July 18, 2023

Acid Reflux? It’s the American Way



  • Silent Nocturnal Respiratory Reflux (SNoRR) is the ice burg not seen below the water line, the dangerous part; that’s SNoRR, and it may affect as many as 100 million Americans.
  • In American culture today, the evening meal is often the major refueling meal of the day; it’s how we entertain; and if you add overeating, fatty foods, and alcohol, and the stage is set for silent nighttime reflux.
  • SNoRR sufferers are unaware that they have reflux because it occurs at night while they sleep ― and the “silence” extends to their unaware physicians who also fail to recognize that reflux is the underlying cause of many of their patients’ respiratory problems.
  • SNoRR can cause or worsen any and all respiratory diseases, including asthma, shortness of breath, chronic bronchitis and cough, ear pressure, tinnitus, laryngitis, post-nasal drip, sinusitis, snoring and sleep apnea, just to mention a few.
  • The Cure? Reflux in all of its forms, not just SNoRR, is actually not a medical problem because no medication or procedure can stop reflux; reflux can only be cured through changes in diet and lifestyle, especially including earlier eating of evening meals.

This article is in part an excerpt from Dr. Koufman’s up-coming book, “Respiratory Reflux: How Silent Reflux Causes Disease,” due to be released in late 2023 or early 2024.

Note: Respiratory Reflux (RR) and Laryngopharyngeal Reflux (LPR) are synonyms and the terms can be used interchangeably. Going forward, I prefer the term RR and so should you; it is easier to pronounce, more intuitive, and implies that RR can affect any and all parts of the respiratory system which it does.

Respiratory Reflux (RR) is often silent, but what does that mean. Well first, no heartburn or indigestion, that is, no symptoms of GERD; second, without heartburn, a person with RR symptom(s), e.g., post-nasal drip, sinus pressure, sore throat, may not make the connection between their symptoms and silent reflux; and finally, a person with SNoRR and  undisturbed sleep may have RR symptoms, but only during the day. I consider this post to be a companion blog to, LPR and GERD Are Different! Because Silent Nocturnal Respiratory Reflux, SNoRR is the most common pattern of reflux in America today.

Case Example: A thin, healthy, 78-year-old retired woman, who was a former patient of mine, recently consulted me because she again had severe reflux. The back story is that several years prior, she had done well with medical treatment, diet, and lifestyle changes, but on TNE examination she had no functional lower esophageal sphincter; it was gaping. So, she had a laparoscopic fundoplication by one of the very best surgeons. This is the best of the procedures for reflux we have, but it doesn’t work if diet and/or lifestyle is reflux-bad.

Since she was refluxing again, the first question I asked was, “What time do you eat dinner,” and she replied “8 o’clock.” I then asked, “And what time do you go to bed?” and she responded “10 o’clock.” And even though she was unaware of it, she refluxed all night every night. The fundoplication (surgical) wrap was still there, but with so much reflux, it had become stiff and swollen due to inflammation. It was no longer working as an effective barrier. 

I put her back on a reflux detox treatment program, including finishing dinner by 5:00 p.m. and sleeping on a 45-degree angle for a month … to let things heal; and within a month, she recovered.

Comment: This case make two important points: (1) there is no “silver-bullet” treatment for reflux that “fixes” it; and (2) SNoRR, silent nocturnal respiratory reflux, is unavoidable when a person eats too late. And by the way, alcohol has  a  multiplier effect; indeed, alcohol is the single most powerful reflux trigger that we consume.

We have known about The Dangers of Eating Late at Night for many years, but the SNoRR trend has escalated so that it is the number one reflux pattern that we find today. The data prove SNoRR.I have been doing reflux testing since the 1980s, and always with the best technology. I have always had an accurate pH (acidity) sensor in the throat.

Prior to writing this blog, I examined the pH-data (ambulatory 24-hour double probe (simultaneous pharyngeal and esophageal) ISFET pH-monitoring) of twenty consecutive patients who had reflux testing in 2018. Nineteen of the twenty (95%) had some nocturnal reflux, and 16 (80%) had pharyngeal (throat) reflux all night long. (Koufman, J. Silent nocturnal reflux predominates in ORL patients with respiratory reflux, unpublished data, 2023)

Besides late eating, there are other risk factors for SNoRR, including obesity, having a nightcap, a high-fat high-acid diet, consumption of trigger foods such as chocolate and alcohol, consumption of foods that exit the stomach slowly such as beef, esophageal dysmotility and gastroparesis. Obviously, all the reflux risk factors are important, but they are beyond the scope of this post.  

How Do I Know If I Have SNoRR?

Before suggesting that there may be warning signs that you have SNoRR, it is often the case that there are none. That said, the affected person will have respiratory reflux symptoms and findings. On examination by a knowledgeable otolaryngologist: (1) cobblestoning of the pharynx including the nasopharynx, thick white mucus in the pharynx, narrowing of the pharynx at the palatal level … and there are more physical findings of SNoRR … but the single finding that makes the diagnosis (in my opinion) is that the back of the larynx is so swollen that it is in contact with the back of the throat, the posterior pharyngeal wall. But even without an examination reflux of the SNoRR type can be deduced from the symptoms, lifestyle pattern, and voice. If you have a “heavy” voice with loss of your singing pitch range this is usually SNoRR-related.

Take the reflux RSI quiz near the bottom of the GERD v LPR post. It will tell you with a reasonable degree of accuracy if you have RR. As common symptoms go, SNoRR usually causes postnasal drip, chronic throat-clearing, and hoarseness (especially in the morning); however, it may also cause any other RR symptom (and the list is long): nasal congestion, sinusitis, shortness of breath, choking episodes, asthma, ear pressure, pain and tinnitus, chronic bronchitis and cough, pneumonia (especially recurrent pneumonia), and COPD. Any part of the respiratory system can be affected by reflux. And to make matters worse, SNoRR can act as an accelerant for pre-existing respiratory diseases such as cystic fibrosis. Finally, here are some big red flag indicators for SNoRR:

Awakening in the morning with heartburn, hoarseness, cough, sore throat, and/or excess mucus

Tasting bitter reflux when you awake in the night or in the morning (the taste is distinctive)

Snoring, sleep apnea, and/or a big uvula This is the big one. I can examine a patient and tell if they have sleep apnea. Further to that, in the last two years of my New York practice I saw 70-80 sleep apnea patients and every single one had SNoRR results on pH-testing.

Having SNoRR for a decade or four is, in my opinion, the cause of snoring sand sleep apnea, not every case but most. I will again blog about this reflux/snoring/apnea connection when I have collected and analyzed the clinical data.

Everyone Refluxes:  What’s To Be Done?

No way to get around it, we live in a culture of reflux; the big meal late with alcohol with friends and family is also our major refueling meal of the day every day; that is a big problem.

How could I suggest that 100 million Americans have SNoRR?  Well, in my experience four out of five “asthma” sufferers actually have reflux and not asthma, and the same is true for allergy, chronic bronchitis and cough, COPD, snoring, and sleep apnea. If half have reflux as the correct diagnosis, we very quickly get to 100 million people ― and the other clincher, eating late is the American way.

There is a tremendous gap between what I am presenting here and the medical establishment status quo. I maintain that SNoRR constitutes a major public health crisis; but mainstream medicine and governmental programs that hand out money such as Medicare are clueless.

The problem is that the “go-to” doctor for reflux is the gastroenterologist; however, s/he is making so much money doing endoscopy that the SNoRR paradigm is viewed as a dangerous invader that could disrupt the gastroenterologists’ lucrative “heartburn business model.” The GIs have effectively prevented any progress in the field of reflux for 50 years. In addition, they have effectively quashed safer and inexpensive technology that might replace them.

Comment: GIs know nothing about respiratory reflux and they have no test for it. That leaves other specialists such as ENT, lung, and allergy doctors completely stumped as to be able to recognize, diagnose, and treat reflux. That said, many billions of dollars are wasted each year on ineffective antireflux drugs and procedures.

So now what? Maybe Congress will make a law that everyone has to eat dinner at 5:00 p.m., no fast food, and no chocolate or alcohol? Not likely. But some trends are moving in the right direction. Soft drink consumption is down, more people are interested in health, and more and more people are interested in understanding reflux because they have symptoms.

Here is an amazing thing on Amazon: As of this writing: Dropping Acid: The Reflux Diet Cookbook & Cure is the #1 Best Seller in Asthma, and The Chronic Cough Enigma is the #1 Best Seller in Respiratory Diseases. These ratings suggest that the general public understands respiratory reflux and that reflux causes respiratory disease, even though most of their physicians don’t.

Here’s the bottom line. The only effective treatment for reflux and its respiratory sequelae is diet and lifestyle. All of the procedures that are sometimes recommended such as Lynx magnets are worthless; although device manufacturers and doctors make a lot of money from procedures. Apparently, talking to people about their diet and lifestyle doesn’t pay.

So, the minimum time from dinner to bedtime? I used to say it was 3 hours, and now I recommend 5-7 hours for refluxers; and after that, 4 hours is best.

For more information about diagnosis and treatment, see my books on Amazon: Dropping Acid: The Reflux Diet Cookbook & Cure and Dr. Koufman’s Acid Reflux Diet. And if you would like to schedule a virtual consultation with me, you can book online.

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