Ear, nose, and throat doctors—including the authors—have listened to their colleagues in gastroenterology (GI) tell them for years that gastroesophageal reflux disease (GERD) is a chronic condition often requiring lifelong treatment, and that GERD patients almost always have heartburn and esophagitis (erosions and ulcerations of the swallowing tube between the throat and the stomach). They said the only way to make the diagnosis was by esophageal endoscopy. We believed them.
That is, we believed them until we figured out that many of our patients were atypical—they didn’t follow the usual progression of what was known as GERD.
Here’s an illustrative case example from Dr. Koufman’s practice:
About ten years ago, Brad, a high-profile patient from Washington, D.C., wasn’t doing well on “maximum anti-reflux therapy.” He had been taking two Prilosec a day and a Zantac before bed. He was reasonable about his diet and avoided late-night snacking. Nevertheless, Brad was still experiencing hoarseness and inflammation of the vocal cords.
One time when Dr. Koufman was visiting him in his office overlooking the Potomac, she noticed that Brad kept sipping a dark brown liquid from a large glass filled with ice. After a few minutes, he went to a small refrigerator and got himself another can of what turned out to be diet cola. Right there was Brad’s reflux Achilles’ heel.
“You sure do drink a lot of that,” remarked Dr. Koufman. “Do you think you have more than a six-pack a day?”
“Oh, magnitudes more,” he responded cheerily.
It turned out that Brad drank diet soda all day, every day, which added up to more than a hundred cans a week. His favorite brand scored a very acidic pH 2.9.
Not surprisingly, Brad’s reflux laryngitis settled down after he quit the diet soda habit. His symptoms stayed under control until two years later, when he was back in Dr. Koufman’s office with a resurgence of his old symptoms. The culprit this time was his latest beverage of choice: a bottled diet lemon iced tea, pH 3.3. Tests of the pH in his larynx and esophagus showed that right after drinking the lemon iced tea, he would reflux for half an hour. Since he drank it all day, the reflux never stopped.
The tea was causing trouble going down and coming up. Once again, Brad’s symptoms abated once he stopped his addiction to a harmless-seeming drink.
Carbonated beverages, especially caffeinated soda, are among the most common cause of patients’ failure to respond to medical anti-reflux treatment. But as Brad’s case demonstrates, even beverages without bubbles can spell trouble below a certain pH.
We should emphasize that colas are among the worst possible beverages for a refluxer. For one thing, the carbonation increases pressure in the stomach, predisposing you to reflux. For another, caffeine and other chemicals in cola cause the lower esophageal valve to relax, permitting reflux. Finally, the acidic low pH activates the destructive effect of tissue-bound pepsin. For more on pepsin, see the chapters “What You Eat Could Be Eating You” (page 21) and “Reflux Science You Can Digest” (page 159).
Citrus fruits and juices are very acidic. Alcohol also causes the esophageal valves to relax and cause reflux at night. Beer and white wine are particularly bad for reflux.
The best things for a refluxer to drink? Water! Certain mild herbal teas are fine (such as chamomile), along with non-acidic smoothies, or low-fat and lactose-free milk.
The challenge of defining a “healthy diet” is that there is so much conflicting information available today, especially on the Internet. Some people, for example, say that drinking acidic apple vinegar is good for reflux because it causes the lower esophageal sphincter to tighten up. Unfortunately, this does not appear to be effective, and we believe that it is particularly counterproductive for patients with throat reflux (silent reflux).
From clinical experience, we know that the diet problems of our reflux patients extend beyond the issue of acid. We have long known that high-fat diets are bad for the heart, blood pressure, circulation, bowels, and digestion, and cause reflux. Fried foods are the worst. The reflux diet is a logical extension of a heart-healthy diet designed to restrict saturated fats.
From the case files of Dr. Koufman
A 35-year-old venture capitalist had a lifestyle he loved: He didn’t eat anything all day so he could save up his calories for night, then he would go out for big, boozy dinners with current and prospective clients. After that, he staggered home late and plopped into bed, only to wake up each morning with a sore throat and do it all over again. He was already on all the available medical treatments, but they didn’t make a dent in his symptoms.
“Nothing will work until you stop living this crazy way,” I told him.
“You don’t understand,” he argued. “It’s part of my job.”
I pointed out that a lot of people do business this way, but that it’s not the only way. “You have a choice,” I told him. “Change your lifestyle or suffer the consequences.”
I battled with this man for six months until he finally agreed to go on The Reflux Diet. Guess what? He managed to get well and still be successful in business.
About a third of reflux patients just have poor esophageal function and may need medical or surgical treatment. Another third experience relief from symptoms after trying The Reflux Diet along with medical treatment. The final third of our patients find they can achieve complete control over all symptoms just by using the diet alone.
Especially for those with silent reflux, diet and lifestyle factors strongly influence reflux symptoms one way or the other. You see, reflux is a vicious cycle. The more you have it, the weaker the esophageal valves get. Conversely, diet and lifestyle improvements can reduce symptoms and strengthen the body’s defenses against them.
The Reflux Diet is essential for the control of disease. It is also essential for healthy self-maintenance. In this book, we offer information that you can use to improve your digestive health overall.
We have extensive clinical experience with The Reflux Diet. Many patients who didn’t respond to medical treatment improved once they started on it. Usually we recommend a stricter diet for the first two weeks in order to trigger “pepsin wash-out” as a kind of reflux detox. This induction period, during which you consume nothing below pH 5, is followed by a more sustainable and less restricted low-acid diet. Most of the patients following this program notice a big difference in their condition, and so do we, using medical measuring devices.
Despite overwhelming clinical evidence, almost no long-term dietary studies have looked at acidity as a factor in reflux management. Dr. Koufman reported that 95% of her patients improved their symptoms on The Induction Reflux Diet. Critics will argue that we have not done long-term controlled studies and therefore have not proven our case against dietary acidity. That is true. However, we believe that the short-term data is too strong to make our patients wait to get relief.
To our knowledge, we are the first physicians to recommend a low-acid diet for reflux patients, and we have basic science to back us up. We also have happy, healthy patients. Additional evidence will come with time, and when it does, some very serious diseases will perhaps be handled quite differently.
For example, we believe that for patients with Barrett’s Esophagus (a form of esophageal pre-cancer attributed to reflux), intense, long-term medical treatment should be combined with a long-term acid-free diet (nothing below pH 6). We have shown that pepsin is found in Barrett’s biopsies (see Figure 1B on page 169), and the best treatment regimen might deactivate it. We also believe there is a major link between reflux and asthma and other lung diseases.
Most healthy eaters don’t reflux. Most people can be free of reflux and live longer, fuller lives by sticking to a relatively low-acid diet rich in complex carbohydrates, healthy proteins, and oils. The body you have is the last one you’re ever going to get. Let this book help you take good care of it!
From the case files of Dr. Koufman
A prominent 55-year-old ambassador developed hoarseness in 1990. After a few weeks, he went to see an ENT doctor who diagnosed an irregularity on his right vocal cord. Soon thereafter, the lesion was biopsied and it turned out to be “dysplasia,” which is a kind of precancer. The patient had smoked lightly for only two years during the Korean War, but otherwise had no risk factors.
Unfortunately, a few months later, he developed another dysplasia on the other vocal cord. And over the next few years, he developed recurrent dysplasias seven times. Each lesion was surgically removed only to have a new one pop up a few months later. The doctor wasn’t sure how to treat the patient, and so in consultation with an oncologist, it was elected to give the patient’s larynx radiation therapy as if he actually had had invasive cancer.
A year after the radiation, the ambassador presented with hoarseness, and his examination showed severe reflux laryngitis. The patient was placed on a strict anti-reflux diet and Prilosec twice a day. Within six months, the larynx appeared to normalize, but because of the radiation and the previous biopsies, the vocal folds were still somewhat scarred and the voice remained husky. In 1998, the author surgically rebuilt the vocal folds and the patient’s voice was restored.
In 2008 the patient, feeling quite well, came off the reflux diet and his medicine (on his own), and a year later he again developed severe hoarseness. In January 2010, he was found to have a superficial left vocal fold cancer. This lesion was completely excised with a laser and the voice was restored.
In the ten years from 1998 to 2008, when the ambassador was on the reflux treatment, his larynx was healthy. When he stopped eating right and stopped taking his reflux medication, that’s when he developed the cancer. Today, he is back on treatment and he adheres strictly to The Reflux Diet; his larynx looks fine and his voice is terrific! The ambassador fully understands what happened to him, and he is now completely compliant in maintaining a low-fat low-acid diet. Neither of us expects that he will ever get laryngeal cancer again.
Comment: In the author’s experience, recurrent reflux-related vocal cord (laryngeal) dysplasia and cancer in the non-smoker will stop if the patient’s reflux is effectively controlled. For more about the relationship between reflux and laryngeal cancer, see pages 167–170 in the chapter “Reflux Science You Can Digest.”