The strategy behind an elimination diet is to address the cause of the disease, which can lead to durable clinical and histological remission without medications. The main options for dietary interventions are an elemental diet consisting of amino-acid based formulas, an empiric elimination diet or elimination diet based on an allergy test.
According to a recent meta-analysis of 33 studies that enrolled a total of 1,317 subjects (1,128 children, 189 adults), a histological remission rate of over 90% can be achieved with an amino-acid based diet.1 However, this form of diet is of little relevance in actual practice as it is poorly tolerated, detrimental to quality of life and frequently invasive (due to the need for a gastric tube).
With an allergy-test-based elimination diet, specific foods are identified for elimination using the results from a prick test, an atopy patch test or an IgE blood test. However, no more than one-third of adults and one-half of paediatric EoE patients achieve histological remission using this strategy.2–4 The overall benefit of an allergy test to establish an elimination diet for EoE patients appears to be quite low.5
Adapted from Arias et al.,2015.1
In the empiric 6-food elimination diet (6-FED), the food categories of wheat, animal milk and dairy products, eggs, soy, nuts as well as fish/shellfish and legumes are completely avoided for at least 6 weeks. This intervention can lead to histological remission in about 70% of patients (see table 4) and clinical improvement in up to 90%.1 However, the 6-FED represents a major impact on nutrition and requires numerous endoscopic examinations during the process of re-exposure to the temporarily eliminated foods. Moreover, biopsies must be collected at each endoscopy to measure the effect of the diet on inflammation. An empiric 4-food elimination diet (4-FED; no animal milk and dairy products, no wheat, no eggs, no soy/legumes) leads to remission in about half of patients and about 40% of patients are successful on a 2-food elimination diet (2-FED, no animal milk and dairy products, no wheat).5
A recent prospective, multicentre study using a three-level step-up elimination diet (2-4-6) reported remission rates of 43%, 60%, and 79%, respectively (see fig. 15).6 However, elimination diets not only greatly impact patients’ daily lives and quality of life through the need to forego numerous foods, but they also represent a financial burden for the patient due to the need to buy substitute products, which are often expensive.7
