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.
The bottom line
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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