Singers strive to maintain a well-oiled machine that we can depend on, especially when the vocal demands get high.
A balanced diet rich in protein and vegetables is considered optimal for general health. We want to keep healthy for optimal brain function, energy and stamina. However, can there be such a thing as too many carbohydrates? Atkins diet made it chic to ditch these back in the early 2000’s, but new research from 2018 Wu et al , has shown that more acid reflux symptoms are found if people who have GERD consume a high carbohydrate diet. Also, according to Fox et al , higher fat diets increased frequency of reflux symptoms This has led to singers ditching carbs and avoiding everything that might lead to reflux.
But Does Reflux Really Mess Up My Voice?
While refluxing any stomach contents may be uncomfortable, does it really cause problems to your vocal folds? According to Randhawa et al 2010 , very few studies have shown correlation between improvement of LPR (LaryngoPharyngeal Reflux) and an improvement of vocal issues. In fact, three times as many dysphonia patients showed allergy when compared with LPR. This means making reflux better did not necessarily make hoarseness go away. Schneider et al 2016, also found weak association, at best, with reflux causing hoarseness. So does LPR really cause vocal problems?
Reflux is Easy to Misdiagnose
Randhawa’s study suggests that LPR may be misdiagnosed in patients who truly have allergic laryngitis, and that people are being placed on PPI’s (Proton Pump Inhibitors like Nexium and Prilosec) all too often. We also need to consider the correct diagnosis of LPR. It is highly subjective, according to Ryan Branski et al 2002, making it likely that an LPR diagnosis may happen even if the patient doesn’t truly have it. Signs that are “hallmarks of LPR” visible on a flexible scope are also found in 70% of people who definitely do not have LPR, according to Hicks et al 2002.
A Practical Diet Decision
So as a vocal performer, should I really steer clear of tomatoes, pizza, onions, spicy foods? Looking at these studies, it does not appear that hoarseness is directly caused by reflux. Pachydermic tissue (or elephant-like skin) in the back of the voice box is an interesting finding in many patients I see for voice issues, but it is unlikely the cause of their dysphonia, as that tissue isn’t the part that vibrates during phonation. If these types of foods make me feel bloated, want to burp (especially in the close vicinity of other performers) I would steer clear immediately prior to a show.
Of course, there are other voice problems beyond dysphonia. One symptom of reflux is globus sensation. This is the feeling of something in your throat, like mucus. Globus Sensation can lead to excessive throat-clearing which can irritate or cause swelling in the vocal folds.
It’s a Wrap.
I think that since the relationship between reflux and hoarseness is not well understood, we have taken a stance of overprotecting. While it’s hard to harm this way, it may drive the search away from what is truly the issue with a person’s vocal problems. This may also make people keen to avoid certain things and become common-place rule without true evidence to back it up. My advice? Read the research, seek second or third opinions in your care providers, and stay well-informed as someone who is a professional voice user.
-Branski RC, Bhattacharyya N, Shapiro J. The reliability of the assessment of endoscopic laryngeal findings associated with laryngopharyngeal reflux disease. Laryngoscope. 2002;112:1019–24.
-Fox M, Barr C, Nolan S, Lomer M, Anggiansah A, Wong T. The effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms. Clin Gastroenterol Hepatol, 2007, Apr:5(4):439-44
-Hamdan AL, Sibai A, Ramen C. Effect of fasting on voice in women. J Voice 2007, Jul; 21(4): 495-501.
-Hamdan AL, Ashkar J, Sibai A, Oubari D, Husseini ST. Effect of fasting on voice in males. J Otolaryngology 2011, Mar-Apr; 32(2): 124-9.
-Hicks DM, Ours TM, Abelson TI, et al. The prevalence of hypopharynx findings associated with gastroesophageal reflux in normal volunteers. J Voice. 2002;16:564–79. [PubMed]
-Schneider GT, Vaezi MF, Francis DO. Reflux and Voice Disorders: Have We Established Causality? Curr Otorhinolaryngol Rep. 2016, Sep; 4(3): 157-167. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5283836/
-Randahawa PS, Mansuri S, Rubin JS. Is dysphonia due to allergic laryngitis being misdiagnosed as laryngopharyngeal reflux? Logoped Phoniatr Vocol. 2010. April; 35(1): 1-5.
-Remier, Christina & Bytzer, Peter. Management of laryngopharyngeal reflux with proton pump inhibitors. There Clin Risk Manag., 2008 Feb; 4 (1): 225-233.
-Wu KL, Kuo CM, Yao CC, Tai WC, Chuah SK, Lim CS, Chiu YC. The effect of dietary carbohydrate on gastroesophageal reflux disease. J Formos Med Association. 2018, Jan 12.
Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.