Today we will be discussing all things Eosinophilic Esophagitis.
I know. You’re saying… Eo-what? It’s a rare condition – however its occurrence is increasing. In fact, here in my own city, a 4 year study saw occurrence increasing 39% year over year. This is partially attributed to better biopsy techniques – BUT even when accounting for that – the rates are rising.
This condition captured my attention – because I’m obsessed with unusual food sensitivities (given I have one of my own), and how our gut microbiota and immune system cause them. And then of course, how we can use nutrition to help manage them!
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Eosinophilic esophagitis, or EoE, is a chronic, immune-mediated condition where your esophagus develops inflammation. Basically – something triggers your immune system to go haywire, causing eosinophils (a type of immune cell) to build up in your esophagus.
Typically, this reaction is worsened by exposure to a food or food component – making nutrition a very important piece of the puzzle in the management of EoE.
There is a LOT we don’t know about food sensitivities that are not typical IgE allergies (think anaphylaxis to peanuts). But what we do know is, their prevalence is INCREASING. This is likely due to a variety of factors, but the gut microbiota is one of them – which is of course why we’re so passionate about helping patients manage their EoE at Ignite!
- There is an increased risk in those with asthma, allergic rhinitis, and eczema – immune dysfunction is thought to play a role in these patients.
- There appears to be a genetic link in EoE.
- It is more commonly seen in males, and average age of adult diagnosis is 30.
- We now believe changes in your gut microbiota may increase risk of immune dysfunction, driving EoE development.
Common symptoms of EoE in adults include:
- difficulty swallowing
- stomach pain
- chest pain
- prolonged chewing
- food impaction
- needing to drink lots of water to get fluids down
Typically, most of our patients come to us with a worsening history of severe reflux and pain when swallowing, or after being admitted to the hospital due to food impaction.
Many patients will describe this as ‘choking’ – however the food is lodged in the esophagus, not the wind pipe, which is why we call it food impaction. You are still able to breathe – however these episodes can be really scary, due to the sensation.
When this occurs, the patient frequently has to go to emergency for an upper endoscopy to remove the food from the esophagus.
EoE is diagnosed by esophageal biopsy. Sometimes gastroenterologists can see the changes and inflammation in the esophagus, however a biopsy is definitive as it is not always visible to the naked eye.
Once treatment is initiated, whether diet or medication, your doctor will re-scope you to ensure you are in ‘histological’ remission- meaning no more eosinophils in your esophagus.
Since EoE is an inflammatory condition, the primary treatment is to reduce inflammation. As dietitians, we team up with the gastroenterologists, and they manage patient medications – however typically we see a proton pump inhibitor prescribed as first line treatment. This helps to reduce inflammation.
If this isn’t sufficient to manage the EoE, a special diet is prescribed, plus or minus corticosteroids to manage inflammation.
After careful review of the literature, what we know about food sensitivities and the immune system, and the inflammatory nature of the disease, our dietitians at Ignite believe diet should be considered as part of first line treatment for EoE.
Our argument is, if you can manage the underlying cause of the inflammation (an inappropriate response to a food or food component), then that would lead to the best outcomes for the patient.
However, given how inflammatory in nature EoE is, we do of course advocate for medication management when necessary – and initially, it might be quite necessary to get the inflammation down – however – use of medications should be re-evaluated when dietary triggers are identified and eliminated.
Immune conditions are tricky. Once your body turns them on, it’s not likely that we will be able to turn it off, despite what ‘Dr. Google’ and anecdotal reports say. There is no supporting evidence at this time that EoE can be cured, however it can be successfully managed through medication and dietary therapy, and go into remission.
As you now know, we are HUGE believers in the role of nutrition in EoE management. The diet that has the best evidence is called the 6 or 8 food elimination diet. They’re the same thing – however the 8-food elimination breaks 2 of the categories into sub categories (peanut/tree nut and fish/shellfish).
The Top 8 Allergens are:
- Tree nut
It is recommended you eliminate these allergens for a minimum of 6 weeks. This can be very challenging to do, because many of these are staples in the diet. At Ignite, we tailor your recommendations to you – what you like, what you eat, and of course, if you have any IgE mediated allergies on top of that.
We’ve created several helpful tools to help people implement this diet with dietitian and doctor supervision, including:
We understand that nutrition counselling isn’t for everyone. If nutrition counselling isn’t covered by your extended benefits (many times, dietitian services are – and if not, they’re a tax deductible medical expense) or you don’t have a dietitian through public health services – be sure to check out our dietitian created menu plans & tools!
While the 8-food elimination diet is successful in approximately 70-80% of patients, it is important to note that, if you fall into the 20-30% other allergens may be causing your reaction.
Often times we see patients eliminating the top 8 allergens, plus others they’ve found online. We do NOT recommend you do this without dietitian supervision. Not only is the risk of malnutrition is real – we’ve had far too many patients come in with an incredible amount of fear, frustration and major impact to their quality of life due to managing their diet on their own.
Elimination diets pose real risks – food, or the lack thereof isn’t benign – malnutrition is a real consequence! Working with a dietitian if you’re not getting symptom relief is highly recommended.
You’re probably wondering – while the majority of patients improve on the 8-food elimination diet, what happens if I’m the one that doesn’t? Don’t panic. If you’re working with a dietitian, we will discuss other high-risk allergens, or potentially a trial of an elemental diet formula to reduce inflammation and be able to reintroduce without risk of malnutrition.
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After the 8 Food Elimination Diet
After elimination is complete, you may have a repeat scope to confirm histological remission. From there, the dietitian will tailor the reintroduction to you and develop a plan to measure symptom response. It is recommended you introduce one food at a time, in increasing amounts for a week. If symptoms remain stable, that food is not likely your trigger.
Typically we start with the lowest risk foods, and work our way to the highest risk foods. In adults. Most patients are found to have 1-3 triggers with milk and wheat being the most common.
After reintroduction, it is important to develop a plan for what life will look like moving forward. EoE can change over time, which is why having a plan is key. At Ignite, we also take a focus on the gut microbiota as we believe that taking care of your gut plays an instrumental role in immune function and inflammation.
Depending on which foods you will need to avoid, it is important to consider what nutrients you’re missing!
Many times, patients aren’t aware that they could become nutrient deficient, even if they’re only missing one of those items – however, risk of nutrient deficiency is common. Working with a dietitian can ensure you get all the nutrients you need on your new diet and that you stay healthy, long term.
The Elemental Diet
Nutrition formulas have been created for those with food sensitivities. What makes these formulas unique is they have no intact proteins in them – all the protein has been broken down to their individual amino acids.
In most cases, the elemental diet should only be used if the primary and secondary interventions fail, and then used a short period of time to allow for histological remission, followed by reintroduction of foods.
Elemental diets can be very expensive, hard to stick to (as you can’t eat while you’re on them otherwise it would defeat the purpose) and tastes not so great. However, there may be some compassion programs or ability to get your formula covered by your insurance provider. This is something your dietitian and gastroenterologist will help coordinate.
Many patients assume an allergy skin prick test is enough to pinpoint food triggers. In fact, EoE is NOT an IgE mediated condition – therefore, the patch test is not likely to identify triggers.
While EoE is NOT an IgE mediated allergy, interestingly, IgE-allergies CAN drive worsening of EoE symptoms.
This is why we advocate for all patients to get a skin prick test for IgE allergies. Many of our patients will find they have IgE allergies worsening their EoE symptoms. This includes seasonal allergies; dust, pollen, and pet dander can all worsen EoE symptoms.
Of note, there is absolutely NO evidence to support Food Intolerance (IgG) testing. It’s expensive, and it’s not evidence based. Don’t be afraid to ask the person suggesting you get this how much money they make off you when you take it! It’s unethical, in our opinion (and our regulatory body’s) to make money from the prescription of tests, medications and herbals. Not everyone’s professional college upholds them to the same standard. To learn more about why IgG testing is not an appropriate test for food intolerance check out the articles here, here and here.
With proper diet and medication management, the majority of patients with EoE will experience histological remission. However, there are some challenging cases. We at Ignite have been lucky in that our patients have had good success, however we are aware of many case studies where management has been more challenging. Working with a team of specialists to give you the best quality of life is key!
We know EoE is hard. Food sensitivities not only affect your health, but the impact on your relationship with food, your quality of life, your ability to enjoy social situations, and the fact that you have a chronic condition can be a lot to adjust to. At Ignite, we take a complete look at your health and wellness, working with other interdisciplinary team members as needed.
We carefully review your entire story, how you eat, and all aspects of health and wellness to make sure no stone is left unturned.
From there we develop a personalized plan – something practical that actually fits within your life. We will work through the elimination diet, and reintroduction of priority allergens to ensure you’re able to liberalize your diet as much as possible. From there, we help to develop a long term plan to manage your EoE and have you symptom free!