March 1, 2021

Singers: How to Save Your Voices


  • Silent acid reflux (often called LPR, a term I coined) poses the single greatest risk to the health of your vocal cords and the strength and quality of your voice. “Silent” implies that you may not be aware that you have it because silent refluxers have neither heartburn nor indigestion, the obvious symptoms of acid reflux.
  • Today, acid reflux ― silent reflux― is ubiquitous, almost cultural. That’s because we eat and drink too late, resulting in respiratory reflux (LPR) during the night. This can have profound negative effects on your voice.
  • For Broadway singers and the like who perform eight performances a week, I recommend that you go home after the performance … but if you DO go out, never eat or drink after the show. Just enjoy being with your friends!
  • Other significant risk factors for silent reflux include too much alcohol, soft drinks (including fruit juices, energy drinks and seltzer), a high-fat diet (especially deep-fried food), and foods that are too acidic (such as citrus and spicy sauce).

It may surprise you to know that today, 70% of us are professional voice users. Obviously, singers and actors, voice-over specialists and media personalities depend upon their voice even more than the rest of us, however, clergy, teachers, trial lawyers, physicians, and other professions all need a good normal, serviceable and reliable voice every day.

Acid reflux can cause vocal fatigue, effortful speaking, even painful speaking, as well as significant changes in vocal quality (e.g hoarseness, voice breaks, loss of vocal range and throat clearing). It may also surprise to you that silent reflux, occurring during the night, is more common than “typical” acid reflux called GERD (gastroesophageal reflux disease) with heartburn and indigestion being the commonest tell-tale symptoms.

The purpose of this post for singers, actors and other people who care about the quality of your voice is to help you avoid the type of reflux that is the greatest risk to your livelihood. In my extensive experience of treating 10,000+ patients, silent nocturnal reflux is what you have to most worry about. Here are the tips and prohibitions that I recommend.

No Nightcaps! And Moderate Alcohol in General

An alcoholic beverage just before bed is the kiss of death. Alcohol directly relaxes the lower esophageal sphincter (LES), which when open, causes reflux events to occur. The more you drink, the greater the negative effect. In addition, if you go to sleep with a “buzz,” you almost certainly will have reflux that night.

For people who have reflux, be it silent (LPR) or GERD, abstinence from alcohol for no less than 2-4 weeks can be an important part of an initial reflux control “detox” program. But even after that, for half of refluxers, any alcohol in the evening is a powerful risk factor for reflux.

No Late Night Eating & Dinner Should Not Be the Your Major Refueling Meal  

Making your evening meal your major refueling meal of the day is a bad idea because if you go to bed with food in your stomach, you are likely to have nighttime reflux. For most people with reflux, it may actually take five hours for the stomach to empty.

And any snack before bed (other than a small amount of water) is bad because it turns on the stomach to produce acid and harmful digestive enzymes (pepsins).

When you go to sleep, you should have empty and quiet stomach.

It goes without saying that overeating anytime puts excess stomach pressure on the LES and makes reflux more likely. So don’t skip meals, eat a good breakfast, have healthy snacks during the day, and if you can, make your lunch your “largest” meal of the day, not dinner. Try to get three-quarters of your necessary calories in before 5 PM. 

Avoid Very Acidic Foods and Beverages

My first book on acid reflux, Dropping Acid: The Reflux Diet Cookbook & Cure, revealed an epiphany: dietary acid ― especially soft drinks and acidic fruits such as citrus ― was a major problem people with as acid reflux. The explanation is counterintuitive.

Although it is called “acid reflux,” most of the inflation and damage to tissue is due to the stomach enzyme, pepsin. Here’s the thing: when you have reflux acid and pepsin comes up, it’s the pepsin that produces most of the damage, but pepsin requires acid to be activated. Therefore, if you have acidic beverages in your food or drink, it will activate the pepsin that’s already stuck on your throat and vocal cord lining.

Here’s the back story: In 1973, following an outbreak of botulism, the food and drug administration (FDA) mandated that anything in a bottle or can crossing state lines must be acidified to kill bacteria. Unfortunately, soft drink manufacturers took it too far and added a ton of citric acid, so now, most bottled drinks are the same acid level as stomach acid.

For any kind of reflux detox program, you cannot drink anything from a bottle or can other than water. No energy drinks, no soft drinks, no fruit juices, no seltzer. The idea is to starve the pepsin of acid. In addition, consuming alkaline water is an important part of treatment since the pepsin molecule can be washed out … pepsin dies at pH 9.

Avoid Foods That Contain Chemicals That Relax the LES

High-fat foods, especially deep-fried, also cause the LES to relax causing reflux. And after two cheeseburgers, fries and a coke, reflux is virtually guaranteed! And so does too much coffee (caffeine). Having one or 2 cups of coffee a day is probably fine for most refluxers, but if you drink a pot of coffee before noon, that much caffeine will completely relax the LES.

In addition, certain foods have chemicals that also have a direct negative effect on the LES and cause reflux. Such include mints, chocolate, cashews and more; see Dr. Koufman’s Reflux Diet. It is the chemical composition of those foods that interacts with muscular receptors in the LES.

It is also necessary to point out that smoking (all tobacco) has similar effects in causing relaxation of the LES. It has been shown in experimental studies that reflux occurs with 80% of cigarette smoked. And tobacco does not have to be inhaled have these effects.

In an unpublished study, I examined the reflux testing results of lifetime 500 non-smokers and 100 active smokers. The smokers had many more reflux events, and those events lasted longer than non-smokers (with a high degree of statistical significance P<0.0001). 

Overweight / Obesity

Having a big round stomach, that is, lots of weight around your middle, is like permanently overeating. That’s because your heavy abdominal fat-mass presses on the stomach when you lie down.

If you are overweight, consider sleeping on an incline and again certainly do mot overeat or not make your evening meal your biggest meal of the day. By the way, not eating at night will help you lose weight. No, you cannot have a pint of ice cream as a snack in the evening!

Are there Other Things That I Can Do Mitigate the Effects of Reflux on My Vocal Cords?

Drink Alkaline Water. Alkaline water helps LPR reflux and it has been unequivocally shown to help. I recommend drinking alkaline water with a pH > 9.0: see my alkaline water reflux blog more information and help you select an bets-choice alkaline water.

Alkaline Water Throat Spray. This adjunctive treatment is amazingly simple and effective for vocal cord swelling and inflammation. When you swallow, the nose and most of the throat closes down tightly so you don’t get whatever you swallow down the wrong pipe. However, if you take your alkaline water and put it in a spray bottle, you can actually deliver treatment (washing out and killing pepsin) to the lower part of your nose and the throat, including the vocal cords. Lower your tongue and inhale when your spray (into your nose or down into your vocal cords) while you spray. This kills the pepsin and helps your vocal cords.

Chew Gum After Meals. Several years ago, we studied the effects of gum chewing on acid reflux. Gum chewing increases salvation, increases salivary bicarbonate concentration, increases swallowing in general. We showed that gum chewing can actually abort reflux events after meals. This combination drives the system in forward and actually can prevent reflux after meals.

Sleep Almost Upright. Most wedges that are sold for reflux are not hard enough to prevent respiratory reflux (LPR). If you have respiratory reflux, voice changes (usually due to vocal swelling from nighttime reflux), you should be sleeping at 45° or higher. If you have a recliner, consider sleeping in it. Do this until the “heaviness” of your voice (vocal cord swelling) subsides.


You do not have to be performing on Broadway for the recommendations in this post to have relevance to you. Late night eating and snacking, overeating, eating the wrong foods, and too much booze and/or soft drinks will have negative effects on your vocal cords and your voice. Silent reflux can affect your vocal range, your vocal endurance, the comfort of using your voice, and how much work it tastes achieve satisfactory performance.

Just so you know, most ENT doctors and gastroenterologists don’t understand how to diagnose and treat respiratory reflux (LPR). In this regard, a word of warning, PPIs should specifically be shunned.

Only a healthy diet and lifestyle can beat reflux. You can find other information that may be of use to you in managing your reflux, even in identifying whether you have it, on this site.

If you’ve read at least one of my books and you’re following this guidance and you still need help, you can book a consultation with me.

Books by Dr. Koufman

Subscribe to the Newsletter Now!

join the email list now to get notified about new blog posts & books from dr. koufman