What is Orofacial Granulomatosis?
Orofacial Granulomatosis (OFG) is a chronic inflammatory disorder that primarily affects the face, mouth and lips. The most common symptoms include lip swelling and redness but mouth ulcers and cracked lips can also occur. OFG can occur on its own but is commonly associated with Crohn’s Disease.
The cause of OFG remains unknown. However, a cinnamon and benzoate free diet has been found to result in significant improvements for people with OFG. It is therefore frequently recommended as a first line treatment option.
OFG symptoms should improve within 6-12 weeks of implementing a cinnamon and benzoate free diet. To get started on the diet, it is important to understand what benzoates are, and to become familiar with those foods, drinks and other products that may contain them.
Dietary treatment
This diet avoids foods and drinks containing cinnamon, benzoates and their derivatives.
These can be found naturally in some whole foods such as spinach, berries, dried fruits and some herbs and spices or added as a preservative in many processed and packaged foods.
Where possible you should keep to fresh or home cooked foods. If you are unsure if a food or drink contains cinnamon or benzoate it is probably best to avoid it.
You will also need to be careful when eating out as you may not always know the exact ingredients and the risk of cross contamination is quite high.
Finally, it is important that you read the labels of any manufactured or prepared foods and drinks you consume, as this will help you choose food that is suitable. The ingredients list can be found on the back, side or on the bottom of the pack.
What do I need to avoid in the diet?
Cinnamon
Cinnamon is a natural substance and because it is often used in very small quantities does not always have to be stated on food labels. Generally, this means avoiding any foods that list spice and spice extracts, ground cinnamon, mixed spice, spice extracts, mixed spice, cinnamon oil, cinnamon or cinnamic aldehyde as an ingredient.
Flavourings
These are chemicals that are often added to foods to improve the flavour. This includes foods such as crisps, biscuits, sweets, soft drinks and ready meals to name a few.
Some flavourings are compounds related to cinnamon and benzoates, and it is therefore advisable to avoid those products labelled with “flavourings” or “natural flavourings” where possible.
Benzoates
Benzoates are chemicals used in food and drinks as a preservative to prevent food spoilage and prolong shelf life. As a result, they are commonly found in a range of processed foods and fizzy drinks. Following a cinnamon and benzoate free diet therefore involves careful reading of food labels. Benzoates include any preservatives with E numbers from E210 to E219.
When reading food labels, The E number or the full name may be used. All the following need to be avoided:
- E210 or Benzoic acid.
- E211 or Sodium Benzoate.
- E212 or Potassium Benzoate.
- E213 or Calcium Benzoate.
- E214 or Ethyl 4-hydroxybenzoate or Ethyl para-hydroxybenzoate.
- E215 or Ethyl 4-hydroxybenzoate, sodium salt or sodium ethyl para-hydroxybenzoate.
- E216/217: banned in foods within Europe.
- E218 or Methyl 4-hydroxybenzoate or Methyl para-hydroxybenzoate.
- E219 or Methyl 4-hydroxybenzoate, sodium salt or sodium methyl-hydroxybenzoate.
To avoid consuming these preservatives it is often easier to simply avoid packaged foods and to eat fresh food cooked from scratch at home. However, a complicating factor is that benzoates can occur naturally in some foods which will therefore need to be avoided on this diet.
Common foods which contain benzoates are as follows:
- Fruits: such as apples, grapefruit, papaya, apricot, cherry, peaches, nectarine, plums, prunes, blackberries, blueberries, cranberries, raspberries and strawberries.
- Any juice, jam, jelly and dried fruits made from the above.
- Avocado, pumpkin, kidney beans, soybeans and spinach.
- Tomato puree and sundried tomatoes (fresh tomatoes are permitted as benzoate levels are less concentrated).
- Most sausages and salamis.
- Cod.
- Blue cheese.
- Spiced or fruit yoghurt.
- Cocoa and chocolate.
- Tea.
- Honey.
- Chewing gum.
- Pickles, bottled sauces, vinegar, marinated fish, beer and fizzy drinks.
List of foods that commonly contain cinnamon and benzoates
Milk and dairy foods
Foods allowed
- All types of milk, cream, sour cream and fromage frais.
- Cheese made with allowed ingredients.
- Ice cream made with allowed ingredients.
- Eggs.
Foods to avoid
- Yogurts with added cinnamon or fruit rich in natural benzoates.
- Cheese with spices.
- Blue and gorgonzola cheese.
Meat and fish
Foods allowed
- Any plain, fresh or frozen meat and meat dishes.
- Any plain fresh or frozen fish and fish dishes.
Foods to avoid
- Meat or fish in spicy sauces.
- Cold meat containing spices.
- Made up meat pie or pastry fillings containing spices or benzoates.
- Over the counter fish.
Fats and oils
Foods allowed
- Pure butter.
- Pure vegetable oils, lard and dripping.
- Margarine.
- Homemade salad dressing.
Foods to avoid
- Ready prepared salad dressings with restricted ingredients.
Cereals, rice and pasta
Foods allowed
- Bread, rice, pasta, flour, sago, tapioca, oats, custard powder and corn flour.
- Crackers, bread, cream crackers, original Ryvita, oat cakes, breadsticks and rice cakes.
- Breakfast cereals without added cinnamon, dried fruits or chocolate.
Foods to avoid
- Tinned spaghetti / ravioli and spaghetti.
- Check labels on packaged pasta dishes.
Cakes and biscuits
Foods allowed
- Plain fresh bread, buns and pizza dough.
- Any homemade or manufactured cakes or biscuits with allowed ingredients.
Foods to avoid
- Any homemade cakes containing spice.
- Fruit cake, carrot cake, gingerbread, apple strudel, mince pies, garibaldi, ginger biscuits are likely to contain cinnamon.
Fruit and vegetables
Foods allowed
- Any fresh or frozen fruit and vegetables not listed in foods to avoid.
- Tinned tomatoes (limit to two to three times per week due to low levels of naturally occurring benzoates).
Foods to avoid
- Dried fruit.
- Avocado.
- Pumpkin.
- Kidney beans, soya beans, baked beans.
- Spinach.
- Berries (blackberry, cranberry, blueberry, strawberry, raspberry).
- Prunes, peaches, papaya, nectarines, naval oranges.
- Tomato puree and sundried tomato.
- Jam / marmalade, fruit sauce.
- Apple & pear preserves.
- Lemon curd.
Crisps and savoury snacks
Foods allowed
- Plain nuts or seeds.
- Plain or ready salted crisps without spices.
Foods to avoid
- Dry roasted nuts.
- Bombay mix.
- Spicy nuts.
- Flavoured crisps.
- Seeds e.g. sunflower, sesame.
Sweets and chocolates
Foods allowed
- All sweets and chocolates with allowed ingredients.
- All other artificial sweeteners.
Foods to avoid
- Cocoa.
- Chocolate spread.
- Chocolate and chocolate products, cake decorations.
- Cola cubes.
- Cinnamon sticks.
- Liquid artificial sweetener.
Drinks
Foods allowed
- All drinks with allowed ingredients.
- Coffee, fruit and herbal infused teas.
Foods to avoid
- Fruit juices containing natural benzoates, e.g. berries, prunes, peaches, papaya, nectarines.
- Tea.
- Fizzy drinks, flavoured bottled water, squash, cordial, glucose drinks.
- Milkshake syrups, flavoured milk, slush puppy, non-alcoholic grape drinks.
Herbs and spices
Foods allowed
- Salt, pepper, herbs, e.g. basil, chives, mint, thyme, oregano, rosemary.
- Single spices such as chilli, ginger, cumin, coriander seed, turmeric.
Foods to avoid
- Cinnamon sticks, cinnamon powder, cloves, nutmeg, sage, curry powder, all spice, mixed spice, cassia, garam masala.
Sauces
Foods allowed
- Oxo.
- Bovril.
- Fat free dressing.
- Fat free mayonnaise.
- Stock cubes.
Foods to avoid
- Salad cream.
- Mayonnaise.
- Pesto sauce.
- Oil and vinegar dressing.
- Gravy granules.
- Ketchups.
- Soy sauce.
- Marmite.
Miscellaneous
Foods allowed
- Sugar.
- Honey.
- Golden syrup, maple syrup, corn syrup.
- Treacle.
- Vinegar.
- Essences.
- Baking powder.
- Icing sugar.
Foods to avoid
- Peanut butter.
Please note
Manufacturers will change ingredients occasionally so you should check the ingredients on the package label.
Important
Some toothpastes, lip balms, hygiene products, deodorants, cosmetics and medicines contain added cinnamon and benzoates. Please therefore ensure that you always check the labels.
Eating out
Eating out can be challenging but manageable with some planning and clear communication. Some cuisines use cinnamon as a spice in their dishes e.g. Indian, Thai and Chinese food and others are less likely to do so such as Japanese, Italian and Greek.
You could opt for fish with no sauce or plain grilled meats with no marinades or spices.
Fast food places are likely to have higher benzoate content than dishes prepared with fresh ingredients so try and choose restaurants that cook fresh meals.
Re-introducing foods
It is unrealistic to stay on the Cinnamon and Benzoate free diet long term. After 12 weeks, you should start gradually re-introducing foods you have been avoiding back into your diet. This may help you identify any foods which trigger your symptoms.
The foods which are most likely to cause symptoms are cinnamon, fizzy drinks and chocolate. You should therefore aim to re-introduce these foods last.
It is advisable to re-introduce foods one at a time over a few days. You should increase the portion size each day e.g. ½ a tablespoon of tomato ketchup for two days, then increase to one tablespoon for two days.
When you reach what you would consider your usual portion size without any reaction you can continue to include this food in your diet. If you have a reaction, you should continue to avoid this food.
Contact us
Children’s Dietitians
With thanks to information provided by Guys and St Thomas Hospitals.