Celiac disease, irritable bowel syndrome, Crohn’s disease, and anaphylaxis are all instigated by food allergies. Doctors order restrictive diets to help patients control inflammation and food reactions. While less well known, eosinophilic esophagitis (EOE) is another inflammatory disease triggered by food allergies. One of the most effective treatments, especially for young children, is a restricted diet that reduces the allergy-induced inflammation.

In a new study, University of Utah Health explored the long-term psychological impact of food restrictions on normal eating patterns in patients. The results are available in the April issue of the Journal of Pediatric Gastroenterology and Nutrition.

“While medically prescribed, restrictive diets are quite common, we have to work to educate families, so they know that all medical interventions have risks and benefits,” said Jacob Robson, MD, assistant professor in Pediatrics at U of U Health and Primary Children’s Hospital and lead author on the paper. “There is no perfect treatment, and it’s all about balance.”

EOE can be a painful and frightening experience, consisting of vomiting, heartburn, and the sensation of food lodged in the throat when eating. Available treatments include proton pump inhibitors (a type of acid blocker) and coating the esophagus with topical steroids. Long-term use of either treatment has adverse health effects, especially in young children. The remaining option is restrictive dieting, which eliminates offending foods such as milk, soy, wheat, egg, fish, and nuts from the dinner plate. However, as children grow older, physicians are beginning to notice a disturbing pattern—avoidant or restrictive food intake disorder (ARFID).

While first described as a condition 25 years ago, the number of cases is on the rise. In this study, Robson and his colleagues identified more than 1,000 children who were newly diagnosed with EOE in Utah in the past 5 years. Of these, 44 exhibited avoidant or restrictive eating patterns. Six of these patients were below the fifth percentile for weight-for-age.

According to Robson, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) only defined two eating disorders—bulimia and anorexia. ARFID is newly defined in the newest edition of the DSM. In the study, Robson highlighted two patients to illustrate the importance of monitoring young patients on a restricted diet.

Patient one was diagnosed with EOE at 3 years of age. As the patient grew older, he expressed frustration with not being able to eat with friends and disdain for food textures and flavors. Despite improvement in his condition, the patient was unable to consume enough calories and preferred obtaining nutrients through a feeding tube.

Patient two was diagnosed with EOE as a teenager. Despite improvement in his condition, he experienced anxiety that the safe foods would cause an EOE response. These anxieties were exacerbated by common teenage stressors, like preparing for college and performance in sports and school. The patient was treated with an anti-depressant (selective serotonin re-uptake inhibitor) and counseling to alleviate anxiety, and eventually returned to regular eating patterns.

“We know [a restrictive] diet is effective, but these patients opened our eyes as to how careful we have to be [when talking to] famil[ies] that use dietary restrictions,” Robson said. “These kids need to be followed very carefully.”

Robson acknowledges more work is necessary, but these findings illustrate the need for family-based treatments and cognitive-behavioral approaches for patients placed on restrictive diets.

“We need to teach patients on medical diet restrictions how to be successful at replacing the calories they cut out,” Robson said. “In our dedicated EOE clinic, we have an MD, a registered dietitian, and child psychologist to keep an eye on these kids.”

Robson was joined on this study by Trevor Laborda, Joseph Andersen, Molly O’Gorman, Stephen Guthery, and Laura Bennett-Murphy at U of U Health and Primary Children’s Hospital; Kathryn Peterson at U of U Health; and Susan Fitzgerald at Intermountain Healthcare and Primary Children’s Hospital.