Efficacy of Elimination Diets in Eosinophilic Esophagitis: A Systematic Review and Meta-analysis

Dietary management of eosinophilic oesophagitis

“…It is frustrating that formal allergy testing (skin prick or patch testing) is also not particularly helpful for predicting response to dietary antigens. Twelve studies have used this approach with combined remission rates of 45.7% (95% CI, 32.0–59.7%), which is lower than an empirical 1FED response of 51.4% (95% CI, 42.6–60.1%) 7 . To refine this approach, more work is needed to understand the mechanism of dietary allergens to improve our understanding and treatment of the disease, given that dietary proteins are hypothesised to be the drivers of eosinophilic infiltration into the oesophagus in susceptible individuals.…”

“…The efficacy of the 6FED has been examined in two systematic reviews, with remission rates reported as 61.3% (95% confidence interval [CI], 53.0–69.3%) and 72.1% (95% CI, 65.8–78.1%) 7,11 . There is substantial variability in remission rates reported across studies (Box 1), likely due to the heterogeneity in remission/response definition, study design, paediatric versus adult cohorts, adherence to diet, and duration of intervention.…”

“…The diagnosis, defined by the Appraisal of Guidelines for Research and Evaluation (AGREE) Consortium, includes meeting the following criteria: i) symptoms of oesophageal dysfunction; ii) confirmation of histological inflammation with ≥ 15 eosinophils per high power field (or ~ 60 eosinophils per mm 2 ) on oesophageal biopsy; and iii) exclusion of non‐eosinophilic oesophagitis disorders that could cause secondary oesophageal eosinophilia 6 . Routine IgE mediated allergy testing has not been considered useful 7 . Around 10% of cases of eosinophilic oesophagitis are genetic 2 and screening of parents or siblings is indicated.…”

“…To address these concerns, a step‐up method of a 2FED (cow's milk and/or all animal milk, wheat and/or gluten) or a 4FED (cow's milk and/or all animal milk, wheat and/or gluten, eggs, soy and/or legumes/peanuts) has been proposed, with remission rates of 43% and 54% respectively when including drop‐outs 14 . These diets are less efficacious, but fewer endoscopies are required to identify the common triggers, which in 70% of cases is animal milk, followed by wheat (48%) and eggs (27%) 7 . Importantly, 70% of patients responding to a 2FED have a single food trigger (animal milk or gluten‐containing cereals) and, thus, patients taking a 6FED approach may be on an overly restrictive diet 14 …”

Can diet change the natural history of gastrointestinal diseases?

“…In a recent meta‐analysis, the six‐food elimination diet (eliminating milk, wheat, soy, eggs, tree nuts/peanuts and fish/shellfish) proved most effective with an overall efficacy of 61%; in contrast to other food allergies, an elimination strategy based on the results of allergy testing was less successful and has led to a lack of enthusiasm for food allergy testing in EoE. 25 However, a recent study demonstrated a modest efficacy for food‐specific IgG4 antibodies in guiding success in response to an elimination diet in EoE. 26 When undertaken, the most usual elimination diet protocol involves beginning with the six‐food protocol and assessing histological response.…”