Jamie Koufman, MD, FACS, Director and founder of the Voice Institute of New York, Clinical Professor of Otolaryngology at the New York Eye & Ear Infirmary of the Mt. Sinai Medical System talks about silent reflux.
Interview conducted by Ivanhoe Broadcast News in July 2018.
How long have you been in practice?
Dr. Koufman: I went in practice in 1978. I have an interesting story about that. I was going to be a general surgeon, but I heard this doctor was doing laser surgery; and actually, he was the pioneer of the laser for use in otolaryngology. When I finished my residency in 1978, I became the first young laser surgeon in the country. That’s how I decided to become a laryngologist. My first set of cards said specializing in laryngology and the voice. And by the way, my real area of expertise became acid reflux, particularly “respiratory reflux,” that is, reflux that affects the respiratory tract.
For our viewers who have heard of acid reflux but they don’t have any experience, what is acid reflux? What are people feeling and what’s happening?
Dr. Koufman: Acid reflux is more than one thing and it’s often not obvious. Although people see heartburn and indigestion advertisements on TV, and by the way those symptoms are rather obvious, more important is respiratory reflux, or reflux when acid and other stomach stuff comes up in to the throat. Respireatory reflux is often silent, occurring at night, associated with allergy-like symptoms, sinus problems, and breathing problems particularly asthma-like symptoms. Reflux, especially silent reflux can affect the respiratory tract and cause any and all respiratory symptoms … and that’s the biggie.
What’s causing it?
Dr. Koufman: What causes acid reflux is unhealthy diet and lifestyle. I was watching a movie last night, “Forks over Knives,” which is a film about food — and it’s amazing how much the American diet has changed in my lifetime. My mother put dinner on the table at six in the evening and we didn’t have any fast food we didn’t have any soda machines. We ate pretty much all clean and there weren’t all these diseases. All the chronic diseases of our time are related to our unhealthy diet.
Tell me about the symptoms with the silent reflux, are they different than when it is truly acid reflux, the heartburn and symptoms that people associate with reflux?
Dr. Koufman: When people say reflux, acid reflux they think of heartburn and indigestion. We now have looked at a large series of patients, and only twenty percent of our patients ever have heartburn or indigestion. So that means the rest of them have other things. What do they have? Hoarseness, a sensation of a lump in the throat, too much throat mucus, chronic throat clearing, chronic cough, sinus symptoms, allergy-type symptoms, nasal congestion, and it goes on and on and on. Almost anything in the respiratory system can be caused by reflux, and most people who have breathing problems have respiratory reflux.
How can people tell what it is that they’re dealing with? Most people think, oh its asthma or a cold, do they not?
Dr. Koufman: The problem with the idea that its asthma or a cold is that the symptoms don’t go away. And even after the asthma is treated, they continue to have the same old symptoms. Maybe the inhaler helps a little bit, with reflux if there is an acute event and the breathing gets acutely worse. But the truth of the “asthma” matter is that if you trouble breathing in, not out, it’s not asthma; it’s reflux. Asthma is associated with only trouble during exhalation. The millions of people with a diagnosis of “asthma” who have trouble breathing have reflux.
What’s happening that we’re not feeling it in the stomach? You said its reflux that goes to the throat. Can you describe physiologically what’s going on?
Dr. Koufman: First of all one of the things that differentiates how I think, is reflux is fixable, reflux is not a chronic disease. And reflux is silent. So the more you reflux the worse your lower valve works. That’s the one that connects the stomach and the swallowing tube or esophagus. And then, the more you reflux. Then the esophagus starts to get sick. And then there’s an upper valve, believe it or not there’s a valve up in the throat, and that valve kicks out. So now when you lie down at night you’re at the Holland tunnel with no tolls, not even an E-ZPass. What is in the stomach, is in the esophagus, is in the throat, and it sits there at night. And by the way, the number one risk factor for reflux of this type is eating too late, and over eating, too. So many Americans don’t eat much breakfast; they grab a sandwich for lunch; they leave work and they go to the gym to workout or they have childcare responsibilities or whatever. And then, they come home and they go to the trough, if you will, at eight o’clock at night. Then, they lie on the sofa to watch the news. And maybe after a while, they get up and they have some ice cream. They’re already refluxing by the time they go to bed. Some people have symptoms, they go “I start clearing my throat or I have you know a sensation of a lump in the throat or something else.” But all those respiratory symptoms are not-so-obviously reflux, but reflux it is!
Why is this not diagnosed so often or misdiagnosed?
Dr. Koufman: It is both under-diagnosed and misdiagnosed, because specialists are too specialized. The gastroenterologists hijacked reflux. They said. “Reflux is heartburn; heartburn is reflux; it’s esophageal, and we own it.” And when they did that, the poor ENT doctors, lung doctors, and allergy doctors didn’t have any way of diagnosing reflux. Here at the Voice Institute of New York we’ve had maybe a hundred thousand patients with this and in the forty years of my practice, maybe two-hundred thousand. I actually look inside the patient with a small instrument, and I can say, “You have reflux. You reflux during the day, you reflux during the night, and by the way do you snore, do you have sleep apnea, do you have sinus symptoms?” So looking carefully on the inside if you’re experienced you can make the diagnosis. And this is an ENT doctor by the way, not a GO doctor.
Is there a danger in not having this diagnosed?
Dr. Koufman: Is there a danger in not having this diagnosed, you bet. We see people with severe lung diseases. I’ve taken patients out of the line to have lung transplants and fixed their reflux, and stopped the progression of the lung disease. I have patients who were coughing up blood with chronic bronchitis, stopped their reflux and the bronchitis went away. So we’re even talking about severe lung disease here, and we’re talking about cancer, too, not just esophageal cancer, but throat cancer and lung cancer are also related to reflux. Over the course of my career I’ve seen a lot of patients with cancer who never once smoked a cigarette.
What are the treatments?
Dr. Koufman: Well the purple pill ship has sailed. There is now a tremendous amount of data that the class of drugs called proton pump inhibitors (PPIs) are dangerous. They’re associated with everything from depression, kidney disease, bone loss, Alzheimer’s, heart attacks and increased risk of esophageal cancer, and death. So the treatment now is the use of H2-antagonists, which is a safe class of acid-suppressive medication; there are three available in this country, Pepcid, Zantac, and Tagamet. We even use H2As in pregnancy, particularly for the night time refluxer. We load them up; one before dinner, and two before bed. Importantly, we would like people who’ve got bad nighttime reflux to eat really, really early, and go to bed sleeping on a forty five degree incline for a period of a month. As well as modify the diet, no alcohol, nothing out of a bottle or a can except water. My first book is called “Dropping Acid” for a Good Reason. The most acidic thing we have is soft drinks. And the manufactures put acids in there, the same acidity as stomach acid by the way, the same pH to kill bacteria. You’ve never heard of anybody getting E-coli from drinking a diet soda? We put them on a detox diet. Remember, we make them eat really early (like 5-6 p.m.), and we elevate the bed a lot, maybe even they sleep in a recliner for a month.
What kind of difference are your patients feeling after the combination of lifestyle, diet change?
Dr. Koufman: We fix reflux, I look patients in the eye and I say to them, and people with servere respiratory disease, people who can’t breathe, people can’t even get up the steps I tell them, “You won’t need me after a year; you won’t be on reflux medication; and my goal is for you to live to be a healthy old man or old lady. The whole idea that diet and lifestyle are the key to longevity and the key to health is a relatively let’s just say, not mainstream medical approach at this point.
What are a couple of the things that people who see this and think they might have the problem what can they think of, how can they tell from their symptoms whether or not this might be an issue for them?
Dr. Koufman: Respiratory reflux: what’s characteristic is that people with it have many symptoms including post-nasal drip, chronic throat clearing, a sensation of a lump in the throat, hoarseness, may be worse in the morning), cough, and shortness of breath. They went out last night and had a big night out and they wake up in the morning and they’re chugging trying to get up out of the subway because they’re short of breath. It’s really a constellation of symptoms and not one thing; whereas other diseases are usually just one symptom. Allergies for example are seasonal. You know, you go by the ragweed stand by the river, and you’re eyes itch, and you start sneezing, and you’re using Kleenex like nobody’s business. So the combination of many respiratory tract symptoms, often requiring multiple specialist visits, is characteristic of respiratory reflux.
Is there anything I didn’t ask you in terms of acid reflux, silent reflux for adults that you want to add?
Dr. Koufman: Yes. I want to make a couple of quick points about respiratory reflux. It’s acid reflux that comes up in to the airway is usually silent, that is, there’s no heartburn. And the reason it is “silent” is that it occurs at night while people are sleeping. So eating too late particularly with alcohol and overeating are the main risk factors for respiratory reflux. So, that’s something that people can address. I think it’s important to realize that respiratory reflux is undiagnosed and undertreated because of over specialization. The doctor who looks at the lungs doesn’t have a test to see if it’s reflux coming up in to the throat and the lungs. The allergist doesn’t have a test to know whether reflux is coming up in to the nose or throat, and the GI doesn’t have a test to tell whether reflux is coming up into the respiratory tract either. Respiratory reflux is a big huge black hole. In my opinion, we waste two hundred billion dollars a year to get reflux wrong.
Do you have an estimate of how many people have this and have not been diagnosed?
Dr. Koufman: We do. We did a study called the “Times Square Study” in which we sent interviewers in to Time Square, and they were comprehensive interviews they weren’t little check boxes. We found that twenty percent of the population had traditional reflux, meaning heartburn, indigestion, and another twenty percent had respiratory reflux. So, forty percent of the American population had reflux. I believe that it’s gone up since that time. When I give talks, I ask the audience if they have respiratory reflux symptoms, and half to two-thirds of the audience raises their hands. So yes, it’s a big deal.
I wanted to talk about this problem in kids. Is it much more prevalent now than it was ten, fifteen, twenty years ago?
Dr. Koufman: When I grew up everyone wasn’t sick. I remember having an ear infection once it was the worse pain I ever felt. Now, if you go to a playground, if you listen, every child is hocking, hoarse, congested, or coughing. Most children today are born healthy, but by age three, they’re all sick. It’s the food. And so if you’re giving your child a bedtime snack of ice cream or cookies and chocolate milk, your child is going to have reflux. Respiratory reflux is the great masquerader of our time, and it affects millions and millions of children. Low-income family children are even more likely to be affected because of the quality of the food that may be available and affordable. Reflux is a public health crisis among children. The misdiagnoses and the amount of medicine they’re receiving to not get their reflux fixed is incredible.
What in your mind is especially important to get it right and get it fixed early?
Dr. Koufman: Children will get diabetes, obesity, and lung disease early. Actually, the worse our diets become, the worse reflux has become at an earlier age. We see children that are obese by age four and five. Also, Americans are addicted to sugar, but the sugar is not the whole story. The sugar is the Trojan horse that lets you in, but it’s all the fat and everything else in those cookies, in that ice cream, that cause obesity and all the other chronic diseases that are associated with it. And our portions are unbelievable. All you have to do is go to a fast food restaurant, and realize that the “super size” is not a good thing.
Is there an age onset for reflux for kids?
Dr. Koufman: I think between age two and three we’re beginning to see symptoms on a regular basis. These children have chronic runny nose, they look like they always have a cold. And recurrent ear infections are rampant; the kids have already had tubes. Somebody wants to take their tonsils out. They’re already on asthma medication or allergy medication or both. I think really we’re seeing this now in the two-to-three year olds, and is as early as you can get. I mean you’ve pretty much gone from breast feeding and formula to soft food; and all of a sudden kaboom, our fast-food kids are sick.
For our parents who are watching give me again some symptoms that they should watch for in their children to make them think that maybe this is something that needs to be addressed and not just a cold or allergies?
Dr. Koufman: If your child always has respiratory symptoms, be it ear symptoms, nose symptoms, cough symptoms, breathing symptoms, allergy symptoms, sinus symptoms, asthma and they’re not getting better … and it goes on and on, think respiratory reflux.
And what do parents do from there?
Dr. Koufman: Well start to educate themselves. Iif you think your child might have reflux, we’ve got a new book out, “Acid Reflux in Children,” which has some quizzes that you can fill out. But here’s a good story. I had a woman who used to work for me who had a child with asthma, a seven-year-old. And she’s not coming in this morning, because they were in the hospital last night with the child’s “asthma.” I convinced her to stop giving her child bed time snacks, and the asthma went away. So if your child likes junk food, limit it to junk once a day, not all day every day. After dinner, have dessert, then bath, then reading and homework, or TV, and then bed, so there’s at least an hour and a half or two hours between the evening meal and bedtime. This would make a big difference to the health of a lot of our kids.
Is there anything I didn’t ask you especially with the book coming out that you want people to know?
Dr. Koufman: I think that acid reflux in children is the biggest silent epidemic we have. It is so pervasive. And the idea that we’re going to have to think carefully about our diet and start limiting things like fast food, juice, chocolate milk, and all of that kind of thing, is a paradigm shift. It’s really something that a parent is obligated to do. Look at your child’s diet.
I know parents are hesitant to put kids on medication, is this something that short term medication is the best way?
Dr. Koufman: Generally speaking when children are put on medication, they stay on the medication for weeks, months, or even years. To me, that is a red flag. Think outside the box and think respiratory reflux. Your doctor may not be able to diagnose respiratory reflux, but you can. If you look carefully at the symptoms and the amount of information that we’ve provided — I have written four books on reflux for the genereal public — you can make your own diagnosis, and then perhaps fis it, or at the least, have a conversation with your doctor.
Is there anything else you’d like to add?
Dr. Koufman: Parents have the power to intervene and make their children and themselves healthy. Fixing the reflux problem and all that it entails requires a family effort. You can’t come home at eight-thirty and start dinner, and expect your child not to have reflux. So dietary planning, you know, less fat less sugar, less juice, etc. And in my family, we put a big huge pitcher of water out for dinner. All the kids and grandkids drink water.
END OF INTERVIEW
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