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“Dropping Acid” Blog

Help Nominate Dr. T. Colin Campbell for Nobel Prize in Medicine

Dr Campbell


The pioneer who has inspired physicians to understand how diet plays a crucial role in causing chronic disease and its healing, Dr. T. Colin Campbell, is being championed by another medical innovator, renowned otolaryngologist Dr. Jamie Koufman. She has created an online petition with the hope of gathering enough signatures to show the Nobel Committee the importance of Dr. Campbell’s work to encourage his nomination for the Nobel Prize in Medicine. As an international authority on the diagnosis and treatment of acid reflux, Dr. Koufman has launched the website, DrCampbell4Nobel.org, to help build public support for the nomination of Dr. Campbell.

It was Dr. Campbell who performed the pioneering research showing the power of a whole food, plant-based diet to not only prevent most chronic disease, but also to reverse serious conditions like heart disease and diabetes. Dr. Campbell directed the landmark China-Cornell-Oxford Project on Diet and Disease and co-authored the best-selling book, The China Study. It was his research that inspired Dr. Koufman to change the diets of her patients, leading to dramatically improved health outcomes.

Dr. Campbell’s body of work stands alone in the world of nutritional science. He is unquestionably the pioneering scientist who proved the link between the Western diet and chronic diseases such as diabetes, heart disease, and cancer.  Dr. Koufman believes that a Nobel Prize awarded to Dr. Campbell would not only acknowledge one of the most important medical discoveries ever made, but also would catalyze a paradigm shift of global proportions in the health care and food industries.

For three decades, Dr. Koufman’s groundbreaking research has focused on acid reflux as it affects the voice and respiratory tract. She is the Founder and Director of the Voice Institute of New York. Dr. Koufman has also written a series of books about reflux for the general public, including the New York Times best-seller, Dropping Acid: The Reflux Diet Cookbook & Cure.

For more information and to sign the petition, please visit:  DrCampbell4Nobel.org

Alkaline Water for Reflux: Why, Which, and When?


What is alkaline water? Alkaline is the opposite of acid. It is sometimes also called “basic.” The way we measure acid is by the pH scale, and this scale can be confusing. pH 7 is neutral, that is, it is neither acidic nor alkaline. Acids are below pH 7, and bases are above pH 7. The lower the number, the more acidic. pH 2 is more acidic than pH 3 and the difference is tenfold. For example, pH 2 is 10 times more acidic than pH 3 and 100 times more acidic than pH 4. (The pH scale is logarithmic like the Richter scale for earthquakes, but in reverse. With the pH scale, lower numbers are more acidic (worse), but with earthquakes, higher numbers are worse.) The commonly available alkaline waters that have the most benefit for refluxers have pH values of 8.0-10.5.

Why alkaline water? Stomach acid is pH 2-4; and by the way, and so are most soft drinks. My first book on reflux, Dropping Acid: The Reflux Diet Cookbook & Cure, focused on the fact that for refluxers, an acidic diet is damaging to the throat and the esophagus. See also our newest book, Acid Reflux in Children: How Healthy Eating Can Fix Your Child’s Asthma, Allergies, Nasal Congestion, Cough & Croup. Kids have the same reflux problems and alkaline water helps them, too.

It is amazing that almost everything in a bottle or can except for still water has the same acidity as stomach acid. The explanation for this has to do with the FDA; in 1973 following an outbreak of food poisoning, the FDA mandated acidification of everything in a bottle or can crossing state lines in order to kill bacteria. They never dreamed that manufacturers would add so much acid to their products. I recommend that people with reflux just drink water, especially alkaline water. (If some kind of milk is needed, too, I suggest almond milk as the best choice.)

The cell biology of reflux explains how reflux damages tissue to cause swelling, inflammation, and even benign and malignant growths. While tissue damage does have something to do with acid, it is the main enzyme of the stomach, pepsin, that is the really bad actor. When you have reflux, pepsin that comes up attaches itself to the tissues of your nose, throat, vocal cords, esophagus, or wherever it lands. In a research paper, we biopsied the throats of people with reflux laryngitis and found tissue-bound pepsin in almost every case. So, here’s the catch, while pepsin does the most damage, it does require acid for its activation. Conversely, pepsin is inactivated — the molecule dies — when it is in contact with pH >8.

In comes alkaline water. In 2012, we published a paper entitled Potential Benefits of pH 8.8 Alkaline Drinking Water as an Adjunct in the Treatment of Reflux Disease. The paper concluded, “Unlike conventional drinking water, pH 8.8 alkaline water instantly denatures pepsin, rendering it permanently inactive. In addition it has good acid-buffering capacity. Thus, the consumption of alkaline water may have therapeutic benefits for patients with reflux disease.” It was that paper started the alkaline water craze.

What does it all mean? Alkaline water is good for reflux as it helps wash out that nasty pepsin enzyme. Furthermore, it helps balance the pH of other consumed foods that may be somewhat acidic. Yes, I recommend alkaline water for all of my patients with acid reflux, especially those with respiratory reflux.

Which alkaline water? Some alkaline waters are manufactured (by adding chemicals to regular water), and others are naturally occurring, that is, they come out of the ground that way.  Given a choice, I recommend naturally occurring alkaline waters over the manufactured ones. In addition, I recommend waters that are bottled in BPA-free plastic. There is one notable exception, cerrawater.com. The Cerra Water Company makes a pitcher that looks like an ordinary water filter pitcher; however, it makes pH 9.5 water out of tap water, day in and day out. I personally use this, and it keeps me from having to cart heavy bottles of water from the store.

The measurements shown below as “Actual pH,” I performed with an Apera SX610 pH tester. I have ranked the products by pH with the highest pH. In addition, I have indicated which test waters are natural and which are manufactured; I believe that the natural waters are preferable. For an alkaline water to be effective for reflux, its pH should be 8.0 or higher.

Product Natural pH Claim Actual BPA-Free
Trader Joe’s Alkaline Water No 9.5 9.8 No
Alkalife TEN Yes 10 9.6 Yes
Essentia No 9.5 9.5 Yes
Aqua Hydrate No 9.1 9.4 Yes
CerraWater No 9.4 No
Nice Iceland Pure Yes 8.88 8.8 No
Evamor Yes 8.8-9.1 8.8 Yes
Iceland Spring Yes 8.88 8.8 No
Islandic Glacial Yes 8.4 8.4 No
Eternal Water Yes 7.8-8.2 7.8 Yes
Bai No 7.5 7.8 No
Nice Spring Water Yes 7.7 No
Fiji Yes 7.7 7.2 Yes
Core No 7.4 7.4 Yes
Evian Yes 7.3 No
Delish Electorlyte Water No 7.3 No
Life WTR No 7.1 No
New York City tap water No 7.1
Nestle Pure Life No 7.0 No
Deer Park Yes 6.5 No
Poland Springs Yes 6.5 No
Aquafina No 5.9 No

When? Alkaline water can be consumed when ever you want. There is no downside, that is, you cannot drink too much alkaline water. It should be used for reflux in the acute phase, especially if you have hoarseness and/or other throat symptoms. Drink alkaline water with your meals and particularly as a “chaser” after any food that is acidic. Such include most fruits (except melons and bananas), tomatoes, spicy foods, and sauces. You do not have to carry your alkaline water into a restaurant; you can drink regular tap water too; but when convenient, drinking alkaline water most of the time is good for you.

Note: I am keeping the bottles of alkaline water tested for several months so see if the pH falls over time; this will be published in the future as a second blog on the shelf-life of alkaline water.




Respiratory reflux

Airway Reflux = Respiratory Diseases = Respiratory Reflux

I was trained as an ENT doctor, but I have evolved to practice Integrated Aerodigestive Medicine (IAM). As an IAM doctor, I am part ENT (ear, nose, and throat) doctor, but I know about the parts of ENT that ENT doctors don’t know about. I am part gastroenterologist, i.e., gastrointestinal (GI) doctor, but I know about the parts of GI that GI doctors don’t know about. And I am part pulmonologist (PUL) (lung and chest physician), but I know about the parts of PUL that pulmonary doctors don’t know about.

I don’t completely over lap with those specialties; however, unlike most specialists, I do take care of whole patients. The focus of my research and medical practice is acid reflux, especially reflux that affects the airway—ears, nose, sinuses, throat, voice box, trachea, bronchial tubes, and lungs. There are many terms for the reflux (backflow) of stomach contents into the esophagus and airway.

Common Terms for Reflux

General Terms
Acid reflux
Gastric reflux

Terms for Esophageal Reflux
Gastroesophageal reflux disease (GERD)
Gastro-oesophageal reflux disease (GORD) [U.K.]
Peptic esophagitis / Esophageal erosions
Esophageal Reflux

Terms for Throat Reflux
Laryngopharyngeal reflux* (LPR)
Extraesophageal reflux disease
Supraesophageal reflux disease
Atypical reflux disease
Reflux laryngitis
Silent reflux*
Airway Reflux*
Respiratory Reflux*

The asterisks (*) mark the terms, which I personally coined. The last one, Respiratory Reflux, is brand new and it is the topic of this post.

First, let me offer a disclaimer: I have almost given up taking to medical colleagues. They don’t listen; and furthermore, I believe that they don’t care a whit for new ideas that challenge the prevailing medical models. The “heartburn business model,” for example, proffered by GI doctors, has cost America $1.5 trillion in the past 40 years and perhaps as many as 55,00 deaths. During that time, reflux, especially respiratory reflux, has become the great public health epidemic of our time, affecting and estimated 125 million Americans, about half with esophageal reflux and half with respiratory (aka airway) reflux. My book, The Chronic Cough Enigma, was written because I couldn’t get the work published in a medical journal. (Yes, the paper was a first-rate piece of scientific research; and yes, there is politics and ugly egotism in the peer-review process.)

So, I am writing this for the lay public and for the medical profession. The truth is that I believe that the term Respiratory Reflux will catch on simply because it is both accurate and intuitive. I came up with LPR specifically to differentiate the problems of my patients from those of GIs with GERD. It was LPR vs. GERD for about 20 years.

Second, I for the past few years, I have been trying to get medical colleagues to abandon the terms LPR and GERD because they are cumbersome and hard to pronounce. Indeed, they are not even accurate terms. I suggested new terms, esophageal reflux and airway reflux (for LPR and GERD respectively) as being more encompassing, precise and intuitive.

Finally, the new term will call attention to the fact that reflux is the great masquerader of our time, that many respiratory diseases are caused by or complicated by acid reflux.

Why Respiratory Reflux Is A Good Term

The most common misdiagnoses in America are allergy, sinusitis, and asthma. These conditions are usually due to “airway reflux”; therefore, it makes great sense to call acid reflux that mimics allergies—post-nasal drip is the single most common symptom of airway (LPR)  reflux—respiratory reflux. As it turns out sinus disease is also often caused by reflux; I see many patients who have had unsuccessful sinus surgery, whose symptoms disappear after the reflux is fixed. Finally, there is asthma. We waste $1 billion per week on inappropriate asthma treatment (that is actually respiratory reflux). These also are respiratory conditions caused by reflux. Therefore, the term respiratory reflux is recommended for all respiratory tract disorders caused by airway reflux. Furthermore, the term itself will call attention to the question of misdiagnosis. See my IN or OUT post for more about the costly problem of misdiagnosed asthma.

Symptoms and Manifestations of Respiratory Reflux

Chronic cough
Difficulty swallowing
Dental caries and erosions
Shortness of breath
Choking episodes
Sleep apnea
Reflux laryngitis
Vocal fatigue
Larynx (laryngeal) cancer
Voice breaks
Endotracheal intubation injury
Chronic throat clearing
Contact ulcers and granulomas
Excessive throat mucus
Posterior glottis stenosis
Post-nasal drip
Arytenoid fixation
Paroxysmal laryngospasm
Globus pharyngeus
Difficulty swallowing
Throat cancer
Difficulty breathing
Shortness of breath
Vocal cord dysfunction
Choking episodes
Paradoxical vocal fold movement
Vocal nodules and polyps
Food getting stuck
Pachydermia laryngis
A sensation of a lump in the throat
Recurrent leukoplakia
Intermittent airway obstruction
Polypoid degeneration
Chronic airway obstruction
COPD (Chronic obstructive pulmonary disease)
Sudden Infant Death Syndrome

In conclusion, the term Respiratory Reflux is recommended for acid reflux that rises up out of the esophagus (swallowing tube that connects the throat and stomach) into the airway. Such reflux causes and mimics many respiratory symptoms and diseases.

Airway reflux = Respiratory Diseases = Respiratory Reflux








IN or OUT? — Asthma that Isn’t Asthma


Asthma: The $50 Billion Dollar Medical Mistake

According to the Centers for Disease Control, 8% of all Americans and 17% of poor, non-white children in the U.S. have asthma. The asthma-related costs of doctors, hospitals, and medication add up to $56 billion per year. But what if doctors had it wrong? What if asthma was one of the most common misdiagnoses in America? What if the real problem was actually silent acid reflux and not asthma at all? We spend billions of dollars on asthma treatment each year, and most of it is a waste!

If you or someone you know has a diagnosis of asthma, you must ask this very important question: When you have trouble breathing during an “asthma” attack, do you have more difficulty getting air IN or OUT? Trouble getting air IN (during inhalation) is NOT ever asthma, trouble getting air OUT (during exhalation) is.

How does this work? The difference between breathing IN and OUT is explained by the anatomy and physiology of the airway. With acid reflux, airway obstruction occurs at the level of the larynx (voice box). The upper part of the larynx contains acid receptors, which act like electrical switches. When triggered by exposure to acid, these receptors close the vocal chords. That results in trouble breathing IN. This type of airway obstruction is similar to that seen in children with croup or whooping cough, who may make loud, crowing sounds when breathing IN.

The mechanism of airway obstruction in asthma is completely different. People with asthma have trouble getting air OUT, because breathing tubes in the lungs (inside the chest cavity) become narrower. This narrowing is usually due to an allergy. Then, during exhalation (breathing OUT), the full lungs exert additional pressure on the already narrowed bronchial tubes, resulting in prolonged expiration, also known as wheezing.

For thirty years, my medical practice has focused on patients with acid reflux, and during that time I have made three observations: (1) Approximately 80% of patients with asthma don’t have it; (2) Silent reflux (acid reflux occurring without the obvious symptoms of heartburn or indigestion) is usually the correct diagnosis; and (3) A problem breathing IN is never asthma. Indeed, people with wrongfully-diagnosed asthma, the INs, don’t respond to asthma treatments, but they do get well when their reflux is adequately controlled.

Everyone with asthma should know this: Reflux affects the throat and causes trouble breathing IN. Asthma affects the lungs and causes trouble breathing OUT.Unfortunately, this important clinical point is not understood by most doctors. Therefore, only when everyone is aware of this will the over-diagnosis of asthma cease. And that will result in better health for millions of people, along with healthcare cost savings in the billions of dollars.  – Jamie Koufman, M.D.

Dr. Jamie Koufman is the Director of the Voice Institute of New York and is the New York Times best selling author of The Chronic Cough Enigma and Dropping Acid: The Reflux Diet Cookbook & Cure.

Contact information: Dr. Jamie Koufman, Director, Voice Institute of New York, 200 West 57th St., Suite 1203, New York, NY 10019, Tel: (212) 463-8014, jamie@voiceinstituteny.com

Editorial: Are Medical Journals Obsolete?


The Internet has changed the world. Traditional medical journals are obsolete and should transition to modern on-line versions. Internet-based journals potentially solve most of the problems of contemporary print-media journals and enhance the peer-review and feedback-communication processes. In addition on-line journals could dramatically increase readership by providing access to information for everyone throughout the Internet. On-line journals would also allow the interactive exchange of ideas and would operate profitably.

For over a century, print medical journals have been around to disseminate information to physicians. I used to enjoy sitting in the stacks of the medical library and scanning the old books. Imagine my glee when as a junior faculty member, I discovered Dr. Casselberry’s Presidential address from the 23rd Annual Congress of the American Laryngological Association in the 1899 edition of The Annals. I had that book in my hand. I loved the old books — but that was then, and this is now. Today, I don’t even keep my medical journals after I read them; storage space is an issue.

Before burying traditional print journals and laying out my vision of the on-line journal of the future, let me briefly recount the history of the written epistle. For the last two millennia, letters travelled by foot, horse, train, plane, truck, and/or ship. A letter might take days, weeks, or months to arrive. The U.S. Postal Service was created in 1792, but the letter sorter to speed things up wasn’t invented till 1957. Both FedEx and email were started in the 1970s, but it wasn’t till the 1990s when personal computers became relatively affordable that email became popular. Looking at my mail today, I find that I get about fifty real emails (not unsolicited or spam) for every item that gets delivered in an envelope. Email is how we communicate in 2014. So, what’s wrong with traditional print journals?

Traditional Print Journals Are Slow To Get Information Out. After a paper is presented at a national meeting, it takes on average from six months to two years to get it published. This has to do with the peer-review process, the speed at which authors revise papers, the volume of publication-worthy material, i.e.,  journal size (page count per issue), and the printing and distribution processes.

Alternatively, on-line journals could publish abstracts and full-texts of articles presented and reviewed within days. For ease of handling, each on-line journal could specify its manuscript style. The page count of on-line journals is irrelevant as a there is no cost per page. In other words, unlike print-version journals, more pages do not cost more.  In addition, color photographs cost no more than black & white.

Traditional Print Journals are Expensive to Produce and Distribute. If the circulation of a journal was 10,000, and if it was sold at a price of $250, it would generate a gross income of $2.5 million. Adding $1 million in advertising revenue, the gross income would be $3.5 million. If the costs of editing, typesetting, printing, sales, distribution, administration, etc. were $3 million, the net profit would be $500,000.

On the other hand, the estimated maximum cost of managing a first-rate web-based journal would be less than $100,000, and so if there were only 2,000 subscribers at $100 each, the journal would break even. (In fact, I will soon start a new on-line journal with a budget of $15,000. Hint: Integrated Aerodigestive Medicine.)

If, however, the on-line journal were open to the public—all the abstracts could be viewed by anyone free of charge—the journal might then charge non-subscribers $2-3 for a PDF of each complete article (or perhaps in the form of a mini eBook). Thus, a popular, well-indexed article might generate a huge income. (I personally believe that excess journal profits should be channeled to fund research through an independent non-profit organization. In other words, the journal should not seek to maximize profit as if it were a strictly commercial entity.) The idea of opening up medical journals to the public, to the whole world, is exciting and appropriate. And every article might have a “layman’s synopsis” and a translator, so that absolutely anyone might be able to understand the ideas of every paper.

Traditional Print Journals Are Biased Against New Ideas and Employ a Sometimes-Defective Peer-Review Process. In our world today, conflicts of interest and corruption are common and sometimes even occur within the peer-review process. In my experience, the peer review process breaks down often, and there are several situations for this; if the reviewer has: (1) a personal dislike of, or personal conflict with, an author; (2) a personal bias for or against a certain way of doing things; (3) unwillingness to consider new ideas that challenge the reviewer’s basic understanding of the status quo; (4) the reviewer either misreads or does not understand the author’s subject; (5) a belief that only “evidence-based” papers deserve to be published, even though such articles may be just as flawed as other papers; and (6) a reviewer’s desire to prevent an author’s publication, because the reviewer wishes to publish a similar subject “first.”

The problem is that when a paper gets rejected, there is no rebuttal. Furthermore, what purpose is served by allowing anonymous reviews? I have been a journal reviewer for many years and I would be happy to have had my name at the bottom of every review. I would argue that if a reviewer can’t own up to her or his review, then it is likely that s/he may have a hidden bias.

In the on-line journal of the future, the peer reviews should be shown at the bottom of the article as the first comments in a string of comments. By making the reviewers’ comments the beginning, and not the end, of the paper’s critique, the review process becomes both more transparent and more complete. I suspect that this format would also make reviewers more respectful and objective.

Traditional Journals Are Insufficiently Interactive. If you write a letter to a traditional journal in response to an article, it may appear months later. With an on-line journal, comments might be posted much sooner. I believe that comments should be screened by the Editor and approved and/or condensed before posting. (Comments would be limited to subscribers, and no commercial references or links would be permitted.)

Having an ongoing commentary is exactly what journals need to make them more relevant. The proliferation of ideas and how they hold up to scrutiny over time is the most important task of good journalism in all of its forms.

Since on-line journals are not cramped for space and computer-friendly; they could be organized and cross-referenced by issues, years, authors, topics, and subtopics. There also could be established galleries of pathology. Certainly, another advantage of on-line journals would be having direct links to video-segments.

In summary, on-line journals will expand the influence of important medical ideas; they will encourage communication across different medical specialties; and they will allow for more rapid proliferation and exchange of ideas. Printed journals have had their day. Now it is time for us to move on-line.

Dr. Koufman’s Reflux-Friendly Gluten-Free Diet

Cover 300dpi


I believe that this book is the only source of reflux-friendly and gluten-free recipes


In 2012, I saw a reflux patient with airway reflux who had completed reflux testing and when I was describing the induction (detox) diet, she interrupted to tell me that was gluten-free. At the time, I did not know enough about this topic to say anything useful and so I just asked her to adapt as best she could to a “reflux-friendly gluten-free” diet. Since that time, I have learned a more about food additives and about gluten, and some from personal experience.

Not long ago I went to see my doctor about my psoriasis. (I have psoriasis on my elbows knees hands and face and I’ve had it for many years; unfortunately, it has gotten worse in the last year.) I also have mild hypothyroidism. My doctor pointed out that certain thyroid conditions and psoriasis are probably autoimmune disorders that they sometimes respond to a gluten-free diet. So, I went on a gluten-free, dairy-free, sugar-free diet; and a week later, I noticed some improvement in my psoriasis.

While the relationship between gluten and autoimmune disease is unproven, there is accumulating evidence to suggest the relationship is real.  Here is a link to a nice review article.

A gluten-free diet is a diet that excludes the protein gluten. Gluten is found in grains such as wheat, barley, and rye. While a gluten-free diet is usually used to treat celiac disease, an inflammatory disease of the small intestines, it may play a role in other autoimmune diseases, e.g., psoriasis, arthritis, scleroderma, thyroid disease. It also is believed to be related to some cases of acid reflux. Eating a gluten-free diet may help some people with the above conditions improve their symptoms.

I am providing here for my readers a hybrid diet that takes into account elements of my reflux diet, that is, a low-fat, low-acid, pH-balanced diet with a gluten-free, dairy-free, sugar-free diet. This is, crude as it is, my reflux friendly gluten-free diet. Caveat emptor and good luck!

Switching to a gluten-free diet is a big change and, like anything new, it takes some getting used to. You may also be surprised to realize how many gluten-free products, such as bread, pasta, frozen foods are now available. Specialty grocery stores like Whole Foods sell lots of different gluten-free foods.

What You Can’t Eat

Barley (NB: malt, malt flavoring, and malt vinegar are usually made from barley)
Triticale (a cross between wheat and rye)
Wheat (avoid all unless labeled gluten-free)
Breads (unless they are labeled gluten-free, dairy-free, and sugar-free)
Cakes and pies (unless they are labeled gluten-free, dairy-free, and sugar-free)
Candies (unless they are labeled gluten-free, dairy-free, and sugar-free)
Cereals (unless they are labeled gluten-free, dairy-free, and sugar-free)
Cookies and crackers (unless they are labeled gluten-free, dairy-free, and sugar-free)
French fries
Imitation meat or seafood
Oats (unless labeled gluten-free)
Processed luncheon meats
Salad dressings (unless labeled gluten-free)
Sauces, including soy sauce
Seasoned rice mixes
Seasoned snack foods, such as potato and tortilla chips
Self-basting poultry
Soups and soup bases (unless labeled gluten-free, dairy-free, and sugar-free)
Vegetables in sauce
Avoid food additives, such as malts, starches and medications and vitamins that use gluten as a binding agent

What You Can Eat

Fruit is free of gluten but some fruits are better than others when it comes to reflux. (Acid fruits are best consumed with alkaline water (pH>8.5) or low-fat almond or soy milk)
Apples (red, not green, in moderation, and only after induction)
Apricot (in moderation, and only after induction)
Blueberries (in moderation, and only after induction)
Honeydew melon
Peaches (in moderation, and only after induction)
Pears (in moderation, and only after induction)
Plums (in moderation, and only after induction)
Raspberries (in moderation, and only after induction)
Strawberries (in moderation, and only after induction)
Zest, the outside of lemon, lime, or orange (not the juice or the fruit)

Vegetables are also naturally free of gluten (fresh or frozen vegetables, that is, not canned)
Brussel Sprouts
Green Beans
Onions (cooked, in moderation, and only after induction)
Potatoes (white and sweet)

Meats are always gluten free unless processed, breaded, or fried with breadcrumbs; also avoid gravy as most gravy does have gluten in it. Fish is included here in the meat category.
Beef (in moderation, and only after induction)
Fish (including shellfish, broiled, baked, grilled, but not breaded or fried)
Pork (white pork, pork tenderloin only, in moderation, and only after induction)

Flours and Grains
Almond Flour
Bean flour
Brown rice
Brown rice flour
Corn flour
Corn meal
Corn starch
Pea Flour
Popcorn (without any coating)
Potato flour
Soy Flour
Tapioca Flour
Taro Flour

Other Gluten-Free Foods
Almonds (in moderation, and only after induction)
Baking Soda
Honey (Manuka honey preferred)
Pistachios (in moderation, and only after induction)
Spices (most)
Wine (in moderation; one glass only and only after induction)

New Book: THE CHRONIC COUGH ENIGMA (“Integrated Aerodigestive Medicine” Excerpted)





Any person with an enigmatic chronic cough will tell you that the specialist model of American medicine has failed. In truth, it has failed for a large number of patients and at many different levels. Not only do we have too many specialists, but too many practice so narrow a specialty that often patients receive incorrect, expensive and wasteful medical care.

An illustration of the chronic cough patient’s predicament with the specialist model of American medicine is the elephant in the fable of the three blind men and the elephant:

The first blind man, feeling the leg of the elephant, exclaims, “I can see it clearly; the elephant is like a big tree.” The second blind man holds the trunk and says, “No, the elephant is like a very large snake.” The third blind man grasps an ear. “You are both wrong,” he proclaims, “The elephant is really like a gigantic leaf.” Each blind man embraces a part of the truth, but none understands its entirety.

In the case of chronic cough, the three blind men are the three medical specialties: (1) the otolaryngologist (ENT, the ear, nose, and throat physician); (2) the gastroenterologist (GI physician); and (3) the pulmonologist (PUL, chest and lung specialist).

The problem is not just ignorance. Today, many doctors behave more like entrepreneurs than healers. Each “profit center” attempts to maximize income by manipulating the medical billing and coding system. Indeed, most medical professional societies offer their physicians advanced training in coding so that they can effectively maximize income.

It is worse than you think. Today in most hospitals, coding specialists routinely make patient-care rounds with the doctors to insure that no code goes unbilled. The idea is that hospitals want to absolutely maximize possible income. And yes, they stretch the truth a lot every day to do so.

Conflicts of Interest and Corruption Are Why Healthcare Is So Expensive

The needs of patients have been lost in a healthcare system dominated by for-profit corporate medicine characterized by conflicts of interest, price fixing, and corruption.

In 2012, I had back surgery, a L3-L4-L5 fusion. I now have two titanium plates and six screws in my back. The hospital billed $111,000 for the hardware alone; unbelievably, it actually was $15,000 per screw. (I know for a fact that you can purchase an excellent quality titanium screw at Home Depot for under a dollar.)

The punch line is not that hospital billed so outrageously, but that my insurance company (United) paid them $146,000 for my surgery ($99,000 for the hardware) and that didn’t cover professional fees. My surgeon charged $117,000, and I believe that he received $104,000. Meanwhile, I am still being billed by the hospital and the surgeon; both want more money.

The total bill for the surgery was $260,000. In Sweden comparable surgery costs about $10,000. One might reasonably ask where the other $250,000 went.

Returning to chronic cough and reflux, there is corruption in endoscopy. Many doctors have profound conflicts of interest because of ambulatory surgery centers. ASCs are big business. Typically, a doctor negotiates an ownership position in an ASC with the understanding that s/he will perform a certain number of procedures, say 1,000 per year, at that ASC. Conflict of interest?  The return on investment is astonishing!  One GI from New York happily informed me that his annual income from his ASC was $800,000.

Last year, there were 10 million sedated endoscopies performed in the U.S. at a facilities fee cost of $10 billion, that is, an average of $1,000 per procedure. And that does not include the professional fees of the gastroenterologist, anesthesiologist, and pathologist.

Also questionable, when GIs perform upper endoscopy for reflux, they routinely examine the entire upper GI tract and perform biopsies. Why? Is it because EGD (esophagogastroduodenoscopy) with biopsy pays much more than a lesser procedure or a procedure without biopsies?

When it comes to non-pulmonary chronic cough, pulmonologists also appear to be inefficient and wasteful. When a patient comes to a pulmonologist with any type of reactive airway disease or shortness of breath, the doctor will usually perform pulmonary function tests (PFTs). S/he may also perform bronchoscopy, endoscopy of the airway and lungs, but these doctors are not trained to examine the throat. When it comes to silent airway reflux, the usual result is misdiagnosis and incorrect treatment.

Most pulmonologists diagnose asthma in all cases of reactive airways disease, because they apparently cannot differentiate inspiratory, airway reflux-caused reactive airway disease from true asthma characterized by expiratory wheezing. The misdiagnosis of asthma is costly. No one knows exactly how much; however, asthma medication costs $56 billion annually in the U.S. See Chapter 7: Asthma that Isn’t Asthma.

Otolaryngologists should be able to examine the larynx (voice box) and throat, but they are generally handicapped by outmoded instrumentation and inadequate training. Thus, most ENTs can neither accurately diagnose nor effectively treat airway reflux.

Perhaps the greatest waste due to inaccurate diagnosis in the otolaryngology area is sinusitis. Many patients come to me after having had multiple unsuccessful sinus surgeries, still suffering the same symptoms. Yes, again it’s airway reflux. Nocturnal (nighttime) reflux in particular can cause sinus symptoms, the most common of which is post-nasal drip.

The typical chronic cough patient who comes to see me has been coughing for more than a decade and has already seen more than a dozen physicians (ENTs, GIs, PULs, allergists, etc.).  One patient who had been coughing for 20 years reported that he had seen 34 doctors, some from four major medical centers, before seeing me.

Restructuring Healthcare

Where did this excessive, inefficient, and unnecessarily expensive medical mess come from? The healthcare industry has shown a strong propensity to chase funding. When Medicare agreed to cover renal dialysis, for example, thousarnds of new dialysis centers quickly sprung up. (Remember, U.S. healthcare is private industry, but much of it is paid for by the government, e.g. Medicare, Medicaid). A big part of the problem is lack of accountability. There is little or no objective scrutiny in healthcare.  What do we get for our money?  Fifteen-thousand dollar a piece screws?

Specialist medicine has proliferated in part because Americans want to have “the best.” They like seeing the best doctors just as they like seeing the best sports teams. The problem, however, is what doctor to see when your self-diagnosis is wrong? The best at what?

Furthermore, while the idea of seeing the “best doctor” is appealing, there is no such doctor when it comes to non-pulmonary chronic cough, silent airway reflux and vagally-mediated neurogenic syndromes.

Today, people are skeptical and cautious, and at this point consumer confidence cannot be restored by the marketing claim, “We are the best.” Patients are rightly mistrustful of the current healthcare system.

People no longer believe that healthcare providers necessarily have their best interests at heart. It is now clear that patients must be their own advocates and that for-profit medicine leads to more attention to gain and less to quality patient care.

We pay almost four times more than any other civilized country for healthcare, and we rank 37th in quality of care. Last year, the price tag for U.S. healthcare was $2.7 trillion. Strip away the excesses and the price would probably have been closer to $700 billion ($0.7 trillion). That’s a lot of excess!

We need a healthcare system that is less fragmented and self-serving. Specialists often do what they do well, but nothing more.

If chronic cough, airway reflux, reactive airway disease, and (vagal) neurogenic syndromes are so prevalent—almost one-out-of-five (18%) Americans has airway reflux3 and falls into one of the above categories—then the current system is wasting massive healthcare dollars on inappropriate diagnostics and ineffective treatments.

Maybe we don’t need so many gastroenterologists, pulmonologists, and otolaryngologists. Maybe we need doctors who take better care of the whole patient with aerodigestive diseases. Reflux is the tip of an appalling iceberg.Integrated Aerodigestive Medicine

I have practiced integrated aerodigestive medicine for thirty years now. What does that mean? I am part otolaryngologist, but I know the parts of otolaryngology that most otolaryngologists don’t know. I am part gastroenterologist, but I know the parts of gastroenterology that most gastroenterologists don’t know. And I am part pulmonologist, but I know the parts of pulmonology that most pulmonologists don’t know.

I don’t practice all aspects of aerodigestive medicine, and I know my limitations. I have almost nothing to do with the liver, colon, heart, teeth, sinuses, etc.

I am an expert in the vagal system, and that includes the whole airway and the whole digestive tract. And yes, all of these parts are connected anatomically and functionally.

As I have become well known as an airway reflux expert, with expertise in non-medical treatment (namely, diet and lifestyle), more and more patients with esophageal reflux (GERD) have come to see me.

A common story is, “I had endoscopy, and I was told that I had Barrett’s esophagus. I was given a pill and told to come back in a year.” Apparently, most GIs think that the only treatment for reflux, no matter how severe, is a purple pill (PPI).

Unlike anatomic (organ-specific) medical specialties, integrated aerodigestive medicine is system-driven and symptom-driven. It combines elements of all of the overlapping aerodigestive tract medical specialties with a special focus on the diagnosis and treatment of airway reflux.  Further, as a preventative approach to wellness, integrated aerodigestive medicine emphasizes dietary health, lifestyle education, and behavior modification.

The aerodigestive tract must be treated as a unified system for which physicians are trained. In addition, precision diagnostics (e.g., laryngeal electromyography, airway reflux testing) are the key to accurate diagnosis, and at present, few physicians perform any, let alone all, of them.

So, if integrated aerodigestive medicine is a new “specialty,” who should see such a physician, and for what?  Shown below is a list of common integrated aerodigestive medicine symptoms.Here is a list of aerodigestive symptoms: allergies, asthma, burning tongue, chest pain (non-cardiac), choking episodes, chronic cough, chronic throat clearing, COPD (chronic obstructive pulmonary disease); difficulty swallowing, esophageal spasm, excessive throat mucus, food getting stuck, globus (a lump-in-throat sensation), heartburn, hoarseness, indigestion, laryngitis, laryngospasm, nausea, painful speaking (odynophonia), paradoxical vocal fold movement, post-nasal drip, regurgitation, shortness of breath, sinusitis, sleep apnea, throatburn, vocal cord dysfunction, vocal fatigue, vocal nodules and polyps, voice breaks, wheezing

The idea that people with these symptoms need to be seen by a committee of different specialist, one for each problem, makes no sense, particularly since reflux and vagal dysfunction are responsible for most.

For people who don’t have chronic cough but have another reflux-related or neurogenic symptom, you could read this by substituting painful speaking or burning throat for chronic cough and the information and approach will still be relevant.

A doctor practicing integrated aerodigestive medicine, as I do, must have certain skills and diagnostic technology: (1) Ability to obtain and interpret high-definition examination of the nose and throat (transnasal videostroboscopy) with still imaging; (2) Ability to diagnose subtle vocal fold paresis; (3) Ability to calculate an accurate reflux finding score;(4) High-definition esophageal manometry; (5) Ambulatory, double-probe, 24-hour (simultaneous esophageal and pharyngeal) pH monitoring; (6) Laryngeal electromyography; (7) Transnasal esophagoscopy; (8) Pulmonary function testing.

Let’s remember, the vagus nerve is the nerve of the entire aerodigestive tract. I am a doctor of the vagus, and therefore I am a doctor of the aerodigestive tract. I do not, however, practice medicine in a vacuum. I have a team of colleagues to whom I refer when appropriate.

It is a big team because I understand that I have limitations. I am not a sinus surgeon and sometimes one is needed; I am not a pulmonologist and sometimes one is needed, and so forth. No less than 25 stacks of business cards sit on my windowsill for those colleagues to whom I refer patients. They form a network designed to enable me to provide comprehensive care for my patients.

My aerodigestive medicine team: acupuncture, allergy, audiology, cardiology, dentistry, endocrinology, gastroenterology, general surgery (for antireflux surgery), internal medicine, otolaryngology, psychiatry, pulmonology, and speech-language pathology.

I refer to all of those professionals as appropriate, but I remain in charge of the overall health and well-being of my patients. I am the quarterback of the team. I call the plays and I insure that we doctors communicate for the benefit of our patients.

In the future, residency programs in integrated aerodigestive medicine will focus on chronic cough and other aerodigestive symptoms with the understanding that reflux plays a huge role in the severity of disease, and that environmental, dietary, infectious, neurogenic, inflammatory, and emotional factors act together. All must be considered as part of the problem, and the solution should be seen as unique for each individual patient.

In my opinion, a major overhaul of the healthcare system is needed. Health is not a commodity and should never be treated as such. Restructuring the American healthcare system will require a compassionate and un-corporate new paradigm. Integrated aerodigestive medicine provides an excellent model of efficient restructuring.





SILENT Reflux Causes Throat Cancer

The whitish lesion is a small vocal cord cancer in a refluxer (life-time non-smoker). The rest of the voice box shows findings of reflux laryngitis.

A recent epidemiologic study reported in the New York Times showed a statistical relationship between heartburn and throat cancer; the authors reported a 78% increase in throat cancer in refluxers with heartburn.

I have spent 35 years studying reflux, particularly the silent type, that is, acid reflux occurring without heartburn. Silent refluxers have symptoms such as hoarseness, chronic throat-clearing and cough, difficulty swallowing, post-nasal drip, and asthma-like symptoms. (See also my Silent Reflux post. Indeed, in 1991, I published data from a serries of 31 patients with throat cancer; 84% had documented reflux, but only 33% had heartburn.

Here below is an excerpt from Dropping Acid: The Reflux Diet Cookbook & Cure on the relationship between reflux and throat cancer.

Reflux and Cancer

One of the most frequent questions patients ask is whether reflux can cause cancer. I believe the answer is an emphatic yes. That is part of the reason this book is so concerned about the acidity of today’s typical diet.

We have not yet proven that reflux causes laryngeal and vocal cord cancer, but there is strong circumstantial clinical evidence along with bench research to support it.1,7,9,39,114,119-124 We believe that one can get laryngeal cancer without smoking, but not without the presence of reflux.4,39 This section presents six arguments to support this concept

1. Many patients with laryngeal cancer are non-smokers or ex-smokers. We prospectively studied 50 adult patients with early vocal cord cancer.9 Of them, 44 percent (22/50) were active smokers, 42 percent (21/50) were ex-smokers with a median duration of smoking cessation of eight years, and 14 percent (7/50) were lifetime non-smokers. Using pH monitoring, we found that 68 percent of the patients had reflux, almost twice as many as those who were actually smokers. And remember, in the study group, there were seven lifetime non-smokers.9

2. Some people get recurrent, small, reflux-related vocal cord cancers that are periodically removed with a surgical laser. We’ve seen many such cases over the years. Significantly, almost half of those patients stop making cancer when their reflux is controlled. The same is true for patients with pre-cancers called dysplasia and leukoplakia.1,114

3. When different groups of patients are tested for reflux, including those with cough, sore throat, etc., the highest proportion of those demonstrating reflux are the cancer patients. In 1991, we reported abnormal reflux testing in 84 percent of patients with laryngeal cancer, five of whom were lifetime non-smokers.1

4. We compared the reflux (pH) testing results of smokers and non-smokers and found that smokers had twice as much reflux, both in the esophagus and the throat. Cigarette smoking is specifically associated with relaxation of the upper and lower esophageal valves within two minutes, and reflux episodes occur with two-thirds of cigarettes smoked.55,138

5. Our laboratory has examined the impact of reflux on a cellular level in human patients and in animal models and found tremendous similarities in the larynx between patients who have LPR and patients who have cancer. Of those studies, the most important was an analysis of biopsies for the presence of pepsin within the laryngeal tissue. Pepsin was found in 5 percent (1/20) of normal controls without reflux. On the other hand, 95 percent of LPR patients with reflux into the throat had pepsin in their laryngeal biopsy tissue, and 100 percent (5/5) of laryngeal cancer patients tested had pepsin within the cancerous tissue.39,47,55 In addition, extraordinary landmark experiments in cell biology by Nikki Johnston et al. 42,47,48,51.53,54,124 showed that pepsin up-regulates the genes that cause cancer in a way that suggests that pepsin is actually the cause of laryngeal cancer.124

6. There are similarities between laryngeal cancer and esophageal cancer. We have shown the presence of pepsin in reflux laryngitis by a special staining technique. In addition, using biopsies of patients with reflux and laryngeal cancer, we have shown that both have similar protein profiles except for one stress protein, HSP70.4,39,47-49

As previously mentioned, esophageal cancer is the fastest growing cancer in the United States, up 850% since the 1970s. We are also finding Barrett’s Esophagus, a known reflux-related form of pre-cancer, in approximately 7 percent of our LPR reflux patients.33,44,52 It is striking and significant to note that Barrett’s Esophagus is found just as often in ENT patients with silent reflux (symptoms of coughing and hoarseness) as in GI patients with heartburn.134

In summary, there is clinical and scientific evidence that reflux, mainly pepsin, may cause cancer of the larynx and esophagus.

One of our biggest concerns is that a huge population of Americans is potentially at risk to develop cancer, and that we have no methodology for identifying the most susceptible. As clinicians, we can certainly say that we are seeing increasingly more and more reflux in increasingly younger patients; in our opinion, this is an ominous warning sign.

We regret that we cannot prove all of our assertions and beliefs just yet. However, our data and clinical impressions deserve to be in the public domain so that other researchers and clinicians can investigate the relationships we’ve presented. We believe that diet is the missing link and that our diet may be killing us and it is time for us to aggressively explore these variables and fix them.

By the way, people who are rightfully worried about cancer deserve to be checked. The technology has changed. Doctors can now look inside while patients are awake, comfortable, and without pain, using a technique called transnasal esophagoscopy.29,33,58,134 The idea that you can only be checked for cancer in a special facility and under anesthesia is archaic.

(If you are interested in the references, they may be found in Dropping Acid on pages 177-185.)

Excerpted from Dropping Acid: The Reflux Diet Cookbook & Cure (by Jamie Koufman, M.D.)

When Stupidity & Greed Collide

Standing in front of this corndog and fried food refluxitorium, Larry the Cable Guy tells us to take one Prilosec in the morning and be heartburn free all day long. He implies that if you take AstraZeneca’s purple pill, you can eat anything you want.

Nothing could be further than the truth. In fact, this strategy—cover up the heartburn but don’t control the disease—is probably why acid-reflux-caused esophageal cancer is the fastest growing cancer in the United States, up a whopping 850% since the 1970s.

Purple pills may stop some symptoms but have little or no effect on the progression of the disease. I should know; I am one of the world’s experts on reflux, and virtually every patient who comes to see me with complications of reflux is already on a purple pill, so in truth they don’t work very well.

Purple pills don’t control reflux! They just cover up its more serious manifestations.

The purple pills are a class of drugs called PPIs (proton pump inhibitors). They do not stop reflux, and they never should have been allowed (by the FDA) to be sold over the counter. Here’s why. After people take a PPI, they may feel better. But when they quit taking the PPI, they get rebound hyperacidity. That’s right, when you quit taking purple pills, you make more stomach acid than before. And so sales of purple pills escalate in a vicious cycle: You have heartburn and take purple pills—get some relief—then you stop purple pill—have rebound (worse acidity than before) —then you have to start taking the pills again. Wow! What a great strategy for the greedy drug companies that make the purple pills.

Much safer (and without the rebound hyperacidity) to take on an as-needed basis are the H2A class of drugs, including ranitidine (Zantac) and famotidine (Pepcid). PPIs should be taken under a doctor’s supervision, and when the patient is ready, tapering of the PPI should be done using H2As.

Fact is, the only really effective, long-term treatment of acid reflux is through a healthy diet and lifestyle. Overeating and overdrinking are key factors, and high-fat, high-acid foods are poison. I have written a lot about this topic in this blog and in my New York Times best-selling book, Dropping Acid: The Reflux Diet Cookbook & Cure.  Click here for more references on my reflux work

When stupidity and greed collide? Wake up America; what you eat may be eating you!