EMPIRIC ELIMINATION DIETS FOR EOSINOPHILIC ESOPHAGITIS IN CHILDREN AND ADULTS Recommendations made by: Dr. Javier Molina-Infante. Hospital Universitario San Pedro de Alcántara, Cáceres, Spain. Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas (CIBEREHD). Dr. Alfredo J. Lucendo. Hospital General de Tomelloso, Ciudad Real. Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas (CIBEREHD). PRACTICAL TIPS 1. Dietary therapy is not a panacea. Current estimates for cure rates rounds 40% with a two-food group elimination diet, 50-60% with a four-food group elimination diet and 70% with a six-food group elimination diet. 2. Through 6-week empiric elimination diets, motivated patients may get to know what food groups cause their disease and see whether they can handle long-term avoidance of those foods. If they achieve symptom and inflammation remission, then they ll have to reintroduce one by one the eliminated foods. Each food should be reintroduced for 6 weeks with further endoscopy for each food. 3. Elimination diet may not be a good therapeutic option for patients with severe esophageal strictures or dysphagia, patients already on multiple food restrictions due to IgE-mediated food allergy or adolescent/young adults (who will have more likely a poor compliance). 4. Due to cross reactivity between foods (your body can also react to different foods with similarities to those eliminated), all dairy products will be eliminated, not only cow s milk (including goat s and sheep s milk). Likewise, gluten-containing cereals (barley, oats, rye) will be eliminated with wheat as well. 5. After any dietary intervention, an endoscopy with biopsies is mandatory. Symptoms do not adequately predict normalization of esophageal mucosa. Sedation for endoscopic procedures may be essential to engage patients with elimination diets. 6. Never combine topical corticosteroids and diets for treating EoE. 7. You may interrupt the reintroduction process. For instance, if a patient responds to a 2- food group elimination diet in May, but wants to restart the process after the summer, he can return to a normal diet during the summer and then, after the summer, reintroduce one food, while eliminating the other, with an endoscopy assessment 6 weeks later. 1
TWO-FOOD GROUP ELIMINATION DIET (ANIMAL MILK AND GLUTEN) You can consume all these kind of foods for 6 weeks, preferably raw, fresh, or uncooked: 1. Vegetables, tubers (potato), and legumes 2. Meat (excepting processed or pre-cooked meats, like sausages and hamburgers) 3. Fish and seafood (excepting processed or pre-cooked fish) 4. Egg 5. Fruit 6. Nuts You cannot consume for 6 weeks any food known to trigger allergic symptoms on you, like itchy mouth, scratchy throat, hives, skin rash, or asthma. Avoid as much as possible eating out to have a better control of foods. Try to always pick fresh raw foods and avoid those cooked with sauces or fried in pans where potential contamination with breaded and/or wheat sources is likely. You can drink coffee, tea (without animal milk), tonic water, soda, cola, fruit juice, wine, gin, vodka and rum. Beer and whisky are forbidden since they are gluten-containing drinks. The most limited food in the day is breakfast. You can have coffee with soy, rice, almond, walnut, nut or quinoa drinks. Gluten free products for celiac patients are allowed provided they do not contain milk (they can contain egg or soy). 1. ANIMAL MILK As a general rule, you should avoid all foods you are not fully sure to be safe. - All cow s, goat s and sheep s milk (whole, low-fat, skim, butter milk, evaporated, condensed, powdered, formula milk, hot cocoa) - Milk products (all kind of cheeses, yogurt, butter, margarine, ice creams, milkshakes, custard, creme caramel, rice pudding) - Foods that may contain milk (biscuits, cookies, donuts, muffins, pancakes, waffles, crackers, cream desserts, sweets, candies, chocolate with milk, wallnut cream, sausages, ham, pork sausage) - Milk, cream, caseinates, hydrolysates, lactalbumin, casein, whey. - E-4511, E-4512, E-4513. - Flavour, animal fat, cream, proteins, dehydrated powder or sauce. 2
FOODS ALLOWED: - Dairy products made of soy, rice, spelt, quinoa, wallnut, and nuts. 2. GLUTEN - All products containing wheat, barley, rye, oats, spelt, triticale, semola, semolina, and kamut. This wide range of products may include: Wheat-containing: Bread, toast, biscuits, cookies, donuts, muffins, pretzel, pancakes, waffles, crackers, cream desserts, sweets, candies, pasta, cream, soups, sauces, malted food, breaded or floured vegetables. Beer, whisky - Flour or floured, farina, wheat enriched, malted or malt added, breaded. - E-1404, E-1410, E-1412, E-1413, E-1414, E-1420, E-1422, E1440, E-1442, E-1450. - Starch, fiber, protein, vegetable protein, semola, hydrolized protein, malt, malt extract, cous-cous, yeast, species, flavour. FOODS ALLOWED: - All products allowed for celiac patients provided they do not contain milk or milk protein. 3
FOUR-FOOD GROUP ELIMINATION DIET (ANIMAL MILK, GLUTEN, EGG AND LEGUMES) You can consume all these kind of foods for 6 weeks, preferably raw, fresh, or uncooked: 1. Vegetables and tubers (potato) 2. Meat (excepting processed or pre-cooked meats, like sausages and hamburgers) 3. Fish and seafood (excepting processed or pre-cooked fish) 4. Fruit 5. Nuts You cannot consume for 6 weeks any food known to trigger allergic symptoms on you, like itchy mouth, scratchy throat, hives, skin rash, or asthma. Avoid as much as possible eating out to have a better control of foods. Try to always pick fresh raw foods and avoid those cooked with sauces or fried in pans where potential contamination with breaded and/or wheat sources is likely. You can drink coffee, tea (without animal milk), tonic water, soda, cola, fruit juice, wine, gin, vodka and rum. Beer and whisky are forbidden since they are gluten-containing drinks. The most limited food in the day is breakfast. You can have coffee with rice, almond, walnut, nut drinks. Gluten free products for celiac patients are allowed provided they do not contain milk, egg or legumes (see below). 1. ANIMAL MILK As a general rule, you should avoid all foods you are not fully sure to be safe. - All cow s, goat s and sheep s milk (whole, low-fat, skim, butter milk, evaporated, condensed, powdered, formula milk, hot cocoa) - Milk products (all kind of cheeses, yogurt, butter, margarine, ice creams, milkshakes, custard, creme caramel, rice pudding) - Foods that may contain milk (biscuits, cookies, donuts, muffins, pancakes, waffles, crackers, cream desserts, sweets, candies, chocolate with milk, wallnut cream, sausages, ham, pork sausage) - Milk, cream, caseinates, hydrolysates, lactalbumin, casein, whey. - E-4511, E-4512, E-4513. - Flavour, animal fat, cream, proteins, dehydrated powder or sauce. 4
FOODS ALLOWED: - Dairy products made of rice, quinoa, wallnut, and nuts. 2. GLUTEN - All products containing wheat, barley, rye, oats, spelt, triticale, semola, semolina, and kamut. This wide range of products may include: Wheat-containing: Bread, toast, biscuits, cookies, donuts, muffins, pretzel, pancakes, waffles, crackers, cream desserts, sweets, candies, pasta, cream, soups, sauces, malted food, breaded or floured vegetables. Beer, whisky - Flour or floured, farina, wheat enriched, malted or malt added, breaded. - E-1404, E-1410, E-1412, E-1413, E-1414, E-1420, E-1422, E1440, E-1442, E-1450. - Starch, fiber, protein, vegetable protein, semola, hydrolized protein, malt, malt extract, cous-cous, yeast, species, flavour. FOODS ALLOWED: - All products allowed for celiac patients provided they do not contain milk, egg and/or legumes (see below). 3. EGG - All products containing egg, baked goods, pasta, cakes, biscuits, cookies, donuts, muffins, pretzel, pancakes, waffles, crackers, cream desserts, sweets, candies, processed meat, goose liver, mayonnaise, coated and wrapped in bread food, breaded or creamed vegetables, processed meat, goose liver, mayonnaise, sauces. - Albumin, apovitellin, binder, coagulant, cholesterol free egg substitute, dried egg, egg white, egg yolk, egg lecithin, egg lysosome, eggnog, egg wash, globulin, lecithin, livetin, lysozyme, meringue, meringue powder, simplesse, surimi, ovoalbumin, ovamucin, ovamucoid, ovomucin, ovomucoid, ovotransferrin, ovovitelin, powdered egg, trailblazer, vitellin, whole egg. 5
4. LEGUMES - Soy, lentils, pea, chickpeas, beans, peanuts, lupin, guar gum, carob bean, alfalfa. - Oil made with any of the aforementioned legumes. - African and Asian ethnic foods often contain soy and peanuts. - Hydrolyzed plant, vegetable protein, plant protein, vegetable gum and vegetable starch. These products are usually present in canned or processed foods. 6
SIX-FOOD GROUP ELIMINATION DIET (ANIMAL MILK, GLUTEN, EGG, LEGUMES, NUTS, AND FISH/SEAFOOD) You can consume all these kind of foods for 6 weeks, preferably raw, fresh, or uncooked: 1. Vegetables and tubers (potato) 2. Meat (excepting processed or pre-cooked meats, like sausages and hamburgers) 3. Fruit You cannot consume for 6 weeks any food known to trigger allergic symptoms on you, like itchy mouth, scratchy throat, hives, skin rash, or asthma. Avoid as much as possible eating out to have a better control of foods. Try to always pick fresh raw foods and avoid those cooked with sauces or fried in pans where potential contamination with breaded and/or wheat sources is likely. You can drink coffee, tea (without animal milk), tonic water, soda, cola, fruit juice, wine, gin, vodka and rum. Beer and whisky are forbidden since they are gluten-containing drinks. The most limited food in the day is breakfast. You can have expresso coffee. Gluten free products for celiac patients are allowed provided they do not contain milk, egg, legumes, or nuts (see below). 1. ANIMAL MILK As a general rule, you should avoid all foods you are not fully sure to be safe. - All cow s, goat s and sheep s milk (whole, low-fat, skim, butter milk, evaporated, condensed, powdered, formula milk, hot cocoa) - Milk products (all kind of cheeses, yogurt, butter, margarine, ice creams, milkshakes, custard, creme caramel, rice pudding) - Foods that may contain milk (biscuits, cookies, donuts, muffins, pancakes, waffles, crackers, cream desserts, sweets, candies, chocolate with milk, wallnut cream, sausages, ham, pork sausage) - Milk, cream, caseinates, hydrolysates, lactalbumin, casein, whey. - E-4511, E-4512, E-4513. - Flavour, animal fat, cream, proteins, dehydrated powder or sauce. 7
FOODS ALLOWED: - Dairy products made of rice, quinoa. 2. GLUTEN - All products containing wheat, barley, rye, oats, spelt, triticale, semola, semolina, and kamut. This wide range of products may include: Wheat-containing: Bread, toast, biscuits, cookies, donuts, muffins, pretzel, pancakes, waffles, crackers, cream desserts, sweets, candies, pasta, cream, soups, sauces, malted food, breaded or floured vegetables. Beer, whisky - Flour or floured, farina, wheat enriched, malted or malt added, breaded. - E-1404, E-1410, E-1412, E-1413, E-1414, E-1420, E-1422, E1440, E-1442, E-1450. - Starch, fiber, protein, vegetable protein, semola, hydrolized protein, malt, malt extract, cous-cous, yeast, species, flavour. FOODS ALLOWED: - All products allowed for celiac patients provided they do not contain milk, egg, legumes and/or nuts (see below). 3. EGG - All products containing egg, baked goods, pasta, cakes, biscuits, cookies, donuts, muffins, pretzel, pancakes, waffles, crackers, cream desserts, sweets, candies, processed meat, goose liver, mayonnaise, coated and wrapped in bread food, breaded or creamed vegetables, processed meat, goose liver, mayonnaise, sauces - Albumin, apovitellin, binder, coagulant, cholesterol free egg substitute, dried egg, egg white, egg yolk, egg lecithin, egg lysosome, eggnog, egg wash, globulin, lecithin, livetin, lysozyme, meringue, meringue powder, simplesse, surimi, ovoalbumin, ovamucin, ovamucoid, ovomucin, ovomucoid, ovotransferrin, ovovitelin, powdered egg, trailblazer, vitellin, whole egg. 8
4. LEGUMES - Soy, lentils, pea, chickpeas, beans, peanuts, lupin, guar gum, carob bean, alfalfa. - Oil made with any of the aforementioned legumes. - African and Asian ethnic foods often contain soy and peanuts. - Hydrolyzed plant, vegetable protein, plant protein, vegetable gum and vegetable starch. These products are usually present in canned or processed foods. 5. NUTS - Almond, Artificial nuts, Brazil nut, Beechnut, Butternut, Cashew, Chestnut, Chinquapin nut, Coconut, Filbert/hazelnut, Gianduja (a chocolate-nut mixture), Ginkgo nut, Hickory nut, Litchi/lichee/lychee nut, Macadamia nut, Marzipan/almond paste, Nangai nut, Natural nut extract (e.g., almond, walnut), Nut butters (e.g., cashew butter), Nut meal, Nut meat, Nut milk (e.g., almond milk, cashew milk), Nut paste (e.g., almond paste), Nut pieces, Pecan, Pesto, Pili nut, Pine nut (also referred to as Indian, pignoli, pigñolia, pignon, piñon, and pinyon nut), Pistachio, Praline, Shea nut, Walnut - Oil made with any of the aforementioned nuts. - African and Asian ethnic foods often contain nuts. - Tree nut proteins may be found in cereals, crackers, cookies, candy, chocolates, energy bars, flavored coffee, frozen desserts, marinades, barbeque sauces and some cold cuts, such as mortadella. Some alcoholic beverages may contain nut flavoring. 6. FISH/SEAFOOD - All kinds of fish (Anchovies, Bass, Catfish, Cod, Flounder, Grouper, Haddock, Hake, Halibut, Herring, Mahi Mahi, Perch, Pike, Pollock, Salmon, Scrod, Swordfish, Sole, Snapper, Tilapia, Trout, Tuna) - All kinds of shellfish (crab, lobster, prawns, shrimps) and mollusks (cockles, mussels, octopus, oyster, snails, squid). 9
- Oil or gelatin made with any of the aforementioned fishes or seafood products. - African and Asian ethnic foods usually contain fish and seafood and are considered highrisk. 10