Dietary Salicylates and AERD (Samter's Triad)
There has been a great deal of debate over whether or not dietary salicylates play any role in AERD. Decades ago, before much was known about AERD, researchers did think that dietary salicyaltes might be causing symptoms. But today AERD experts discourage patients from trying to avoid them. Dr. Laidlaw of the Brigham & Women's AERD Center has recommend that patients follow a diet low in omega 6 fatty acids and high in omega 3 fatty acids.
What is a Low Salicylate Diet?
Salicylates are natural substances found in many plant-based foods, including most fruits and vegetables, tomato sauces, herbs and spices, and wine. A low salicylate diet, as the name suggests, involves avoiding foods high in salicylates - which means avoiding most fruits and vegetables. It is not a very healthy diet.
Does a Low Salicylate Diet Help?
Given the known contribution of aspirin (a potent salicylate) to the respiratory reactions in AERD (Samter's Triad), it seems like a logical jump to suppose that that removing salicylates from the diet might have a beneficial effect. One of Max Samter's earliest theories was that AERD symptoms persisted due to the dietary contribution of salicylates. Today, however, experts do not believe that dietary salicylates are responsible for AERD reactions. Inhibition of COX-1 is the mechanism by which aspirin and other NSAIDs cause AERD (Samter's Triad) reactions. AERD experts do not recommend a low salicylate diet because dietary salicylates do not inhibit the COX-1 enzyme. There is no scientific reason why avoiding dietary salicylates would have any benefit.
The chemical name for aspirin is acetyl salicylate. The the "acetyl" part of this compound is the one that inhibits COX-1, not the salicylate. Because dietary salicylates are non-acetylated and do not have this effect, there is no reason to think that they play any role in AERD. Studies (such as this one and this one) have been done to demonstrate that we do not have reactions to salicylates. In these studies, AERD patients were given high doses of sodium salicylate and found to have no reaction.
Despite this, patients continue to try this diet. According to Scripps AERD Patient Survey, 37% of AERD patients had tried a low salicylate diet. Of those patients who had, 7% reported worsening symptoms, 34% reported no improvement, and 34% reported moderate to significant benefit.
There is one small study that found AERD patients who followed a low salicylate diet for 6 weeks showed improvement. However, one difficulty with this study is that patients following the diet would have needed to avoid wine and beer. They may have avoided alcohol completely. Other research has shown that the majority of AERD patients have reactions to alcohol, so this alone would be expected to have beneficial effects. Experts believe that the reason patients react to alcohol is due to the polyphenol content - not salicylates. A 2017 study found that catechins (a type of polyphenol) in red wine provoked reactions in patients with asthma, sinusitis, and alcohol sensitivity.
If salicylates aren't related to AERD, then why do some patients report a benefit from eliminating them? People who are attempting to manage a disease with diet often make many changes at once. In addition to making diet changes they may start exercising, reduce alcohol intake, and start taking supplements. They may also begin taking new medications. If they feel better, it can be difficult to tell which factors are responsible. It is also common for there to be a placebo effect with dietary interventions.
But There's No Harm in Avoiding Salicylates, Right?
Those following this diet need to eliminate many nutritious fruits, vegetables, and almost all spices. It can be very limiting. It may not be healthy to follow this diet long term. A diet rich in fruits and vegetables is known to have many health benefits, such as lower rates of heart disease and cancer. One of the primary reasons AERD experts discourage patients from following this diet, other than the lack of evidence showing a benefit, is that it is not a very healthy diet.
AERD Experts Strongly Discourage Low Salicylate Diets
The most knowledgeable AERD (Samter's Triad) specialists in the world advise patients not to follow a low salicylate diet. Dr. Andrew White of Scripps Clinic has written a Guide for AERD Patients, in which he has this to say on the matter:
"Probably the best known salicylate is Acetyl Salicylic Acid also known as 'aspirin'. You may know that aspirin was discovered from the bark of a tree and found to have medicinal qualities. It was ultimately purified and now most of the world has access to this drug. We know that in AERD, you react to aspirin because it blocks the enzyme COX-1. That is why you also will react to ibuprofen, naproxen, ketorolac, etc. But these last three NSAIDs are NOT salicylates. Furthermore, there are several medications that exist that are salicylates that DO NOT block COX-1. These are commonly used in gastroenterology or rheumatology to treat autoimmune diseases. These medications have been studied in AERD and you will not react to them. This is not surprising, because we know that they do not block COX-1. Somewhere along the line, someone got the idea that if acetyl salicylic acid (aspirin) is bad, then maybe there are aspirin-like products in the diet (salicylates) that should be avoided. I think that the implication is that if you are eating salicylates in your diet you are keeping your sinuses inflamed. But this does not make as much sense now that we know a lot about desensitization. We know that if we desensitize you to aspirin, you will stay desensitized for 48 hours before you start to react again. And as discussed in a previous chapter, being on aspirin DAILY actually is beneficial for a majority of patients. So if being on aspirin daily is helpful for you, then why would dietary salicylates daily be harmful and you would continue to react to them? To me, the argument to be on a low salicylate diet comes out something like this: Aspirin is a salicylate and salicylates start with the letter ‘S,’ so you should avoid all foods that start with the letter 'S'.”
Dr. Tanya Laidlaw of the Brigham & Women's AERD Center and Dr. John V. Bosso of the Penn Medicine AERD Center have also weighed in on the low salicylate diet. You can hear their comments by watching the videos below.
Dr. Laidlaw Discusses the Low Salicylate Diet at 48:09
"It's a bad diet and it doesn't work. Don't do it."
-Dr. Tanya Laidlaw
Dr. Laidlaw Discusses the Low Salicylate Diet at 46:30
"There isn’t any biologic explanation for a low salicylate diet being helpful at all.”
-Dr. Tanya Laidlaw
Dr. Bosso Discusses the Low Salicylate Diet at 36:30
"Does a low salicylate diet have any benefit? The simple one-word answer is no.”
-Dr. John V. Bosso
The Samter's Society does not recommend a low salicylate diet. It is a restrictive diet and there is no scientific reason why it would be beneficial. AERD experts strongly discourage patients from following a low salicylate diet. For those interested in making diet changes, experts have recommended dietary fatty acid modification.
If you've reviewed the above information and choose to try a low salicylate diet anyway, you should be aware that there is an enormous amount of questionable information on the internet regarding salicylates. Proponents of low salicylate diets have recommended them to treat everything from autism to bed wetting to joint pain. Many of these websites are attempting to sell something and much of the information they present is inaccurate. These websites typically contain long lists of vague symptoms and scant reference to peer reviewed research.
Join the Facebook Samter's Society Support Group to connect with other patients!