Elimination eosinophilic esophagitis diets are effective most patients, but their use is limited by the complexity of the diets and the need for multiple endoscopies. Up to three fourths of patients are found to have just one or two food triggers, most commonly milk and wheat/gluten. Complete elimination diets are hard to follow and difficult to continue long term. If allergy testing is negative for foods, step up empiric elimination diets have been favored for its efficacy and cost savings.
A recent study looked at 2-4-6 eosinophilic esophagitis diets in 130 patients with the disease. All patients underwent an initial 6 week diet eliminating the two most common foods, milk and wheat/gluten. Nonresponders to the diet (less than 15/hpf on esophageal biopsy) proceeded to a 4-food elimination diet, eliminating eggs and legumes. If there was still no response, they then proceeded to a 6-food elimination diet, further eliminating nuts and fish/seafood.
For the patients who completed the study, remission rates were:
- 2 food elimination-43%. (52% of those was from milk, 28% wheat/gluten, 16% both).
- 4 food elimination-60%
- 6 food elimination-79%
Many patients who had to go to the 4 or 6 food elimination diet, had more than two food triggers.
This step up therapy of an eosinophilic esophagitis diet can lead to remission of the disease while shortening the diagnostic process and requiring fewer endoscopies and reduce the burden associated with adherence to more extensive elimination diets. It is important if your gastroenterologist (GI) doctor diagnoses you with eosinophilic esophagitis, he/she needs to work closely with an allergist to help manage and identify potential food and environmental triggers that can exacerbate your condition. Besides elimination diets, there are medications and procedures than can be done to treat this condition. To read more about eosinophilic esophagitis, please read our previous blog posts.
Update June 20, 2023
Dairy avoidance similar to 6-food elimination diet in eosinophilic esophagitis
A recent study published in the Lancet Gastroenterology Hepatology (Feb 2023) sought to identify the main food triggers in EoE. Empiric elimination diets are used to induce remission, but patient adherence is restrictive. The study compared the 6 elimination diet (animal milk, wheat, egg, soy, fish and nuts) versus milk alone (1 food elimination diet).
Notably similar rates of remission were observed in both diets (35-40%). About half of the subjects who failed 1FED achieved remission after transitioning to 6FED. These results support using a single elimination diet of animal milk initially for EoE with a step up to 6FED if necessary.
Starting with the elimination of animal milk alone may be an acceptable alternative to starting with the more difficult 6 food elimination diet for EoE. Patients may see elimination therapy as a more desirable therapy than can serve as an alternative to pharmaceutical drugs.