Evolving Management of Eosinophilic Esophagitis: From Diagnosis to Early Intervention - Episode 11
Dietary Elimination Approaches in EoE
Panelists discuss how dietary elimination therapy for eosinophilic esophagitis (EoE) involves empirically removing common food triggers (dairy, wheat, eggs, soy, seafood, nuts), with less restrictive approaches such as eliminating 1 to 2 foods being more feasible than the traditional 6-food elimination. The panelists emphasize the critical role of dieticians, avoiding combination therapies when possible, and allowing flexibility with “diet holidays” while monitoring for symptom recurrence.
Dietary elimination therapy represents a nonpharmacological treatment option that appeals to patients seeking natural approaches to managing EoE. The traditional 6-food elimination diet removes the most common EoE triggers: dairy (animal milk), wheat, eggs, soy, seafood (shellfish and fin fish), and tree nuts. However, recent approaches favor less restrictive strategies, starting with elimination of the most common triggers (dairy alone or dairy plus wheat) before progressing to more comprehensive restrictions, as data suggest single-food elimination can be as effective as 4-food elimination diets.
The empirical elimination process involves removing suspected trigger foods, followed by endoscopic evaluation to assess disease remission, then systematic food reintroduction to identify specific individual triggers. This approach requires significant patient motivation and adherence, as it demands careful attention to food labels, hidden ingredients, and meal planning. Dietitian involvement is crucial from the beginning, providing expertise in label reading, identifying hidden food sources, and guiding both elimination and reintroduction phases that gastroenterologists may lack.
Implementation considerations vary significantly by patient demographics and life circumstances. Younger children may benefit from family-controlled environments that facilitate dietary adherence, whereas adolescents face social challenges with peer dining and activities that complicate restrictive diets. University-aged patients often struggle with meal preparation independence, making dietary therapy less feasible. Combination therapy with medications is generally discouraged due to adherence challenges, though proton pump inhibitors may be continued for concurrent reflux disease. Flexibility strategies, including “diet holidays” for special occasions, can improve long-term sustainability in adult populations, though this approach may confuse younger children regarding dietary consistency. The ultimate goal involves identifying specific individual triggers rather than the permanent elimination of all 6 food categories, making long-term management more feasible while maintaining effective disease control without medications.
