shocking but it’s true: since 1972, the FDA mandated that acid be added to most packaged foods to protect against bacterial spoilage and extend shelf life. Just pick up a box or carton of whatever and scan the ingredients list; you’re bound to find “ascorbic acid” or one of its cousins as a preservative. That “vitamin C” isn’t for your immune system; it’s to keep things fresh. It’s damn near everywhere.
Even otherwise healthy foods (like fresh berries or an orange) can be very acidic and so should be avoided or blended with alkaline sources like almond milk to remove their acidic bite. (Here’s my preferred way to get vegetables and fruits: I blend frozen berries, an avocado, spinach and almond or coconut milk in the morning. It’s super healthy and quite tasty as well.)
The science behind the low acid diet makes a lot of sense to me, although I can’t claim to understand why a highly acidic diet or high-risk behavior (late night eating, alcohol abuse, etc.) affect some people but not others. Personally, it explained why my symptoms initially persisted even though I was taking medication; I was still ingesting large quantities of acidic food and drink daily (and right before bed). It also explains why so many young and otherwise healthy people, who eat well most of the time, nevertheless are in chronic pain.
Reassuringly, Dr. Kaufman asserts that for the majority of patients, severe reflux is also highly reversible with sustained diet and lifestyle changes; that has been my experience thus far.
That’s the ten-second version; I highly recommend you pick up one or both of the books above for more details.
What about medication? PPIs, H2-antagonists and antacids (amongst others)
There are different classes of medication, including acid-suppressants (PPIs including Prilosec, Nexium, Protonix, Dexilant and H2-antagonists including Zantac) and acid-neutralizers (an alkaline substance like Tums). Dr. Kaufman writes that she often starts patients on a protocol of medication as well as diet and lifestyle changes with the goal of tapering medication use when symptoms significantly improve (often within 4-8 weeks).
Unfortunately, medication isn’t a silver bullet. I took Dexilant — generally regarded as the strongest PPI on the market today — for several months and it didn’t put a dent in my symptoms until I made substantial lifestyle and dietary adjustments as well. Even if a PPI does control your symptoms — and for many, they do — it’s preferable not to take them long term if possible as they may pose risk of side effects.
H2-antagonists (Zantac) and Tums are generally safer but less effective and are still recommended for occasional use (as opposed to daily, long-term use).
What else? More good ideas.
Besides eating a low-acid diet, these things have also helped me and thousands of other people find significant and lasting relief.
- Drink alkaline water. Drinking alkaline water appears to deactivate tissue-bound pepsin. For years, I bought Evamor brand at Whole Foods (until they stopped carrying it), but you can get other brands elsewhere, including Amazon. On the cheap, you can mix 8oz of regular, filtered water with 1tsp of baking soda; I drink one in the morning and one at night, before bed. (This should go without saying, but don’t overdo it.)
- Achieve a healthy weight. Belly fat increases intragastric pressure and reduces LES tone. (Besides that, it is a known risk factor for virtually every human disease.)
- Eat smaller meals. Heavy meals also increase intragastric pressure.
- Begin a meditation practice. Yes, I know, I write about this all the time. But it’s true; reducing stress can also improve reflux. Yoga can help too.
- Avoid common “trigger” foods including alcohol, coffee, caffeine, chocolate, tomato products, onions and spicy food. Once your condition improves, you can reintroduce each of these into your diet, slowly and in moderation. Many trigger foods affect people differently or in some cases, not at all; determining their effect on your body requires patient, trial-and-error experimentation. For instance, I’ve been surprised to find that chocolate doesn’t seem to affect me (huge, sigh of relief). As always, your mileage may vary.
- Eat the majority of your calories prior to dinnertime. There is evidence that our LES becomes slightly less effective as the day goes on.
- Don’t lay down or go to bed for at least three hours after eating. During the day, gravity typically helps to keep stomach acid where it belongs; for many people, reflux is worst or only happens during the night (although it’s thought that some with LPR are primarily daytime refluxers).
- Sleep on your left side as much as possible. It helps, though it’s not completely understood why.
- Sleep on an incline. After much research, I settled on this model of a memory foam wedge from MedSlant; it’s surprisingly comfortable and seems to work. You could also buy a wedge which fits between your entire mattress and box spring; some people prop the head of their bed by placing two cinder blocks underneath the legs.
- Try eliminating wheat and dairy for at least a couple of weeks. For years, I assumed that people who were “gluten sensitive” just enjoyed being high maintenance, but Dr. Kaufman observes that many patients in her practice saw improvement or complete resolution of their symptoms when they eliminated wheat and dairy from their diets. Personally, I tried going wheat and dairy free for a short time, but didn’t notice a difference.
- Try the “fast tract” digestion diet. This is a very different diet, authored by Norman Robillard, a Ph.D. microbiologist. The concept is that for some people, poorly-digested carbohydrates “ferment” in the small intestine, creating lots of gas which causes reflux. The proposed science also makes some sense to me, although I tried it for about ten days and saw no difference before discontinuing it. The studies cited in his book are small but there are dozens of testimonials on Amazon.
- If all else fails, there are surgical options. The “gold-standard” treatment is Nissen fundoplication, a laproscopic procedure in which the top portion of the stomach is wrapped around the esophagus; this essentially mimics the function of a healthy LES. There are also other promising but lesser-established surgical interventions including Stretta and LINX.
“Natural” supplements which may or may not help
I generally don’t mind taking medication, but if there is an equally effective, natural way to avoid it, then I’d prefer that instead. (If weight loss can reduce my blood pressure just as well as a statin, then I’d prefer weight loss.)
Having said that, medication is often an important component of any treatment plan, even if it means the possibility of unwanted side effects. For all their bad press, PPIs are remarkably safe; conversely, the safety of most “natural” treatments is not studied nearly as rigorously.
I spent hours poring over various “natural” remedies and ultimately tried just about anything that seemed safe. With the exception of alkaline water, I found most of them to be unhelpful, personally. (Although I still supplement with magnesium and a probiotic for other reasons as well.)
However, for each of the products I list below, there are many enthusiastic testimonials to be found on Amazon and elsewhere across the interwebs. In most cases there is limited, small-study, or anecdotal evidence that these may help treat reflux, even if there isn’t a coherent explanation of exactly how it does so. I file most of them under things which probably didn’t help me much, but which may help you and probably don’t hurt.*
* Some supplements may interact with various prescription and over-the-counter medications; please do your homework and discuss any supplementation with your doctor.
- Gaviscon advance. This forms an “alginate raft” which sits at the top of your stomach and helps to prevent reflux. Gaviscon Advance is imported from the UK: apparently, the United States version has much less active ingredient and also contains aluminum which may or may not be harmful.
- Aloe vera juice. Aloe vera juice may help to soothe inflammation. Please note that it must be specially processed in order to make it edible, to remove ingredients that will otherwise irritate your digestive tract. In other words, do not ingest the stuff that goes on your arms for a sunburn.
- Manuka honey. There is anecdotal evidence of many benefits of Manuka honey, including antibacterial properties and the healing of damaged tissue. Manuka honey is delicious; unfortunately, it’s imported directly from New Zealand, so it’s also obscenely expensive.
- D-limonene. I have no idea how the hell this is supposed to work, but apparently for some people, it does. D-limonene is extracted from citrus peel; you take 1,000mg every other day or every day for at least ten days. I didn’t actually mind the orange-tasting burps.
- DGL. There are scores of people who swear by DGL for everything from gastritis to ulcers to reflux. DGL is extracted from licorice root and apparently has healing properties.
- Mastic gum. Mastic gum (derived from the sap of a particular tree) has been used for thousands of years to treat a variety of ailments.
- Probiotic. Some people theorize that reflux is a result of bacterial imbalances in the gut; a probiotic may help. I still take one daily.
- Melatonin. This small study reported complete resolution of symptoms in 100% of patients who took a cocktail of supplements including 6mg nightly of melatonin, for eight weeks.
- Magnesium. Many Americans are magnesium deficient; however, of these people, few actually suffer noticeable symptoms. Magnesium may relax spastic muscle and promote peristalsis (clearance of acid reflux) in the esophagus. The Natural Calm brand is my favorite; .
- L-glutamine. L-glutamine is an essential amino acid which has been used for years by athletes and bodybuilders to help repair muscle tissue. It is thought to help accelerate the healing process in those with reflux.
A bonus tip
Personally, there are two more habits that I’ve recently adopted which have made a big difference for me.
First, chewing gum. I have never, ever enjoyed chewing gum, but it really improves my remaining symptoms. Research is sparse and inconclusive, but suggests that habitual gum-chewing may help to stimulate the vagus nerve and improve esophageal motility (often severely impaired with reflux).
Second, intermittent fasting. I became interested in IF for other health-related reasons but have noticed that skipping dinner also virtually eliminates any reflux-related symptoms the next day. I have been pleasantly surprised to discover that skipping dinner is actually pretty easy to do and may offer numerous, other health benefits as well. (It also makes intuitive sense: our ancestors survived and thrived for thousands of years without three square meals a day.)
As always, please consult with your qualified healthcare professional before initiating any fasting regimen and exercise caution as you become familiar with how your body adapts.
It seems like we all know someone, even many people, who eat whatever they want, whenever they want, without any consequences. If there is one thing I have learned, it is that once you have been diagnosed with chronic reflux, you are no longer one of those people.
Short of an invasive and uncertain surgery, arguably the two greatest changes you can make are to reduce or eliminate acidic food and beverage from your diet and to quit eating (or drinking anything but water) within 3-4 hours of bedtime.
I spent hours writing this post in hopes that it may help you or someone you love. Above all, don’t be discouraged; reversing the course of this disease takes time, but eventually, you will find the answer.
Recommended further reading
- Silent Reflux: An Overview
- Dr. Koufman’s Acid Reflux Diet: With 111 All New Recipes Including Vegan & Gluten-Free
- Killing Me Softly From Inside: The Mysteries & Dangers Of Acid Reflux And Its Connection To America’s Fastest Growing Cancer With A Diet That May Save Your Life
- Consider using PPIs (Prilosec, Nexium, Protonix, Dexilant) and H2-antagonists (Zantac) under a doctor’s supervision, but recognize that medication without lifestyle changes may not be enough and that long-term use may cause side effects;
- Don’t lay down or go to bed for at least three hours after eating;
- Sleep on a wedge; sleep on your left side as much as possible;
- Avoid common trigger foods (alcohol, coffee, caffeine, chocolate, tomato products, onions and spicy food) until you can figure out which are problematic for you;
- Avoid acidic foods; many pre-packaged foods are preserved with acid;
- Try drinking alkaline water (I like Evamor from Whole Foods, but you can even make your own);
- Eat smaller, more frequent meals;
- Consider use of supplements but understand that evidence for their efficacy is weak;
- Remain diligent but be patient; healing takes time, even if you’re doing everything right.
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A whopping 1 in 3 Americans experience heartburn or acid indigestion. If you’re one of them, you may want to consider a recent study that found what you eat is just as effective as medication at easing the burning that can happen when stomach acid flows back into your esophagus.
Patients following the Mediterranean diet plan had fewer symptoms of heartburn, acid indigestion and gastroesophageal reflux (GERD) than those taking proton pump inhibitors (PPIs), the primary medication prescribed for people suffering from acid reflux, according to a study in JAMA Otolaryngology. A Mediterranean diet favors fish, fruits, vegetables, grains and nuts and is light on dairy and red meat.
Beyond that, these key foods can help keep symptoms of acid reflux at a minimum, according to the International Foundation for Functional Gastrointestinal Disorders (IFFGD).
Non-citrus fruits Opt for bananas, melons, apples and pears, which are less acidic than citrus fruits. Some research suggests bananas may help thicken mucus in the stomach and protect against painful ulcers, a common problem for people suffering from GERD.
Oatmeal Research shows that high-fiber foods, such as oatmeal and whole-grain bread, are linked to a reduced risk of acid reflux symptoms because they help absorb acid. Oatmeal is also high in selenium, which can help coat and protect your esophagus from painful acids.
Green and root vegetables Potatoes, parsnips and sweet potatoes contain easily digestible fiber that can help neutralize stomach acid. Green vegetables such as spinach, kale and Brussels sprouts are alkaline and can help decrease stomach acid, too.
The way you eat can be helpful, too, the IFFGD found. Keep these tactics top of mind at mealtime:
Chew gum After eating, gum helps increase saliva production and reduces the amount of acid in the esophagus.
Eat small portions If your stomach gets too full or full too quickly, it puts extra pressure on the lower esophageal sphincter (the valve connecting the stomach and esophagus) causing acidic stomach juices to overflow into the esophagus.
Sit up straight Good posture while eating and for at least two hours after a meal will keep gastric juices flowing in the right direction. Avoid eating a full meal less than three or four hours before bedtime.
Acid Reflux Food To Avoid For Your Reflux Baby
Acid reflux food to avoid for your baby suffering from infant reflux. Super important when starting them on blended or solid foods! This info should help put your little refluxer on the right track to eating healthily!
Nearly all vegetables, especially green ones, are alkaline which means they are the opposite of acidic (check out our acid & pH page). Vegetables tend to be easy for young digestive systems for your little reflux baby, and are an excellent type of first food for babies. Even more so when they are blended. You can even add a drizzle of good quality olive oil which is also very alkaline. If your baby is new to food, butternut squash, sweet potatoes or green beans are great places to start.
Cook the vegetables until they’re soft. That can mean, boiling them or baking them, then puree or blend them until smooth. You can add water, broth, formula or breast milk to your puree if the consistency is too dense.
Fruits – Acid Reflux Food to Avoid
Avoiding any citrus and acidic fruits like oranges, lemons, limes, grapefruit and nectarines is a good idea as they are high in acid and the acidity in the fruit can cause burning of the already damaged and raw esophageal tissue caused by baby reflux.
There are tons of non-acidic fruits from which to choose from. In fact, many parents choose certain fruits to be their child’s first food, babies love the sweet taste and they are less likely to spit them out until the develop more mature tastes.Apples, bananas, pears, papaya (which have known digestive enzymes) and avocados are all great fruits to start with. Of course avocados and bananas do not need cooking. Just mash them up and spoon them in! you can steam, boil or bake the apples and pears and then puree them. Add a little liquid like milk, breast milk, or water.
All grains are low-acid foods but one of the most popular first foods for babies is rice cereal. Although most of you are sick of hearing “just add rice to thicken food” as a remedy to infant acid reflux! Most infant rice cereals are specifically formulated for babies with reflux, and have added iron to assist in the inhibited absorption from infant reflux medications. If your baby becomes constipated after eating rice cereal, you may want to switch to a non-iron-fortified brand. Infant cereals most typically come in rice, barley or oat varieties, and all are easy to prepare. Follow the directions on the package to determine how much liquid to add, briefly heat and serve.
Meats – Acid Reflux Food To Avoid
All meats tend to me acidic, though in most cases the acidity is fairly low. However, if your baby is suffering from acid reflux, you may want to hold of introducing meats to their diet. Chicken and turkey are super low in acidity, more than beef or pork, and are also easier to digest. Chicken and turkey are usually recommended to be a baby’s first meat.
Discuss this with your baby’s pediatrician and ask what age is best to introduce meat. Some doctors recommend that meat be introduced earlier than others. When preparing meat for your child, always make sure the meat is fully cooked or well-done, showing no pink inside. Again, adding water or even a little olive oil can be helpful and nutritious.
A version of this acid reflux food to avoid article came from: How to parent