Illuminating Elimination Diets: Controversies Regarding Dietary Treatment of Eosinophilic Esophagitis

Abstract

Eosinophilic esophagitis (EoE) is an immune-mediated disease triggered by food antigens for which dietary elimination treatment can induce and sustain histologic remission. Our review aims to describe the state-of-the-art regarding dietary treatment of EoE, highlighting a number of areas of controversy related to dietary therapy in EoE, including novel modalities for determining food triggers, making the empiric dietary elimination process more efficient, issues of crosscontamination and "dosing" of how much food to avoid or add back, costs and effects on qualityof-life, long term efficacy, and the risk of developing immediate IgE-type reactions after initial dietary elimination. Elemental formulas, empiric elimination diets, and targeted allergy testdirected elimination diets are well-described treatments for EoE. Although elemental diets are most efficacious, their clinical use is limited by cost and the palatability of an exclusively liquid diet. While empiric elimination is less effective than elemental formula-based diets, they are more easily implemented and often sustainable. Since the comparative effectiveness of elimination diets with proton pump inhibitors and swallowed topical steroids remains unknown, there are multiple areas to address with future research.

Immunogenetic, Molecular and Microbiotic Determinants of Eosinophilic Esophagitis and Clinical Practice—A New Perspective of an Old Disease

“…Skin allergy tests are less effective and are not generally recommended but empiric eliminations are more effective and easier to follow. Nevertheless, long-term efficacy and adherence should be investigated further regardless of the chosen approach, also in comparison with pharmacological treatment [ 116 , 117 ].…”

Emerging therapies for eosinophilic esophagitis

“…A 4-food elimination diet eliminating dairy, wheat, egg, and soy/legumes has been shown to be effective in 54% to 64%. 56 Because milk frequently represents the culprit food in children with EoE, cow's milk elimination attempts have been made. Recently, a randomized controlled trial in 63 children has shown similar histologic remission rates for milk elimination compared with a 4-food elimination.…”

Gastrointestinal involvement of primary skin diseases

“…23 Elimination diet avoiding food triggers is the only therapy targeting the cause of the disease, but the efficacy remains controversial, because none of the currently available allergy tests can adequately predict food allergens for EoE. 24 Up to 50% of patients diagnosed with EoE also had atopic dermatitis, 25 and EoGEC in Japan associated with atopic diseases. 11 While EoE can be considered as an involvement of allergic march in childhood, 26,27 the true prevalence of EoE and EoGEC in patients with atopic dermatitis remains to be determined.…”

“…Whole‐genome mRNA expression analysis on tissue specimens from patients with EoE, AD and AA indicated a greater involvement of the IL‐13‐driven molecular pathways in EoE than AA or AD, and a significantly higher overlap of EoE with AD than with AA 23 . Elimination diet avoiding food triggers is the only therapy targeting the cause of the disease, but the efficacy remains controversial, because none of the currently available allergy tests can adequately predict food allergens for EoE 24 …”