Elimination diets in eosinophilic esophagitis: wheat-free or wheat, barley and rye-free?

Published Online: December 24, 2015

Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease of the esophagus that is mainly triggered by food proteins. Eliminating the six foods commonly associated with food allergies (milk, wheat, soy, egg, nuts, and fish) from the diet is an effective treatment for the majority of patients with EoE. Barley and rye have proteins that are similar to proteins in wheat and may also be processed with wheat. Some clinicians have asked whether barley and rye should also be removed from the diet because of risks of cross-reaction and/or cross-contamination with wheat.

In a rostrum article recently published in The Journal of Allergy & Clinical Immunology (JACI), Kliewer and colleagues in the Consortium of Gastrointestinal Eosinophilic Disease Researchers (CEGIR) examined the available evidence for/against extending the six-food elimination diet for EoE from wheat-free to wheat-, barley-, and rye-free (gluten-free) and provided recommendations until further studies can be conducted.

The authors indicate that the risks to patients with EoE from cross-contamination and cross-reactions of wheat with barley and rye are theoretical and cannot be predicted from published studies to date or unpublished data from CEGIR centers. The downsides of extending a wheat-free elimination diet to a gluten-free diet consisted of fewer food selections, increased food cost, and increased burdens of label reading.

The authors conclude that the data are too limited to speculate whether total gluten elimination in a six-food elimination diet might be more effective in achieving EoE remission than elimination of only wheat. They advise against broadening a wheat-free elimination diet to exclude all gluten-containing grains unless more evidence becomes available to do so. They call on CEGIR and others to conduct clinical studies to measure the difference between the effectiveness of a wheat-free and gluten-free six-food elimination diet and to conduct studies to predict cross-reactions among wheat, barley, and rye in EoE.

In summary, these leading EoE researchers do not recommend using a gluten-free six-food elimination diet instead of a wheat-free only six-food elimination diet unless further data emerges supporting the necessity of gluten free. This is good news for patients and families with EoE.

The Journal of Allergy and Clinical Immunology (JACI) is the official scientific journal of the AAAAI and is the most-cited journal in the field of allergy and clinical immunology.

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