Dr. Michael Ruscio, DC is a clinician, Naturopathic Practitioner, clinical researcher, author, and adjunct professor at the University of Bridgeport. His work has been published in peer-reviewed medical journals and he speaks at conferences around the globe.
Your Guide to the Most Effective Dietary Strategies for LPR
Finding the right diet is one of the most important components of managing laryngopharyngeal reflux (LPR), or “silent reflux.” But what’s the best LPR diet?
Certain foods and drinks, including acidic foods, spicy foods, and alcohol, have been shown to both contribute to the development of LPR and trigger symptoms.
Underlying food sensitivities or imbalances may also contribute to LPR symptoms indirectly by feeding bacterial overgrowth, promoting the production of stomach acid, or causing inflammation in the digestive tract.
Implementing the right diet can lead to significant symptom improvement or even complete resolution. At the very least, a healthy and individualized diet serves as a healthy foundation from which to approach other treatments.
In this article, we’ll guide you through the different kinds of diets that may help with LPR and show you how to determine which LPR diet is best for you.
LPR Diet Snapshot
What does determining and optimizing your ideal LPR diet look like? Before we get into the details, here’s a quick overview of the steps you can take.
Eliminate common LPR triggers
Find your ideal LPR diet
Start with a low-acid Paleo diet
If symptoms do not improve, consider:
Low histamine diet
Low FODMAP diet
Modify dietary habits
Avoid lying down after eating
Stop eating 2-3 hours before bedtime
Eat slowly and in moderation
Add supplements as needed
Probiotics to support a healthy gut and digestive system
Melatonin, l-tryptophan, prokinetic herbs to reduce stomach acid
What is LPR or Silent Reflux?
Laryngopharyngeal reflux (LPR), like other reflux disorders, involves contents of the stomach traveling back up into the esophagus (which connects the stomach and the throat).
In the case of LPR, reflux reaches the pharynx (throat) and the larynx (voice box), typically leading to symptoms like cough or hoarseness.
Because the symptoms are often non-specific and may or may not include classic signs of indigestion like heartburn, LPR is commonly referred to as “silent reflux”.
LPR differs from the better known gastroesophageal reflux disease (GERD), which occurs when stomach contents travel back up into the esophagus but do not reach the throat. GERD typically causes classic reflux symptoms like heartburn and regurgitation.
What Causes LPR?
There are several possible causes of LPR, and multiple factors may contribute to the development of the condition.
LPR often overlaps with GERD, and some research suggests that GERD causes LPR 2. The same is true of irritable bowel syndrome (IBS) 3.
Some research has also found that the same gastrointestinal issues often underlie both IBS and GERD, suggesting that they may share a common cause 4.
Other possible causes of LPR include:
Low esophageal motility (esophageal contractions that should move food towards the stomach are weak) 5
Consumption of certain foods including acidic foods, spicy foods, alcohol, caffeine, sugary beverages, and fermented foods 101112
Can Certain Foods Cause LPR?
Certain foods may both contribute to the development of LPR and cause reflux symptoms 101112. And if you have LPR, you may have noticed that your symptoms tend to worsen when you eat something spicy or drink alcohol.
Some dietary triggers may be less obvious, which is why an elimination diet is often helpful. And in some cases, certain kinds of foods may indirectly contribute to reflux without necessarily causing immediate symptoms.
For example, if small intestinal bacterial overgrowth (SIBO) is an underlying cause of digestive dysfunction including reflux, then high FODMAP foods that feed bacterial overgrowth may worsen the condition.
Foods and drinks that have been associated with the development of or symptoms of LPR include 101112:
Acidic foods (including citrus fruits and tomatoes)
High carb foods
Your LPR Diet Plan
A natural LPR treatment plan involves a few different steps, starting with diet as a foundation and moving on to improving the gut microbiome, supporting stomach acid, and adding additional therapies as needed.
Diet alone can have a tremendous impact on your LPR symptoms and your digestive health.
For example, one study found that a plant-based Mediterranean diet combined with alkaline water (water that has been treated to render it less acidic) was slightly more effective than proton pump inhibitors (PPIs) for the treatment of LPR 13.
This speaks to the power of diet in general when it comes to silent reflux treatment.
There are a few different options to consider when it comes to developing your own LPR diet plan. We’ll cover a few different options, including Paleo, low histamine, and low FODMAP diets, below.
First, here are the fundamental steps to take in order to find your ideal LPR diet:
Eliminate known reflux triggers. Acidic foods, spicy foods, alcohol, and coffee, which are common triggers of reflux symptoms, should be eliminated as a starting point.
Identify and eliminate personal trigger foods. For this piece of the puzzle, some experimentation is required. An elimination diet based on the framework of a healthy anti-inflammatory diet (like the Paleo diet) can help you to determine which foods agree with you and which ones don’t. Follow your chosen diet for 2-3 weeks and monitor improvements. If your symptoms don’t improve with the first diet you try, you can move on to a more specialized diet.
Experiment with re-introduction. Once you’ve found a general diet framework that improves your symptoms, experiment with re-introducing certain foods one at a time and monitor how you feel. This will allow you to settle on a diet with as little restriction as possible. Keep in mind that objectively unhealthy foods like sugar and processed foods should continue to be avoided as much as possible.
Maintain your diet. Once you’ve found a diet that works for you, stick with it. Keep in mind that you can always try to re-introduce additional healthy foods further down the road as your condition improves.
If your symptoms have improved with diet but are still problematic, you can move on to the next stage of treatment (identifying and treating gut health imbalances). Your healthy diet will likely have built a solid foundation.
Should You Follow a Low Acid Diet?
A 2020 systematic review concluded that a low acid diet in combination with alkaline water could help to reduce symptoms of LPR 14. However, this diet hasn’t been well defined, and it may be best to simply avoid highly acidic foods as one component of your LPR diet plan.
The general principle of a low acid diet is to eliminate acidic foods (like citrus fruits) and other foods that have been shown to trigger acid reflux, like oily or fried foods. Some food lists will go a step further, rating foods based on measurements of their acidity or alkalinity.
Avoiding acidic foods and other known reflux triggers is important, but focusing too much energy on the level of acidity of every food item you eat may be counterproductive, as it may lead to anxiety around food and distract from underlying issues.
A more balanced approach may be to follow a better defined healthy diet (like the Paleo diet), modifying it as needed to remove highly acidic foods and other triggers.
I often recommend the Paleo diet as a starting point, as it eliminates many common triggers, has been shown to reduce inflammation and improve gut health, and allows for the intake of a variety of whole foods 15.
The Paleo diet removes processed foods, additives, grains, and dairy products. It emphasizes a balanced intake of fruits and vegetables, healthy fats, grass-fed or pasture-raised meat and poultry, fish, and eggs.
Within a Paleo (or any) diet framework, personal modifications can always be made. For example, while tomatoes and citrus fruits may be fine for most people following a Paleo diet, they’ve also been shown to trigger reflux, so they may need to be eliminated.
During the reintroduction phase of your Paleo diet, you may find that you can tolerate certain kinds of whole grains or dairy products in moderation, and your ultimate diet may end up looking more like a Mediterranean diet, which is less restrictive.
I would recommend trying a Paleo diet if:
Your current diet contains common triggers like processed foods or grains, and;
You don’t have any known intolerances or conditions that may require a more specialized diet.
Low Histamine Diet
One of the functions of histamine in the body is promoting the production of stomach acid, so for those whose acid production may be too high, reducing histamine is likely to be helpful. This is why antihistamine medications (H2 blockers such as Zantac) are often recommended for reflux.
The low histamine diet aims to naturally reduce histamine levels by eliminating foods that are high in histamine as well as those that trigger the production or release of histamine.
A low histamine diet eliminates fermented foods, aged foods, alcohol, and certain fruits and vegetables, including citrus fruits and tomatoes.
Although the low histamine diet hasn’t been studied for the treatment of LPR, several high histamine or histamine-releasing foods have been shown to trigger reflux and LPR symptoms.
I would recommend trying a low histamine diet if:
Symptoms do not improve on a low acid or Paleo diet, and;
The low FODMAP diet eliminates various kinds of fermentable carbohydrates that feed excess gut bacteria. High carbohydrate foods and diets have been associated with LPR symptoms 10.
Low FODMAP and similar low-carb diets have been shown to reduce heartburn and other reflux symptoms for those with GERD 161718. The low FODMAP diet is also a common treatment for SIBO and IBS. It’s been shown to significantly improve digestive and non-digestive symptoms of both 192021.
As there’s a great deal of overlap between LPR, GERD, and IBS, the low FODMAP diet may help with LPR as well. If symptoms improve on a low FODMAP diet, it may also point to an underlying bacterial overgrowth (like SIBO), which can then be treated.
The low FODMAP diet has also been shown to significantly reduce levels of histamine in the gut microbiome, which may help to reduce excess stomach acid production 22.
I would recommend trying a low FODMAP diet if:
Symptoms do not improve on a low acid or Paleo diet, and;
You have suspected or diagnosed SIBO, IBS, or GERD.
Other Diet Tips
A healthy diet is about more than what you eat. Eating habits, including how and when you eat, can also affect your digestion and your LPR symptoms.
Habits and lifestyle changes that may help to prevent LPR symptoms include 2324:
Finish eating for the day at least two hours before bedtime
Try to eat smaller meals and avoid overeating
Avoid lying down for as long as possible after eating
Be cautious about fasting
Should You Drink Alkaline Water?
Alkaline water has been ionized in order to reduce its acidity. While it’s unlikely to hurt, alkaline water is probably not a key component of an effective LPR diet.
Limited research has suggested that alkaline water may be helpful in the treatment of LPR and other reflux conditions. One systematic review concluded that a plant-based Mediterranean diet combined with alkaline water improved symptoms of LPR 13.
However, the alkaline water was not separated from the diet, so it’s unclear whether or to what extent it contributed to the improvements.
If you’re interested in trying alkaline water, you can purchase an at-home ionizer or look for packaged alkaline water at your local health food store.
Supplements for LPR
Certain kinds of supplements may be helpful alongside your LPR diet.
Probiotics, which help to restore balance in the gut microbiome, have been shown to improve symptoms of GERD 25.
There are also a few supplements that may help to normalize sphincter function, reduce esophageal damage, and improve reflux symptoms:
Prokinetic herbs (herbs that strengthen GI motility) 14, 28
The Best LPR Diet Is Personalized
What and how you eat can make a huge difference when it comes to managing laryngopharyngeal reflux.
Certain kinds of foods have been shown to contribute to LPR development, trigger symptoms, or both. Dietary changes have been found to improve the condition.
Finding an ideal LPR diet plan for you involves removing common reflux triggers as well as identifying and eliminating your personal trigger foods. Paying attention to when you eat and supporting your gut with probiotics may also be helpful alongside your diet changes.
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