Mediterranean diet with alkaline water might ease laryngopharyngeal reflux

Last Updated: 2017-09-13

By Will Boggs MD

NEW YORK (Reuters Health) - Combining a Mediterranean diet with alkaline water appears to be as effective as protein pump inhibitor (PPI) therapy for treating laryngopharyngeal reflux (LPR), according to a retrospective study.

"I think these findings strongly suggest that if LPR is suspected as the cause of a patient's symptoms, then a plant-based diet, alkaline water, and standard reflux precautions should at least be strongly encouraged prior to taking a PPI (or any drug for reflux)," Dr. Craig H. Zalvan from New York Medical College, in Valhalla, told Reuters Health by email.

"Given the significant evidence that exists demonstrating an overall health benefit from a mostly plant-based diet," he said, "there is nothing to lose and only improved health to gain, not to mention the cost savings of billions of dollars, as well as avoidance of potential complications (heart disease, stroke dementia, kidney damage, and death were all suggested in other scientific articles this past year)."

LPR is thought to result from exposure of the laryngopharynx to an acidic environment in the presence of pepsin. Exposing pepsin to alkaline water inactivates it, suggesting that alkaline water might be useful as adjunctive therapy for LPR.

Dr. Zalvan and colleagues compared two matched cohorts of patients with LPR: 85 patients treated from 2010 to 2012 with a PPI and standard reflux diet and precautions; and 99 patients treated from 2013 to 2015 with alkaline water (pH >8.0), a plant-based Mediterranean-style diet, and the same reflux precautions.

Patients were excluded if they had a concomitant diagnosis of a benign disorder causing dysphonia, a concurrent presumed neuropathic cough or prior treatment with a neuropathic pain medication, a history of laryngeal malignant abnormality and/or radiation therapy; a concurrent diagnosis of allergic rhinitis, sinusitis, or recent upper respiratory illness; current smoking; an unrelated diagnosis causing dysphagia, or a nasopharyngeal or oropharyngeal mass.

With response defined as a 6-point reduction in Reflux Symptom Index (RSI), statistically similar percentages of PPI patients (54.1%) and diet/alkaline water patients (62.6%) achieved a response at 6 weeks.

Mean RSI improvement was statistically similar in the PPI group (5.92) versus the diet/alkaline water group (7.05), according to the September 7 JAMA Otolaryngology-Head and Neck Surgery online report.

"We found and continue to find that patients who follow the plant-based diet actually do better than with PPI treatment and for longer periods," Dr. Zalvan said. "I think this is simply because a plant-based diet is a healthier diet and promotes weight loss. My patients who follow the diet lose 6 to 8 lbs (2.7 to 3.6 kg) on average (by) the first follow-up."

"I suspect the less animal protein in the diet results in less acid secretion in the stomach and less pepsin secretion, the digestive enzyme that breaks down protein," he said. "Thus, less pepsin and less acid mean less LPR."

Dr. Robert T. Kavitt from the University of Chicago, who wrote an invited commentary related to this report, told Reuters Health by email, "A dietary approach is a reasonable option to offer patients, particularly in this era when patients frequently raise concerns regarding the chronic use of PPIs due to the potential adverse effect profile."

"The intriguing findings in this well-designed retrospective study have the potential to alter the treatment paradigm of patients with LPR with a dietary approach, particularly if the findings are reproduced in future prospective trials," he said.

Dr. Yusuf Serdar Sakin from Gulhane Training and Research Hospital, Ankara, Turkey, who recently investigated methods for diagnosing LPR, told Reuters Health by email, "This article is retrospective, and the collection of the patients in the groups are taken from different times. So, the differences of the results may be due to differences in environmental or other changes."

He added, "There is no documentation how the diagnosis of LPR was made . . . And, it is important that we are still trying to find the exact diagnostic method to (distinguish) LPR from other causes of these symptoms."

Dr. Thomas L. Carroll from Brigham and Women's Hospital and Harvard Medical School, in Boston, has extensively researched LPR and its treatment. He told Reuters Health by email, "If you use the RSI to diagnose reflux, you aren't diagnosing reflux. Thus, the validity of this study is completely absent. Papers have shown that RSI is elevated in people with conditions other than LPR."

"We should, as a society lean toward more diet and lifestyle changes to combat LPR," he said. "Some patients may still require PPIs, but fewer than we previously thought. The cost of PPIs up front is probably 40% higher than up front pH impedance testing."

"Diet change, alkaline water, and precautions won't hurt anyone," Dr. Carroll concluded, "but if you are treating LPR, it might be best to actually diagnose it before recommending treatments."

SOURCES: http://bit.ly/2jiwXLb and http://bit.ly/2eTbLpS

JAMA Otolaryngol Head Neck Surg 2017.