Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus, often triggered by food proteins, which causes a buildup of white blood cells called eosinophils. This immune response leads to inflammation, which can cause difficulty swallowing, chest pain, and food getting stuck in the esophagus. While medication is a common treatment, dietary modification is also a cornerstone of managing the condition, with various strategies available to identify and eliminate specific food triggers. A specialized dietitian plays a critical role in guiding patients through this process to ensure they maintain nutritional health.
Types of dietary therapy for EoE
There are three main nutritional approaches used to treat EoE, each with different levels of restrictiveness and efficacy. The choice of diet often depends on the patient's age, disease severity, and lifestyle, and should always be made in consultation with a healthcare team.
Elemental diet
The elemental diet is the most restrictive but also the most effective nutritional therapy, with remission rates often exceeding 90%.
- What it involves: The patient consumes only a liquid formula made of amino acids, which are the simplest form of protein. This approach removes all potential food-based allergens, allowing the esophagus to heal completely. The diet is typically followed for 6 to 12 weeks.
- Who it's for: This is generally reserved for severe or refractory cases of EoE, or for young children who are failing to thrive. It can also be a temporary measure to achieve rapid remission before transitioning to a less restrictive diet.
- Challenges: The elemental formula can have an unappealing taste, and the diet is extremely restrictive, which can lead to compliance issues, especially in older children and adults. It can also be very costly.
Empiric elimination diets
These diets involve removing the most common food triggers for EoE from the diet without prior allergy testing, which is often unreliable for EoE. These diets can be implemented in a “top-down” (starting with more eliminations) or “step-up” (starting with fewer eliminations) approach. After a period of elimination, foods are reintroduced one by one to identify the triggers.
- Six-Food Elimination Diet (6FED): This was historically the most common empirical approach. It removes the six most common food allergens: milk, wheat/gluten, egg, soy, nuts (including peanuts and tree nuts), and fish/shellfish. It has a high success rate, around 72% overall.
- Four-Food Elimination Diet (4FED): A less restrictive option that removes milk, wheat, egg, and soy. This is often a good starting point for patients, especially adults, achieving remission in over 50% of cases.
- Two-Food Elimination Diet (2FED): Targeting the two most common EoE triggers—milk and wheat—this is the least restrictive empirical diet and may be used as a first step in a step-up approach.
- One-Food Elimination Diet (1FED): Focused solely on cow's milk, recent research suggests this less restrictive option may be an effective first-line therapy for many adults.
Allergy test-directed diet
This approach uses allergy testing (such as skin prick or patch tests) to identify specific triggers for elimination. However, this method is less consistently reliable for EoE triggers compared to other allergies. Its use is declining in favor of empirical elimination, though some doctors may still use it for guidance.
Comparison of EoE dietary therapies
| Feature | Elemental Diet | Empirical Elimination Diet (e.g., 6FED) | Allergy Test-Directed Diet |
|---|---|---|---|
| Efficacy Rate | >90% for remission | Up to 72% for 6FED | Lower and less predictable |
| Restrictiveness | Extremely high; liquid formula only | High for 6FED, lower for 4FED/2FED | Varies based on test results |
| Adherence | Low; often challenging for older kids and adults | Variable; requires strict label reading | Can be less restrictive if testing is clear |
| Cost | Can be very expensive | Varies; requires finding specialty alternatives | Varies; based on test and food costs |
| Identification of Triggers | Clear during reintroduction phase | Reliably identifies triggers via reintroduction | Tests are often unreliable for EoE |
| Ideal For | Severe or refractory cases, young children with failure to thrive | Most patients seeking a balance between effectiveness and practicality | Not a preferred primary strategy |
The dietitian's role and nutritional considerations
Given the restrictive nature of EoE diets, particularly the 6FED or elemental diet, professional guidance is essential to prevent nutritional deficiencies and ensure long-term success. A registered dietitian will:
- Conduct nutritional assessment: Evaluate the patient's dietary intake and risk for deficiencies, which is especially important for children's growth.
- Provide guidance: Offer education on which foods to eliminate, how to read labels, and how to prevent cross-contamination.
- Develop meal plans: Suggest appropriate substitutions for trigger foods to maintain a balanced diet.
- Monitor nutrient intake: Recommend specific nutritional supplements, such as calcium, vitamin D, iron, and vitamin B12, which can be lacking in restrictive diets.
- Manage reintroduction: Supervise the food reintroduction process and monitor for symptoms.
- Offer emotional support: Address the psychosocial challenges of living with a highly restricted diet.
Conclusion
Nutrition therapy is a highly effective treatment for eosinophilic esophagitis, with a range of options available. The elemental diet, while highly successful, is extremely restrictive and often reserved for severe cases. For most patients, an empirical elimination diet, such as the 6FED, 4FED, or 2FED, provides a practical and effective method for identifying food triggers and achieving remission. A step-up approach, starting with fewer eliminations, can also be used to minimize dietary restrictions. The cornerstone of any successful dietary management plan is working closely with a dietitian to ensure nutritional adequacy, patient compliance, and a balanced, sustainable approach to eating.
Potential nutritional supplements to consider
When following an elimination diet for EoE, certain nutrients may be more difficult to obtain from food alone. Supplements may be recommended by a healthcare provider after assessing your specific needs.
- Calcium and Vitamin D: Important for bone health, especially when dairy is eliminated.
- Iron: Necessary for red blood cell production, especially if red meat is restricted.
- Vitamin B12: Essential for nerve function and blood cells; supplementation may be needed if animal products are limited, particularly for long-term restrictions.
- Omega-3 Fatty Acids: Have anti-inflammatory properties and can be obtained from supplements like fish oil, flaxseed, or chia seeds.
- Probiotics: May help maintain a healthy gut microbiome, which is often imbalanced in EoE, although more research is needed.
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Consult with a qualified healthcare professional before making any dietary changes.
Key takeaways
- Elemental diets offer the highest efficacy rates for treating EoE, but their extreme restrictiveness limits long-term use.
- Empiric elimination diets (6FED, 4FED, 2FED) are common and effective, identifying food triggers by systematically removing and reintroducing common allergens.
- The six most common food triggers in EoE are milk, wheat, egg, soy, nuts, and fish/shellfish.
- Allergy test-directed diets are less reliable for identifying EoE triggers than empirical elimination.
- Professional dietitian guidance is crucial to manage elimination diets, ensuring nutritional completeness and adherence.
- Careful food reintroduction after a period of elimination is required to pinpoint specific allergens.
- Nutritional supplements may be necessary to fill gaps in restrictive diets, especially for nutrients like calcium, vitamin D, and iron.
