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Because food allergens can trigger eosinophilic esophagitis (EoE), their removal via elimination diets or use of hypoallergenic elemental feeding can induce remission. The six-food elimination diet, which excludes dairy, wheat, eggs, soy, nuts and seafood, has been the mainstay for both pediatric and adult patients. Whether elimination of fewer foods could be equally efficacious is of interest.
In a prospective multicenter trial, researchers evaluated the efficacy of a four-food elimination of dairy, eggs, wheat, and soy in 78 children (aged 1–18 years) with EoE. The 8-week histologic remission rate was 64%. Complete symptom resolution was 36%, and decreased symptom scores were evident in 91%. Cow's milk was the most common allergen (in 85%), followed by eggs (35%), wheat (33%) and soy (19%). Allergy testing did not predict these food triggers.
Kagalwalla AF et al. Efficacy of a 4-food elimination diet for children with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2017 Jun 8; [e-pub]. (http://dx.doi.org/10.1016/j.cgh.2017.05.048)
Eluri S and Dellon ES.Towards more efficient dietary elimination therapy for eosinophilic esophagitis: The fantastic 4? Clin Gastroenterol Hepatol 2017 Jul 26; [e-pub]. (http://dx.doi.org/10.1016/j.cgh.2017.07.022)
Comment
In an accompanying editorial, an expert group considers these results within the context of other recent evidence. Dietary elimination of dairy alone has shown response rates of 43% to 65% in pediatric and adult patients. A recent abstract presentation of elimination of two foods (milk and gluten), expanded up to four (plus eggs and legumes) and then six foods (plus seafood and nuts) in cases of nonresponse, showed histologic responses of 42%, 58%, and 71%, respectively. I agree with the editorialists' conclusion that, as nuts and seafood appear to be infrequent triggers, beginning with a four-food elimination seems to be a prudent change to incorporate now when initiating dietary exclusion treatment.