New Research Reveals Considerable Overlap Between Severe Allergies and Chronic Food Allergies: The potential role of an elimination diet and possibly enteral nutrition with a formula that has elimination diet characteristics

The last decade has seen dramatic rises in the incidence of eosinophilic esophagitis (EoE), an inflammatory and autoimmune condition of the esophagus where children experience both pain and difficulty with swallowing.  Many epidemiologists have considered this new epidemic to be puzzling with no clear causes.  A recent investigation at Children’s Hospital of Philadelphia however, raises an important question about the role of severe food allergies.

“The more allergies a child has, the higher is that child’s risk of developing EoE,” said study leader David A. Hill, MD, PhD, an allergist at Children’s Hospital of Philadelphia (CHOP). “The connection among these allergies suggests a common underlying biological cause, and also may imply that if we can successfully treat an earlier type of allergy, we may prevent later allergies.”

It has been established with other autoimmune diseases that the chronic presence of foreign, food-based antigens in a child’s system, whether through increased dietary exposure or intestinal permeability, can create increased “self attack”within the innate immune response.  EoE is not always categorized as an autoimmune disease, but its primary etiology is representative of classic autoimmunity.

Eosinophils are a type of white blood cell that is heavily involved in guarding the lining of the digestive tract against foreign proteins that may be associated with pathogens.  When these eosinophils are challenged with particular dietary proteins on a regular basis, they often lose the ability to determine friend from foe.  This results in their attack on specific areas of associated exposure, in this case the esophagus.

Children with skin and respiratory allergies are much more likely to develop EoE.  This recent study showed that early dietary intervention in these cases offered a dramatic reduction in a child’s risk of later developing EoE.  It is clear that other allergies are warning signs of dietary allergies (1).

Over this period of sharp rise in EoE incidence, numerous case studies have demonstrated the efficacy in applying an elimination diet to produce complete remission (2,3).  The research in this area clearly supports the elimination of the following foods: wheat, dairy, soy, corn, eggs, chicken, beef, and pork (4).  Many researchers feel that the benefits demonstrated from eliminating chicken, eggs, and pork, may be because animals are typically fed diets very high in soybeans and research has shown that soy often survives digestion and can end up intact within an egg or chicken meat.

An enteral intervention may be needed when there is difficulty in swallowing with advanced EoE.  In these cases, it is highly recommended that an enteral formula most closely resembling an elimination diet be the first choice.

~ John Bagnulo MPH, PhD.

Resources:

1. David A. Hill, Robert W. Grundmeier, Mark Ramos, Jonathan M. Spergel. Eosinophilic Esophagitis Is a Late Manifestation of the Allergic March. The Journal of Allergy and Clinical Immunology: In Practice, 2018.

2. Okimoto E, Ishimura N, Okada M, et al. Successful Food-Elimination Diet in an Adult with Eosinophilic Gastroenteritis. ACG Case Reports Journal. 2018;5:e38. doi:10.14309/crj.2018.38.

3. Philpott H, Dellon E. Histologic improvement after 6 weeks of dietary elimination for eosinophilic esophagitis may be insufficient to determine efficacy. Asia Pacific Allergy. 2018;8(2):e20. doi:10.5415/apallergy.2018.8.e20.

4. Zhan T et al. Model to Determine the Optimal Dietary Elimination Strategy for Treatment of Eosinophilic Esophagitis. Clin Gastroenterol Hepatol. 2018 May 3. pii: S1542-3565(18)30369-0.