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There is one word that sums up the key to controlling GERD without

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There is one word that sums up the key to controlling GERD without

    Managing Acid Reflux Without Medication

    by Valerie Coates

     “It has been estimated that half of otolaryngology (ORL) patients with laryngeal and voice disorders have laryngopharyngeal reflux (LPR) as the primary cause 1or as a significant etiologic cofactor.” Furthermore, clinical studies have shown that

    70% of patients with conditions associated with vocal overuse or misuse, such as 2hematomas, nodules, ulcers, granulomas and Reineke‟s Edema, also have LPR. The

    data strongly suggests a correlation between the two. Even what appears to be vocal fold 3paralysis can actually be “laryngeal fixation” resulting from reflux. I suffered for years

    intermittently with a condition called paroxysmal laryngospasm as a result of chronic reflux. 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 Christopher J. Loughlin, M.D. and James A. Koufman, M.D, titled “Paroxysmal 4Laryngospasm Secondary to Laryngopharyngeal Reflux (LPR),”the puzzle pieces all fit

    together. Now that my reflux symptoms have resolved, so have the spasms.

    What is Acid Reflux?

    Two bands of muscle, the lower and upper esophageal sphincters, which are situated between the stomach and esophagus and the esophagus and throat respectively, normally remain closed during digestion, but due to weakness, one or both may open and allow stomach acid back up into the esophagus (GERD or Gastroesophageal Reflux Disease), or further up into the back of the throat (LPRD or Laryngopharyngeal Reflux Disease). The pressure put on these sphincters by singers contributes to the weakening process. Other factors, such as obesity, pregnancy, and age, can cause the sphincters to weaken as well.

    Common Symptoms of LPRD/GERD

    “Most of the reflux events that can damage the throat can happen without the 5patient ever knowing that they are occurring.” 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 lump in throat

    Managing Acid Reflux Without Medication. Valerie Coates copyright 2004. 1

    ; Problems while swallowing

    ; Bad/bitter taste in mouth (especially in the morning)

    ; Asthma-like symptoms or asthma exacerbation

    ; Referred ear pain

    ; Post-nasal drip

    ; Spasm of vocal folds (laryngospasm)

    ; Singers: longer warm-up periods required, trouble with high notes, a “veil”

    over the voice.

    ; Chest pains/heartburn

    Many of these symptoms can also be indications of other disorders, so always consult an otolaryngoligist when you experience any symptoms.

    Reflux Management Resources

    After I was finally diagnosed with acid reflux two years ago, I went through a year and a half of alternating prescription medications that 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 and 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.

     There is one word that 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) 6in the subsequent rehearsal period.” In order 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; however, each small action that you take, stress-reduction technique you add or nutritional supplement Managing Acid Reflux Without Medication. Valerie Coates copyright 2004. 2

    you include will contribute in some way to the end result. It is therefore important that you see the picture as a whole to which each element contributes a share.

    The first thing I recommend that you do is visit the website www.heartburn-

    help.com. Under “Websites” 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 should be avoided by reflux patients as well as low acid coffee beans. There is a bulletin board on this website as well, and the postings offer useful information about how others have overcome GERD symptoms.

    As a starting point for my program, I used the 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.

    ; Lose weight if you‟re overweight.

    ; Don‟t wear tight clothing or belts around the waist.

    ; Eat smaller meals.

    ; Reduce stress.

    ; Avoid exercising immediately after eating

    ; Avoid bending down after eating.

    ; Stop eating 3-4 hours before bedtime.

    ; Avoid pain relievers such as aspirin and ibuprophen.

    ; Avoid the following foods and beverages:

    o Tomatoes and any food containing tomato sauce

    o Citrus fruits and juices

    o Spicy foods

    o Fatty and fried foods

    o All types of mint

    o Chocolate

    o Anything containing caffeine, including tea

    o Carbonated beverages

    o Alcoholic beverages

    o Coffee, including decaffeinated

    o Vinegar (salad dressings and other foods containing vinegar, such as

    pickles)

    o Foods made with refined flour and sugar

    o Milk products: milk, cheese, butter, ice cream

    o Uncooked vegetables including salads

    o Onions

Managing Acid Reflux Without Medication. Valerie Coates copyright 2004. 3

    Okay, 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 strictly adhered 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, and 3) foods that might be problematic. The “might be” category included foods that I had eaten in combination with other untested items in the same meal that had not digested well. Eventually, as your digestive tract heals, you will most likely be able to reintroduce some foods into your diet, but you will probably 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. New

    Jersey: The Career Press, Inc., 2002.

    Digestion slows down as the day progresses. Stopping intake of food for the recommended 3-4 hours before bedtime simply wasn‟t sufficient for me, so I make my midday meal the final meal of the day and stop all food intake by 3:00 p.m. You may find that 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 one‟s voice. If I‟m really starving and it‟s only 5:00 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 has the added benefits of keeping one‟s weight down, saving on the food bill, and it saves 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 1-2 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, Managing Acid Reflux Without Medication. Valerie Coates copyright 2004. 4

    lunch or brunch, but I have met people for herbal tea or Perrier while they had dinner in order to maintain my eating schedule. Do not succumb to peer pressure, but if you absolutely must eat, order something small, such as an appetizer. There will also be times while you are experimenting with different foods, 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 form over-the-counter acid reducer and some antacid liquid as a precaution. Occasional antacids will not interfere with your program; however, frequent use of them can cause a rebound effect, in which the stomach produces more and more acid in order 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 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 your food about 30-40 times before swallowing. This allows enzymes in the 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 in order to reduce the stress of having to rush off to the next appointment. One of the most challenging times to eat a meal is during a one hour dinner break between rehearsals. Not only are we gulping down the meal, 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 cannot be done, eat a smaller amount than you normally would.

    50 Ways to Relieve Heartburn, Reflux and Ulcers by M. Sara Rosenthal, New York:

    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, which caused a relapse of the reflux symptoms and delayed the healing process. Later, while reading this book, 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.

    Following is a list of the supplements that 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. Many herbal supplements should not be taken by women who are pregnant or nursing. Some information can be found 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. Lominger, Jr., Steve Austin and Forrest Batz,

    (Three Rivers Press (CA), 1999). If you do not live near a health food store that sells Managing Acid Reflux Without Medication. Valerie Coates copyright 2004. 5

    vitamins or supplements, all of these products can be ordered 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 or gel Helps to heal the digestive tract lining. Drink between 1 and 2 cups a day.

DGL (Deglycyrrhizinated Licorice) tablets Licorice is an anti-inflammatory agent

    often used to treat ulcers. There are side effects associated with licorice, so do not use for extended periods of time and do not exceed the recommended amount. People with hypertension should generally not use licorice products; however, the deglycyrrhizinated variety is safer. The tablets have to be chewed (not swallowed whole) 20- 30 min. before eating in order to be effective.

    Flax Seed Oil a 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 used by Native Americans for healing 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, which soothes the esophagus on the way down to the stomach. Slippery Elm lozenges are also beneficial and convenient.

    Supplements that facilitate digestion

    Acidophilus - A probiotic 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

    the 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 does not Managing Acid Reflux Without Medication. Valerie Coates copyright 2004. 6

    contain animal pancreatic enzymes (pancreatin). Whole foods rich in enzymes are avocado, pineapple, papaya and banana.

Fennel Seed and whole fennel Aids digestion, reduces gas, 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 A long revered digestive aid used in ancient Chinese, Indian and Arabic medicine. Either use fresh ginger in cooking 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. This product is packaged by Enzymatic Therapy 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; however, mint and caffeine relax the esophageal sphincters. I do 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 hayfever

Catnip Laura‟s favorite! Traditionally used for indigestion, Catnip is also an herb

    recommended for stress-reduction.

Managing Acid Reflux Without Medication. Valerie Coates copyright 2004. 7

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.

Licroice 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 that you should be avoiding, like licorice.

    Yerba maté Many reflux sufferers swear by 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 another whole article, but there 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 2 cups of Epsom salts, 1 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 of time.

     The holistic approach is not for everyone, but if you stick with the program, your efforts will more than likely pay off in the long run.

     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. ndKorovin, 2. 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 website, www.bgsm.edu. 4 Wake Forest University Baptist Medical Center website, www.bgsm.edu. 5 The Patient Education page on Texas Voice Center website: www.texasvoicecenter.com. Managing Acid Reflux Without Medication. Valerie Coates copyright 2004. 8

6Brenda Smith, DMA and Robert T. Sataloff, MD, DMA, “Choral Pedagogy and Vocal Health” in NATS

Journal of Singing, v. 59 no. 3 Jan/Feb 2003, p. 238.

Managing Acid Reflux Without Medication. Valerie Coates copyright 2004. 9

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