Acid reflux. It’s more than an opera-sized case of heartburn; it is a serious medical condition that can damage a singer’s vocal health. A recent article in a medical journal, for example, says that laryngopharyngeal reflux (LPR) is either the primary or a significant cause in as many as half of all cases of laryngeal and voice disorders.1 Furthermore, clinical studies show that 70 percent of patients with conditions associated with vocal overuse or misuse—such as hematomas, nodules, ulcers, granulomas and Reineke’s Edema—also have LPR.2 Even what appears to be vocal fold paralysis can actually be “laryngeal fixation” resulting from reflux.3
Because of chronic reflux, I suffered intermittently for years with a condition called paroxysmal laryngospasm. I would wake up during the night, gasping for breath, because my air passage was closing up. Eventually it became chronic, as my reflux condition worsened.
At the time, I thought my problem was sleep apnea, but after reading the results of a study conducted by Drs. Christopher J. Loughlin and James A. Koufman, “Paroxysmal Laryngospasm Secondary to Laryngopharyngeal Reflux (LPR),”4 the puzzle pieces all fit together. Now that my reflux symptoms have been eliminated, so have the spasms.
What is Acid Reflux?
Two bands of muscle, the lower and upper esophageal sphincters—located between the stomach and esophagus, and the esophagus and throat, respectively— normally remain closed during digestion, but weakness may cause one or both to open and allow stomach acid back up into the esophagus (GERD or Gastroesophageal Reflux Disease), or farther up into the back of the throat (LPRD or Laryngopharyngeal Reflux Disease). The pressure singers put on these sphincters contributes to the weakening process. Other factors—such as obesity, pregnancy, and age—also can cause the sphincters to weaken.
Common Symptoms of LPRD/GERD
Acid reflux can be a stealthy disease. “Most of the reflux events that can damage the throat can happen without the patient ever knowing that they are occurring,” says the Texas Voice Center .5 Most singers who have acid reflux disease don’t have a clue that they have it.
A colleague just mentioned to me recently that for a long time she thought her constant need to clear her throat of mucous was due to allergies. Eventually, she found out that the cause was reflux. Here is the basic list of symptoms:
• Hoarseness
• Chronic cough
• Frequent throat clearing
• Pain or sensation in throat
• Feeling of a lump in the throat
• Problems while swallowing
• A bad or bitter taste in the mouth (especially in the morning)
• Asthma-like symptoms or asthma exacerbation
• Referred ear pain
• Post-nasal drip
• Spasm of the vocal folds (laryngospasm)
• Singers: Longer warm-up periods required; trouble with high notes; a “veil” over the voice
• Chest pains or heartburn
Many of these symptoms also can be indications of other disorders, so always consult an otolaryngologist when you experience any symptoms.
Reflux Management Resources
After doctors finally diagnosed my condition as acid reflux two years ago, I went through a year and a half of alternating prescription medications—which dried out my throat and caused abdominal cramping—with over-the-counter remedies that were only mildly effective, and periods of dietary modifications without medication. But I kept having relapses that delayed healing of the esophageal damage. Coincidentally, one of my cats, Laura, also has digestive problems, so I had already done some research on natural remedies for cats. I’d heard of gastrointestinally challenged felines who showed marked improvement within six months, when given digestive enzyme supplements along with other natural remedies and dietary changes. I figured, if it works for cats, why not humans?
I got on the Internet and compiled a list of all herbs and supplements that are known to aid digestion, then put together a regimen for myself. In addition, I refined my anti-reflux diet and eating schedule, raised the head of my bed six inches off of the floor, and continued to practice my regular stress-reduction techniques, which include exercise and meditation. Today, my esophagus is healed and I am able to eat many of the foods that gave me serious problems six months ago. Laura is doing well, too.
For those of you who are unwilling or unable to take medication, there are alternatives. I do not profess to have any special knowledge or training in nutrition or health care. Everything I am about to share with you is the result of my own reading and research, and is based on my personal experience and that of my colleagues, students and acquaintances who suffer with reflux.
One word sums up the key to controlling GERD/LPRD without medication: discipline. Not only is it necessary to eat certain foods on a specific schedule; it is also necessary to abstain from a variety of foods and decline after-concert dinner invitations, or pass up that cookie during evening rehearsal break.
“If the refreshments consumed during the break contain chocolate, refined sugars, caffeine, or citrus, the voices of many of the singers will be at risk for gastroesophageal reflux disease (GERD) in the subsequent rehearsal period,” says an article by Brenda Smith and Dr. Robert T. Sataloff in the NATS Journal of Singing.6 For any holistic regimen to be effective, you must have patience and perseverance. Changes are gradual and subtle, and it will probably be three to six months before you see a noticeable improvement.
No single alteration that you make is going to cause a dramatic difference—but each small action that you take, each stress-reduction technique you add, each nutritional supplement you include will contribute in some way to the end result. So it is important that you see the picture as a whole.
The first thing I recommend you do is visit the Web site www.heartburn-help.com. Under “Web sites” on the main menu, you will find links to an abundance of medical articles, information on voice disorders caused by GERD/LPRD, and just about anything you want to know about acid reflux and its implications. If you want to do further reading and exploration about the topics mentioned in this article, click on “Diet,” “Drugs” and “Herbs.” The authors of the site even sell a line of natural products designed to reduce the acid in the foods that reflux patients should avoid, as well as low acid coffee beans. The Web site also includes a bulletin board, and the e-mail postings offer useful information about how others have overcome GERD symptoms.
As a starting point for my program, I used these universally recommended lifestyle changes:
• Raise the head of your bed 4-6 inches off of the floor. Do not prop your body up with pillows, as this causes a bend in the waist and can further exacerbate reflux.
• If you smoke, stop.
• If you’re overweight, lose weight.
• Don’t wear tight clothing, or belts around your waist.
• Eat smaller meals.
• Reduce stress.
• Avoid exercising immediately after eating.
• Avoid bending down after eating.
• Stop eating three to four hours before bedtime.
• Avoid pain relievers such as aspirin and ibuprofen.
• Avoid the following foods and beverages:
• Tomatoes and any food containing tomato sauce
• Citrus fruits and juices
• Spicy foods
• Fatty and fried foods
• All types of mint
• Chocolate
• Anything containing caffeine, including tea
• Carbonated beverages
• Alcoholic beverages
• Coffee, including decaffeinated
• Vinegar (salad dressings and other foods containing vinegar, such as pickles)
• Foods made with refined flour and sugar
• Milk products: milk, cheese, butter, ice cream
• Uncooked vegetables including salads
• Onions
OK, you’re reading the “Foods to Avoid” list and thinking, “What can I eat?” Don’t despair. Everybody’s metabolism is different, so you may be able to eat some of the things on the list, and not be able to eat some things that aren’t on the list. If you are able to eliminate all of the foods on the list without feeling deprived, I recommend that you do it, at least in the initial stages of healing, but you don’t want to feel so deprived that you just give up and resort to the medication again.
Coffee and chocolate are two things that I could not bear the thought of giving up permanently, so once the severity of my symptoms had decreased a bit, I experimented to see if I could get away with drinking one cup of coffee in the morning and eating one chocolate item after lunch (a brownie, or a piece of cake or candy) and still make progress toward esophageal/gastrointestinal healing.
In the early stages, I eliminated chocolate altogether and just had a half a cup of coffee in the morning. Later on, I discovered that it was fine to allow myself these exceptions, as long as I adhered strictly to the time schedule and limited the portion. Since I wasn’t sure exactly what I could and could not digest easily, besides the obvious fried foods and tomato sauce, for two months I kept a list of foods in three categories:
1) foods that definitely gave me problems,
2) foods that digested easily,
3) foods that might be problematic. The “might be” category included foods that had not digested well which I had eaten in combination with other untested items in the same meal.
Eventually, as your digestive tract heals, you will probably be able to reintroduce some foods into your diet, but it is likely you will never be able to go back to your former indiscriminate eating habits. You might consider trying the low-acid varieties of tomatoes, orange juice and coffee. For further reading and help tailoring your diet to your own needs, read Tell Me What to Eat if I Have Acid Reflux, by Elaine Magee (The Career Press, Inc., 2002).
Digestion slows down as the day progresses. Experts recommend that reflux sufferers stop eating three to four hours before bedtime, but that wasn’t sufficient for me, so I make my midday meal the final meal of the day and stop all food intake by 3 p.m. You may find you can stop eating a little later than that and have no occurrences of reflux during the night.
Eating small amounts of food throughout the day is another option. If you are away from home all day, it is best to bring your own food from home. Most restaurant food should be avoided, since it is usually prepared with way too much oil and fat to be digested easily.
Sometimes I feel hungry when I go to bed, but a little hunger is a small price to pay, if it means saving my voice. If I’m really starving and it’s only 5 p.m., the rule I follow is to eat a small portion of “anything that is a liquid or can melt to a liquid,” like a 6-oz. cup of soy yogurt or miso soup. The goal is to have an empty or nearly empty stomach by the time you lie down to sleep.
Eating two meals a day also brings the added benefits of keeping your weight down, saving on the food bill, and saving the time and hassle of preparing and cleaning up after yet another meal. If I have to take a nap after lunch, I sleep sitting up. You should not drink any liquids other than water after your final meal of the day, and even stop the water intake one to two hours before going to bed.
Unless you are a hermit with no social life, you will inevitably end up in a situation where you have to eat a late meal. Hunger is no excuse to weaken your resolve and eat a late meal or snack, but when eating is absolutely unavoidable, you’ll need a contingency plan.
Most of the people I see socially know I’m only available for breakfast, lunch or brunch, but I have maintained my eating schedule by meeting people for herbal tea or Perrier while they had dinner. Do not succumb to peer pressure, but if you absolutely must eat, order something small, such as an appetizer.
While you are experimenting with different foods, there will be times when something just doesn’t digest very well and you end up with indigestion that lingers until bedtime. On the rare occasion that I have too much food remaining in my stomach at bedtime, I take a tablet of over-the-counter acid reducer and some antacid liquid, as a precaution. Occasional antacids will not interfere with your program; frequent use, however, can cause a rebound effect, in which the stomach produces more and more acid to compensate for acid neutralization.
As singers, we have all been advised to drink plenty of water. As GERD/LPRD sufferers, we have to drink our quota of water away from meals. Stop drinking liquids about 30 to 45 minutes before eating and do not resume drinking for one hour after eating. You may take a few sips of liquid during meals, but do not gulp large quantities. Large amounts of water taken with a meal interfere with digestion and can exacerbate reflux.
Chew each bite about 30-40 times before swallowing. This allows enzymes in your saliva to partially digest the food so that the stomach doesn’t have to work so hard. Try to give yourself ample time for meals, to reduce the stress of having to rush off to the next appointment.
Those one-hour dinner breaks between rehearsals are some of the most challenging times to eat a meal. Not only are we gulping down the food, but we are also singing immediately after eating, which forces the food back up into the esophagus. If possible, plan meals so that you won’t have to sing for at least an hour after eating. If this isn’t practical, eat a smaller amount than you normally would.
50 Ways to Relieve Heartburn, Reflux and Ulcers, by M. Sara Rosenthal: (McGraw-Hill, 2001) contains a lot of information about different types of reflux, reflux medications, and other medications that aggravate the symptoms of reflux. I was prescribed amoxicillin for a throat infection several months after being diagnosed with GERD/LPRD. The antibiotic prompted a return of my reflux symptoms and delayed the healing process. Later, while reading “50 Ways,” I discovered that amoxicillin is indeed an irritant to the digestive tract. If you know which antibiotics and other medications irritate the stomach, you can ask your doctor for a different prescription.
The following is a list of the supplements I have found to be most effective. A word of caution: Do not take any supplement without being informed about side effects and drug interactions. Just because something is “natural” doesn’t mean it can’t be harmful if not used properly. Women who are pregnant or nursing, for example, should not take many herbal supplements. You can find some information on these topics at www.intelihealth.com. Just click on “Index of Herbal Medicines and Supplements.”
Two thorough reference books are Prescription for Nutritional Healing: A Practical A-Z Reference to Drug-Free Remedies Using Vitamins, Minerals, Herbs and Food Supplements, by Phyllis Balch and James Balch, (3rd ed., Avery Publishing Group, 2000), and The A-Z Guide to Drug-Herb and Vitamin Interactions,
by Schuyler W. Lininger, Jr., Steve Austin and Forrest Batz, (Three Rivers Press (CA), 1999). If you don’t live near a health food store that sells vitamins or supplements, you can order all of these products online at
www.vitaminshoppe.com.
Generally, I just follow the dosages recommended on the bottle.
Supplements that soothe irritation and promote healing of the digestive tract
• Aloe Vera juice: Helps heal the digestive tract lining. Drink one to two cups a day.
• DGL (De-glycyrrhizinated Licorice) tablets: Licorice is an anti-inflammatory agent often used
to treat ulcers, but there are side effects associated with licorice, so don’t use it for extended periods and do not
exceed the recommended amount. In general, people with hypertension shouldn’t use licorice products; however, the deglycyrrhizinated variety is safer. To be effective, the tablets have to be chewed (not swallowed whole) 20-30 minutes before eating.
• Flax Seed Oil: This source of Omega 3 and 6 oils facilitates healing of the digestive tract. Fresh ground flax seed is ideal, if you can grind it yourself. Ground flax sitting on the store shelves loses its potency. I take the cold pressed liquid form.
• Fenugreek: A mucilaginous herb used to soothe inflammation of the digestive tract.
• Marshmallow root: Its mucilaginous consistency produces a soothing effect on the digestive tract. Take powdered form with meals.
• Slippery Elm: Another mucilaginous substance Native Americans used to heal wounds, burns and inflammation, and used in Ayurvedic and Chinese medicine for intestinal problems. Also recommended for Irritable Bowel Syndrome. You can take as much of this as you want without any harmful effects or interactions, but it can reduce the absorption and effectiveness of medications you may be taking. I recommend taking the powdered form with meals and drinking the tea between meals. The tea soothes the esophagus on the way down to the stomach. Slippery Elm lozenges are also beneficial and convenient.
Supplements that facilitate digestion
• Acidophilus: A pobiotic that promotes a healthy balance of intestinal flora.
• Bromelain A digestive enzyme derived from pineapple. Take as directed on the bottle with meals.
• Digestive enzyme combination formulas: Enzymes are essential for breaking down food for proper digestion and absorption and are, therefore, among the most important supplements. If you are a vegetarian, be sure to get a vegetarian formula that doesn’t contain animal pancreatic enzymes (pancreatin). Whole foods rich in enzymes include avocado, pineapple, papaya and banana.
• Fennel Seed and whole fennel: Fennel aids digestion, reduces gas and promotes healthy bowel activity. “Its leaves are served nowadays with salmon, to correct its oily indigestibility” (www.botanical.com/botanical/mbmh/f/fennel). Fennel has a mild licorice flavor.
• Ginger root: Ginger root is a long-revered digestive aid used in ancient Chinese, Indian and Arabic medicine. Use fresh ginger in cooking, or take capsules with meals. Some people claim to find tremendous relief from digestive problems by drinking fresh ginger juice, while for others, the opposite is true. I have personally used the capsules during episodes of indigestion with great success.
• Papaya Enzyme: Papaya enzyme is usually available in a chewable tablet form. It is often included in the combination formulas, but I find it helpful to take a few additional tablets after meals. Eating fresh papaya and drinking papaya juice is helpful too, and you can chew the seeds for additional benefit, but be forewarned, the seeds are bitter.
Additional Supplements
• Calcium: The active ingredient in antacids is calcium carbonate. By taking a calcium supplement, you get the acid-neutralizing benefit of an antacid without all of the other additives. Take with meals.
• d-Limonene (orange peel extract): This is an odd one, and from what I’ve seen of the research, even the doctors who conducted the studies aren’t sure exactly why it works (see www.ATDonline.org, “Heartburn & GERD – Orange Peel Extract” by Dr. Decker Weiss). It works for me. Enzymatic Therapy packages this product under the name Heartburn Free for about three times the price. Solaray manufactures the generic form, available online from the Vitamin Shoppe.
Teas to aid digestion
Mint is often the herbal tea recommended for indigestion; mint and caffeine, however, relax the esophageal sphincters. I list two teas containing caffeine that you may want to avoid. I only suggest them as possible alternatives for those of you who are addicted to caffeine and would suffer severe withdrawal symptoms from giving up coffee. Coffee should be avoided because of its high acidity as well as its caffeine content.
• Chamomile: Should be avoided by people with allergies or hay fever.
• Catnip: Laura’s favorite! Traditionally used for indigestion, catnip is also an herb recommended for stress-reduction.
• Fennel: As described above.
• Fenugreek: Very bitter taste. Drink teas you enjoy rather than dread.
• Ginger: As described above.
• Green tea: Ancient digestive aid usually taken after meals; contains caffeine.
•Licorice: Do not use if you have hypertension.
• Slippery Elm: Slippery Elm is the main ingredient of most herbal “throat comfort” teas; however, you should read the box to be sure the tea does not contain other ingredients you should be avoiding, like licorice.
• Yerba maté: Many reflux sufferers swear by it. It contains caffeine, so if you are looking for a coffee alternative, this might be a good choice.
Stress-Reduction Techniques
Stress-reduction is really the topic of a whole other article, but here are some basic stress reduction tips I can offer:
• Get regular exercise (a combination of aerobic and stretching is best).
• Take hot baths to loosen muscle tension (add two cups of Epsom salts, one cup of baking soda and a few drops of oil). Use a heating pad for sore back muscles.
• Get enough sleep.
• Meditate (even a few minutes a day of sitting quietly with your eyes closed and focusing on your breath is beneficial).
• If you are a workaholic or often find yourself overextended, learn to say “no.”
• Spend some time in nature, even if it’s a city park.
• Try some of the stress formula teas and herbal remedies on the market, but be sure to read the list of ingredients so you know exactly what you’re taking. As always, be informed about the side effects and contraindications of all herbal supplements before you take them. Do not use any of them for an extended period.
The holistic approach is not for everyone, but if you stick with the program, your efforts are likely to pay off in the long run.
*For more information on acid reflux, see Classical Singer’s archives at www.classicalsinger.com.
(Endnotes)
1 James A. Koufman, M.D. and Milan Amin, M.D., ‘Laryngopharyngeal Reflux and Voice Disorders,’ in Diagnosis and Treatment of Voice Disorders, edited by John S. Rubin, Robert T. Sataloff and Gwen S. Korovin, 2nd Ed. Albany, NY: Delmar Learning, 2003, p. 301.
2 Ibid., p. 384.
3 James A. Koufman, M.D. and Michael Cummins, M.D., “The Prevalence and Spectrum of Reflux in Laryngology: A Prospective Study of 132 Consecutive Patients With Laryngeal and Voice Disorders,” Wake Forest University Baptist Medical Center Web site, www.bgsm.edu.
4 Wake Forest University Baptist Medical Center Web site, www.bgsm.edu.
5 The Patient Education page on the Texas Voice Center Web site: www.texasvoicecenter.com.
6 Brenda Smith, DMA and Robert T. Sataloff, M.D., DMA, “Choral Pedagogy and Vocal Health” in NATS Journal of Singing, v. 59 no. 3 Jan/Feb 2003, p. 238.
