Your Personalized LPR Diet to Treat ‘Silent Reflux’

Use These Dietary Interventions to Improve LPR.

One of the most important parts of a laryngopharyngeal reflux (LPR), or “silent reflux” treatment plan, is diet. With so many options out there, what is the best LPR diet? 

Diet can improve symptoms of LPR for a few different reasons. Certain foods and drinks have been shown to both contribute to the development of LPR and trigger symptoms. Spicy foods and acidic foods as well as alcohol are contributors. 

Not only can foods trigger symptoms, but underlying imbalances or food sensitivities may indirectly contribute to LPR symptoms by promoting the production of stomach acid, feeding bacterial overgrowth, or causing inflammation in the gastrointestinal tract. 

Finding the right LPR diet for you can decrease symptoms, help you feel better, and possibly resolve symptoms completely. No matter what, a healthy personalized diet creates a strong foundation on which to build your other treatments. 

In this article, we will take a look at the dietary interventions that can help with LPR and help you discern which diet is best for you.

LPR diet: person touching their neck

LPR Diet Overview 

Every person will have an optimal LPR diet, but here are a few principles of diet that help most people with silent reflux: 

  • Remove common LPR triggers
    • Acidic foods
    • Spicy foods
    • Alcohol 
    • Oily foods 
  • Find your ideal LPR diet 
    • Start with a low-acid Paleo diet. 
    • If symptoms do not improve, consider: 
      • Low histamine diet 
      • Low FODMAP diet 
  • Improve dietary habits
    • Do not lie down after eating. 
    • Finish eating 2-3 hours before bedtime. 
    • Eat slowly. 
    • Eat smaller meals.
  • Use supplements as needed
    • Add probiotics to create a healthy gut and digestive system. 
    • Use melatonin, l-tryptophan, and prokinetic (stimulates the muscles of the esophagus and/or gastrointestinal tract) herbs to reduce stomach acid. 

What Is Laryngopharyngeal Reflux or LPR?

LPR diet: Upper Digestive Tract infographic by Dr. Ruscio

Laryngopharyngeal reflux (LPR) is a reflux disorder. In reflux disorders, contents of the stomach travel back up into the esophagus (the tube that goes from the stomach to the throat) and/or as high as the throat, rather than staying in the stomach and then continuing to move through the gastrointestinal tract for digestion. 

When many people think of reflux, they think of heartburn and indigestion. The symptoms of LPR, though, are not always limited to this indigestion, burning, or heartburn. Those are more commonly found in gastroesophageal reflux disease (GERD), which is when stomach contents travel back up into the esophagus but don’t reach the throat. 

In LPR, the reflux goes to the throat (pharynx,) voice box (larynx,) and even sinuses, which often results in symptoms like a sore throat, coughing, or hoarseness. LPR is often called “silent reflux” because its symptoms are not always easily associated with reflux. 

Common Symptoms of LPR are [1]

  • Sore throat 
  • Hoarseness 
  • Chronic cough
  • Postnasal drip
  • Sleep disruption
  • Frequent throat clearing
  • Feeling like there is a lump in your throat 
  • Difficulty swallowing 
  • Heartburn 

What Causes LPR?

Many possible factors contribute to the development of LPR. Silent reflux also often overlaps with other conditions, such as GERD. In fact, some research suggests that GERD may cause LPR [2].

Some people with LPR may also struggle with IBS (irritable bowel syndrome). One large study found that about 63% of people who had IBS also had GERD [3].

Overall, LPR is most often caused by one or a combination of these three factors:

1. Slow motility of the esophagus, meaning that food is moving towards the stomach too slowly [1, 4].

2. Improper levels of digestive enzymes or stomach acid.

3. Poor sphincter function, where the ring of muscle (sphincter) that closes sections of the digestive tract once food moves past are weak. This may allow the contents of your stomach to flow back up into your esophagus [1].

Other possible contributors to LPR symptoms include: 

  • Sleep apnea [5]
  • Hiatal hernia (when part of the stomach pushes up into the chest) [6]
  • H. pylori infection [7]
  • High levels of pepsin (a digestive enzyme) [8]
  • Certain foods, including acidic foods, spicy foods, alcohol, caffeine, sugary beverages, and fermented foods [9, 10, 11]
LPR diet: raw chilis and chili powder

Foods That Trigger LPR

Many people observe that their LPR symptoms increase when they eat certain foods, such as spicy or acidic foods. Research supports what patients report, as you can see in the list below.

Foods and drinks that have been associated with the development of or symptoms of LPR include [9, 10, 11]:

  • Acidic foods (including citrus fruits and tomatoes) 
  • Spicy foods 
  • Alcohol 
  • Chocolate 
  • Coffee 
  • Peppermint
  • Oily foods 
  • Fatty foods
  • Fermented foods
  • Sugar 
  • High carb foods

Some dietary triggers are not as noticeable. In fact, some foods may contribute to reflux but may not cause immediate symptoms such as coughing or sore throat. 

In some cases, small intestinal bacterial overgrowth (SIBO) is an underlying cause of reflux, particularly in people who have LPR with IBS [3, 12, 13]. 

In those cases, a diet high in FODMAPs (foods that feed bacterial overgrowth) may worsen LPR. This is why an elimination diet can be so helpful as part of the treatment plan to resolve LPR. 

Your LPR Diet Plan

LPR diet: Natural Strategy for Silent Reflux & LPR infographic by Dr. Ruscio

The right diet creates a strong foundation for your LPR treatment plan. It helps remove foods that may be triggering symptoms, helping you feel better right away. A solid diet also creates a healthy environment for supporting the gut microbiome, proper stomach acid levels, and any other therapies that may be needed. 

One common traditional treatment of LPR is using proton pump inhibitors (PPIs) which reduce the amount of acid in the stomach. PPIs are used because stomach acid is often thought to be the cause of LPR. 

However, PPIs do not work for some people, possibly because PPIs don’t resolve the underlying issues that cause the imbalance of stomach acid. Diet can help improve underlying issues that cause an imbalance in stomach acid levels.

A few different diets have been shown to be helpful in improving symptoms of reflux. We will look at Paleo, low histamine, and low FODMAP diets below. 

But first, let’s look at the overall principles that can help you to find your ideal LPR diet: 

  • Eliminate known reflux triggers. Start off with removing common triggers for reflux symptoms, such as spicy foods, acidic foods, alcohol, and coffee. 
  • Discover your personal trigger foods. Every person is different, and there may be more foods that trigger your symptoms than just the ones mentioned above. Trying an anti-inflammatory elimination diet, such as the Paleo diet, is a great way to discern what foods are not a good fit for you. Follow your diet for 2-3 weeks, tracking improvements. If your symptoms don’t get better, you can move on to a more specialized diet. We talk about a few of those diet options later in this article so you have a plan to follow. 
  • Use food reintroduction to find your ideal diet. When you find the anti-inflammatory elimination diet that works best for you, try re-introducing foods one at a time and note any changes. If a food causes a symptom flare, you know it is one you shouldn’t eat. However, if a food doesn’t trigger symptoms, this helps you expand your diet to be as diverse as possible. Do remember that, generally, unhealthy foods such as sugar, processed foods, and a diet very high in carbohydrates should continue to be avoided. 
  • Maintain your LPR diet. Once you’ve gone through the re-introduction process and found a diet that works for you, stick with it. As you heal, you can try and re-introduce other healthy foods that may have caused symptoms before. Sometimes our gut heals and our stomach acid levels out enough for a food to be safe to eat again. 

Your symptoms may resolve just with the right diet, but if you’re still struggling, then you may want to look at working with a functional medicine practitioner to identify and treat any gut imbalances that may be contributing to your symptoms.

For now, let’s take a look at some of the diet options you can try. 

What About a Low Acid Diet

LPR diet: sliced orange and grape fruit

We often hear about using a low acid diet to treat LPR. While a review of multiple research studies supports that a low acid diet in combination with alkaline water can help reduce symptoms of LPR, not all studies had the same definition of what a low acid diet is [14]. Overall, your best approach is to avoid highly acidic foods as part of your larger LPR diet plan. 

In general, a low acid diet eliminates acidic foods, like citrus fruits and tomatoes, and other foods that have been shown to trigger acid reflux, like oily or fried foods. Some lists even give exact acid ratings for individual foods.

While avoiding acidic foods and other known reflux triggers is important, stressing over the acid level of every food you eat can be too overwhelming and increase anxiety, which isn’t good for gut or general health. 

A more balanced approach may be to follow a healthy diet (like the Paleo diet) and modify it as needed to remove highly acidic foods. 

Paleo Diet

What to Eat on the Paleo Diet infographic by Dr. Ruscio

The Paleo diet is where I start most often with my patients in our clinic. The Paleo diet allows you to eat a variety of whole foods while removing common trigger foods. It has been shown to reduce inflammation and improve gut health [15]. 

The Paleo diet removes processed foods, sugar, grains, legumes, and dairy products. It includes fresh vegetables, healthy fats, and grass-fed or pasture-raised meat and poultry, fish, and eggs.

You’ll still want to personalize your Paleo diet, especially removing common LPR trigger foods, such as acidic and spicy foods. For example, both tomatoes and citrus fruits are acidic, and while those are in the Paleo diet framework, they may not work for you since acidic foods can trigger symptoms. 

During the reintroduction phase of your Paleo diet, some more commonly successful re-introductions are moderate amounts of dairy products and some gluten-free whole grains. 

I recommend trying a Paleo diet if: 

  • Your current diet contains common triggers such as processed foods, sugar, or grains, and; 
  • You don’t have any known food intolerances, sensitivities, or other conditions that may require a more specialized diet. 

Low Histamine Diet

Histamine Rich Foods infographic by Dr. Ruscio

There’s an interesting link between histamine and stomach acid, which is helpful to know when discussing reflux. 

The body produces histamine in reaction to something inflammatory. This is why some people take an antihistamine for seasonal allergies. One other function of histamine though is assisting in the production of stomach acid. For this reason, in people who have high stomach acid, reducing histamine may be helpful. In fact, antihistamine medications (H2 blockers such as Zantac) are often recommended for reflux. 

Histamine is also found in foods, particularly in leftovers, slow-cooked foods, aged foods, and fermented foods. Additionally, some foods trigger a histamine response. A low histamine diet reduces these foods, thus reducing overall histamine load in the body. 

A low histamine diet eliminates fermented foods (such as kefir, sauerkraut, and kombucha) aged foods (such as aged meats and cheeses), alcohol, and certain fruits and vegetables, including citrus fruits and tomatoes. 

Currently, a low histamine diet has not been studied in relation to the treatment of LPR. However, as you can see from the list of eliminated foods, we do know that some high histamine foods, or histamine-releasing foods, like tomatoes, have been shown to trigger reflux and LPR symptoms. 

I recommend trying a low histamine diet if: 

  • A low acid or Paleo diet did not relieve symptoms, and; 
  • You have histamine intolerance or a mast cell disorder (when mast cells, which are cells responsible for acute allergic reactions, are activated too often or at the wrong stimulus). 

Low FODMAP Diet 

Probiotic-rich food

For some people, an inability to properly digest certain carbohydrates, for various reasons, may be a contributing factor to LPR. A low FODMAP diet is a lower carbohydrate diet because it eliminates fermentable foods such as apples, mangos, dairy, asparagus, wheat, beans and lentils. These fermentable foods, when not digested well, sit in the gut and ferment, causing numerous symptoms, such as gas and bloating, but also reflux in some people. 

High carbohydrate foods (of which FODMAP foods are) and diets have been associated with silent reflux symptoms [9]. 

Low FODMAP and low-carb diets have been shown to reduce reflux symptoms in people with GERD [16, 17, 18].

Earlier we discussed SIBO and IBS, which are often associated with reflux. The low FODMAP diet is used to treat both SIBO and IBS, significantly improving digestive and non-digestive symptoms of both [19, 20, 21].

Because LPR, GERD, and IBS often occur together, a low FODMAP diet may help with LPR as well.

A low FODMAP diet is also a great way to discern if you may have an underlying issue, such as a bacterial overgrowth (like SIBO) or histamine intolerance. Not only does a low FODMAP diet improve symptoms due to bacterial overgrowth, but it reduces levels of histamine in the gut, which may help reduce excess stomach acid [22].

I would recommend trying a low FODMAP diet if: 

  • Neither a low acid, Paleo, or low histamine diet improve your symptoms, and;
  • You suspect or have been diagnosed with SIBO, IBS, or GERD. 

Additional Diet Changes 

How you eat can be just as important as what you eat for resolving LPR. 

The following eating habits and lifestyle changes may help to prevent LPR symptoms [23, 24]:

  • Make your last meal of the day no later than two hours before bedtime. 
  • Eat smaller meals and avoid overeating. 
  • Avoid lying down for as long as possible after eating. 
  • Be careful with fasting. 

Should You Drink Alkaline Water?

Pouring water from a pitcher to a glass

Alkaline water, which has been ionized in order to reduce its acidity, is mentioned in a few studies of dietary interventions for LPR. Alkaline water will not hurt you or make symptoms worse, but the research that shows it is effective for LPR is limited.

One systematic review did conclude that a plant-based Mediterranean diet combined with alkaline water improved symptoms of LPR [25].

However, the alkaline water and diet were done together, so it’s not clear how important the alkaline water was in resolving symptoms. 

If you’re interested in trying alkaline water, start off trying packaged alkaline water you can buy at your local health food store, rather than buying an ionizer for your home. 

Best Supplements for LPR

A few supplements may be helpful to use with your LPR diet. 

Probiotics can help improve your gut microbiome and have been shown to improve symptoms of GERD [26].

A few supplements may also help improve reflux symptoms: 

  • Melatonin with L-tryptophan, which, in some studies, has been shown to work as well as PPI’s [27, 28, 29]
  • Sodium alginate, which provides a protective barrier between the stomach and esophagus [14]
  • Prokinetic herbs, which improve esophageal and gastrointestinal motility [14, 30]

The Best LPR Diet Is Individualized

Silent reflux can be a difficult condition to manage, but I hope this article helps you discover that you have options for improving your symptoms of laryngopharyngeal reflux. 

To find your ideal LPR diet, remove common reflux triggers and use an elimination diet to identify and remove your personal trigger foods. Being aware of when you eat, eating small meals, and improving your gut microbiome with probiotics may also be helpful alongside your diet changes. 

You can learn more about improving your gut health in my book Healthy Gut, Healthy You. For more personalized guidance to resolve your LPR symptoms, you can request an appointment at our functional medicine center.

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