Eosinophilic esophagitis (EoE) is an immune- or antigen-mediated disease. It is a clinical pathologic diagnosis, meaning that you have both symptoms of esophageal dysfunction, as well as evidence of esophageal inflammation. Symptoms evolve as patients age. In infancy, you can see feeding problems, and as the child progresses to adulthood, you will see them complain about vomiting, abdominal pain, difficulty swallowing, food impaction, and all of this may cause them to avoid eating certain foods, eat very slowly, or avoid social situations where food is involved.
Symptoms can be triggered by a number of different factors, including food or aeroallergens. That being the case, diet therapy was one of the earliest therapies shown to be effective for eosinophilic esophagitis.
Elemental formula diet, also known as hypoallergenic formula diet, is the strictest diet on this list, but also extremely effective. There was a study done in the mid-nineties that showed that the elemental diet could normalize the esophagus, but it relapses very quickly when you start reintroducing food back into the diet. That was a big clue that EoE is diet-driven.
The formula is made of amino acids, is developed to meet the nutritional needs of the patient, can be flavored or unflavored, and is free from common allergens so as not to trigger the patient’s EoE.
Data from several single-arm observational studies have shown strikingly high rates of symptomatic and histologic remission with the elemental formula diet. However, being single-arm observational studies, they are limited by a lack of a control group or a placebo arm: subjects were just treated with the formula and it was observed that they did extremely well.
However, as good as this sounds, this diet is not for everybody. You may have more success trying this approach in very young patients or in somebody who is being fed by a G-tube because the formulae are not very appetizing, making this approach very challenging. It will work in all ages, but you may find compliance to be easier in your younger patients.
Another thing to keep in mind with the elemental formula diet is that it will require frequent endoscopies when you start reintroducing foods back into your patient’s diet, so it is important to make sure your patient is okay with that approach.
Another diet is empiric elimination. In this diet you are taking anywhere from 1, 2, 4, or 6 food group(s) out of a patient’s diet and trying to discover which food group(s) is the aggravating factor in their EoE. Generally, 4 to 6 food group elimination diets are the most common variations. There is also a step-up approach where 2 food groups are eliminated and if the patient experiences no improvement, another 2 groups are eliminated – and so on until the 6 food groups are eliminated. Conversely, less restrictive elimination diets that limit only 1 to 2 food group(s) have been studied with some efficacy.
This diet has been proven to be highly effective with moderate-to-high rates of remission in single-arm trials.
It is important to note that this can be a lot of food and can be difficult, particularly for kids in low-income families, those on food assistance programs, and in children with failure to thrive. For instance, eliminating “seafood” requires the elimination of over 80 different allergens. Eliminating “tree nuts” includes 7 different types of nuts. So, this can be a lot of food that is being taken out of the diet. However, it is still less restrictive than the elemental formula diet since less food is being eliminated and a patient may prefer this approach, especially as there are popular diets now that feature allergen-free foods that may make this diet a little easier to comply with today than ever before (eg, gluten-free diets, diary-free diets, etc). This diet may also lead to the nonspecific elimination of something that maybe was not bothering them. Similar to the elemental diet, it will require multiple endoscopies for reintroduction of food groups.
Finally, the style most allergists are probably highly comfortable with is the targeted or tailored elimination diet. This is driven by skin patch testing to some degree (older studies) and possibly even using serum-specific IgE. In this diet, you are specifically looking to eliminate foods that are identified as a trigger based on the results of a test.
This diet can have some technical difficulties and can be technique-dependent to some degree. For instance, it can be uncomfortable for the patient to leave a skin-test patch on their back for 72 hours. The skin testing is also operator-dependent to some degree and there is always the risk of false positive tests. Although allergy tests tend to be very sensitive, they are also poorly specific. In EoE, however, it is actually the other way around – they are poorly sensitive, but often highly specific.
Finally, similar to the other 2 diets listed above, when you are taking foods out, you have to reintroduce them back in one-by-one. So, this, like the other 2, also comes with the risk of repeat endoscopy.
All these diets will work, so which one do you pick? This is where patient communication comes in: Who are you talking to? What are they looking for in terms of a choice in diet? The decision is preference sensitive. Tailor it to your patient and you can bounce between the strategies if needed.
Reference: Gonsalves NP, Aceves SS. J Allergy Clin Immunol. 2020;145(1):1-7.
For more on this, check out Addressing Barriers to EoE Diagnosis and Treatment: The Role of Updated Guidelines and Novel Therapies, A Series of Expert Panel Discussions Featuring an Experienced EoE Patient
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