Friday, June 7, 2013

Eosinophilic Esophagitis - Food Allergies and Using an Elimination Diet and Symptom Diary

Eosinophilic esophagitis is an inflammatory condition of the esophagus or feeding tube that is characterized by the abnormal presence of eosinophils (a type of white blood cell involved in allergic reactions) in the lining of the esophagus. Eosinophils are thought to migrate to the esophagus in response to foods that trigger an allergic response. The most common foods reported are milk, egg, soy, corn, wheat, beef, chicken, potato, oats, peanuts, turkey, barley, pork, rice, green beans, apples, pineapple, tree nuts and seafood.

Interestingly these very foods cause the majority of food allergies and food sensitivities or intolerance and are foods that contain many of the lectins that are suspected of causing problems in the gut, joints, skin and the brain. Restriction of these foods frequently improve symptoms in the gut and outside the gut in many people. If specific foods identified by allergy testing can be avoided improvement is usually noted. However, the symptoms and signs of eosinophilic esophagitis frequently, if not usually, return after stopping steroids unless accompanied by dietary manipulation that includes elimination of problem foods.

When food allergy testing is negative or equivocal, elimination diet may be the only way to determine what food or foods may be causing ongoing or recurrent eosinophilic esophagitis. Strict elimination diet has been most effective but is difficult to follow long term for most adults and children. More recently, Kagalwalla published success with a six food elimination diet (SFED) in children with eosinophilic esophagitis. The SFED restricted foods from six of the most common food allergens. The SFED eliminated cow's milk protein (casein), soy, wheat, egg, peanut/tree nuts, and seafood. This SFED was compared with an elemental diet (ELED), that consists of proteins broken down into simple forms in a liquid, such as what protein intolerant infants are fed. Such a diet is expensive, tastes poor and is not well received.

In this particular study it was noted that though the SFED was not quite as effective (74% versus 88% achieving significant improvement), the six food elimination diet has better acceptance, cost and likelihood of people complying with the diet. I would point out that the SFED is actually not a six food elimination diet. Not only are more than six food categories eliminated (peanuts are legumes and separate from tree nuts) but much more than six foods are eliminated considering there a multiple nuts and seafood. Processed foods containing any known or suspected foods must also be eliminated during an elimination diet.

The helpfulness of a diet symptom diary prior to an elimination diet is that sometimes it is difficult to identify problem foods and relate their elimination and re-introduction to various symptoms. Various simple diet diaries exist in print form and online formats that can be printed out to record manually foods eaten and symptoms noted. However, an online diet diary that provides an ongoing tracking of diet and symptoms as well as feedback does not exist, especially those customized according to an individual's health history.

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