Elimination diets in the management of eosinophilic esophagitis

Figures & data

Table 1 Summary of studies of elemental formula

Reference	n	Population	Design	Mean age, years	Clinical response	Histologic response	Residual eosinophil count
Kelly et al^Citation17	10	Children	Prospective	4.8 (8 months to 12.5 years)	10/10 (100%)	<20 eos/hpf: 9/10 (90%)	41 → 0.5 (P=0.005)
Markowitz et al^Citation18	51	Children	Retrospective	8.3±3.1	49/51 (96%)	<20 eos/hpf: 49/51 (96%)	33.7 → 1.0 (P<0.01)
Liacouras et al^Citation19	172	Children	Retrospective	8.1±4.3	160/164 (98%)	<20 eos/hpf: 160/164 (98%)	38.7 → 1.1 (P<0.001)
Kagalwalla et al^Citation20	25	Children	Retrospective	6.4	25/25 (100%)	≤10 eos/hpf: 22/25 (88%)	58.8 → 3.7 (P<0.001)
Peterson et al^Citation25	18	Adults	Prospective	34±12	No clinical improvement	≤10 eos/hpf: 13/18 (72%)	54 → 10 (P=0.0006)
Henderson et al^Citation22	49	Children	Retrospective	5.6	Not available	<15 eos/hpf: 47/49 (96%)	51.0 → 1.0 (P<0.0001)

Abbreviation: eos/hpf, eosinophils per high-powered field.

Table 2 Food reintroduction approach in eosinophilic esophagitis

Start (least allergenic)			End (most allergenic)
A	B	C	D
Vegetables (nonlegume) Carrots, squash (all types), sweet potato, white potato, string beans, broccoli, lettuce, beets, asparagus, cauliflower, Brussels sprouts Fruit (noncitrus, nontropical) Apple, pear, peaches, plum, apricot, nectarine, grape, raisins Vegetables Tomatoes, celery, cucumber, onion, garlic, any other vegetables	Citrus fruit Orange, grapefruit, lemon, lime Tropical fruit Banana, kiwi, pineapple, mango, papaya, guava, avocado Melons Honeydew, cantaloupe, watermelon Berries Strawberry, blueberry, raspberry, cherry, cranberry Grains Rice, millet, quinoa	Legumes Lima beans, chickpeas, white/black/red beans Grains Oat, barley, rye other grains Meat Lamb, chicken, turkey, pork	Fish/Shellfish Corn Peas Peanut Wheat Beef Soy Egg Milk

Table 3 “Freebie” food list

Below are ingredients allowed on elemental diet, during the food reintroduction phase. Please check the label on every product, every time it is purchased, as ingredients can change. If you have any questions, please contact a registered dietitian from the eosinophilic esophagitis program • Artificial flavors and/or colors • Artificial sweeteners • Ascorbic acid (vitamin C) • Baking soda • Baking powder • Corn syrup • Corn starch • Dextrose • Extracts (eg, vanilla, peppermint) • High fructose corn syrup • Maltodextrin • Malic acid • Margarine/shortenings made from vegetable oils • Molasses • Maple syrup • Oils: canola, vegetable, safflower (except cold pressed, expeller-pressed, or extruded oils) • Potato starch • Rice syrup • Rice starch/dextrin • Tartaric acid • Tapioca starch • Salt • Sugar (white/brown) • Vinegar (distilled) • Xanthan gum • Water • Yeast

Candies and drinks should contain only sugar and artificial flavors and colors: limit to 1–2 servings/day • Dum Dum lollipops • Kool-Aid • Crystal Light • Pedialyte^® (Abbott Laboratories, Abbott Park, IL, USA) not Pedialyte Advanced Care: contains milk • FlaVor-Ice freezer pops (artificially flavored)

Table 4 Summary of allergy test-directed elimination studies

Reference	n	Population	Design	Mean age, years	Type of allergy testing	Clinical response	Histologic response	Residual eosinophil count
Teitelbaum et al^Citation49	11	Children	Prospective	8±0.9	SPT, RAST	No improvement	Not available	Not available
Spergel et al^Citation29	26	Children	Prospective	6.93±3.5	SPT, patch	24/24 (100%)	<15 eos/hpf: 18/24 (75%)	55.8 → 8.4
Spergel et al^Citation27	146	Children	Retrospective	6.5±4.5	SPT, APT	131/146 (89%)	<5 eos/hpf: 72/146 (49%)	48.4 → 1.1
Simon et al^Citation41	6	Adults	Prospective	25.83±9.0	SPT	1/6 (17%)	0/1 (0%)	Not available
Rizo Pascual et al^Citation38	11	Children	Prospective	9	SPT, APT	5/11 (45%)	<10 eos/hpf: 5/11 (45%)	Not available
Molina-Infante et al^Citation39	15	Adults	Prospective	34 (18–62)	SPT, PPT, APT	5/15 (33%)	≤15 eos/hpf: 5/15 (33%)	68 → 39 (P=0.53)
Henderson et al^Citation22	23	Children	Retrospective	5.2	SPT, APT	Not available	<15 eos/hpf: 15/23 (65%)	38.0 → 7.0 (P=0.003)
Spergel et al^Citation28	319	Children	Retrospective	Not available	SPT, APT	Not available	<15 eos/hpf: (53%)	Not available

Abbreviations: SPT, skin prick testing; RAST, radioallergosorbent test; APT, atopy patch testing; PPT, prick-prick test; eos/hpf, eosinophils per high-powered field.

Table 5 Summary of empiric elimination studies

Reference	n	Population	Design	Mean age, years	Diet	Clinical response	Histologic response	Residual eosinophil count
Kagalwalla et al^Citation20	35	Children	Retrospective	6.2	SFED	34/35 (97%)	≤10 eos/hpf: 26/35 (74%)	80.2 → 9.4 (P<0.0001)
Gonsalves et al^Citation47	50	Adults	Prospective	40 (19–76)	SFED	94%	≤10 eos/hpf: 70%	44 → 13 (P<0.0001)
Kagalwalla et al^Citation21	17	Children	Retrospective	5.5±3.2	Milk only	17/17 (100%)	<15 eos/hpf: 11/17 (65%)	76 → 2* (P<0.01)
Henderson et al^Citation22	26	Children	Retrospective	6.6	SFED	Not available	<15 eos/hpf: 21/26 (81%)	76.5 → 2.5 (P=0.005)
Lucendo et al^Citation48	67	Adults	Prospective	33.4±11.0	SFED + legumes, rice and corn	Significant Improvement	<15 eos/hpf: 49/67 (73%)	47.9 → 3.5* (P<0.001)

Note:

* Study reported the residual counts of responders only, not all subjects.

Abbreviations: SFED, six-food elimination diet; eos/hpf, eosinophils per high-powered field.

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