Elimination Diet Leads to 54% Histologic Response in Eosinophilic Esophagitis

An elimination diet that identifies food triggers should be considered an alternative to medical therapy for adults with EoE.

A majority of adults with eosinophilic esophagitis (EoE) who completed the Six-Food Elimination Diet (SFED) with food reintroduction achieved histologic response, according to study results published in the American Journal of Gastroenterology.

The retrospective study sought to determine the outcomes of SFED in adult patients with EoE from a single academic, tertiary hospital from 2006 to 2021. After at least 6 weeks of dietary elimination of milk, wheat, egg, soy, nuts, and seafood, researchers confirmed study participants’ response to the diet via endoscopy with biopsy. After the SFED, nonresponders were defined as having at least 15 eos/hpf, and responders were defined as having less than 15 eos/hpf.

For patients who wanted to enter the reintroduction protocol, the least likely to the most likely causative food triggers were introduced and recorded. When a causative agent was identified, participants were told to remove the food trigger for a wash-out period of 4 to 6 weeks before reintroducing the next food group.

A total of 213 patients (women, 46%; White, 91%; average age at diagnosis, 35.3 years) completed the SFED and were included in the analysis. Of the cohort, 131 patients (62%) had a histologic response after SFED, with 54% achieving less than 15 eos/HPF.

Overall SFED histologic response was 54%, which increased to 58% with one additional round of diet therapy, suggesting that 31% may respond on second attempt.

The responders had an average baseline inflammation of 54 eos/hpf, compared with 58 eos/hpf for nonresponders. After the SFED, responders had an average of 11 eos/hpf vs 64 eos/hpf for nonresponders. The total mean Endoscopic Reference Score improved from 3.6 to 2.4 (P <.05) in responders and worsened from 3.8 to 4.4 (P =.06) in nonresponders.

Of the responders, 77% had improvement in dysphagia symptoms after SFED, and 37% of nonresponders had improvement in dysphagia after SFED.

Among the initial nonresponders, 11 participated in another 6-week round of SFED, and 15 patients underwent another 6-week round of SFED plus additional food restrictions, most commonly corn, beef, legumes, and poultry. Of the 11 patients who followed the SFED again, 27% had less than 15 eos/HPF. Among the 15 patients who followed the SFED as well as additional restrictions, 33% achieved less than 15 eos/HPF.

The 2 groups differed regarding whether a patient reported a history of food allergy — 26% of responders (37/143) vs 47% (33/70) of nonresponders (P <.002).

Approximately 78% of patients with a histologic response underwent food reintroduction to identify food triggers: 69% had 1 food trigger identified, 24% had 2 allergens identified, and 4% had 3 allergens identified. A total of 11 participants completed the full reintroduction without any trigger identified and maintained sustained remission. The most common SFED allergens were dairy (37%), wheat (26%), and soy (13%).

Study limitations include the retrospective design and an inability to generalize the findings due to the fact the analysis was completed at a dedicated eosinophilic gastrointestinal disease center with specialized interest in dietary therapy and dietary services.

“Most of the patients undergoing SFED with food reintroduction were found to have just one food trigger, making long-term management with dietary more feasible,” the study authors noted. “Further research into understanding the predictors of response with dietary therapy will be critical in advising patients on pursuing this treatment approach.”

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Zalewski A, Doerfler B, Krause A, Hirano I, Gonsalves N. Long term outcomes of the six food elimination diet and food reintroduction in a large cohort of adults with eosinophilic esophagitis. Am J Gastroenterol. Published online August 12, 2022. doi:10.14309/ajg.0000000000001949