While the cause or causes of the increase in allergic disorders is hotly debated, one must acknowledge the obvious increase in food reactions across the population. One of the diseases we are seeing more often is a condition called eosinophilic esophagitis. With an increasing number of patients experiencing this frustrating illness, more therapies are being tried besides just the conventional steroid approach. Even conventional medicine has recognized food avoidances as beneficial in these patients. However, a big debate has continued over which foods and how many; this study worked to answer that question.
Eosinophilic esophagitis arises in the esophagus, the tube connecting your mouth to your stomach, when something triggers an accumulation of immune system eosinophils in the lining of the esophagus. These immune cells are part of the allergic arm of the system and secrete various chemical mediators like histamine. These mediators then cause a variety of symptoms like redness, swelling, itching, pain, and more. Patients experience painful swallowing and sometimes choking due to foods getting stuck on the way down due to the swelling. This can be both very uncomfortable and scary.
While the use of some steroid swallowed can lower the swelling, a better goal is to find the trigger and remove it so that the swelling does not occur in the first place. Even in the early 2000’s conventional medicine recognized that a 6-food elimination diet could help lower the reactivity of these eosinophils and this became a standard. This included milk, egg, wheat, soy, fish, and nuts. Since then various other combinations of 1 to 4 of these foods have been tried in studies.
Researchers from the National Institute of Allergy and Infectious Diseases, the National Center for Advancing Translational Sciences, and the National Institute of Diabetes and Digestive and Kidney Diseases worked across multiple clinical sites to conduct this study. Looking at 129 adults from age 18 to 60 years old with EOE, they randomized the participants to either a 1 food elimination diet of only animal milk or the standard 6 food elimination diet. They then repeated an esophageal scope after 6 weeks to compare eosinophil numbers.
After 6 weeks, 34% of the 6-food elimination and 40% of the milk only elimination were considered in remission. The difference was not statistically significant in this small study. By symptoms there was little difference as well. For those on the 1 food elimination diet who did not go into remission, they were advanced to the 6 food elimination trial. About half of these ended up going into remission. If they failed the 6 food trial, oral steroids were given and about 80% of these resolved.
The researchers were trying to determine how aggressive the food elimination had to be in order to get a response. For those who have eliminated even 1 food completely from their diet for a number of weeks, you know that it is harder than it sounds. So many foods we eat regularly have a multitude of ingredients. While the challenge is easier now with the options available in stores, it still takes work and serious lifestyle changes to cut out milk or wheat or soy or eggs. If one could start with a single food like milk and get a good chance and a positive outcome, why make the treatment harder than it needs to be.
For those with suspected or confirmed EOE, a 6-week trial of avoiding all milk products is worth the trouble. Two out of five people will see significant benefit if not full recovery. Then you know that milk is a problem for your condition and you continue to avoid it life-long. However, for those who do not improve, they should try the 6 food elimination for another 6 weeks. The harder part is that if this works, you are off these 6 foods for possibly a lifetime. At that point, you could try to reintroduce 1 food every 2-3 weeks from that 6 food list and see if symptoms return. Maybe you don’t need to avoid all of them forever.
As you consider the possibility of EOE on yourself, do not depend on your own self-treatment if symptoms are moderate to severe. A 6-week milk-free trial is no big deal unless you are actually suffering from something worse. If your doctor thinks you have EOE, talk to them about these options for food elimination trials. If you are seeing a functional medicine provider, you should also ask about food antibody testing which might reveal other foods that are specific to you as a trigger. We have occasionally found other foods not in this list of 6 that contribute to the reactions.
Helping patients restore a healthier more abundant life requires the wise application of studies like this one into daily clinical care of patients in our office. Our multi-disciplinary team, including a nutritionist and health coach, makes this even more successful.
Kara L Kliewer, Nirmala Gonsalves, Evan S Dellon, David A Katzka, Juan P Abonia, Seema S Aceves, Nicoleta C Arva, John A Besse, Peter A Bonis, Julie M Caldwell, Kelley E Capocelli, Mirna Chehade, Antonella Cianferoni, Margaret H Collins, Gary W Falk, Sandeep K Gupta, Ikuo Hirano, Jeffrey P Krischer, John Leung, Lisa J Martin, Paul Menard-Katcher, Vincent A Mukkada, Kathryn A Peterson, Tetsuo Shoda, Amanda K Rudman Spergel, Jonathan M Spergel, Guang-Yu Yang, Xue Zhang, Glenn T Furuta, Marc E Rothenberg. One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trial. The Lancet Gastroenterology & Hepatology, 2023; DOI: 10.1016/S2468-1253(23)00012-2
Thanks to Science Daily:
NIH/National Institute of Allergy and Infectious Diseases. “Forgoing one food treats eosinophilic esophagitis as well as excluding six, study finds: Results of first multi-site randomized trial comparing the two diets.” ScienceDaily. ScienceDaily, 27 February 2023. <www.sciencedaily.com/releases/2023/02/230227193303.htm>.
Sanctuary Functional Medicine, under the direction of Dr Eric Potter, IFMCP MD, provides functional medicine services to Nashville, Middle Tennessee and beyond. We frequently treat patients from Kentucky, Alabama, Mississippi, Georgia, Ohio, Indiana, and more... offering the hope of healthier more abundant lives to those with chronic illness.