Acid Reflux Could Have a Negative Effect on Your Voice

Dr. Jamie Koufman, founder and director of the Voice Institute of New York, tells us what singers can do to combat the harmful effects of acid reflux.

Do you cough or clear your throat a lot after eating a meal? Wake up in the middle of the night coughing or short of breath? Is your throat hoarse or sore in the morning? Do you have the sensation of a lump in your throat or difficulty swallowing? Are you plagued with post-nasal drip?

If you answered yes to any of these questions, you may have acid reflux—the backflow of acid and digestive enzymes from the stomach and esophagus into the throat. If left untreated it can lead to more serious problems, such as esophageal cancer.

In her office right across the street from Carnegie Hall, Jamie Koufman, M.D., director of the Voice Institute of New York, sees many singers and performers with one or more of these symptoms. Reflux is threatening not only their health but also their careers. In working with these professionals, Koufman has found that many of the symptoms of reflux can be alleviated with a change in diet. Dropping Acid: The Reflux Diet Cookbook and Cure, written with physician colleague Jordan Stern and master chef Marc Bauer, offers 75 low-fat, low-acid recipes to help combat reflux.

We asked Dr. Koufman to tell us more about what she has discovered about reflux.

Chorus America: Reflux is such a terrifying thing for choral singers because it is messing with something very precious to them: their voice. Why is reflux such an epidemic?

Jamie Koufman: Reflux has increased by about four percent a year since 1976. Esophageal cancer during the same period has increased 850 percent. Based upon our research, we believe the reason is that in 1973, following an outbreak of food poisoning, the FDA was asked by Congress to provide safe manufacturing criteria and standards. At that time the decision was made to use acid as a preservative.

So if a singer drinks enough acidic stuff—like six diet colas a day—he or she can have acid pharyngitis, which is throat inflammation even without having actual reflux or backflow of stomach juice. So the acidification of the American diet to kill bacteria like e. coli that are responsible for food poisoning ends up being almost as big a risk for voice problems as reflux. My big pitch to singers is to avoid too much acidity. A lot of singers eat raw food and a lot of fruit, which are also very acidic.

You believe that a lot of reflux symptoms can be addressed by diet.

Yes, but singers who have reflux do need to see a doctor. Some will need to be on medicine in addition to the diet. I saw a patient today who has laryngeal polyps. He will have the polyps taken off with a laser. You don't want a patient to have reflux on top of his surgery. The patient won't heal well. The reflux could result in scarring. So he is on the medicine and the diet.

How does the diet work?

What we do is put people on a two-week Reflux Induction Diet, a kind of detox for the throat. That means nothing carbonated, no citrus of any kind, and the only fruit you can have are bananas and melons. You also can eat grains, fish, poultry, and vegetables. One cup of coffee or tea day is allowed; otherwise people go crazy! One cup does not seem to cause reflux. Those who drink a pot of coffee before noon are the ones who have trouble. And chamomile tea you can drink all day long. Ginger candy is good. Oatmeal and tofu are great.

The other big rule is no nighttime eating. Many, many singers, particularly professional singers, have a performance and afterward they all go out, have a big party, and eat and drink, which can cause reflux later on in the night.

So after the Reflux Induction Diet, what comes next?

Once you get off the Reflux Induction Diet, you can transition to a maintenance diet. Really, this is the healthiest diet in the world. It is low-fat, not no-fat. It is low-acid, not no-acid. The concept is pH balancing. Here is an example: People love to snack on raisins, but raisins are acidic. But there is nothing wrong with raisins in Raisin Bran because the raisins float around in a sea of milk, which is very non-acidic. Likewise, raisins are fine in oatmeal. For people who like fruit, such as berries, I recommend that they have them with their cereal in the morning, because you have the buffering of the milk. On the pH scale, milk is a 7 and certain fruits are between 3.4 to 3.7.

I wonder if certain foods affect people differently. Do some people have trouble with fruit, for example, and others don't?

Yes, there are trigger foods—something that you can't eat because it causes problems for you. One of the most common trigger foods, unfortunately, is chocolate. Some trigger foods are not intuitive. I recently met a patient who has a problem with tuna fish. When she eats it, it burns all the way down and causes reflux. If you eat something and it burns, that is probably a trigger food for you. It should be avoided, even if it is on the "good foods" list for refluxers.

I wonder if there is a misconception about reflux. People see the commercials on TV and there's someone with a big stomach ache. But reflux doesn't always present itself like that.

Right. I lot of people have reflux who do not have heartburn. We interviewed people waiting in the half-price ticket line in Times Square recently. Folks were from all over, so it was a national sample. The age range was 18 to 87. We asked them about symptoms and medications and we concluded that 40 percent had reflux. But 22 percent had heartburn and typical reflux. So that means 18 percent had silent reflux. It is silent reflux that causes the most trouble for the singer.

Why is it called "silent"?

Well, one reason is that it occurs at night when you are asleep. If you are a singer and your voice is worse in the morning when you wake up, you are probably having reflux. People with other kinds of voice problems usually experience the voice getting worse as the day goes on.

Silent reflux may or may not be connected to esophageal disease—that's when the upper valve in the throat that is supposed to keep stuff from the esophagus out just doesn't work very well. We studied people who had silent reflux and only one in five had esophageal disease. This is important because you could have big-time reflux, but if a gastroenterologist put a scope down your throat, everything might look fine.

What about all the antacid medications advertised on TV? Aren't you supposed to have acid in your stomach?

There are huge misconceptions about that. People think that you take this medicine and you don't make any acid anymore. You see on TV those little acid pumps giving up at the sight of a little purple pill. In truth this doesn't happen. You would make a lot of acid even if you took 15 of those pills a day.

If you take all the people with reflux, about 30 percent really have trouble and they are going to need medicine and treatment. The other two-thirds will respond to diet with or without a doctor's care, with or without medicine temporarily.

With singers who are waking up hoarse in the morning, we take a look at what they're doing. We often find that they are going out at night and drinking and carousing and they are going home and refluxing all night. If they stop that the reflux will get better.

Diet is very important for the majority of patients, but not all.

If you don't address the reflux, it can lead to other problems, right?

Yes, esophageal cancer is the fastest growing cancer in the United States. So people who have reflux at some point need to see a doctor, particularly if they are over 30. We are seeing the same kind of disease in 30 year-olds that we used to see in 50 year-olds. They need to have the esophagus checked. About 10 percent of patients who have reflux have Barrett's Esophagus, which is a pre-cancer disorder in which the lining of the esophagus is damaged by stomach acid. They must be followed closely by a doctor.

You have worked with a lot of singers. Are there some interesting stories of singers struggling with reflux?

Ninety percent of my patients are singers. There was a star on Broadway who was sent to me by a lung doctor. He was having terrible wheezing and asthma-like symptoms. He was having trouble getting through the show. His reflux was out of control and he had been on medicine for months. He was recommended to have reflux surgery. When we ended his reflux, it ended the asthma and it saved his career.

Reflux surgery basically makes the opening at dome of the stomach tighter so that what is in the stomach stays in the stomach. Of all the treatments it is the most effective. Unfortunately it has complications and should not be taken lightly. You do it if you have to. This man needed the reflux surgery. He was one of the few.

I saw a young comedienne who was living on diet colas. I asked her, "Do you drink more than a six pack a day?" She said, "From the moment I get up till the moment I go to sleep." She gave it up and that was all that was needed for her voice to get better.

Another young singer came to see me who had a good diet. But here's what she was doing: After dinner, which was her big meal of the day, she would do yoga for an hour and a half and then she would have apples before bed. Apples are very acidic. All we had to say was, "Cut out the apples and do your exercise on an empty stomach not a full stomach." She got better.

There was a rock star who was traveling with his own cook and eating a lot of raw stuff. It was either high acid or high fat. So when we said, "You can't eat cherries and macadamia nuts all day," he got better.

Reflux has been grossly underestimated by the medical establishment. Our work is finally starting to hit the public's consciousness. And patients are starting to go to their doctors and demand help.