Description: Co-hosts Ryan Piansky, a graduate student and patient advocate living with eosinophilic esophagitis (EoE) and eosinophilic asthma, and Holly Knotowicz, a speech-language pathologist living with EoE who serves on APFED’s Health Sciences Advisory Council, interview Bethany Doerfler, MS, RDN, a clinical research dietician specializing in lifestyle management of digestive diseases at Northwestern Medicine. Ryan and Holly discuss managing nutritional deficiencies in patients with non-EoE EGIDs and a study Bethany worked on. Disclaimer: The information provided in this podcast is designed to support, not replace the relationship that exists between listeners and their healthcare providers. Opinions, information, and recommendations shared in this podcast are not a substitute for medical advice. Decisions related to medical care should be made with your healthcare provider. Opinions and views of guests and co-hosts are their own. Key Takeaways: [:50] Co-host Ryan Piansky introduces the episode, brought to you thanks to the support of Education Partners Bristol Myers Squibb, Sanofi, Regeneron, and Takeda. Ryan introduces co-host Holly Knotowicz. [1:17] Holly introduces today’s topic, common nutritional deficiencies that affect those with eosinophilic gastrointestinal diseases that occur in the GI tract lower than the esophagus (non-EoE EGIDs). [1:31] Holly introduces today’s guest, Bethany Doerfler, a clinical research dietician specializing in lifestyle management of digestive diseases, including gastroesophageal reflux disease, motility disorders, and eosinophilic diseases. [1:45] Bethany currently practices as part of a multi-disciplinary team in a digestive health institute at Northwestern Medicine. [2:03] Bethany began working with this disorder almost 20 years ago. She worked with Dr. Gonsalves and Dr. Hirano at Northwestern. Dr. Gonsalves invited her to work with EoE patients. Bethany had not heard of EoE. [2:59] Bethany says the lens that we’ve used to look at food as the trigger and also a therapeutic agent in the esophagus, we’re looking at in non-EoE EGIDs as well; at the same time, trying to make sure that we’re honoring the other parts of our patient’s lives. [3:27] Before Bethany started working in GI at Northwestern, she worked in the Wellness Institute, doing nutrition for patients at Northwestern. Bethany has a research background in epidemiology and she wanted to see better nutrition research in GI. [3:56] Through a friend, Bethany connected with the Chief of GI at that point. Northwestern had never had a dietician working in GI. [4:08] Bethany is pleased to see a trend in healthcare of thinking about the patient as a whole person, including diet, psychological wellness, physical health, exercise, sleep, and more. Bethany wanted to see more research on GI disorders. [4:38] Bethany says that eosinophils in the esophagus indicate that something is irritating the tissues, such as reflux, food triggers, aeroallergens, and other things. [4:58] Eosinophils do belong in the stomach, the small intestine, and the colon. The challenge for researchers has been, how many, where are they supposed to live, and what are they supposed to look like. [5:10] There is eosinophilic gastritis, where eosinophils can infiltrate the stomach, causing a lot of inflammatory responses that make patients sick. We see that in all parts of the small intestine and less commonly, in the colon, as well. [5:32] It’s a good reminder for listeners that eosinophils are white blood cells. When they’re in the tissues, they can swell things up and cause the body to have this inflammatory response in these lower GI tract organs. [5:49] The symptoms patients can experience are vomiting, diarrhea, and abdominal pain, among other things. [6:14] The nomenclature for this subset of eosinophil-associated diseases has changed and Bethany says to hang tight, there is lots of work underway to nail this down further in the next couple of months to a year. [6:29] The last guidelines were published by a Delphi Consensus in 2022. The experts in the field got together and voted on the scientific accuracy of certain statements to develop cut points for how to grade. [6:48] The experts are asking questions like: What counts as eosinophilic gastritis? What do we think are some of the symptoms and the clinical findings so that we all are looking at things through the same lens? [7:02] To get to these consensus statements, there’s a lot of discussion, agreement, and good collegial discussions about making sure that we’re looking at this accurately. [7:12] We’re trying to give the right names to the right disorders and give clear diagnostic criteria, so that we’re helping our patients get a diagnosis, and we’re not labeling something incorrectly and sticking someone with an inaccurate diagnosis. [7:36] The proper terminology is eosinophilic gastritis in the stomach, eosinophilic enteritis in the small intestine, eosinophilic colitis in the colon, and eosinophilic gastroenteritis where the stomach and the small bowel are involved. [7:53] There’s more to come on the clinical criteria of what makes that diagnosis but we’re getting the names and the numbers right. [8:03] Holly agrees that having the symptoms given a named diagnosis is important to patients, knowing that researchers are looking into their illness. [9:00] Bethany notes that the diagnosis also means that there are opportunities for medical therapy, cut points for which medicines or therapies work or not, and billing codes. If we can’t bill insurance companies, patients might not get certain services. [9:28] Ryan tells how beneficial it was for him to have access to multi-disciplinary teams and see specialists he might not have seen without the proper diagnosis and just thought it was a GI issue. He was fortunate to see a dietician and start dietary therapy. [9:53] Bethany says the dietician’s priority is the patient’s health and wellness. [10:13] These disorders carry clinical non-gastrointestinal manifestations: fatigue, concern over what to eat, food access issues, family support, and other food allergies. These are important things for a dietician to consider. [10:37] Are patients growing as they should? Do they feel like they have enough to eat? Do they feel excluded in social settings? There’s a list of important things that we want to be looking at. That’s why it’s important to have a multi-disciplinary approach. [11:07] First, Bethany wants to see that her patients are physically and nutritionally well. That’s a priority if we’re going to try to get rid of some of the food triggers that could be exacerbating the disease. [11:20] Before Bethany takes anything out of someone’s diet, she wants to make sure that they’re getting enough of the good stuff to help them feel good and grow. [11:29] From a diet therapy perspective, Bethany is trying to apply a food removal or substitution protocol to other spots outside the esophagus. They’re seeing that some of the triggers are very similar, both in the stomach and small intestine. [12:09] Dr. Gonsalves, Dr. Hirano, and Bethany did a study, The Elemental Study, where they wanted to uncover if food proteins carried the same trigger risk in the stomach and small intestine as they do in the esophagus. [12:35] They put their patients on a hypoallergenic elemental formula for a period, followed up, and looked at their biopsies of the stomach and small intestine. Fifteen wonderful patients made it through the trial. [12:56] One hundred percent of the patients achieved disease remission and felt better. There were some genetic alterations in the patients. Then they started the process of reintroducing foods over the year. [13:15] That was not part of the original grant but was the team’s clinical interest to see what it is that people are allergic to. Some of the common suspects: wheat, dairy, eggs, soy, and nuts, were found to be very common triggers for EoG and EoN, as well. [13:47] The benefit of working with a dietician as part of your team is, first, we can remediate things the disease has caused nutritionally, and second, we can think about how diet can be a therapeutic tool to use with medications or instead of medication. [14:15] If you want to use nutrition therapeutically, you don’t have to stay there if it’s not the right time to be taking things out of your diet. We have some good, safe, medical therapies. You can find your food triggers but you don’t have to pick that lane forever. [14:42] Holly and Ryan relate their experiences with traveling abroad and going on medical therapies when they can’t stay on their diets. [15:57] Bethany says low levels of vitamins and minerals in the blood can be caused by a disorder or an elimination diet. In the U.S., dairy is the biggest source of protein for young kids. It’s also the biggest source of calcium and vitamin D. [16:22] Dieticians often say, if we are going to use dietary therapy for EoE or non-EoE EGIDs, we have to think of this as a substitution diet. If we remove something, we have to replace it with something equally nutrient-dense. [16:39] Bethany and her group look at serum values of Vitamin D, B12, and iron they assess for patients. For kids, instead of drawing blood, they piece together what they’re taking against what they need and see if there are gaps to fill with food or supplements. [17:32] In patients with non-EoE EGIDs, Bethany says we see the disease intersect with the food supply. When we take milk out, we’re cutting the biggest source of calcium and Vitamin D. We have to replace calcium and Vitamin D. [17:55] In the 1950s, a public health law allowed wheat to be enriched with folic acid