Eosinophilic Esophagitis? Change Your Diet.

Eliminating specific foods from your diet can reduce symptoms of eosinophilic esophagitis (EoE), according to the June issue of Gastroenterology.

EoE is an immune disorder in which eosinophils cause inflammation of the esophagus, leading to difficulty swallowing and food impactions. Many adults cope for years with swallowing difficulties and do not seek medical attention until they experience a long-lasting food impaction that requires emergency endoscopy.

Researchers have found that certain food allergens can cause the disease in children, so Nirmala Gonsalves et al. investigated whether a food-elimination diet might reverse the disorder in adults.

They placed 50 adults with EoE on a 6-food elimination diet—avoiding milk, soy, egg, wheat, peanuts or tree nuts, and shellfish or fish—for 6 weeks. Patients were then given questionnaires about symptoms and quality of life, and evaluated by endoscopy and biopsy analyses.

The study subjects were also given skin-prick tests for airborne allergies against tree, grass, ragweed, mold, house dust mite, cat, dog, and cockroach, along with the foods included in the elimination diet.

After 6 weeks on the diet, patients’ peak eosinophil densities decreased significantly in the proximal and distal esophagus; 78% of patients had >50% reduction in their peak eosinophil density.

Histologic features of EoE in a patient before the elimination diet (A) including >15 eosinophils/hpf, superficial layering, eosinophilic microabscesses, and epithelial hyperplasia. (B) Resolution of histologic features of EoE in the same patient after 6 weeks on the elimination diet.

Dysphagia symptom scores decreased in 94% of patients after the elimination diet, and endoscopic features improved in 78%. Physical and mental components also increased after the elimination diet, based on answers to questionnaires.

Twenty patients who had a full response to the diet participated in a food reintroduction study. The foods that caused their symptoms were identified (although results from skin-prick tests could not identify these). When these were placed back in the patients’ diets, their symptoms returned, along with endoscopic and histologic features of the disorder, in a median time of 3 days.

The most common food triggers were wheat (60%) and milk (50%), followed by soy (10%), nuts (10%), and egg (5%). Seafood was not found to induce EoE in this study. Three patients had more than one food trigger. Interestingly, none of the patients knew they had food allergies before the study.

The results of the reintroduction study show that food antigens do cause EoE, and provide insight into the pathogenesis of this inflammatory response. The findings also indicate that despite the phenotypic differences of adult and pediatric EoE, they are likely to be similar diseases.

One of the features of patients who responded to the elimination diet was that they had frequently complained of heartburn, despite acid suppression with proton-pump inhibitor therapy. This means that the EoE symptoms were not caused by acid reflux, but rather that heartburn can be caused by allergic responses to certain foods.

Although these results provide new insight into the pathogenesis of EoE in adults and provide a new treatment approach, the authors acknowledge that this was an uncontrolled study, so there might have been a selection bias for patients who were willing to undergo dietary elimination.

Nonetheless, Gonsalves et al. conclude that a 6-food elimination diet, with food reintroduction, is the most reliable method to identify foods that induce EoE in adults, and is an effective therapeutic alternative to corticosteroid therapy.

In an editorial that accompanies the article, Alex Straumann states that these findings offers a new therapeutic approach for adults with active EoE—this might be important for patients who respond inadequately to medical therapy or for those who refuse corticosteroids. It also demonstrates that adult EoE is a food-driven disease, with wheat and milk as the leading causative agents, and that adult and pediatric EoE represent a single entity, despite their different clinical manifestations.

More Information on EoE:

Read the article online. This article has accompanying CME activities.
Gonsalves N, Yang G-Y, Doerfler B, et al. Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology 2012;142:1451–1459.e1.

Read the accompanying editorial.
Straumann A. Treatment of eosinophilic esophagitis: diet, drugs, or dilation? Gastroenterology 2012;142:1409–1411.

About Kristine Novak, PhD, Science Editor

Dr. Kristine Novak is the science editor for Gastroenterology and Clinical Gastroenterology and Hepatology, both published by the American Gastroenterological Association. She has worked as an editor at biomedical research journals and as a science writer for more than 12 years, covering advances in gastroenterology, hepatology, cancer, immunology, biotechnology, molecular genetics, and clinical trials. She has a PhD in cell biology and an interest in all areas of medical research.
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6 Responses to Eosinophilic Esophagitis? Change Your Diet.

  1. Pingback: Eosinophilic Esophagitis? Change Your Diet. | | Acid Reflux Disease Diet

  2. Amber Long says:

    Is there a website I can visit for menu ideas for my ten year old, he has EE and needs to be put on the 6 food elimination diet with and no pork.

    • Richard Higgins says:

      I am on week #6 of my elimination diet and frankly it’s been rather difficult. It is depressing to go to a restaurant with friends or family and end up eating a dry salad. I’m 37 and can only imagine how a 10 year old would feel.
      I’ve found a lot of good choices at Trader Joe’s or other organic food stores. Raisins, prunes, dried apricots and dried bananas are a good alternative to other treats. My goto snacks have been corn chips, hummus, salsa and peanut butter (peanuts are ok for me). My wife keeps a bag of rice noodles around too. Above all, keep reading ingredients. I’m amazed how many foods how wheat and soy byproducts.

  3. Kiran says:

    My son is was diaganoised with EE last year and we stopped wheat and soy, he was scoped again and the EE is still there. Doctor from mount sinai, ny is asking him to go on an elimination diet with just 3 things and baby formula. It’s so difficult for a 7 year old to drink baby formula all the time. We are trying to get another opinion at children’s hospital of Philadelphia . Any comments on this anyone, please suggest if any.

  4. Thank you so much for posting about EE. We get lots of kids with EE at our allergy-friendly bakery called Sensitive Sweets in California. My son suffers form severe food allergies, and he’s the reason why we are now able to spoil other children and families that have food sensitivities.

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