Food Is Medicine for Those Who Live with Eosinophilic Esophagitis, But Prescriptions May Vary

Dietary therapy is effective as a sole intervention for eosinophilic esophagitis (EoE), however, finding the right diet can be a challenge. Kristle Lynch, MD, associate professor of medicine at the Perelman School of Medicine, University of Pennsylvania discussed the advantages and drawbacks of different diets for patients with EoE during the Tachi Yamada, MD, Lecture at the Digestive Disease Week 2024 meeting.

Dietary therapies that have been considered for the management of EoE include targeted elimination diets, elemental diets, and empiric elimination diets. Targeted elimination diets, which are guided by allergy testing, have shown a limited response in adults with EoE. Moreover, results from single-arm observational studies are difficult to interpret because of variability in the methods of testing used in different trials (eg, skin-prick testing, serum-specific Immunoglobulin E [IgE] testing, atopic patch testing, or combinations). “We know that EoE is not a primarily IgE-mediated disease,” Lynch said. “Diet limitation based on IgE-mediated testing is not currently recommended [for patients with EoE].”

The elemental diet consists of single amino acid-based enteral formulas with low antigenic properties, which are formulated to meet full nutritional needs without supplementation. Limited prospective data have shown that this dietary approach is effective in controlling EoE but can be difficult to maintain in adults. Lynch noted that some patients abandon the diet on day 1, while many others report dietary non-compliance.

Many clinicians recommend the Six Food Elimination Diet (SFED), which involves the simultaneous elimination of the six most common food allergen groups: eggs, dairy, wheat, soy, seafood, and nuts. “There is a high risk for nutritional imbalance,” the speaker said. “It is very difficult to undergo the entire elimination process while maintaining a balanced, nutritional diet.” Ideally, patients should collaborate with a dietician to overcome challenges related to this approach, including finding meal ideas and deciphering labels for packaged foods. While many packaged foods from allergen-friendly brands are available, not all products sold by those brands are free of all allergens. The elimination diet process begins with adherence to SFED for 6 to 8 weeks, followed by an endoscopic examination with biopsies. If symptomatic and histologic improvement is noted, patients can reintroduce one or two food groups in 4 to 6-week intervals, followed by endoscopic evaluations with biopsies every time a group is reintroduced.

Adherence to SFED requires time and energy, may be costly, and is associated with a high endoscopic burden. Variations of this approach include the four-food, two-food, and single-food group elimination diets. Trials comparing the one-food elimination diet and those eliminating several food groups showed a similar histologic response between groups, but also revealed a relatively low overall response rate. In the alternative, patients may try a step-up diet, which initially requires eliminating one or two food groups. If remission is not achieved, additional food groups can then be eliminated.  

“When sustained, elimination diets result in symptomatic, endoscopic, and histologic disease control,” Lynch said. “However, long-term studies reveal significant drop out over time.” Cost, endoscopic burden, and time constraints may limit the utility of dietary approaches in the management of EoE. In a study designed to evaluate barriers to EoE care, Lynch and colleagues analyzed 92,000 social media posts (X) and found that dietary challenges constituted the most common barrier. Other barriers to care included limited treatment options, lack of community support, lack of physician awareness of disease, and misinformation (Thanawala SU et al. Dis Esophagus 2024; 14:doae043).

Although most dietary approaches have disadvantages and are difficult to sustain in adults, they offer a medication-free option for treating a chronic disease. “Consideration of patient preference, lifestyle, resources, and support are key when choosing a therapy,” the speaker concluded.