Laryngopharyngeal Reflux (LPR): How Nutrition Can Help You Manage Silent Reflux

Do you find yourself constantly clearing your throat, dealing with a hoarse voice, or feeling like there’s a lump in your throat? You might be dealing with laryngopharyngeal reflux (LPR). Although the term ‘reflux’ is in the title, LPR often presents without heartburn, unlike typical acid reflux or GERD. 

As a registered dietitian who specializes in digestive health concerns, I often see clients who have been prescribed reflux medications with little relief from these upper throat symptoms. That’s because LPR is frequently driven by non-acidic reflux, including substances like pepsin – which can irritate the throat even in the absence of acid. 

The good news? Nutrition can help make a difference. In this post, we’ll explore what LPR is, how it differs from GERD, and the role dietary changes can play in minimizing symptoms and supporting long-term healing.

Table of Contents

• What is LPR?
• What triggers LPR symptoms?
• How is LPR diagnosed?
• Treatment for LPR
• Best Diet for LPR
• Is alkaline water helpful for LPR?
• How weight influences LPR
• Pharmacological Management of LPR

What is Laryngopharyngeal Reflux (LPR)?

Laryngopharyngeal reflux (LPR), often called “silent reflux,” earns its name because it typically doesn’t cause the classic symptom of heartburn. Instead, it affects the upper airway, leading to symptoms in the throat and voice box (larynx) – often without any noticeable chest discomfort. That said, we do see some patients who deal with both ‘traditional’ reflux symptoms and LPR symptoms simultaneously.

In LPR, stomach contents flow back up the esophagus and reach the larynx (voice box) and pharynx (throat). These stomach contents can include acid, bile, or digestive enzymes like pepsin. The delicate tissues in the larynx and pharynx are not equipped to handle even small amounts of reflux, and repeated exposure over time can cause irritation and inflammation.

Common Symptoms of LPR:

• Chronic cough (often dry and unexplained)
• Frequent throat clearing
• Hoarseness or voice changes
• Sensation of a lump in the throat (globus sensation)
• Post-nasal drip or excess mucus in the throat
• Difficulty swallowing or feeling like food “sticks”

However, these symptoms overlap with many other conditions – including allergies, asthma, or even anxiety. This can commonly lead to LPR being misdiagnosed or overlooked entirely, especially if there’s no heartburn present.

What Triggers LPR Symptoms?

As mentioned earlier, LPR isn’t solely caused by stomach acid. Symptoms can be triggered by a range of factors, including both acidic and non-acidic reflux. While acid is a well-known irritant, non-acidic reflux, which still contains digestive enzymes like pepsin, can also lead to inflammation and tissue damage in the larynx and pharynx. This helps explain why individuals with LPR may continue to experience symptoms even when taking acid-suppressing medications like proton pump inhibitors (PPIs). 

Research indicates that up to 50 to 60% of those with isolated LPR symptoms don’t have any signs of gastroesophageal reflux and therefore won’t respond to anti-reflux therapies that target acid suppression.  

The Role of Pepsin in LPR

Pepsin is an important digestive enzyme that breaks down proteins in the stomach. However, when pepsin is refluxed into the upper airway, it can attach to tissues in the throat and remain there even after the reflux episode ends. Later exposure to acidic foods or beverages can reactivate pepsin, leading to further tissue damage and symptom flare-ups, often without the classic “burning” sensation of acid reflux.

How is LPR Diagnosed?

There is currently no single gold standard test for diagnosing LPR. Because the symptoms can be quite non-specific, diagnosis often involves ruling out other potential causes such as allergic rhinitis or chronic sinusitis. The diagnostic approach can vary depending on the nature of an individual’s symptoms and the resources available. This may include:

• ENT evaluation: An ear, nose, and throat specialist may perform a laryngoscopy to look for signs of redness, swelling, or tissue damage in the throat or vocal cords.
  
• pH monitoring: This test measures acid levels in both the esophagus and throat over 24 hours to assess how far the reflux travels.
  
• Empirical treatment trials: In some cases, a diagnosis is made based on how a patient responds to reflux treatments (like PPIs or dietary changes).

Because symptoms can be subtle and progress slowly over time, it’s not uncommon for people to go months or even years without a clear diagnosis. 

Treatment for Laryngopharyngeal Reflux

Managing LPR typically involves a combination of nutrition strategies, pharmacological treatments, and lifestyle modifications. Other proposed approaches include speech therapy, surgery, and behavioural therapies like clinical hypnotherapy and cognitive behavioral therapy (CBT).

What is the Best Diet for LPR?

Although the underlying mechanisms between LPR and traditional acid reflux are a bit different, these two conditions do have some overlapping nutrition management strategies. For starters, reducing intake of common reflux triggers is often still helpful. This includes:

• Citrus fruits (e.g., oranges, lemons)
• Tomatoes and tomato-based products
• Spicy foods (hot sauce, hot peppers, cayenne)
• Fatty foods (especially fried or processed foods)
• Chocolate
• Peppermint/spearmint
• Caffeinated beverages (coffee, soda)
• Alcohol

While every individual may have different sensitivities, these are some common culprits. It’s important to track which foods consistently trigger your symptoms – and work with a dietitian if possible. Dietitians have a trained eye for helping to pinpoint specific triggers!

Emerging Evidence: Plant-Based Diets for LPR

Recent research suggests that plant-based diets may be beneficial for those with LPR. It is thought to help with recovery of inflammation in the larynx and pharynx by altering the microbiota. While the research is still fairly new, the supporting theories make a lot of sense. Plant-based diets tend to be higher in fiber and antioxidants, which support overall digestive health and reduce inflammation. In addition to the anti-inflammatory properties of plants, a reduced fat content may also be a factor in the potential success of plant-based diets for LPR. 

Should I Drink Alkaline Water for LPR?

You may have heard that alkaline water can help manage LPR symptoms. There are a few studies suggesting that alkaline water (with a pH of 8.0 or higher) may help deactivate pepsin. However, it’s important to note that these studies were done in vitro (in a test tube/culture), not in humans. This means we can’t say for sure whether drinking alkaline water will have the same effect in the human body. 

That said, there’s generally no harm in drinking water that’s slightly more basic, and some people do find it soothing. Just keep in mind it’s not a guaranteed fix, and should be part of a broader LPR management plan.

Eating Pattern and Meal Timing

Even when we choose the “right” foods, eating them at the wrong times or in excessive amounts can still trigger LPR symptoms. Consider these strategies to help better manage LPR:

• Small frequent meals: Large meals can put additional pressure on the lower esophageal sphincter (LES), the muscle that helps prevent stomach contents from rising into the throat. Opting for smaller meals every 3-4 hours can help reduce this pressure.
• Avoid eating close to bedtime: It’s important to give your body time to digest food before lying down. Aim to eat at least 2-3 hours before bedtime to allow your stomach to empty and reduce the likelihood of reflux.
• Chewing food thoroughly: Eating slowly and chewing food well can prevent overeating and reduce the amount of time needed for food to break down in the stomach, reducing the risk of reflux.
• Upright posture during meals: Sitting or standing while eating allows gravity to aid in digestion, preventing food and stomach acids from traveling up into the throat. Avoid reclining or slouching during or after meals.
• Bonus: Avoid tight clothing: Although this has less to do with how you eat, it’s still important! Wearing tight-fitting clothes, especially around the waist, can increase abdominal pressure and contribute to reflux symptoms. Opt for looser, more comfortable clothing to help reduce this pressure and avoid triggering symptoms.

How weight influences LPR

Interestingly, higher body mass index and obesity appear to be more correlated to esophageal reflux (GERD) than LPR. In a study of 285 people with diagnosed LPR, researchers looked at how obesity might affect reflux. They found that as BMI increased, there were more abnormal reflux events in the esophagus. However, they did not find a similar connection between BMI and reflux events in the throat area. This suggests that being overweight might be linked to more reflux in the esophagus, but not necessarily in the throat. 

While weight may not contribute to LPR as significantly as it does GERD, some people find that weight management may help to relieve symptoms. While weight loss isn’t the primary focus in managing LPR, you may find that symptoms improve as a result of following a balanced diet. This may be attributable to both dietary changes and any accompanying weight loss. Excess weight, particularly around the abdomen, can increase intra-abdominal pressure, which may in turn affect the function of the upper and lower esophageal sphincters.

Pharmacological Management of LPR

While lifestyle and dietary changes play a big role in managing LPR, many individuals also benefit from targeted medication support – especially when symptoms persist or significantly impact quality of life. Pharmacological options can help reduce acid production, support tissue healing, and minimize the irritation of sensitive throat and airway tissues. 

Medications used in LPR management include:

• Proton Pump Inhibitors (PPIs) – These are often the first line of treatment prescribed for LPR, as they work by significantly reducing stomach acid production. However, the effectiveness of PPIs in managing LPR specifically has been debated. Systematic reviews of the research have shown mixed results, with some patients reporting improvement in symptoms, while others see little to no benefit. 
  This inconsistency may be due to the complex, multifactorial nature of LPR – where acid isn’t always the only culprit – as well as significant variability in study design, and the specific PPIs used. PLUS, we can’t forget the non-specific nature of LPR symptoms, which means some patients included in research may not actually have true LPR.
• H2 Blockers – Medications like ranitidine and famotidine are generally considered a secondary intervention for LPR. While they do reduce acid, they offer a shorter duration and lower overall effectiveness in acid suppression compared to PPIs. That said, they may still have a role in symptom management, particularly for individuals who experience partial relief with PPIs but continue to have some breakthrough symptoms. 
  However, similar to PPIs, their effectiveness depends heavily on whether acid is truly the underlying driver of LPR symptoms. Given the multifactorial nature of LPR, if acid is not the primary trigger, the benefits of H2 blockers may be limited.
• Alginates – These types of medications, like Gaviscon, form a protective barrier that floats on top of the stomach contents after a meal. This barrier helps prevent acid as well as non-acidic contents (like bile and pepsin) from refluxing into the esophagus and reaching the throat. Unlike PPIs or H2 blockers, alginates don’t suppress acid production but instead focus on physically blocking the upward flow of gastric contents. This is especially helpful in LPR, where symptoms may be driven by non-acidic reflux, and when timing symptoms around meals is a key concern. As dietitians, we find timing is important when it comes to medications like this. Alginates are best used after meals and at bedtime.
  While the research on alginates in LPR is still emerging and results have been somewhat mixed, this class of medication is generally very well tolerated. Given their safety profile and mechanism of action, alginates may play a valuable role in LPR management, particularly for people who haven’t experienced significant relief from taking a PPI. 

In Summary

Laryngopharyngeal reflux is a complex and frequently overlooked condition that can significantly impact quality of life. Unlike traditional acid reflux, LPR symptoms tend to show up in the throat and voice box, often without the hallmark sign of heartburn. This can make diagnosis and treatment more challenging – but not impossible! By understanding the unique features of LPR and the many factors that may contribute to it, we can begin to create more individualized management plans.

While medication can play a role in treatment and symptom relief, diet and lifestyle changes are foundational for long-term success. Paying attention to trigger foods, adopting more plant-based and reduced fat eating patterns, adjusting meal timing, and incorporating mindful eating strategies can all help reduce symptom frequency and severity. 

If you’re struggling with persistent throat symptoms and suspect LPR might be the cause, working with a registered dietitian who understands this condition can be a positive step in the right direction!