Weight Loss with Eosinophilic Oesophagitis (EoE) in South Africa

What Is Eosinophilic Oesophagitis?

EoE is defined by greater than 15 eosinophils per high-power field on oesophageal biopsy. It is distinct from GORD (gastro-oesophageal reflux disease), though the two conditions overlap and are often confused. EoE does not respond adequately to standard acid-suppression therapy alone in most cases, though proton pump inhibitor-responsive eosinophilic oesophagitis (PPI-REE) is now recognised as a variant worth trialling first.

EoE is driven by food allergen sensitisation — not IgE-mediated allergy (which causes immediate anaphylaxis) but a delayed T-cell and IgE-independent immune response. This means standard skin-prick allergy tests are unreliable for identifying EoE trigger foods; empirical elimination diets followed by structured reintroduction with endoscopic confirmation are the diagnostic-therapeutic gold standard.

EoE in the South African Context

EoE is globally underdiagnosed, and South Africa is no exception. Diagnosis requires endoscopy and biopsy, which depends on access to gastroenterology services. Private sector patients with atopy (asthma, eczema, allergic rhinitis) and unexplained dysphagia should specifically request oesophageal biopsies during upper endoscopy — they are not always taken routinely. Public sector diagnosis is limited by scope availability but is improving at academic centres (Groote Schuur, Steve Biko, Inkosi Albert Luthuli).

Dietary Approaches to EoE: Understanding Your Options

Three dietary strategies are used in EoE, typically under gastroenterologist and dietitian supervision:

1. Six-Food Elimination Diet (SFED)

The original and most studied approach. Eliminates the six most common EoE triggers simultaneously for 6-8 weeks, followed by endoscopic reassessment and then step-wise food reintroduction with repeat biopsies after each food group is reintroduced.

2. Four-Food Elimination Diet (FFED)

A simplified version eliminating dairy, wheat, eggs, and legumes (soy/lentils/beans). Evidence shows comparable remission rates to SFED in many patients with fewer restrictions. This is increasingly preferred as first-line because it is less nutritionally demanding and easier to sustain.

3. Targeted Elimination Based on Testing

Using a combination of skin-prick testing, patch testing, and serology to guide elimination. Less reliable in EoE than in standard food allergy because EoE is not a classic IgE-mediated reaction. May be useful as a complement to empirical elimination but should not replace structured reintroduction endoscopy.

Nutritional Deficiencies in EoE: What to Watch

The dietary restrictions in EoE create real nutritional risk, particularly when multiple food groups are removed simultaneously:

Request blood tests for iron studies, calcium, vitamin D, and zinc at diagnosis and again after 3 months on elimination. South African public labs cover these through most hospital outpatient referrals.

Safe Food Textures: Managing Dysphagia for Weight

One of the biggest weight challenges in EoE is that swallowing difficulty makes eating painful and stressful, leading to inadequate calorie intake and unintentional weight loss — particularly during flares or before effective treatment. Understanding safe textures helps maintain adequate nutrition:

Texture Guide for Active EoE

• Soft and moist is safest — mashed sweet potato, pap, soft-cooked rice, ripe banana, avocado, scrambled eggs (if not on egg elimination)
• Soups and stews — chicken vegetable soup with soft pap, lentil soup, blended butternut soup. Blend any chunky pieces if swallowing is difficult
• Avoid dry fibrous textures — dry bread, steak, raw carrots, nuts, pineapple — these are the most common impaction triggers
• Always have water with meals — sip water between bites to keep the oesophagus clear; small bites and thorough chewing are mandatory
• Meat: cook until very tender — slow-cooked or pressure-cooked chicken and beef are far safer than grilled steak or dry biltong

Weight Loss vs Weight Preservation in EoE

Unintentional Weight Loss: The Real Problem

Many EoE patients actually lose too much weight because:

• Eating causes pain and anxiety — meal avoidance develops
• Elimination diets are so restrictive that calorie intake drops dramatically
• Food impaction episodes create fear around eating
• Multiple food groups eliminated simultaneously without dietitian guidance leads to nutrient-poor restriction

If you are losing weight unintentionally with EoE, this needs to be addressed as urgently as disease control. Weight loss increases fatigue, worsens immune function, and reduces quality of life. A calorie-dense, soft-textured, elimination-compliant diet is the goal.

Intentional Weight Management in Stable EoE

Once EoE is in remission (confirmed by endoscopy) and trigger foods are identified, sustainable weight management becomes possible:

• Work with a dietitian to ensure the elimination diet provides adequate protein (1.2-1.6g/kg/day) without excess calories
• Focus on whole foods — maize, rice, lean chicken, vegetables, fruits, legumes (if not eliminated) — rather than highly processed elimination-diet replacement products which are often calorie-dense and expensive
• Exercise is safe and important in remission; dysphagia resolves substantially on effective treatment
• Keep trigger food elimination strict — reintroducing trigger foods causes oesophageal eosinophil accumulation that may not be immediately symptomatic but causes progressive fibrosis over time

EoE in Children: A Note for SA Parents

EoE in children presents differently — feeding refusal, failure to thrive, vomiting, and poor weight gain rather than dysphagia. Children with EoE often have associated atopic conditions (eczema, asthma, allergic rhinitis). Exclusive elemental formula diet (amino acid-based formula) achieves near-100% remission rates and is sometimes used short-term while trigger foods are identified — though it is expensive and not widely available through public sector in SA. Discuss with your paediatric gastroenterologist at a tertiary hospital.

Practical SA Meal Plan: SFED-Compliant and Nutritious

Day Example (Dairy, Wheat, Egg, Soy, Nut, Seafood-Free)

• Breakfast: Maize meal porridge with mashed banana, rooibos tea with oat milk
• Mid-morning: Ripe avocado on gluten-free rice cakes
• Lunch: Slow-cooked chicken stew (chicken, sweet potato, carrots, onion, tomato) served soft, rice
• Afternoon snack: Stewed apple or ripe mango, pumpkin seeds (if tolerating seeds)
• Dinner: Blended butternut and lentil soup (lentils only on FFED, not SFED as legumes allowed), maize meal
• Hydration: 8 glasses water; rooibos; oat milk

Getting Support in South Africa

• Gastroenterology Society of South Africa (GESSA) — specialist directory for gastroenterologists experienced in EoE
• ALLSA (Allergy Society of South Africa) — allergysa.org — EoE sits at the intersection of allergy and gastroenterology; ALLSA members in food allergy field
• ADSA (Association for Dietetics in South Africa) — adsa.org.za — essential for managing elimination diets nutritionally; look for dietitians with GI or allergy experience
• Academic hospitals — Groote Schuur (Cape Town), Steve Biko Academic Hospital (Pretoria), Inkosi Albert Luthuli (Durban), Charlotte Maxeke (Johannesburg) all have gastroenterology units with endoscopy