Understanding the role of food in EoE
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease of the esophagus, primarily triggered by food antigens. In patients with EoE, certain food proteins provoke an allergic-type reaction, causing a buildup of eosinophils (a type of white blood cell) in the lining of the esophagus. This inflammation can lead to symptoms like dysphagia (difficulty swallowing), food impaction, chest pain, and abdominal discomfort. Dietary therapy is a frontline treatment that targets the root cause of this inflammation by removing the offending foods, aiming to induce and maintain long-term remission without medication.
Types of EoE nutrition therapy
There are three primary dietary strategies used for managing EoE, each differing in restrictiveness and methodology. The choice of which approach to use often depends on a patient's age, motivation, and the severity of their condition.
Elemental diet: The most restrictive approach
This is the most effective and restrictive dietary approach, consisting of a liquid, amino acid-based formula that is completely free of food proteins.
- How it works: For 6 to 8 weeks, patients consume only the hypoallergenic formula, providing the esophagus time to heal by completely eliminating all potential food triggers.
- Efficacy: It boasts the highest remission rates, often exceeding 90% in both children and adults.
- Usage: It is typically reserved for cases where other dietary approaches have failed or for young children who are unable to cooperate with elimination diets.
- Drawbacks: The formula has poor palatability, is expensive, and is socially limiting, which often leads to poor long-term adherence.
Empiric elimination diets: Removing common triggers
These diets involve removing the most common food allergens, followed by a systematic reintroduction of food groups to identify the specific triggers. This strategy is often preferred due to better palatability and higher adherence than elemental diets.
- 6-Food Elimination Diet (6FED): This approach removes milk, wheat, egg, soy, nuts, and seafood. It has shown high efficacy, with remission rates often over 70%.
- 4-Food Elimination Diet (4FED): A less restrictive alternative, this diet removes milk, wheat, egg, and soy. Remission rates are lower than the 6FED but still significant, particularly in children.
- 2-Food Elimination Diet (2FED): Removing just milk and wheat, the two most common food triggers, this is a much less restrictive option. Studies have shown varying success rates, but it represents a good starting point for a "step-up" approach.
- 1-Food Elimination Diet (1FED): Focusing solely on milk protein, the single most common trigger, this diet is the least restrictive empiric option. Efficacy rates are more variable but can be effective for some patients.
Targeted elimination diet: Based on testing
In this approach, potential food triggers are identified through allergy testing, such as skin prick or atopy patch tests.
- How it works: Once tested, only the foods that provoke a positive reaction are eliminated from the diet. However, allergy testing is not consistently reliable for identifying EoE food triggers.
- Efficacy: This approach is generally less effective than empiric diets, particularly in adults, and is not recommended as a standard practice by most guidelines.
The process: Elimination, reintroduction, and maintenance
Regardless of the type, nutrition therapy for EoE follows a three-step process:
- Elimination Phase: The diet is initiated by removing the identified food(s) or food group(s) for a set period, typically 6 to 8 weeks. This phase aims to reduce inflammation and achieve clinical and histological remission, which is confirmed with an endoscopy and biopsies.
- Reintroduction Phase: If remission is achieved, foods are systematically reintroduced one at a time over several months. After each food reintroduction, another endoscopy with biopsies is performed to monitor for returning inflammation. This tedious process is crucial for identifying the specific triggers.
- Maintenance Phase: Once all triggers have been identified, the patient continues to avoid only the confirmed allergenic foods long-term. This personalized, long-term dietary plan allows for maximal food variety while controlling the disease.
Comparison of EoE diet therapies
| Feature | Elemental Diet | Empiric Elimination Diets (e.g., 6FED) | Targeted Elimination Diet |
|---|---|---|---|
| Effectiveness | Highest (>90% remission) | High (6FED > 70%; 4FED ~54-64%; 2FED ~43%) | Low to moderate (~40%) |
| Restrictiveness | Most restrictive (liquid formula only) | Moderately restrictive (removes common food groups) | Least restrictive (removes only tested foods) |
| Palatability | Poor | Good | Good |
| Compliance | Low long-term | Moderate to high | Variable (relies on test accuracy) |
| Cost | High (specialized formula) | Moderate (can require substitutions) | Low to moderate (testing not reliable for EoE) |
| Diagnostic Burden | Requires multiple endoscopies for reintroduction | Requires multiple endoscopies for reintroduction | Not recommended due to inaccuracy of testing |
The importance of a multidisciplinary team
Successfully managing nutrition therapy for EoE requires a team approach, most notably involving an experienced registered dietitian. A dietitian helps patients and families navigate the complexities of restrictive diets, ensuring nutritional needs are met and providing guidance on label reading and cross-contamination. For children, dietitians monitor growth and prevent nutritional deficiencies, which can be a risk with overly restrictive approaches. This multidisciplinary care improves long-term adherence and overall quality of life for patients. The American Academy of Allergy, Asthma, and Immunology provides guidance and resources for dietary management of EoE.
Conclusion
Nutrition therapy is a proven and effective method for treating the underlying cause of eosinophilic esophagitis. While options range from the highly restrictive elemental diet to the more palatable empiric elimination diets, the common goal is to identify and remove the specific food triggers responsible for esophageal inflammation. With the guidance of a dietitian and a clear, phased approach of elimination, reintroduction, and maintenance, many patients can achieve long-term remission and avoid the need for ongoing medication. The ongoing evolution towards less restrictive approaches and a step-up diagnostic strategy offers patients more manageable and personalized pathways to control their condition effectively.
