Tag Archives: six food group elimination diet

Elimination Diets for Eosinophilic Esophagitis in Adults

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A recent study shows that elimination diets, including a six-food group elimination diet (SFED) can be effective in adults with eosinophilic esophagitis (EoE) (Clin Gastroenterol Hepatol 2014; 12: 1272-79).

This retrospective study identified 31 adults (mean age 36 years) who underwent dietary therapy between 2006-2012.  22 had a targeted elimination diet (TED) and 9 had SFED.

Key findings:

  • Symptoms improved in 71% (68% TED, 78% SFED)
  • Endoscopic appearance improved in 54% (53% TED, 56% SFED)
  • 39% had eosinophil count drop below 15 eos/hpf (32% TED, 56% SFED).  Overall in the entire cohort, mean eosinophil count dropped from 78 eos/hpf at baseline to 43 dos/hpf.
  • Among the nine responders with food reintroduction, the most common foods identified as triggers (using food reintroduction) were milk (4), egg (4), wheat (2), shellfish (1), and legumes (1).

 

SFED works for EoE!

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A recent study confirms that an empiric ‘6-food elimination diet’ (SFED) works in adults  with eosinophilic esophagitis (EoE) as well as it has been shown to work in kids (J Allergy Clin Immunol 2013; 131: 797-804)).  Thanks to Seth Marcus for this reference.

This Spanish study recruited 67 consecutive adult patients (17-60 years) who were treated with an exclusive diet which eliminated milk (avoided goat’s milk too), wheat/cereals (avoided rice and corn too), eggs, fish/seafood, legumes/peanuts, and soy for 6 weeks.  Subsequent rechallenge followed with repeated endoscopies every 6 weeks.  A food was considered a trigger for EoE if eosinophilic infiltrate ≥ 15 Eos/hpf after reintroduction.

Prior to reintroduction, 73% (n=49) responded to SFED with peak Eos < 15/hpf. Among responders, 37 patients achieved a complete response with Eos 0-5/hpf.  Subsquently rechallenges were instituted and 42 patients completed this part of the study. A single food was identified in 36%, 2 food triggers in 31%, the remainder had at least 3 food triggers.  Cow’s milk was the most common food trigger, in 62%, followed by wheat (29%), eggs (26%), and legumes (24%).

Allergy testing (ImmunoCap IgE-based testing, and skin prick testing) showed no concordance with food reintroduction challenge results.  All patients maintained on avoidance of offending foods maintained remission for up to 3 years.

In the general scheme of food reintroduction, it is interesting that the authors often tested for wheat and milk first.  Also, the Table 1 listed numerous characteristics of responders and nonresponders and none of these had a significant predictive effect.  This table listed symptoms including dysphagia, vomiting and pain, caliber of esophagus, mucosal appearance, atopic history, atopic family history, and eosinophil counts.

Related blog entries:

Picking the right diet for EoE

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A study from Philadelphia/CHOP offers more insight into food selection diets for eosinophilic esophagitis (EoE) (Spergel JM, et al, J Allergy Clin Immunol 2012; 130: 461-7) –thanks to Seth Marcus for forwarding this article to my attention.

For this study, the authors examined their database of 1187 patients.  While the data was collected prospectively, this was a retrospective study.  Of this 1187, the authors excluded patients with proton pump inhibitor-responsive EoE (n=191) along with patients with more extensive eosinophilic GI diseases (n=55).

Among the remaining 941, the male-to-female ratio was 2.8:1 and the average age was 6.4 years. Concurrent atopic disorders were common: 64% had rhinitis, 50% had asthma, and 24% had atopic dermatitis.  Only 18% had no atopic disorders.

The actual number for the study though was 319.  Among the 941 noted above, 148 were receiving medications (n=130 for topical steroids), and causative foods were not identified in 474.  In some of these patients, families were content to stick with a multiple food elimination without determining with certainty which foods were truly necessary.

In less than 5% of patients, a strict elemental diet was used.  In this group, the population was younger (average 2.8 years).  Biopsy improvement was noted in “upward of 98%.”

Key findings:

  • Elimination of foods based on combined skin prick tests (SPT)/atopy patch tests (APT) had an identical response to the six food group diet –53%.  The allergy testing group had less eliminated foods (average 3.2 foods) compared with 8 food groups in SFED.
  • Elimination of milk with SPT/APT testing resulted in 77% response.  Authors note that there was a “particularly high false-negative rate (34%)” with milk testing (SPT/APT).
  • Elimination of top 8 allergens: milk, soy, egg, wheat, and meats [chicken, turkey, pork, beef] had an identical response of 77%.
  • Elimination of milk, egg, and wheat had a success rate of 48%.  Milk only elimination had a 30% response rate.
  • Most common foods by biopsy: milk (35%), egg (13%), wheat (12%), soy (9%), corn (6%)
  • Most common foods by symptoms: milk (19%), egg (11%), wheat (9%), soy (10%), beef (8%)
  • IgE-mediated foods:  milk (10%), egg (17%), soy (4%), peanut (22%)

Additional useful information in the addendum of methods notes their technique for APT testing (which is not standardized across centers).  The authors use 2 g of dry foods in 2 mL of isotonic saline solution for most foods; for milk, they use 3 g of powdered milk with 1 mL of isotonic saline.  Then these mixtures are placed in aluminum cups (6- or 12-mm Finn chambers on Scanpore).  These cups are placed on patient’s backs and removed at 48 hours and read at 72 hours.

In addition, for each food, their tables list predictive values (positive predictive value, negative predictive value, sensitivity, and specificity) for SPTs, and for APTs.  Overall, the predictive values are quite variable and much different from the general population. For example, in the general population, the negative predictive value is essentially 100% for combination of SPT/APT.

Previous related blog entries:

Choosing topical therapy for EoE | gutsandgrowth

Guidelines for Eosinophilic Esophagitis | gutsandgrowth

Looking better or feeling better in EoE?

Look of improvement on an EoE diet

Eosinophilic Esophagitis -Six Food Group Diet

MicroRNA signature for eosinophilic esophagitis

The undiscovered country

Comparing diets in EoE

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There remains a limited number of therapeutic options with EoE.  Dietary therapy can be effective as well as burdensome.  A closer look at dietary treatment effectiveness was recently published (J Allergy Clin Immunol 2012; 129: 1570-8 –thanks to Seth Marcus for alerting me to this article).

Due to eligibility requirements, only 98 patients of an initial 513 met criteria.  The findings from this study may be difficult to generalize because of the following:

  • Highly selected patient population
  • Retrospective study.   Dietary therapy was NOT chosen randomly.
  • Study originates from a specialized center (Cincinnati) which attracts atypical cases of EoE

That being said, the study asks some important questions. What is the remission rate for skin test-directed elimination diet in comparison to six food group elimination diet (SFED) and to an elemental diet?  The SFED actually composed two groups (in my opinion, this is a significant flaw in the study design & has a limiting effect on the conclusions).  The ‘classical’ SFED (42% or 11/26) eliminated the six most common food groups (milk, soy, wheat, egg, nuts, fish/shellfish) whereas a ‘modified’ SFED (58% or 15/26)  combined the classical SFED with foods eliciting positive skin-testing.

Some of the authors terminology:

  • Complete remission: 1 or fewer eosinophils/hpf
  • Partial remission: 2-5 eos/hpf
  • Partial resolution: 6-14 eos/hpf
  • Remission: <15 eos/hpf
  • Non-remission: >15 eos/hpf

Skin prick tests (SPFs) were performed to as many as 62 foods and 11 environmental allergens and graded 0-4.  0 equated to negative control & 4 equated to histamine control -all interpreted at 15 minutes after placement.

Atopy patch tests (APTs) were interpreted at 48 hours with scoring between 0-4.  A score of 2 indicated “erythematous with generalized induration.”  Any score of 2 or higher was considered positive.

Food reintroduction process: “Food reintroductions were initiated only when the peak eosinophil count was less than 15 eosinophils/hpf. If symptoms occurred after reintroduction of a food, patients were instructed to discontinue that food, wait approximately 10 to 14 days, and then reintroduce another food…. A food reintroduction was considered successful if no symptoms were reported and the postpeak eosinophil count was less than 15 eosinophils/hpf.”

Why were so many patients excluded?  The main causes were 181 patients did not meet strict EoE criteria, 122 patients received glucocorticoids, and 52 patients had another eosinophilia-associated condition; less common reasons included patient age >21, being part of a separate drug trial, obvious noncompliance, different diet regimen, and not having 2 consecutive EGDs separated by dietary intervention.

How many endoscopies are needed for dietary therapy?   In this study, the average patient had 8.5 EGDs at Cincinnati.  The greatest number of EGDs took place among patients assigned to an elemental diet (average >11); these patients also had a longer followup period compared to the other two groups: 2.9 years compared with 1.1 for SFED and 2.1 for directed diet.

  • All three diets resulted in improvement in eosinophil count.
  • Overall Remission rates: 96% elemental, 81% SFED, 65% directed diet
  • Complete Remission rates:  59% elemental, 39% SFED, 30% directed diet

One interesting set of data is in Table 4.  This gives the pass rate for various foods with single and multiple food reintroductions.  Milk for example had a pass rate of 35% among the 17 patients who had this as a single food reintroduction.  The values ranged from a low pass rate of 29% for strawberries to a high pass rate of 78% for cocoa and 75% for pork. Soy, eggs, and wheat all hovered near 60% pass rate.

Conclusions by authors:

1. “SFED is no less successful than directed diet and consistent with unreliability of skin testing …Our data…undermine the value of skin test-directed dietary management. ” This is due to the fact that the disease mechanism is not an IgE-mediated disease (skin testing primarily detects IgE-mediated allergens).

2. Elemental diet is superior at inducing histologic remission. However, “multiple studies indicate that adherence is inversely related to the number of foods eliminated.”

Previous related posts:

Guidelines for Eosinophilic Esophagitis

Looking better or feeling better in EoE?

Look of improvement on an EoE diet

Eosinophilic Esophagitis -Six Food Group Diet

MicroRNA signature for eosinophilic esophagitis

The undiscovered country

 

Look of improvement on an EoE diet

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In this month’s Gastroenterology, 50 adults with Eosinophilic esophagitis (EoE) were treated with a 6-food elimination diet (SFED) (Gastroenterology 2012; 142: 1451-1459).  Repeat endoscopy after 6 weeks determined responsiveness.  Histologic response was defined by having <5 eosinophils/high power fields (eos/hpf).  In 20 patients, reintroduction of foods followed by repeat endoscopy was undertaken.

After SFED, 32 (64%) had peak eosinophil counts <5 eos/hpf.  Symptom scores decreased in 94%.  After trigger food reintroduction, eosinophil counts returned to pretreatment values.  The changes are clearly visible in Figure 5.  The pictures are almost like the weight loss commercials on TV –striking improvement.  I contemplated putting in a scan of the Gastroenterology cover, but have not received permission from the publisher.  Check out this link to view it yourself:

http://download.journals.elsevierhealth.com/pdfs/journals/0016-5085/PIIS0016508512006257.pdf

Based on reintroduction, the foods most commonly associated with EoE were wheat (60%), and milk (50%).  Skin-prick testing predicted only 13% of foods associated with EoE.  In general, these study results mirror results from pediatric studies, with the exception that milk allergy has been found to be more common in some pediatric studies.

Only 20 patients completed the reintroduction process.  This process involved adding 1 food group every 2 weeks.  If the patient had symptoms during reintroduction or remained on regimen for 4 weeks, then  endoscopy with biopsies was performed.  If recurrence noted based on symptoms or histology, this required a 6 week washout before additional food reintroduction.  Of note, median time for recurrence of symptoms was 3 days after reintroduction.

Six foods: milk, wheat, eggs, soy, shellfish/fish, nuts.

This study shows that, as in children, adult EoE is predominantly a food-allergy disease

Related blog entries:

Eosinophilic Esophagitis -Six Food Group Diet

Guidelines for Eosinophilic Esophagitis

MicroRNA signature for eosinophilic esophagitis

The undiscovered country