Bringing dietary therapy for eosinophilic oesophagitis under scientific scrutiny

Abstract

In The Lancet Gastroenterology & Hepatology, Kara L Kliewer and colleagues report results from the first major multicentre, randomised trial of dietary therapy in patients with eosinophilic oesophagitis. 1 Kliewer KL Gonsalves N Dellon ES et al. One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trial. Lancet Gastroentrol Hepatol. 2023; (published online Feb 27.)https://doi.org/10.1016/S2468-1253(23)00012-2 Google Scholar The detailed study of patient outcomes, along with the assessment of transcriptomic and other markers, give valuable insights into the benefits and limitations of dietary therapy. Their objective evidence shows that the value of dietary therapy, in particular the six-food elimination diet (6FED), might have been overestimated in previous studies. 2 Gonsalves N Yang GY Doerfler B Ritz S Ditto AM Hirano I Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology. 2012; 142: 1451-1459 Summary Full Text Full Text PDF PubMed Scopus (480) Google Scholar , 3 Lucendo AJ Arias A Gonzalez-Cervera J et al. Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease. J Allergy Clin Immunol. 2013; 131: 797-804 Summary Full Text Full Text PDF PubMed Scopus (305) Google Scholar , 4 Infante J Modolell I Alcedo J et al. Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: the 2-4-6 study. J Allergy Clin Immunol. 2018; 141: 1365-1372 Summary Full Text Full Text PDF PubMed Scopus (140) Google Scholar In their study, histological remission to less than 15 eosinophils per high-power field (eos/hpf) occurred in only 23 (34%) of 67 patients on the one-food elimination diet (1FED; eliminating animal milk) and 25 (40%) of 62 patients on the 6FED at 6 weeks. Kliewer and colleagues also show that the margin between 1FED and 6FED is not significant in terms of both histological remission and symptom improvement. Given the complexity of life when trying to avoid six foods and the great difficulty in sustaining such an effort for more than a year, this evidence on the value of keeping dietary therapy simple is important. As well as being easier to comply with, a single-food elimination diet (or perhaps a two-food elimination diet avoiding milk and wheat 2 Gonsalves N Yang GY Doerfler B Ritz S Ditto AM Hirano I Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology. 2012; 142: 1451-1459 Summary Full Text Full Text PDF PubMed Scopus (480) Google Scholar ) requires fewer repeat endoscopies than the seven endoscopies needed to determine which foods are relevant in the multifood approach. One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trialHistological remission rates and improvements in histological and endoscopic features were similar after 1FED and 6FED in adults with eosinophilic oesophagitis. 6FED had efficacy in just less than half of 1FED non-responders and steroids had efficacy in most 6FED non-responders. Our findings indicate that eliminating animal milk alone is an acceptable initial dietary therapy for eosinophilic oesophagitis. Full-Text PDF