Entry #: 13
Date: 20 September 2017
Section: Laryngopharyngeal reflux
Topic: Mediterranean diet and reflux
Type: Human volunteer trial

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D. Elizabeth McCord, Nancy B. Ray and Tom C. Karagiannis


A comparison of alkaline water and Mediterranean diet vs proton pump inhibition for treatment of laryngopharyngeal reflux


Zalvan H et al

Citation / Year

(1) / 2017


larygopharygeal reflux, reflux symptom index, proton pump inhibitors, alkaline water, Mediterranean diet


Laryngopharygeal reflux is an important clinical problem and is known to lead to numerous medical complications ranging from chronic dysphonia and persistent cough to laryngospasm, subglottic stenosis and carcinoma (1). The use of proton pump inhibitors is currently a frontline therapeutic approach however, effectiveness has been called into question (2, 3). Further significant costs (13 billion in the USA in 2009), are associated with the use of proton pump inhibitors (4). This is an interesting retrospective chart review study aimed at comparing the efficacy of 1) an alkaline water, 90-95% plant-based Mediterranean-style diet with standard reflux precautions (AMS group) vs 2) the conventional proton pump inhibition with standard reflux precautions (PS group), on reflux symptoms. The reflux symptom index (5) was used to measure differences in the AMS (n=99 people; median age = 57 years [18-93]) and PS (n=85 people; median age = 60 years [18-82]) groups. Changes in the reflux symptom index was recorded after approximately six weeks following the initiation of treatment.

Key points and implications

Overall, the findings indicated that a clinically meaningful, six or higher point, reduction in reflux symptom index was achieved in 62.6% of the AMS group compared to 54.1% in the PS group. Using the reflux symptom index as a tool and a six point reduction as the accepted clinical standard, these findings suggest that proton pump inhibition with standard reflux precautions is not significantly better than an alkaline water, plant-based Mediterranean-style diet with standard reflux precautions for the management of laryngopharyngeal reflux. Although the strict statistical differences between the groups is questionable, the findings do highlight the potential to effectively improve symptoms of laryngopharyngeal reflux with the dietary approach. This could potentially be advantageous with respect to costs and adverse effects, compared to the current pharmacological approach with proton pump inhibitors. As highlighted by the authors, large-scale randomized clinical trials are required to substantiate these findings. Such trials are warranted on the basis of the findings presented in this study.

Related publications

  1. C. H. Zalvan, S. Hu, B. Greenberg, J. Geliebter, A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux. JAMA otolaryngology– head & neck surgery, (2017).
  2. E. Sheen, G. Triadafilopoulos, Adverse effects of long-term proton pump inhibitor therapy. Digestive diseases and sciences 56, 931-950 (2011).
  3. P. D. Karkos, J. A. Wilson, Empiric treatment of laryngopharyngeal reflux with proton pump inhibitors: a systematic review. The Laryngoscope 116, 144-148 (2006).
  4. D. O. Francis et al., High economic burden of caring for patients with suspected extraesophageal reflux. The American journal of gastroenterology 108, 905-911 (2013).
  5. P. C. Belafsky, G. N. Postma, J. A. Koufman, Validity and reliability of the reflux symptom index (RSI). Journal of voice : official journal of the Voice Foundation 16, 274-277 (2002).