Are Less-Restrictive Diets Possible Among Patients With EoE? Study Says Yes

Modifying the diet of a patient who has eosinophilic esophagitis (EoE) by way of dietary therapy has been shown in a new study to have great potential at inducing both histological and clinical remission in this population, according to recent study findings published in Clinical Gastroenterology and Hepatology.¹

The efficacy of 4 diet types were investigated in the authors’ analyses: the 6-food elimination diet (SFED; n = 701), 4-food elimination diet (FFED; n = 302), 1-food elimination diet (OFED; n = 306), and targeted elimination diet (TED; n = 453). Thirty-four studies published between February 2005 and August 2022, which accounted for 1762 patients. PubMed, Scopus, and Web of Science were searched from inception through September 2022. The primary outcome was histological remission, or no more than 15 eosinophils/HPF from any biopsied samples. For the study, EoE diagnosis was based on 3 criteria:

• Clinical symptoms of esophageal dysfunction
• Presence of more than 15 eosinophils/HPF as detected by esophagogastroduodenoscopy
• Exclusion of non-EoE disorders known to cause esophageal eosinophilia

“Several studies have analyzed the efficacy of elimination diets in general and in comparison to steroid therapy. This data was first summarized in a meta-analysis published in 2014,² which underlined the efficacy of elemental diets and SFED,” the study authors wrote. “Since then, there have been many reports on the efficacy of dietary therapies, especially on the use of FFED and OFED, thus justifying the need for a new qualitative analysis.”

Among the included studies, dietary treatment lasted a median (IQR) 6 (6-8) weeks, and the overall rate of histological response was 53.8% (95% CI, 48.0%-59.6%). Among the plans evaluated, histological response was highest with SFED, at 61.3% (95% CI, 53.0%-69.3%), followed by 51.4% with OFED (95% CI, 42.6%-60.1%), 49.4% (95% CI, 32.5%-66.3%) with FFED, and 45.7% (95% CI, 32.0%-59.7%) for TED.

Significant correlations were not seen between plan type and histological response, nor for age (P = .22), sex (P = .62), total patients (P = .57), or dietary therapy duration (P = .10), and moderate to high heterogeneity was seen between the studies in the present meta-analysis.

Another analysis investigated potential outcome differences for histological remission between the pediatric (n = 915) and adult (n = 847) patients included in this study. Age did not influence this outcome (P = .15), with similar remission rates for the pediatric patients (57.2%; 95% CI, 50.2%-64.1%) and the adult patients (48.9%; 95% CI, 40.5%-57.4%), noted the study authors.

As with histological response, those receiving dietary treatment via the SFED had the highest histological remission rate, at 60.2% (95% CI, 46.0%-73.6%); FFED had the second highest rate, at 56.3% (95% CI, 33.8%-77.6%), followed by 55.3% (95% CI, 48.8%-61.7%) with OFED and 52.6% (95% CI, 35.9%-69.1%) with TED.

Further, adding an amino acid–based formula (AAF) to SFED was linked to a higher histological response. Within the SFED group, a subanalysis saw 573 treated with SFED only and 128 treated with SFED plus AAF. The latter had a 79.4% response rate compared with 56.3% in the SFED-only cohort, and the authors deemed AAF to be a significant influence (P = .011).

A final subanalysis of 387 patients from the SFED and FFED groups showed that dairy, wheat, eggs, and legumes were the biggest food triggers for EoE, with 70.5%, 48.0%, 27.6%, and 20.7%, respectively, of patients having reactions. In this analysis, foods were reintroduced in a stepwise manner after the patients had achieved histological and clinical remission.

“When translating our findings into clinical recommendations we have to highlight the nonsuperiority of highly restrictive dietary regimes in achieving histological remission,” the authors wrote. “Remission rates of FFED and OFED were slightly inferior to SFED. TED, on the other hand, also showed no significant advantage over the empirical dietary regimes.”

Because of these conclusions, the study authors recommend a step-up approach to dietary restrictions or adding AAF, both to increase treatment efficacy, and incorporating ongoing evaluation of dietary intake/dietary modification among patients with EoE to improve remission rates.

Reference

1. Mayerhofer C, Kavallar AM, Aldrian D, Lindner AK, Müller T, Vogel GF. Efficacy of elimination diets in eosinophilic esophagitis: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. Published online January 30, 2023. doi:10.1016/j.cgh.2023.01.019

2. Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic esophagitis: a systematic review and meta-analysis. Gastroenterology. 2014;146(7):1639-1648. doi:10.1053/j.gastro.2014.02.006