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Ask the Nutritionist

Trouble Swallowing?

If you experience difficulty swallowing, you might have a recently recognized condition called eosinophilic esophagitis, which may be caused by food allergies.

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Q: I make the meals for myself and my 58-year-old husband, who has just been diagnosed with eosinophilic esophagitis. Can you tell me more about this condition, and if there is anything I can do, nutritionally speaking, to help my husband alleviate it?

A: In the early 1990s, doctors began describing a new condition affecting the esophagus, the muscular tube connecting the throat with the stomach. This issue seems to afflict patients who are predisposed to allergies, including food allergies, asthma, and eczema. Symptoms include difficulty swallowing and/or feeling like food is moving too slowly through the esophagus. Known as eosinophilic esophagitis (EoE), this condition has become increasingly prevalent since the early 2000s.

Those who suffer from EoE have a large number of eosinophils—a type of white blood cell—and inflammation of the esophagus. The condition can cause difficulty in swallowing and heartburn, and in severe cases it can lead to food becoming stuck in the esophagus. In children, it can lead to problems with feeding, poor growth, or weight loss. If it’s not properly diagnosed and treated, EoE may lead to permanent scarring or narrowing of the esophagus. Patients with this condition also have an increased risk of multiple autoimmune diseases.

The good news is that simple dietary changes can often help. There’s a strong food allergy connection to EoE, and elimination diets that remove common allergens from the diet are a key treatment for the condition.

Why Is EoE on the Rise?

EoE can affect both males and females of any age, but is most common in men in their 30s and 40s. It’s estimated to affect up to one in 2,000 adults in the U.S., and evidence suggests that those numbers have been growing. A review published in 2019 of nearly 30 studies in Europe and North America found that there has been a progressive increase in the number of new EoE cases since the early 2000s.

The exact reasons for this rise in cases are unknown. Some hypothesize that changes in food production, such as genetic modification of crops, chemical additives, and pollutants, may be at the root of the problem. Others believe that the increasing use of acid-suppressing medications might be changing microbes in the esophagus, leading to more food allergies and inflammation.

The 6 Most Common Food Allergens

There is no accurate test to identify the food allergies connected with EoE, so medical experts recommend an elimination diet to help identify problem foods and improve the condition. The six foods most commonly associated with the allergic response that leads to EoE are wheat, dairy, soy, eggs, nuts, and seafood/shellfish.

Some doctors also recommend removing gluten-containing grains(e.g., wheat, rye, barley, einkorn, spelt, and kamut) from the diet. That’s because there is a gluten connection to the disease. People with EoE are nine times more likely than the general population to have celiac disease. EoE is also sometimes associated with non-celiac gluten sensitivity. A medical case reported in 2017 found that gluten triggered EoE in a 52-year-old male patient who did not have celiac disease. In that patient’s case, gluten produced inflammation of the esophagus, but it didn’t produce the inflammation of the stomach or small intestine that occurs with celiac disease.

The EoE Elimination Diet

A successful elimination diet involves three steps:

Step 1: Plan—Decide on the best time to start the diet, and work with a nutritionist or doctor who specializes in elimination diets for EoE if you need help.

Think about how some of your eating habits may have to change. For example, if you’re accustomed to eating eggs or cereal for breakfast, understand that you have to eat something different. If you’re in the habit of eating wheat-based sandwiches, you will need to switch to large salads or stir-fries.

Once you’ve made your plan, prepare by buying the foods you will need to keep on hand, which often includes purchasing substitutes for the allergenic foods you’re avoiding. Then prep as much as you can in advance to make cooking easier.

Step 2: Eliminate—Completely remove all six problem foods listed above from your diet. It’s best to eat a whole-foods diet so that you clearly know you’re avoiding allergens that may be hidden in packaged/processed foods. And be careful when dining out because it’s difficult to know all the ingredients used in restaurant meals.

Step 3: Challenge—If your symptoms haven’t improved after four weeks, follow up with your health provider.

If your symptoms have improved, that’s good news: You know that at least one of the foods you removed from your diet was producing an allergenic response. Now it’s time to identify which specific foods are problematic for you by adding back the foods you stopped eating, one at a time.

When you reintroduce a food, make sure to write down your symptoms. It’s common for EoE food reactions to occur hours or even a few days after you eat the offending food, so keep good notes. Symptoms of a reaction may range from mild acid reflux to severe cramps, vomiting, difficulty swallowing, or feeling like food is “stuck” in the esophagus.

Introduce one new food (e.g., dairy, wheat or gluten, soy, eggs, nuts, or shellfish) per week. Start with one serving, and continue to eat at least one serving of the food per day. If it doesn’t cause adverse symptoms after a week, consider that food safe, but wait to add it back into your diet until you’ve finished testing the other five foods.

By completing four weeks of an elimination diet and six weeks of testing each of the common allergenic foods, you should not only gain relief from the discomfort in your esophagus, you should also learn which foods trigger an allergic response and inflammation, so you can develop your very own personalized therapeutic diet moving forward.

Elimination Diet Variations

6-Food Elimination Diet

The most commonly prescribed elimination diet for EoE, which is increasing in prevalence, is the 6-food elimination diet, or 6FED, as described above. But there are a few useful variations that may also be worth trying out, including:

5-Food Elimination Diet + Avoiding Gluten (Instead of Just Wheat)

Research shows that there is a gluten connection to some cases of EoE, so some doctors go a step further by asking patients to avoid all grains, or at least gluten grains (e.g., wheat, rye, barley, einkorn, spelt, kamut, and oats not certified as gluten-free), in addition to the other five foods during the elimination diet. This is especially true if a person with EoE eats a lot of grains or suspects grains may be the problem.

Simplified Elimination Diet

If you don’t think that you can forgo all of these foods at once, consider starting with a simplified elimination diet: Completely avoid the two most common food allergens: dairy and wheat—or preferably dairy and all gluten grains—to begin the process of determining which groups of foods are causing your EoE symptoms.