Our data, from the first FFQ in a large series of Italian HHT patients, suggest that different dietary items may have an impact on occurrence of epistaxis.
However, although a possible association between diet and nose bleeds has been previously suggested, caution should certainly be taken in questionnaire data interpretation. In fact, the presence of possible pre-existing biases on the healthfulness or the detrimental effects of certain dietary items, which could have affected the responses to FFQ, has to be taken in consideration. Further studies on larger population are necessary to further elucidate the relationship between diet and epistaxis and inherent pathophysiological mechanisms.
With this caveat in mind, in our study the dietary items reported to exacerbate epistaxis were spices (especially chili pepper), chocolate, alcohol consumption, strawberries and ginger.Similarly a previous study also observed chocolate and strawberry to be perceived as precipitants for nose bleeds in 37/265 (14%) and in 25/256 HHT patients (9.6%), respectively (7). Finnamore et al. also reported citrus fruit intake to be possibly associated with nosebleed exacerbation, but this result has not been confirmed in the present study (7). Finally, no previous study has reported associations with alcohol, ginger and spice consumption. On the other hand, the present study suggested, for the first time, that some dietary items may have a protective effect on epistaxis in HHT patients. The most commonly reported protective aliments were blueberries and red fruits, green vegetables and legumes. Finnamore et al. investigated the presence of dietary items that could reduce nosebleeds in HHT patients, but the results were inconclusive, with only 3.73% and 2.32% of patients reporting green vegetables and meat or fish, respectively, as possibly helping epistaxis.
The pathophysiological mechanisms underlying the relationship between dietary items and nose bleeds have not been clarified. It can be hypothesized that foods rich in salicylates (such as chocolate, strawberries and alcohol) may facilitate the occurrence of epistaxis (11). Additionally, dark chocolate has been reported to inhibit different enzymatic pathways involved in platelet activity (12). However, dietary salicylates comprise several foods; thus, other mechanisms likely play a role in nosebleed onset. Finally, to date, few studies have addressed the possible protective effects of dietary items on epistaxis.
Of note and not unexpectedly in our study, a substantial proportion of patients reported that they modified their diet both avoiding items perceived to provoke nosebleeds or increasing the consumption of protective foods (58% and 46% of patients, respectively). Importantly, vitamin and micronutrient deficits (mostly calcium, folate and iron) are well-known consequences of self-prescribed and unbalanced exclusion diets in different gastrointestinal disorders (8, 13). The importance of dietary restriction in the setting of HHT has not yet been investigated; however, inadequate iron intake is of special concern in these patients considering their predisposition to iron-deficiency anemia. Thus, a careful assessment of iron intake was performed in the present study. The mean dietary iron intake in HHT patients was 8.46 ± 2.78 mg, without a significant difference between HHT patients who reported modifying their diet to reduce/ameliorate epistaxis and patients who did not modify their diet. Further studies are necessary to evaluate the impact of dietary modifications on other vitamins and micronutrients.
The data on dietary iron intake showed that the mean dietary iron intake in male HHT patients and female HHT patients aged > 50 years was significantly higher than the AR. However, for female patients aged < 50 years, the mean dietary iron intake was lower than the AR, with inadequate intake in up to 70% of patients. Thus, a careful nutritional evaluation is particularly important for the subgroup of women < 50 years to optimize dietary iron intake.
Finally, iron medications and supplements are frequently prescribed for HHT patients, and in most cases, a protective effect on nosebleeds is observed. However, a recent report from Shovlin et al. suggested that iron treatments worsened epistaxis in a small subgroup of patients (4.8% of iron tablet users and 6.5% of iron infusion users) (14). The data from our survey demonstrated a significant proportion of HHT patients (26%) reported taking iron medications to reduce nosebleeds; however, in 7 cases (6.4%), iron therapy seemed to worsen nosebleeds. These observations support the idea that a subgroup of HHT patients may be more prone to develop rapid changes in serum iron levels, leading to endothelial damage and, ultimately, hemorrhage. Therefore, in this subgroup of patients, it is of paramount importance to ensure a proper dietary iron intake.
Limitations of this study consist in the relatively small sample size for an epidemiological study. Further studies with larger sample size and external validation are needed to confirm our results. Moreover, we acknowledge the limitation of evaluating the association between epistaxis and dietary items based on patients’ perception, thus entailing a risk of placebo or nocebo effect and reducing the reproducibility of the results.