Eosinophilic Esophagitis (EoE) is a chronic immune condition causing inflammation of the esophagus, the tube the connects the mouth to the stomach. Those with EoE may find certain triggers, specifically foods, that worsen the condition. If left untreated, EoE can eventually cause esophageal strictures and fibrosis, leading to serious health consequences. This article reviews EoE from a dietary perspective to help answer the question, “What should I eat if I have Eosinophilic Esophagitis?”

What is Eosinophilic Esophagitis?

Let’s start with: What are eosinophils?

Eosinophils are a type of white blood cell (the soldiers of the immune system). There are a collection of diseases involving eosinophils known as eosinophilic gastrointestinal diseases (EGID). The most common type of EGID is eosinophilic esophagitis. Eosinophils may also infiltrate other parts of the gastrointestinal tract including the stomach, small intestine and colon. 

In those with EoE, eosinophils are present in large numbers in the esophagus where they do not usually reside, and release chemical mediators that promote inflammation. Usually eosinophils protect the body, but when elevated and found in the wrong location in the body, their response causes harm. 

Some consider EoE a specific type of allergy. However, EoE presents differently than classic IgE allergy, which is a response mediated by a different type of white blood cell called mast cells, not eosinophils. Both Allergists and Gastroenterologists may take part in the diagnosis and care of those with EoE. 

Prevalence:

EoE prevalence has increased over the past 20 years and reportedly impacts 0.03% of the US population. It is most commonly present in whites compared to other ethnic groups and impacts men more so than women. EoE is a lifelong disease that may be managed, but does not have a cure. 

Symptoms:

Symptoms of EoE change over an individual’s lifespan and may present as follows:

  • Young children– failure to thrive, gastroesophageal reflux symptoms 
  • School-aged children– abdominal pain or vomiting
  • Older adolescents & Adults– food impaction, dysphagia (difficulty swallowing)

The most classic of EoE symptoms include:

  • Vomiting
  • Regurgitation (of food or watery fluid)
  • Difficulty swallowing
  • Choking on food
  • Heartburn
  • Poor eating
  • Poor weight gain/weight loss

While many of these symptoms may mimic those of gastroesophageal reflux disease (GERD), there is an important distinction to keep in mind. Those with EoE may trial reflux disease medication like proton-pump inhibitors (PPIs) such as Prevacid or Nexium with little to no symptom improvement. A 2-month PPI trial is a component of the EoE diagnosis process, however a negative PPI response does not necessarily indicate presence of EoE (1). 

Diagnosis of Eosinophilic Esophagitis:

Diagnosis includes a variety of information gathered by the physician. A thorough medical history as well as a 2-month PPI trial without benefit and an esophageal endoscopy and biopsy are all part of the workup. The endoscopy reviews the appearance of the esophagus including the presence of eosinophils. Additionally, the biopsy must reveal >15 eosinophils per high-powered field (HPF) in the absence of other causes. 

How does food allergy play a role in Eosinophilic Esophagitis?

Typical IgE-mediated food allergy results in symptoms like hives, swelling, vomiting, diarrhea, abdominal pain and sometimes anaphylaxis. EoE symptoms solely impact the esophagus; therefore, appears very different than an allergy. However, approximately 50% of those with EoE also have food and environmental allergies and should be tested to rule this out.

Often, the most common food allergens are the same foods that trigger EoE. These foods include egg, cow’s milk, soy, wheat, corn, peanuts, tree nuts, shellfish, beef, and rye. 

What diet should I follow if I have Eosinophilic Esophagitis?

In conjunction with topical steroids and dilation, diet therapy is a first line therapy for those with EoE. But, this question is a bit complex, so stay with me!

Some with EoE have food allergies, while others do not. It is vital to remove all positively diagnosed food allergies from the diet. Even if IgE food allergies test negative, avoiding certain foods often helps improve symptoms. In this scenario, endoscopy findings often reveal no change in inflammation upon examination. This finding could translate to mean that some foods are irritating, but not necessarily the root cause of the EoE. I told you…this question is quite complex!

It is challenging to identify problematic foods due to delayed symptom response that commonly occurs in those with EoE. This type of response differs from IgE-mediated food allergy that produces a fairly immediate response. Because of this added complexity, a few strategies have been devised:

  1. 6 Food Elimination Diet

    • This elimination plan removes the six most commonly problematic foods from the diet for about 8 weeks or until one has significant symptom improvement. The six foods include cow’s milk, soy, egg, wheat, peanut/tree nuts, and fish.
    • This approach is typically effective, but the most challenging part is the reintroduction process. I recommend trying this plan out for even just a few weeks to find out if it helps your symptoms. If not, then move on to the next diet plan on the list…
  2. Oligoantigenic Diet (Few Foods Elimination Diet)

    • This plan is a bit more challenging to implement. The individual is limited to a diet that only includes the foods least likely to trigger a response. Pick out a few of the safest foods from each food group (i.e. fruits, vegetables, proteins, grains, legumes, etc.).  Due to the super restrictive nature of this diet, it should not last more than 14 days before undergoing the reintroduction process.
    • I typically use the LEAP protocol to help design the oligoantigenic plan. Using the results of MRT food sensitivity testing, I am able to figure out which foods promote a heightened immune response.  Typically, this plan works very well! But, if this does not produce desired results, it is time for the last and least desired option…
  3. Elemental Diet

    • When all else fails, some attempt an elemental diet. An elemental diet is essentially a nutritional formula one consumes in place of any real food to determine if foods contribute to EoE symptoms.
    • Elemental diets are used as a last resort and only for a short duration. The formulas contain all of the necessary calories and macro/micronutrients one may need, but honestly, do not taste so good and are pretty pricey. Formulas like Vivonex and Tolerex are used for adults, with separate options for children. Food is slowly reintroduced after just a few days on this formula. 

Reintroduction:

After achieving symptom relief, start the food reintroduction process. Bring one food back into the diet in increasing portions throughout the day. After trialing the new food, be sure to wait a few days and up to a week to experience any delayed reactions. Then, you may decide if the food is “safe” or not.

If the food triggers symptoms, remove it from the diet and consider retesting it at a later time. As you bring in new foods, consider rescoping the esophagus throughout the process to check in on the eosinophil count. 

Conclusion:

Eosinophilic Esophagitis requires individualized diet therapy to help improve symptoms. While it is important to avoid all diagnosed food allergies, many with EoE have negative food allergy findings. Consider following one of the elimination diet plans under the guidance of a Registered Dietitian Nutritionist (myself included). The goal is to eat a variety of healthy foods without promoting symptoms and avoid any unnecessary dietary restrictions over the long run. 

 

References:

The Health Professional’s Guide to Food Allergies and Intolerances by Janice Vickerstaff Joneja, PhD, RD. 2013. 

The Health Professional’s Guide to Gastrointestinal Nutrition by Laura Matarese, Gerard Mullin, and Janice Raymond. 2105. 

http://www.aaaai.org/conditions-and-treatments/related-conditions/eosinophilic-esophagitis