Changing the Dietary Approach with Eosinophilic Esophagitis

A recent study (AF Kagalwalla, JB Wechsler, K Amsen, S Schwartz, M Makhija, A Olive, CM Davis, M Manuel-Rubio, Seth Marcus et al.  Clin Gastroenterol Hepaot, 2017; 1698-1701) is going to help shake up the dietary management of eosinophilic esophagitis (EoE).  Our group GI Care for Kids, led by Seth Marcus, was one of the four centers which participated in this study of a four food elimination diet (FFED or 4-FED).

This prospective study enrolled 78 patients. IN those who did not respond to twice daily proton pump inhibitor therapy, subjects were instructed to restrict cow’s milk, wheat, egg, and soy. Patients underwent serial challenges (8 week for a challenge) with followup upper endoscopy to each food to determine response; 25 patients completed the challenge to all four foods. Key findings:

  • 64% (n=50) had remission (Eos <15/hpf) with the FFED
  • Symptom scores decreased in 91% of the histologic responders
  • Among those who completed additional challenges: 22/26 (85%) had reactions to cow’s milk, 10/30 (33%) had reactions to wheat, 14/40 (35%) had reactions to eggs, and 8/43 (19%) had reactions to soy
  • Among those (n=25) who completed challenges to all four foods, reactions to food: 84% milk, 28% wheat, 8% eggs, 8% wheat
  • Among those (n=25) who completed challenges to all four foods, reactions occurred to a single food-groups in 64%, two food-groups in 20%, three-food groups in 8%, and four-food groups in 8%.  Thus 36% had more than a single-food group reaction.

This study shows that the FFED provides similar efficacy to the six-food elimination diet (SFED) and is less restrictive.  It offers the prospect of less time to complete food reintroduction and fewer upper endoscopies

Limitations: nonrandomization, absence of control group, selection bias.  The fact that 24 patients dropped our before completing reintroduction highlights the difficulty of maintaining these diets in clinical practice.

In the associated editorial (S Eluri, ES Dellon, pages: 1668-9), the authors reiterate that the SFED (or 6-FED), which includes nuts and seafood, had histologic response rates typically between 69%-72% and that this study shows a similar response. They note that dairy elimination alone has had response rates ranging from 43% to 65%.

In addition, they discuss a 2-food elimination diet (milk and wheat).  In a recent study (J Molina-Infante, et al. Gastroenterol 2017; 152: S207), the authors started with a 2-FED with histologic response of 43% and if not responding would advance to 4-FED and 6-FED.  This approach was more efficient and further limited endoscopies.

My take: In those patients who are treated with a dietary approach, the 4-FED is a sensible initial therapeutic approach and an improvement from the 6-FED.  Though there is slightly higher initial response to 6-FED, the 4-FED allows more efficiency at identifying the trigger foods and lessened patient burdens with regard to endoscopy, diet complexity, and cost.

Related study: EA Erwin et al. JPGN 2017; 65: 520-5. This study showed that patients multiple IgE antibodies (≥ 0.1 IU/mL) to foods correlated with the likelihood of identifying eosionphilic esophagitis (≥ 15 eos/hpf):

  • In this cohort, among males, positive IgE antibodies to zero foods had a positive predictive value of 22%, 1-3 foods 52%, and 4-5 foods of 77%
  • In this cohort, among females, positive IgE antibodies to zero foods had a positive predictive value of 10%, 1-3 foods 29%, and 4-5 foods of 56%

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.


Four Food Group Diet for Adults with Eosinophilic Esophagitis

A recent study published online (here’s a link: EoE 4-food Group Diet) shows that a four food elimination diet was effective in 54% of the adults in this study.  Here’s the abstract:


Eosinophilic esophagitis (EoE) is an esophageal disorder predominantly triggered by food antigens. A six-food group elimination diet (SFGED) achieves remission in more than 70% of adult patients with EoE. After individual food reintroduction, just 1 or 2 food triggers for EoE can be identified in 65% to 85% of the patients, so some dietary restrictions and endoscopies after food challenge may be unnecessary.


To evaluate the efficacy of a four-food group elimination diet (FFGED) (dairy products, wheat, egg, and legumes) for adult patients with EoE.


Prospective multicenter study. All patients were reevaluated after 6 weeks on an FFGED. Response to the FFGED was defined by clinical and histologic (<15 eos/hpf) remission. Responders underwent reintroduction of each individual food over 6 weeks followed by endoscopy and esophageal biopsies. Nonresponders were offered a rescue SFGED.


A total of 52 adult patients were included, of whom 12 patients (23%) had previous failure to topical steroid therapy. Twenty-eight of the 52 patients (54%) achieved clinicopathologic remission on the FFGED and 6 of the 19 (31%) nonresponders to the FFGED were successfully rescued with the SFGED. Twenty-two of 28 responders to the FFGED (78%) finished the individual food reintroduction challenge. Milk was identified as an EoE trigger in 11 patients (50%), egg in 8 (36%), wheat in 7 (31%), and legumes in 4 (18%). All patients had just 1 or 2 food triggers, with milk being the only causative food in 27% of the patients.


An FFGED achieved clinicopathologic remission in 54% of adult patients with EoE. An SFGED was effective in almost a third of FFGED nonresponders, resulting in a combined efficacy of 72% of both strategies.

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