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LPR Diet – Why PPIs Do Not Work for LPR (Laryngopharyngeal Reflux)?

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  • Are PPIs safe and effective for LPR (Laryngopharyngeal Reflux)?

LPR Diet – Why PPIs Do Not Work for LPR (Laryngopharyngeal Reflux)?

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Question

Is it safe to use a PPI (Proton Pump Inhibitor) over the short term to determine if I actually have LPR as opposed to chronic sinus infection? Also, if it is (reflux-related) LPR, is it necessary to go on medication? My doctor keeps telling me that it would be worse to have acid in my esophagus/pharynx as it can have cancerous implication in my future.

Answer

Although PPI drugs are relatively safe short term (a couple of weeks), they are absolutely NOT safe longer term, and I have written about the many risks in this article, GERD – Why standard treatments are ineffective.

Beyond the safety issue, there is no evidence that taking a PPI is effective for LPR, so it won’t be an effective way to diagnose or treat this condition.

According to this systematic review of several clinical studies, Management of laryngopharyngeal reflux with proton pump inhibitors “Data from these trials show that PPI therapy is no more effective than placebo in producing symptom relief in patients suspected of LPR”.

The same conclusions were reached by this 2016 meta-analysis of more recent studies, Meta-analysis of the efficacy of proton pump inhibitors for the symptoms of laryngopharyngeal reflux: “The difference between PPIs and placebo groups in overall improvement of symptoms in adult patients with LPR was not statistically significant. The difference in cough improvement was also not significant between PPIs and placebo groups.”

As a result, “the American Gastroenterological Association guidelines for GERD recommended against the use of acid-suppression therapy for acute treatment of patients with potential extraesophageal GERD syndromes (laryngitis, asthma) in the absence of typical GERD symptoms” cited in this study, Optimal treatment of laryngopharyngeal reflux disease.

Why PPIs Do Not Work For LPR

The most likely reason that PPIs don’t work for LPR is because they only reduce stomach acid and have no effect on the reflux of pepsin, bile salts, bacteria and pancreatic enzymes which may be even more damaging in the absence of stomach acid. To effectively address LPR, one must therefore control reflux itself. PPIs can work against you here because PPIs promote SIBO and dysbiosis which I have proposed as underlying causes of reflux.

A proof of principle supporting this idea is the use of fundoplication surgery for LPR. A 2011 study titled Impact of Nissen fundoplication on laryngopharyngeal reflux symptoms showed that LPR patients who underwent the surgery reported a 73 to 83 % improvement of voice fatigue, chronic cough, choking episodes, sore throat, lump in throat, and throat clearing. Even asthmatic symptoms showed improvement, though to a lesser extend (60%).

The dramatic improvement in LPR symptoms following fundoplication supports the idea that stopping reflux is the key in controlling LPR symptoms as opposed to blocking acid. Although fundoplication surgery is effective for LPR, this invasive procedure involves risk of infection and a variety of side effects that are mostly associated with trapped gas covered here

A Natural And Science-Based Alternative for LPR

To keep all these (pepsin, bile salts, bacteria and pancreatic enzymes) non-acid components where they belong, we need to address the root cause of reflux, which I firmly believe is SIBO (small intestinal bacterial overgrowth) and / or dysbiosis (an imbalance of gas-producing intestinal bacteria). Several potential underlying conditions can promote SIBO and dysbiosis, but the single biggest problem is over-consumption of hard-to-digest carbohydrates for most people.

Here is the mechanics of how hard-to-digest carbohydrates drive SIBO / dysbiosis. When you over-consume hard-to-digest carbohydrates, they often escape digestion and absorption potentially overfeeding gut bacteria. The overfed bacteria produce excess gas in your intestines which drives reflux.  I.e. Mentos in a coke bottle. Carbohydrates, not proteins and fats are the preferred energy source of these bacteria, hence dietary intervention that restricts hard-to-digest carbohydrates is the best way to control reflux.

This is different from the pervasive online dietary advice for LPR which is the same as that for acid reflux / GERD such as avoidance of acidic, spicy, and fatty foods as well as alcohol and caffeine, etc. And this trigger food approach has been proven to be ineffective according to this systemic review of lifestyle modifications for GERD in 2006.

It has been over 10 years since I proposed SIBO / dysbiosis as the underlying cause of reflux in my first book, Heartburn Cured. Since then, my approach based on the original theory has been transformed into the Fast Tract Diet and our individual consultation program based on the holistic 3 Pillar Approach:

  1. Dietary modification to control hard-to-digest carbohydrates 
  2. Pro-absorption (gut friendly) behaviors and practices
  3. Identifying and addressing other potential underlying causes of SIBO/Dysbiosis

To address LPR at its core without PPIs or other drugs, read the Fast Tract Digestion Heartburn book and get the Fast Tract Diet mobile app to give the Fast Tract Diet a serious try.

BE COMPLIANT and FOLLOW THE DIET EXACTLY AS THE BOOK AND APP OUTLINE. Many of my readers and clients are pleasantly surprised by the effectiveness of the Fast Tract Diet approach.

Looking for a community of Fast Tract Dieters?

Fast Tract Diet Group on FacebookJoin the Fast Tract Diet Discussion Group on Facebook for questions, support and inspiration.

 

Please Share

If you suffer from LPR and are prescribed a PPI, please share this article with your doctor. If your family and / or friends suffer from LPR, please share this article with them.

We are committed to changing the way the world perceives digestive health. Our goal is to elevate science-based holistic dietary solutions to first line therapies for a broad range of digestive and systemic disorders at the grassroots level. 10 million people off drugs and antibiotics.

Thank you for your assistance. 

By | 2017-02-09T22:29:21+00:00 December 10th, 2016|Diet and Digestive Health|31 Comments

About the Author:

Norman Robillard, Ph.D., is a microbiologist and researcher who spent 20 years in the pharmaceutical industry before founding the Digestive Health Institute. His goal is to develop holistic treatments for digestive illnesses based on a clear understanding of the underlying causes of disease. Norm was the first to recognize a connection between bacteria in our intestines, nutritional malabsorption and the symptoms of acid reflux. Based on his extensive research, he created the clinically proven Fast Tract Diet, a safe and effective alternative to proton pump inhibitor (PPI) and H2 blocking drugs. Fast Tract Digestion books are now available for Heartburn and IBS on the books page. Bacterial overgrowth fueled by nutritional malabsorption is a factor in several other digestive health conditions. Research in this area is the main focus of the DHI. Additional versions of Fast Tract Digestion are in the works for a number of these conditions. Norm received his Ph.D. at the University of Massachusetts, Amherst and completed post-doctoral training at Tufts University.

31 Comments

  1. Steph December 11, 2016 at 4:27 am - Reply

    LPR can be very frightening – the vocal cords can go into spasm so that no air passes through, and I was left gasping and unable to breathe first thing in the morning, with my partner wondering whether he should call an ambulance. Fortunately I stumbled on Norm Robillard’s work which was completely successful at curing my SIBO and LPR. I’m eternally grateful, so thought I’d take the opportunity to say thanks, Norm!

    • Norm Robillard January 25, 2017 at 4:19 pm - Reply

      Congratulations Steph. Thanks for sharing your success!

    • Aleta Thomas February 13, 2017 at 11:38 am - Reply

      That’s amazing ! I’m so glad you were cured !

      I have LPR and am struggling to find a cure.

      I’ve come across Dr Robillard’s book and website, and have scheduled 3 sessions with him.

      How long did it take before your symptoms subsided ?

  2. Lynn grant December 12, 2016 at 3:38 am - Reply

    I wonder if you can tell me i am on ppi i have too much bike in stomach after having gb out n bike salt malabsorption x really bad nawing pain in stomach if i stop these can this help doc doesnt seem to know cause

    • Norm Robillard January 25, 2017 at 4:23 pm - Reply

      Sounds like you have a couple of things going on there Lynn. I can’t comment on individual issues outside our consultation program, but don’t give up. More and more is becoming known about how bile acid pools are regulated (gut bacteria play a role too) and there is definitely help available.

  3. Dennis Durost December 12, 2016 at 10:48 pm - Reply

    I had the typical LPR symptoms and my ENT doctor put me on Prilosec. After two weeks with no symptom improvement I stopped the Prilosec and started doing some research on LPR. I came across the works of Dr. Robillard and Dr. Wright. Both Docs have slightly different approaches to treatment so I decided to try both concurrently. My initial improvement came when I tested myself for low stomach acid and determined it was low. Within a week after supplementing with Betaine Hydrochloride with Pepsin, all my symptoms vanished. I also began to avoid the hard to digest foods identified by Dr. Robillard. I believe correcting a low stomach acid condition promotes improved digestion and Dr. Robillard’s diet recommendations certainly help in that regard.. It has been six months and I remain symptom free.

    • Melissa Copenhaguen January 30, 2017 at 11:10 pm - Reply

      Hey Dennis,
      since being symptom free, have you tried adding any carbs that you cut out completely?

    • Aleta Thomas February 9, 2017 at 5:24 pm - Reply

      Hello Dennis

      How did you test yourself for low stomach acid ?

      How are you feeling now ? Are you still symptom free ?

  4. Norm Robillard December 13, 2016 at 8:42 am - Reply

    Congratulations on your success Dennis. By the way, Fast Tract Digestion Heartburn does have a section on diagnosing and treating low stomach acid in Chapter 6, Treating Underlying Factors.

  5. Anne December 14, 2016 at 4:27 pm - Reply

    Hello. I started the fast track diet after getting off of my PPi’s (which were not helping me) to try to help my LPR. I have been battling this disease for years alone since my ent specialist were ignorant of gerd causing upper respiratory and sinus infections. I progressed to having gerd symptoms toward the end of three yrs since symptoms began
    After starting the diet I had three a couple of hard weeks of symptoms, then they eased, improved, and I had 1 mth of no symptoms (only occasional tingling after eating). But now symptoms have returned. What am I doing wrong?
    I must have the severe form as i couldn’t tolerate the jasmine rice and the nuts, cheese, smoothy,etc cause symptoms all through this.

    Want to return to symptom-free. Will this take. Many weeks again? Any advise would help

  6. Norm Robillard December 14, 2016 at 6:43 pm - Reply

    Anne – these are the troubleshooting questions to ask yourself:

    1. What is your daily FP?
    The most common problem is that your FP points became too high, or you’re consuming hidden higher FP carbs.

    2. Are you incorporating the pro-absorption (gut friendly) behaviors outlined in the Fast Tract Digestion book / Fast Tract Diet app?

    3. Have you read the troubleshooting sections in the book / mobile app?

    4. Did you take actions based on the the troubleshooting tips?

    5. Do you need individualized help via our consultation program?

  7. Anne January 10, 2017 at 5:56 pm - Reply

    Thank you so much for answering my question. I went back to square one of the diet, lowering the FP of my diet, as you suggested. It is slowly improving. I find that though I’m not lactose intolerant, the sugars in the lactose caused symptoms. Also the nuts, and jasmine rice were aggravating my LPR and Gerd symptoms. So two questions please: what besides meat can I eat? (as many of the recipes contain rice or lactose.)
    And 35% cream lists sugar at 0. Is this so?

    Thank you So so much for being the first real help for me.
    Anne from Ontario Canada

  8. lili January 13, 2017 at 7:17 pm - Reply

    Hello. I don’t know yet what do I have. It can be LPR. My only symptom is Post Nasal drip when I sleep It’s moderate. I have feel sometimes that the mucus decreased, maybe its something I am eating. I have take blood test for food allergy and the results were negative. I don’t know how reliable the blood test is for food allergy. I have had gastroscopy and laryngoscopy with negative results for reflux. I did also get esophageal motility test and it was OK. I have decided to take the Peptest. I live in Europe. I am going to take also a SIBO test and stool analysis. I don’t know what else I can do. Now I am pregnant and I wonder whether is advisable or not to follow the fast track diet. I bought the book. Thanks

    • Norm Robillard January 25, 2017 at 4:30 pm - Reply

      Hi Lili, I can’t comment on your specific situation, but diagnosing LPR is tricky and most commonly its done based on symptoms. Food allergy testing is not dependable and the Peptest is not validated. A SIBO breath test is a possibility, but many people who suspect they have LPR just try the diet for 4-6 months. It’s based on whole foods, so there is no reason to believe its problematic with pregnancy. Anyone at risk for gestational diabetes should further reduce carbs as needed to help control blood sugar.

  9. Melissa Copenhaguen January 30, 2017 at 11:34 pm - Reply

    Hello,
    For years I have suffered from what my Dr. said was acid reflux. I would eat everything from healthy to not healthy. The only time I would feel sick was when I over did it on the really bad food like chips and soda, or fast food. My symptoms would be pain right below my chest (right in the middle) and would extend to my left side and my back. When that happened I had a hard time catching my breath and sometimes would get Diarrhea and or would vomit. My mother would have the same symptoms. So we would take pepcid ac to relieve the pain. Then one day after being sick from a really bad cough that would make me choke, I started to feel like I was going to get a cold or flu again, but I didn’t instead I was left feeling like there was something stuck in my throat. I started to get panic attacks and anxiety, because I didn’t know what the heck was going on. A month later I went to my Dr. who sent me home saying it was probably stuff left from the cough I had. Then I went back a couple of wks later and saw the other Dr. there who said it’s probably my acid reflux. By this time I was feeling the excess mucus in throat and clearing my throat constantly. 2nd Dr. sent me to ENT and I had the tube going through your nose to the back of your throat and they said it was clear, ENT saw how desperate I was and did a barium swallow which also came back negative. So they put me on Prilosec. After to 14 day boxes I gave up. I was so desperate I went to Tijuana to see a Dr. there that was recommended. He said it wasn’t acid reflux and was treating me for post nasal drip and sinus. That didn’t work… I was panicking so much I did Reiki and meditation to help. Finally a little more calm from my anxiety I went online and put my symptoms in and LPR showed up. Through there and with no luck I started to try and find a cure. It’s been 9 months now and finally I came across Dr. Robillard and Chris Kresser. Both talking about SIBO and I decided to start the FPD because Dr. Robillard was the only one that I found talked about LPR. I’ve been doing the FTD for about 2 wks now, still learning but my symptoms have improved a lot from when I first started. I want to go back to the DR. and get re-checked for everything… what are the test I should tell them to do? Also, I mentioned my mom had the same symptoms but never got the LPR symptoms, is there a reason why I got it and she didn’t? Sorry this was so long, but aside from here, I have no-one else to ask or talk to about this!

  10. Matt February 21, 2017 at 10:58 am - Reply

    Hi Norm,

    I was hoping you could give us some advice on my wife’s situation. My wife has always had some stomach issues, mainly gastritis and possibly a hiatal hernia, but never had any type of heartburn, LPR, or reflux. She was prescribed a PPI to get over an episode of gastritis and was on it for over 6 months under a doctors direction and improved greatly. She got pregnant and wanted to get off all medication so she stopped the PPI once we found out she was pregnant. At about 8 weeks she started getting severe chest pains that were attributed to heartburn, (we ruled out all other possibilities through tests) so she got back on the PPI and it seemed to help. Shortly after that at about 12 weeks she started getting throat symptoms including a severe dry, tight throat, lump in throat, etc. After seeing an ENT who looked at her throat and confirmed there was some minor irritation in her throat that he said could be LPR. Hearing this we did a bunch of research and found your book. At 20weeks pregnant now, she has been on your diet for about a week and a half with not much improvement. I am wondering though as she is still on the PPI (nexium 40mg), could this affect her improvement possibilities? Could doing your diet while on a PPI make her systems worse? Would it make sense for us to try to ween her off the PPI and focus on the diet to improve her overall stomach balance? She is in pretty severe pain most of the day so we are doing anything to try to get her some relief.

    • Norm Robillard February 24, 2017 at 8:42 am - Reply

      Sorry to hear about your wife’s situation. LPR symptoms can be challenging. Unfortunately, PPIs are not effective for LPR. And they block stomach acid one of the control mechanisms to keep bacteria from overgrowing in the small intestine. I recommend discussing these ideas with your doctor and a plan to wean off the PPIs while diligently employing the Fast Tract Diet. Also, you might re-read the trouble-shooting sections in the book or mobile app. You need to be very strict for the first several months with LPR. She can also join the Fast Tract Diet Official Facebook group where several people with LPR regularly discuss their progress.

  11. Dr ujwal Bokare April 22, 2017 at 5:37 am - Reply

    Hello Norman,. I’m a pediatrician , suffered from lpr 3 years back ,was given ppi with prokinetic ,l was ok but became dependant on it & continued for 3 years, now the situation is that inspite of taking these drugs continuously the symptoms recurred since last 6 months , my grandma was a pt of gerd & died of oesophageal carcinoma. Please help. Secondly l am an Indian & l fear the food you suggested may not be available at my place. Please comment .

    • Norm Robillard April 22, 2017 at 8:54 am - Reply

      Hi Dr Bokare,
      Keep in mind that all animal/fish-based foods are zero points and there are at least 50 different vegetables listed that are below 5 points. If you are interested in consulting with us, we use Skype and you can contact us under the consultation page.

      • SkepticallyJoined May 22, 2017 at 9:33 am - Reply

        Hello Norm,

        I see you note that all animal/fish based foods are zero points (a fish BEING an animal of course). I had a good day and then had a dinner with spinach, just sautéed with water, sweet potato baked, no butter, and one chicken thigh. I started having reflux symptoms. Since traditional reflux advice is to avoid high fat, I presumed it was the chicken, since dark meat is fattier. I had been eating only white meat chicken before then and had done well.

        What’s going on here?

        Background. I’m 47, and was told I was “A little GERDY’ years ago but the doctor did an endoscopy, said I came back great. though I did have a small hiatal hernia, and then a few years awent by and I didn’t think I was having many symptoms outside of gas. Looking back, I had LPR symptoms for a time and didn’t realize it.

        Also I had a plate of spaghetti with white clam sauce two nights ago and except for feeling full, felt fine. Those are carbs.

        • Norm Robillard May 22, 2017 at 10:27 am - Reply

          HI SJ, If you can avoid symptoms by food combinations that are different from those recommended in the Fast Tract Diet, I have no problem with that. But most people develop symptoms from consuming too many carbs, especially hard to digest carbs. The proof is in the clinical success of low carb, low starch, low FODMAP, paleo, elemental (only carb is glucose, generally absorbed quickly), etc. I am unaware of a low fat high pasta diet that has achieved similar results.

          One thing you might examine if the possibility of delayed fermentation in your symptoms. Some meals with complex/hard-to-digest carbs take awhile to ferment fully. You can get symptoms from something you ate yesterday. And guess who gets the blame? The last thing you ate.

  12. Sally Clark May 8, 2017 at 10:07 am - Reply

    I suffered from LPR for about 5 years. Went to two doctors who both recommended antacids which I was completely opposed to using. I downloaded your FP food info app and used it for about two weeks. I ate a lot of pickles, (plain) yogurt, DGL tabs & apple cider vinegar. Results were amazing – total relief. That was about a year ago and now when I feel it coming back every so slightly I start eating lots of fermented foods again, reduce my food intake, eat slowly & voila…..total relief again. So amazing & I thank you from the bottom of my heart!

  13. Rich May 31, 2017 at 9:10 pm - Reply

    Hi Norm, I’ve had LPR for the past 4 months and taken PPIs – with zero symptom relief. What are your thoughts on the low acid diets – most prominently advocated by Dr. Jamie Koufman & Dr. Jonathan Aviv? I’ve tried these for a couple of weeks and not had any success. A lot of conflicting advice around the net so wondered what your own thoughts are on this approach?

    • Norm Robillard May 31, 2017 at 9:34 pm - Reply

      Hi Rich, The low acid approach is an interesting idea – to minimize the activating pepsin (potentially refluxed and deposited on tissue in the throat, esophagus, etc.) by limiting acidic foods.

      The FTD approach on the other hand, aims to address through diet and behaviors what I consider to be the fundamental problem, gas produced by bacteria fermenting carbs. The idea is to stop reflux itself so pepsin, acid, bile, other enzymes, etc. don’t reach the esophagus and throat to begin with.

  14. Rich June 1, 2017 at 5:08 am - Reply

    Thanks for the quick reply, Norm. I can definitely see the sense in how it works. I’m really keen to give the FTD approach a go. I just have one concern: I’m about a stone underweight (always had trouble putting weight on, in fact) and can’t afford to lose anymore.

    Am I likely to drop weight with FTD? If so, I’d really appreciate any recommendations you have to counter this possibility?

  15. Rich June 1, 2017 at 5:09 am - Reply

    Thanks for the quick reply, Norm. I can definitely see the sense in how it works. I’m really keen to give the FTD approach a go. I just have one concern: I’m about a stone underweight (always had trouble putting weight on, in fact) and can’t afford to lose any more.

    Am I likely to drop weight with FTD? If so, I’d really appreciate any recommendations you have to counter this possibility?

    • Norm Robillard June 1, 2017 at 8:23 am - Reply

      Anytime carbohydrates are reduced, one can loose a few lbs over the first week or so. Provided one is consuming adequate amounts of protein and especially fat, weight should quickly stabilize.

  16. Richard June 1, 2017 at 10:19 am - Reply

    Great, thanks Norm.

  17. Nan June 21, 2017 at 5:46 pm - Reply

    Hi Norm,
    Just bought your book two days ago and kind of started the diet but I had question. I just finished one YEAR of antibiotics (three high powered ones) for MAC (mycobacterium avium complex) in my lungs. About four months into the antibiotics my GERD sort of seemed to blow-up like a volcano and then I got LPR where all I do is constantly clear my throat. Had an EGD and they said “higher than normal reflux). Took PPI’s for two months but then stopped because I didn’t like taking them and was following Dr. Gundry’s suggestion of taking a prebiotic supplement with my probiotics (because he believes that probiotics need probiotics to really turn your gut bacteria to normal. But the PREBIOTHRIVE supplement that I’m taking is “fiber”, right? It has organic acacia gum, organic agave inulin, organic flaxseed, galactic-oligosaccharides and organic guar gum. Does this mean that this is producing gas? Can I continue to take it or stop while I’m trying to do your diet? It’s one scoop a day with water or juice and it has 7 grams of fiber. Thank you.

    • Norm Robillard June 22, 2017 at 12:11 am - Reply

      Hi Nan, Antibiotics can mess with your microbes, so I am not surprised that your reflux got worse after taking them. As for prebiotics, as you will see in the book, each gram of fiber is a gram of FP points. I would not waste 7 of my points (there could be more depending on what else is in this concoction) on this type of supplement. The biggest problem in my view for those of us affected by functional GI conditions is “overfeeding” our gut microbes, not under feeding them.

  18. Nan June 22, 2017 at 9:18 pm - Reply

    Thank you so much, Norm.

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