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Long-Term Outcomes of the Six-Food Elimination Diet and Food Reintroduction in Patients With Eosinophilic Esophagitis
Eosinophilic esophagitis (EoE) is an immune-mediated inflammatory condition with tissue eosinophilia resulting in esophageal dysfunction. The six-food elimination diet (SFED) is an EoE treatment approach that removes milk, wheat, soy, eggs, tree nuts/peanuts, and fish/shellfish. After histologic remission, food reintroduction occurs to identify a food trigger. Outcomes from large series of adults undergoing SFED and food reintroduction as clinical care are not known.
A retrospective review (2006-2021) of adult patients with EoE from an academic center was completed. Patients were classified as full responders (<15 eos/hpf) after SFED. If reintroduction was pursued, food triggers identified were recorded.
Two hundred thirteen patients completed SFED. One hundred fifteen patients (54%) had response <15 eos/hpf after SFED. Seventy-seven percent of responders had symptom improvement. Thirty-two percent of initial nonresponders underwent repeat dietary elimination. Fifty-eight percent of patients (n = 123) achieved <15 eos/hpf after either initial or extended SFED. Seventy-eight percent of responders underwent food reintroduction. Sixty-nine percent had 1 food trigger identified, 24% had 2 allergens identified, and 4% had 3 allergens identified. The most common food triggers identified were milk, wheat, and soy.
This study describes the largest cohort reported of adult patients with EoE completing SFED with food reintroduction. The overall SFED histologic response was 54%, which increased to 58% with 1 additional round of dietary therapy, suggesting that 31% may respond in a second attempt. Most patients who completed food reintroduction had a single food trigger identified. Dietary elimination with specific food trigger identification is a feasible alternative to medical therapy for adults with EoE.
Disclosure statements are available on the authors' profiles:
Long-Term Outcomes of the Six-Food Elimination Diet and Food Reintroduction in a Large Cohort of Adults With Eosinophilic EsophagitisAm. J. Gastroenterol 2022 Dec 01;117(12)1963-1970, A Zalewski, B Doerfler, A Krause, I Hirano, N Gonsalves
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
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Six-food elimination diet for eosinophilic esophagitis
Eosinophilic esophagitis (EoE) is the result of immune triggers along the esophagus. The easy therapy is to prescribe a proton-pump inhibitor (PPI) or a topical steroid to suppress the symptoms. However, to get to the root of the problem, this study shows that we should start by eliminating the food trigger instead of just suppressing the symptoms.
This is the largest study to date and it included 213 patients with biopsy-proven EoE who completed a six-food elimination diet (ED) off wheat, dairy, soy, eggs, tree nuts/peanuts, and fish/shellfish. After 6 weeks, a repeat EGD with esophageal biopsy was performed. Initially, 54% of the patients responded with an average number of eosinophils per high-power field (eos/hpf) dropping from 64 before the ED to 11 eos/hpf after the ED. The nonresponders were given the choice to repeat the same six-food ED or expand the foods eliminated to include corn, beef, legumes, and poultry. This intervention increased the number of responders from 54% to 58%. Of note, 77% percent of these responders also had improvement in dysphagia symptoms.
For the patients who responded to the elimination diet, a rechallenge involving food triggers was performed, with follow-up endoscopy and biopsy to determine which foods were the most likely eosinophilic triggers. Most of the patients had just one food trigger, with dairy being the most common at 37%, followed by wheat at 26%, soy at 13%, egg at 10%, nuts at 6%, seafood at 4%, corn at 1%, and poultry at 1%.
How to do an elimination diet?
Unlike an immediate food allergy, a food intolerance that triggers EoE can be more delayed and chronic. Although this study removed the food for 6 weeks before biopsy, previous research suggest that the food should be eliminated for a minimum of 2 weeks. Although endoscopy with biopsy was necessary for this objective research, an elimination diet is often a subjective process based on how the patient feels. To avoid overly restrictive diets, it is a good practice to rechallenge with the most common foods last. For example, reintroduce nuts and seafood first and wheat and dairy last.
A sample elimination diet
For 2 weeks, eliminate the 6 foods, dairy, wheat, soy, eggs, tree nuts/peanuts, and fish/shellfish.
If there is an improvement in symptoms (eg, dysphagia), start one food rechallenge to see which food may be the culprit. Encourage eating the foods regularly for 2 to 3 days at the beginning of each 2-week challenge. Every 2 weeks, if there is no worsening of symptoms, add the next food in this order: seafood, nuts, eggs, soy, wheat, and dairy.
Since dairy and wheat were the most common triggers, for simplicity, you could start by eliminating just these two foods and then do a rechallenge with just dairy and wheat over a 6-week period. This would involve 2 weeks for the initial elimination and then 2 weeks for each rechallenge for dairy and wheat.
Do an elimination diet during a relatively stable time in the patient’s life. It is hard to do an elimination diet while the patient is traveling or if there is a significant emotional stressor since this can also cloud the accuracy of the test.
Something to consider
We should start by first eliminating the potential food trigger of EoE. And, if the patient is a nonresponder, then we can suppress the process with topical fluticasone. However, I have concerns about using PPIs as first-line therapy. Pepsinogen needs acid to form pepsin protease. We need protease to help break down food into smaller, less triggering subunits. Even though PPIs help reduce symptoms of EoE, could they be perpetuating the problem? It takes just 5 days of a PPI to reduce the effectiveness of the enzymes we need to break down food into more digestible, less immunogenic subunits.
The GI tract is a dynamic interactive ecosystem. The astute clinician is an ecologist.