Most of us, and especially those of us who have experienced pregnancy, are familiar with the uncomfortable sensation of heartburn. Heartburn is very common; around 40% of Americans complain of heartburn symptoms. That full, burning sensation at the top of your abdomen or in your lower chest can be a sign that acid is refluxing out of your stomach (where it belongs) into your esophagus (where it hurts), which is known as gastroesophageal reflux. The acid can even reach all the way up to your throat, voice box, and vocal cords, which is when you may be referred to an otolaryngologist for evaluation and treatment.
Laryngopharyngeal reflux, or stomach acid that causes inflammation and irritation in the larynx and vocal cords, is a common cause of frequent throat clearing, hoarseness, cough, and a sensation that something is stuck in the throat. Patients may feel a tight sensation, difficulty swallowing or even pain in their throat. OFTEN PATIENTS DO NOT EXPERIENCE HEARTBURN WITH THESE SYMPTOMS!
Understanding and Treating the Root Cause
The diagnosis and treatment of gastroesophageal reflux (stomach acid in the esophagus) and laryngopharyngeal reflux (stomach acid in the throat) differ. If you have heartburn, your doctor might recommend acid reducing medications on a trial basis, then order more tests to further evaluate if the symptoms persist. Studies have shown that maintaining a healthy weight and smoking cessation are helpful in decreasing GERD symptoms–and improving overall health–but diets eliminating specific foods do not have robust evidence to support their use.
But patients who have inflammation of the larynx, or laryngitis, and laryngopharyngeal reflux symptoms don’t necessarily feel heartburn. Cough, throat clearing, hoarseness, or an abnormal sensation in the throat might be the only signs that acid is affecting the airway. This reflux can cause further problems down the road if left untreated.
In order to make the diagnosis, we may need to visualize the vocal cords or measure the pH in the throat. And while there is a role for acid reducing medications in treatment, they may not work right away to alleviate the symptoms. Fortunately, there are changes that you can make to your diet and sleep habits to decrease the symptoms. These techniques can be used alone or in combination with medication therapy prescribed by your doctor.
When Pepsin and Protein Meet
Overhauling your diet and sleep habits isn’t an easy task, so in order to understand why the lifestyle changes are successful, learning a little bit of the science behind laryngopharyngeal reflux is helpful.
The enzyme responsible for digesting protein in the stomach is called pepsin. Pepsin is secreted in an inactive form and doesn’t start working until it is exposed to stomach acid. Laryngopharyngeal reflux occurs when gastric juices containing pepsin and acid make their way up to the throat. So, if pepsin in the presence of acid is causing the problem, it stands to reason that we need to decrease pepsin and alkalinize the environment to treat the issue.
Since pepsin is an enzyme designed to digest protein, eating animal products rich with protein stimulates the body to produce more of it. We Americans consume quite a bit of animal protein through meat and dairy, so switching to a predominantly plant-based diet and limiting animal protein can make a big impact on laryngopharyngeal reflux symptoms. This could include foods like vegetables, fruits, beans, nuts, avocados and olives.
Evidence-based Diet and Lifestyle Recommendations
Research shows that this hypothesis is a good one–people really do feel better when they make changes to their diet and sleep habits. Based on scientific evidence and my experience treating patients with laryngopharyngeal reflux, here are my recommendations:
- Eat a plant-based Mediterranean diet, limit animal protein
- Limit tomatoes, peppers, and spicy foods
- Limit processed food
- Eliminate fried food
- Limit caffeine intake
- Limit or eliminate carbonated beverages
- Limit alcohol
- Do not use artificial sweetener
- Refrain from eating 3 hours prior to bedtime
- Drink 2 to 3 ounces of alkaline water (look for a pH greater than 8) at night prior to bedtime (examples are Smart Water and Essentia)
- Elevate the head of your bed 6 inches while sleeping
In some studies, patients went all-in on these lifestyle changes, took medications as prescribed by their doctor, and had great results. Once the symptoms are under control, some patients are able to liberate their diets slightly to include limited meat and dairy. We will work together to determine the best long-term regimen to control your symptoms, and if they persist, discuss next steps to help you feel better.
If throat pain, hoarseness, chronic cough, or difficulty swallowing is an ongoing issue for you, a physician evaluation is indicated. Call (317) 844-7059 or request an appointment online today.
Mehta RS, Song M, Staller K, Chan AT. Association Between Beverage Intake and Incidence of Gastroesophageal Reflux Symptoms. Clin Gastroenterol Hepatol. 2020;18(10):2226-2233.e4. doi:10.1016/j.cgh.2019.11.040
Ness-Jensen E, Hveem K, El-Serag H, Lagergren J. Lifestyle Intervention in Gastroesophageal Reflux Disease. Clin Gastroenterol Hepatol. 2016;14(2):175-82.e823. doi:10.1016/j.cgh.2015.04.176
Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease [published correction appears in Am J Gastroenterol. 2013 Oct;108(10):1672]. Am J Gastroenterol. 2013;108(3):308-329. doi:10.1038/ajg.2012.444
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Zalvan CH, Hu S, Greenberg B, Geliebter J. A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux. JAMA Otolaryngol Head Neck Surg. 2017;143(10):1023–1029. doi:10.1001/jamaoto.2017.1454
Yang J, Dehom S, Sanders S, Murry T, Krishna P, Crawley BK. Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications. Am J Otolaryngol. 2018;39(1):50-55. doi:10.1016/j.amjoto.2017.10.014
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