For children with eosinophilic esophagitis (EoE), a chronic immune disease often triggered by food allergens, a new study indicates that eliminating just one food, animal milk, may be as effective as more restrictive diets.
The research, published in The Journal of Allergy and Clinical Immunology, compared a four-food elimination diet (4FED) with the elimination of animal milk alone (1FED). According to Marc Rothenberg, MD, PhD, senior author, these findings mirror promising results seen in adults, although the foods eliciting disease activity differ between adults and children.
Validating a Simpler Approach for Pediatric EoE
EoE is characterized by an accumulation of eosinophils in the esophagus, leading to painful symptoms such as difficulty swallowing, food impaction, vomiting, reflux, malnourishment, and poor appetite. Food elimination diets can alleviate these symptoms, but the process is often a challenging trial-and-error approach. Current therapies involve either eliminating all foods and slowly reintroducing them or eliminating specific trigger foods one by one. These strategies can be time-consuming, costly, and difficult to maintain. Many patients opt for steroid therapy instead, despite known side effects.
Researchers, supported by the Patient-Centered Outcomes Research Institute (PCORI), sought to determine if a simpler, more tolerable diet could serve as an effective initial therapy. The team compared the efficacy of a one-food (animal milk) elimination diet (1FED) to a four-food (animal milk, egg, wheat, soy) elimination diet (4FED).
Comparable Efficacy Demonstrated in Multi-Site Trial
The study, a randomized, multi-site, comparative effectiveness clinical trial, involved 63 patients with active EoE across 10 sites in the United States. Participants were randomized to either 1FED or 4FED for 12 weeks. Experts then evaluated patient-reported outcomes and reviewed esophageal biopsies.
The results indicated that 1FED and 4FED achieved similar remission rates with comparable improvements in symptoms and histologic and endoscopic features. "We found that both diets were similarly effective across multiple metrics. We concluded that it is reasonable to start with the elimination of milk alone for children—which may be easier for patients—and ‘step up’ to a more restrictive diet only if needed," says Rothenberg. "This may increase the number of patients willing to try diet to manage their EoE."
These findings may also bolster clinicians' confidence in advising patients on the efficacies of different elimination diets. The study's data, gathered from clinical sites throughout the United States, enhances the generalizability of the results and better reflects efficacies commonly observed in clinical practice compared to previous studies.
Rothenberg added, "We found a dramatic esophageal transcriptome response to diet that was different between diet histologic responders and non-responders, presenting evidence that diet therapy is sufficient to molecularly reverse the diverse pathogenic pathways associated with the disease. Current studies with artificial intelligence are aimed at predicting which patients will respond to which diets, using a variety of patient assessments including clinical phenotype, biopsy characteristics, and molecular markers."
