Dietary Management of Eosinophilic Esophagitis

Three Diets to Help Manage Your Eosinophilic Esophagitis

Esophagus
Esophagus. Science Picture Co/Getty Images

Eosinophilic esophagitis, or allergic esophagitis, has become recognized as disease of the esophagus that is emerging in prevalence or at least more readily identifiable. In eosinophilic esophagitis, the lining of the esophagus becomes inflamed and examination of the lining shows a high cell count of the white blood cell eosinophils. Eosinophils are found in relation to allergies and are not typically found in the lining of the esophagus.

Common physicians involved in your care can include a gastroenterologist or an allergist. While there are medications like inhaled corticosteroids to help with the treatment of eosinophilic esophagitis, there is growing support for using dietary changes to help with symptom management. There are 3 main diets being used to help support management of symptoms include the elimination (at varying degrees) of allergen-containing foods that may be causing a hypersensitive reaction in the esophagus.

Allergy Test-Directed Elimination Diet

Of the three diets discussed in this article, the allergy test-directed elimination diet offers the most flexibility by trying to limit foods based upon foods that you have a known allergy. Allergies are confirmed by performing both skin prick testing as well as atopy patch testing. Both tests are performed to increase the accuracy of the allergy. Foods that cause a reaction are eliminated from the diet in addition to the removal of cow’s milk (as people have a high risk of having an allergy but having a negative result).

Despite the desire to utilize this method, it has only been proven to be effective in less than 50% of the studied cases. This may be a result of have test results from extracts turn out negative that are actually positive when eaten fresh or based upon preparation techniques. An additional complicating factor includes the prolonged length of reintroduction of foods when compared to the empiric elimination diet.

Empiric Elimination Diet

The empiric elimination diet is similar to the allergy-test directed elimination diet, however rather than trying to individualize the diet to your specific allergies, this test eliminates the most commonly reported allergens from your diet. This diet has also become known as the six-food elimination diet or SFED. The 6 most commonly associated foods that cause allergies and have been reported to cause damage to the esophagus includes:

  • Cow’s milk
  • Egg
  • Peanuts & tree nuts
  • Seafood (fish & shell fish)
  • Soy
  • Wheat

Studies have shown that following an empiric elimination diet is more effective than the allergy test-directed elimination diet. 70% of people on the empiric elimination diet showed an improvement in symptoms as compared to the less than 50% efficacy of allergy directed dieting. Studies have shown that from the 6 food items eliminated in SFEDs, cow’s milk and wheat were the foods that caused the greatest number of symptoms. Some alterations of SFED also includes the additional elimination of legumes, rice, corn, and meat (chicken, beef, turkey, and pork) with favorable results.

In order to maintain a proper nutrition and balanced diet, it is helpful to use food substitutes to replace the 6 types of food.

Elemental Diet

Perhaps the most difficult diet to follow, however shown to be the most effect diet is the elemental diet, or amino acid-based diet. This is a liquid formula diet that is free of all allergens. In children, this diet has been shown to be greater than 90% effective in resolution of symptoms. However this data has been difficult to compare in adults, because adults in general have found it difficult to adhere to this diet.

Elemental diets, while the most effective diet, are difficult to maintain due to the associated costs of the formula as well as the taste. In some cases, the taste is perceived so badly that the only option is to provide the formula through a tube feeding. In this case, a feeding tube is inserted into the nose and guided into the stomach. The elemental formula can then be given through the tube to avoid the taste.

While the elemental diet is difficult to maintain, there is not a concern for malnutrition with this diet. Other diets discussed can have associated malnutrition if proper variety of important nutrients is not maintained from other food sources that were not eliminated from the diet.

Reintroduction of Foods After Dietary Management

Foods can be reintroduced to your diet under supervision or guidance from your physician. Common dieting occurs for about 6 to 8 weeks and then introduction of food occurs one to two items at a time, based upon discussion with your physician. If there is no increase in symptoms, you maintain the same dietary regimen for an additional 4 to 6 weeks. Often your physician will want endoscopic evaluation of your esophagus after the diet and subsequent addition of food items to evaluate any changes that occur due to the reintroduction of the specific foods.

When introducing foods, it is best to follow this order (based on allergenic properties):

  1. Nonlegume vegetables and noncitrus/nontropical fruit
  2. Fruit (citrus, tropical, melons, and berries), rice, and quinoa
  3. Legumes, oats, barley, rye, and meat (other than beef)
  4. Seafood, corn, peas, nuts, wheat, beef, soy, egg and milk

It is important to remember when introducing foods again into the diet to be very aware the recurrence of symptoms. It is also important to be aware that the most common triggers identified in eosinophilic esophagitis is related to milk, wheat and legumes. Any recurrence of symptoms (with changes found with endoscopy) during the reintroduction process will identify that food item as a food allergy and one of the triggers of your eosinophilic esophagitis and should be avoided in the future.Symptoms that occur without any evidence of reaction in the esophagus will result in further investigation of irritable bowel syndrome or GERD.

Cautions

It is important before undergoing any of these diets to consult a physician. Malnutrition can be a very serious concern and detrimental to your health if you are not getting enough nutrients while eliminating foods from your diet.

Sources:

Aceves, S.S. (2015). Dietary management of eosinophilic esophagitis. Accessed on November 30, 2015 from http://www.uptodate.com (subscription required).

Dellon, E.S., Gonsalves, N., Hirano, I., Furuta, G.T., Liacouras, C.A., & Katzka, D.A. (2013). Evidenced Based Approach to the Diagnosis and Management of Esophageal Eosinophilia and Eosinophilic Esophagitis (EoE). Am J Gastroenterol 2013; 108:679–692; doi:10.1038/ajg.2013.71.

Wechsler, J.B., Schwartz, S., Amsden, K., & Kagalwalla, A.F. (2014). Elimination diets in the management of eosinophilic esophagitis. Accessed on November 30, 2015 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4043711/pdf/jaa-7-085.pdf.

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