Silent Reflux: A Hidden Epidemic

Jamie Koufman, MD, F.A.C.S. Founder & Director, Koufman Reflux Director, Voice Institute of New York

What you don't know can kill you. Silent reflux is acid reflux that does not produce heartburn or indigestion. You don't know you have it, and yet it can still cause cancer.

Often overlooked and misdiagnosed, silent reflux affects over 50 million Americans. The backflow of stomach acid and digestive enzymes (pepsin) can wreak havoc on your esophagus (the food passage that goes from your throat to your stomach), as well as your ears, nose, throat, vocal cords, sinuses, mouth, and lungs. Pepsin, in the presence of acid, digests protein and damages tissue. Outside the protected stomach, pepsin, bathed in acid, digests you! And when pepsin attacks your sensitive airway and esophageal tissues, you can suffer all kinds of problems.

The most common silent reflux symptoms are hoarseness, chronic cough, throat-clearing, post-nasal drip, sinusitis, sore or burning throat, difficulty swallowing, shortness of breath, snoring, sleep apnea, bad breath, tooth decay, asthma, and COPD. Unfortunately, your doctor is probably unaware that these symptoms may be caused by silent reflux and that it could be controlled with the proper diagnosis and treatment.

Did you know that asthma is one of the most common misdiagnoses, because silent reflux mimics asthma? Here's a big tipoff: When you have trouble breathing, do you have more difficulty getting air IN or OUT? People with reflux have trouble getting air IN during inspiration (not out during expiration). People with asthma have difficulty getting air OUT of the lungs. In truth, many people with “asthma" may not actually have it, and, consequently, asthma medication doesn't really help much if at all. The fact is that once the correct diagnosis is made, effective anti-reflux treatment can permanently cure this asthma-like breathing problem.

How Do I Know If I Have Silent Reflux?

One of the characteristics of silent reflux is that most people who have it have several different symptoms all at the same time, but often heartburn isn't one of them.

To find out if you may have silent reflux, take this simple quiz. Just circle the number for each symptom and add up the numbers.

The quiz is actually known as the Reflux Symptom Index (RSI), and it is a great first test to see if you have reflux. If your RSI is 15 or more (and you have a zero or one for heartburn), you may have silent reflux; you should see a specialist trained in detecting reflux by examination of both the throat and esophagus. Doctors who only scope the esophagus are missing the boat.

Why Is Reflux Sometimes Silent?

What makes silent reflux different than heartburn is that the silent reflux sufferer may be unaware of having it, and his or her doctor may not suspect the diagnosis. A lot of reflux is needed to damage the esophagus, but very little reflux can severely damage the more sensitive throat, sinuses and lungs. Many people with silent reflux have never even once experienced classic heartburn.

How the term “silent reflux" came to be is instructive. In 1987, Walter Bo, a medical school colleague, was my patient. As a result of nighttime reflux, he had terrible morning hoarseness. This was because he had a habit of eating dinner very late and then falling asleep on the sofa. Hence, he would reflux into his throat all night.

I tried explaining the problem, but Walter repeatedly denied having reflux. As it turned out, Walter affirmed that he thought that heartburn and reflux were the same. When I was able to explain that one could have reflux without heartburn – as in this example, when it occurred during sleep – Walter rolled his eyes and said, “I see. I have the silent kind of reflux." I declared, “Yes, Walter, that's it! You have silent reflux!"

Why Doesn't My Doctor Know About This?

Unfortunately, people with silent reflux symptoms, even if they ask their doctor, are usually incorrectly told they do not have reflux. The medical specialties are broken down by parts of the body, and doctors are experts in, and only test for, those parts of the body in which they specialize. The problem is that reflux does not care where your doctor trained and how it might affect the different medical specialties – the esophagus treated by gastroenterologists, the throat and sinuses treated by ear, nose and throat specialists (otolaryngologists), and the trachea and lungs treated by lung specialists (pulmonologists).

The Solution: Integrated Aerodigestive Medicine

Only a trained reflux specialist who knows what to look for in all affected areas and who has the right diagnostic tests is equipped to make an accurate diagnosis. Otherwise, a doctor may guess wrong and treat you for an illness that you don't have. Some of the symptoms of silent reflux can sometimes be caused by other diseases, which doctors try to treat unsuccessfully, leaving you miserable, frustrated, and having wasted money on useless tests and drugs.

Instead of focusing on the patient's diet and lifestyle – the root cause of almost all reflux disease – doctors often employ pills, usually the wrong pills, that rarely correct the problem. In truth, reflux medications are grossly misused and over-used today.

A new medical field is emerging, one devoted to the comprehensive diagnosis and treatment of reflux symptoms and all reflux-related breathing and digestive tract diseases. The name for this new field is Integrated Aerodigestive Medicine (IAM). This approach represents the leading edge of change in American healthcare. For the first time in the nation, Integrated Aerodigestive Medicineis available in New York City at The Koufman Reflux Center of New York. This groundbreaking approach is based upon my 30 years of scientific research and clinical experience.

You don't have to be on medication for life; you can change your life, and you can be cured.

Silent Reflux Is an Epidemic

I am often asked if reflux is more common today or if we are just more aware of it? The answer is both. But make no mistake about it, reflux is now an epidemic. Esophageal and silent (airway) reflux have skyrocketed since the 1970s. The actual prevalence of reflux in America has increased from 10% in 1976 to a staggering 40% today.

What You Eat Could Be Eating You

The reflux epidemic appears to be related to too much acid in the food supply! How did this happen? Following an outbreak of food poisoning in 1973, the Food and Drug Administration (FDA) set Good Manufacturing Guidelines for all food and beverages in bottles and cans. And what did they mandate? Acid, acid, acid. By law, everything in a bottle or a can must be acidic. This kills bacteria and prolongs the shelf life of products, but it also causes reflux disease.

Pepsin, the main digestive enzyme that digests protein, needs acid to work. Every time you reflux, pepsin is washed onto your sensitive tissues. Once a pepsin molecule is bound to, say, your throat or esophagus, any dietary source of acid can reactivate it: soda, salsa, strawberries. That's why I say what you eat may be eating you.

Reflux medication is not the answer for most people. People who have reflux should see their doctors, because medication can just cover up the underlying problem. Just the same, if you have reflux, there is a lot that you can do by changing what you eat and when you eat it.

Reflux Can Be Cured Through Healthy Eating

Healthy eating. What's that when it comes to reflux? First, no late-night eating. If you go to bed with a full stomach, you are likely to reflux all night. Besides, reflux is the most common cause of disturbed sleep and it is even associated with snoring and sleep apnea. Second, restrict all highly acidic foods and beverages. If you have reflux, the only thing you should drink out of a bottle is water, and alkaline water is best. Alkaline water kills off pepsin; look for alkaline waters with a pH above 8.0. After over-eating, soft drinks (all of them) are the next greatest cause of reflux. Finally, your diet should be low-fat as well as low-acid. It works! Do a strict, two-week induction ("detox") low-acid diet, and then follow it up with a moderate low-acid, low-fat, pH-balanced diet for 3-6 months.

Table 1 shows the recommended reflux diet in a nutshell, and Table 2 shows the best-for-reflux food list.

Table 1: Basic Elements of Dr. Koufman's Reflux Diet

  • Nothing out of a bottle or a can except water (alkaline is best)
  • Alcohol in moderation (one drink), and no late-night eating
  • Eat lots of fish, poultry, vegetables, breads, and grains
  • Use and order all dressings, cheeses, and sauces on the side
  • Minimize fatty meats; some beef and pork, and portion control!
  • Avoid excessive consumption of acidic foods like citrus fruit
  • Avoid reflux-causing foods like mints, chocolate, and fried food

Table 2: Dr. Koufman's Short Best-For-Reflux Food List

  • Grilled/baked/broiled/boiled fish, shellfish, and poultry
  • All veggies (except onions, tomatoes, garlic, and peppers)
  • Breads, rice, grains (low-sugar cereals), oatmeal, and tofu
  • Alkaline water, low-fat cow, soy, almond, and coconut milk
  • Melons, bananas, ginger, chamomile tea, Manuka honey

Finally, if you are going to be on a low-acid diet, you must know if there is acid added to something. You have to read the ingredients on labels. What should you look for? Phosphoric acid, ascorbic acid, citric acid, and “vitamin C added or enhanced" all mean that what's in the bottle may be as acidic as stomach acid. And if you have significant reflux symptoms, avoid it! Learn more about silent reflux prevention.

Try these recipes from Dr. Koufman's cookbook, Dropping Acid, The Reflux Diet Cookbook & Cure: