Development of a Practical Guide to Implement and Monitor Diet Therapy for Eosinophilic Esophagitis

Abstract

Dietary therapy for short- and long-term management of eosinophilic esophagitis is an effective yet poorly understood and underutilized treatment strategy. Despite several prospective trials demonstrating the efficacy of dietary therapies, successful clinical implementation is hampered by the need for a multidisciplinary approach including dietitian support and provider expertise. The availability of these resources is not readily available to most gastroenterologists. Without standardized guidance on starting or completing the diet for gastrointestinal providers and/or consulting dietitians, provider attitudes toward dietary therapy vary greatly depending on familiarity and knowledge gaps in using diet therapy. This review aims to summarize evidence in support of dietary therapy in eosinophilic esophagitis while providing guidance on initiation and implementation of dietary therapy for providers. Dietary therapy for short- and long-term management of eosinophilic esophagitis is an effective yet poorly understood and underutilized treatment strategy. Despite several prospective trials demonstrating the efficacy of dietary therapies, successful clinical implementation is hampered by the need for a multidisciplinary approach including dietitian support and provider expertise. The availability of these resources is not readily available to most gastroenterologists. Without standardized guidance on starting or completing the diet for gastrointestinal providers and/or consulting dietitians, provider attitudes toward dietary therapy vary greatly depending on familiarity and knowledge gaps in using diet therapy. This review aims to summarize evidence in support of dietary therapy in eosinophilic esophagitis while providing guidance on initiation and implementation of dietary therapy for providers. Eosinophilic esophagitis (EoE) is a chronic inflammatory immune-mediated disease affecting both children and adults, characterized by symptoms of esophageal dysfunction, eosinophilia, and fibrosis of the esophagus. A diagnosis of EoE is made based on symptoms such as dysphagia, food bolus obstruction, and less commonly heartburn, globus, or poor feeding; endoscopic mucosal findings of longitudinal furrows, rings, and strictures; and the presence of esophageal eosinophilia (>15 eosinophils per high-power field [eos/hpf]).1Furuta G.T. Liacouras C.A. Collins M.H. et al.Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment.Gastroenterology. 2007; 133: 1342-1363Abstract Full Text Full Text PDF PubMed Scopus (1407) Google Scholar, 2Dellon E.S. Gonsalves N. Hirano I. et al.ACG clinical guideline: evidence based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE).Am J Gastroenterol. 2013; 108: 679-692Crossref PubMed Scopus (846) Google Scholar, 3Lucendo A.J. Molina-Infante J. Arias A. et al.Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults.United European Gastroenterol J. 2017; 5: 335-358Crossref PubMed Scopus (619) Google Scholar This eosinophil-predominant inflammation characteristic of EoE is driven and precipitated by food antigens as affirmed by effective treatment of the disease with diet elimination of specific food allergens.4Markowitz J.E. Spergel J.M. Ruchelli E. et al.Elemental diet is an effective treatment for eosinophilic esophagitis in children and adolescents.Am J Gastroenterol. 2003; 98: 777-782Crossref PubMed Scopus (512) Google Scholar, 5Kagalwalla A.F. Sentongo T.A. Ritz S. et al.Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic esophagitis.Clin Gastroenterol Hepatol. 2006; 4: 1097-1102Abstract Full Text Full Text PDF PubMed Scopus (601) Google Scholar, 6Spergel J.M. Brown-Whitehorn T.F. Cianferoni A. et al.Identification of causative foods in children with eosinophilic esophagitis treated with an elimination diet.J Allergy Clin Immunol. 2012; 130: 461-467Abstract Full Text Full Text PDF PubMed Scopus (305) Google Scholar, 7Gonsalves N. Yang G.Y. Doerfler B. et al.Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors.Gastroenterology. 2012; 142: 1451-1459Abstract Full Text Full Text PDF PubMed Scopus (504) Google Scholar, 8Peterson K.A. Byrne K.R. Vinson L.A. et al.Elemental diet induces histologic response in adult eosinophilic esophagitis.Am J Gastroenterol. 2013; 108: 759-766Crossref PubMed Scopus (195) Google Scholar, 9Lucendo A.J. 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: 797-804Abstract Full Text Full Text PDF PubMed Scopus (321) Google Scholar, 10Gonsalves N. Doerfler B. Schwartz S. et al.Prospective trial of four food elimination diet demonstrates comparable effectiveness in the treatment of adult and pediatric eosinophilic esophagitis.Gastroenterology. 2013; 144S-154Abstract Full Text PDF Google Scholar, 11Arias A. Gonzalez-Cervera J. Tenias J.M. et al.Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic esophagitis: a systematic review and meta-analysis.Gastroenterology. 2014; 146: 1639-1648Abstract Full Text Full Text PDF PubMed Scopus (386) Google Scholar, 12Molina-Infante J. Arias A. Barrio J. et al.Four-food group elimination diet for adult eosinophilic esophagitis: a prospective multicenter study.J Allergy Clin Immunol. 2014; 134: 1093-1099Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar, 13Warners M.J. Vlieg-Boerstra B.J. Verheij J. et al.Elemental diet decreases inflammation and improves symptoms in adult eosinophilic oesophagitis patients.Aliment Pharmacol Ther. 2017; 45: 777-787Crossref PubMed Scopus (66) Google Scholar, 14Kagalwalla A.F. Wechsler J.B. Amsden K. et al.Efficacy of a 4-food elimination diet for children with eosinophilic esophagitis.Clin Gastroenterol Hepatol. 2017; 15: 1698-1707Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 15Wechsler J.B. Schwartz S. Ross J.N. et al.Cow's milk elimination for treatment of eosinophilic esophagitis: a prospective pediatric study.Gastroenterology. 2017; 152S-855Abstract Full Text PDF Google Scholar, 16Mayerhofer C. Kavallar A.M. Aldrian D. et al.Efficacy of elimination diets in eosinophilic esophagitis: a systematic review and meta-analysis.Clin Gastroenterol Hepatol. 2023; (Jan 31 [E-pub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Current first-line effective treatments aimed at targeting inflammation and preventing fibrostenotic complications such as esophageal strictures and food impactions include food elimination diets and medications such as proton pump inhibitors, topical corticosteroids (TCSs), and the recently approved anti-interleukin-4 receptor biologic, dupilumab.17Dellon E.S. Rothenberg M.E. Collins M.H. et al.Dupilumab in adults and adolescents with eosinophilic esophagitis.N Engl J Med. 2022; 387: 2317-2330Crossref PubMed Scopus (35) Google Scholar, 18Hirano I. Chan E.S. Rank M.A. et al.AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis.Gastroenterology. 2020; 158: 1776-1786Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 19Hirano I. Dellon E.S. Hamilton J.D. et al.Efficacy of dupilumab in a phase 2 randomized trial of adults with active eosinophilic esophagitis.Gastroenterology. 2020; 158: 111-122.e10Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar Medications offer short response time and relative ease of use, but out-of-pocket payments can incur high costs for patients and require inconvenient and nonstandard preparations. Elimination diets offer a nonpharmacologic alternative to disease control, and studies to date demonstrate efficacy similar to that of medications, but require adherence to a strict diet and frequent endoscopies to identify food triggers. Studies to date show that both diet and medications are effective in inducing and maintaining long-term disease remission, reducing the risk of food impactions, and improving health-related quality of life.20Cotton C.C. Eluri S. Wolf W.A. et al.Six-food elimination diet and topical steroids are effective for eosinophilic esophagitis: a meta-regression.Dig Dis Sci. 2017; 62: 2408-2420Crossref PubMed Scopus (59) Google Scholar, 21Dellon E.S. Woosley J.T. Arrington A. et al.Efficacy of budesonide vs fluticasone for initial treatment of eosinophilic esophagitis in a randomized controlled trial.Gastroenterology. 2019; 157: 65-73Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar, 22Kuchen T. Straumann A. Safroneeva E. et al.Swallowed topical corticosteroids reduce the risk for long-lasting bolus impactions in eosinophilic esophagitis.Allergy. 2014; 69: 1248-1254Crossref PubMed Scopus (98) Google Scholar, 23Reed C.C. Fan C. Koutlas N.T. et al.Food elimination diets are effective for long-term treatment of adults with eosinophilic oesophagitis.Aliment Pharmacol Ther. 2017; 46: 836-844Crossref PubMed Scopus (65) Google Scholar, 24Safroneeva E. Coslovsky M. Kuehni C.E. et al.Eosinophilic oesophagitis: relationship of quality of life with clinical, endoscopic and histological activity.Aliment Pharmacol Ther. 2015; 42: 1000-1010Crossref PubMed Scopus (67) Google Scholar As such, both are recommended as first-line treatments for EoE.2Dellon E.S. Gonsalves N. Hirano I. et al.ACG clinical guideline: evidence based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE).Am J Gastroenterol. 2013; 108: 679-692Crossref PubMed Scopus (846) Google Scholar To date, there are no comparative efficacy studies between diet and pharmacologic treatments.25ClinicalTrials.gov. Search results: eosinophilic esophagitis.https://clinicaltrials.gov/ct2/results?cond=eosinophilic+esophagitis&term=&cntry=&state=&city=&dist=Date accessed: May 13, 2021Google Scholar Diet therapy can be burdensome for patients to navigate and challenging for clinicians to implement. Consequences of poorly executed diet therapies include overly restrictive food elimination, compromised nutrition or micronutrient deficiency, lack of patient compliance or inadvertent exposures to food antigens, excess costs, “wasted” endoscopic evaluations, misinterpreting refractory disease from nonadherence, and ultimately persistent disease.26Wolf W.A. Huang K.Z. Durban R. et al.The six-food elimination diet for eosinophilic esophagitis increases grocery shopping cost and complexity.Dysphagia. 2016; 31: 765-770Crossref PubMed Scopus (40) Google Scholar Success with diet therapy can be augmented by partnering with a dietitian, but access to this clinical resource is not universal and diet education often falls to the clinician.27Chang J.W. Kliewer K. Katzka D.A. et al.Provider beliefs, practices, and perceived barriers to dietary elimination therapy in eosinophilic esophagitis.Am J Gastroenterol. 2022; 117: 2071-2074Crossref PubMed Scopus (5) Google Scholar,28Groetch M. Venter C. Skypala I. et al.Dietary therapy and nutrition management of eosinophilic esophagitis: a work group report of the American Academy of Allergy, Asthma, and Immunology.J Allergy Clin Immunol Pract. 2017; 5: 312-324.e29Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar To date, no standardized dietary resources for EoE exist. Our aim is to equip providers for EoE patients with evidence-based and knowledge to support patients in starting and an elimination diet for The of food in the of EoE in a study of children with EoE demonstrating clinical and histologic remission on a A.J. et al.Eosinophilic esophagitis to with an Full Text PDF PubMed Scopus Google Scholar several prospective studies a high of disease remission on children and include poor high lack of and food reintroduction several the of this strategy. to this restrictive elimination diets aimed at the most food are the dietary strategy. to the implementation of diet therapy include the need to foods such as milk or and the lack of to identify food diets by specific as a approach to EoE food findings from studies of children and adults with EoE show poor between and that is to identify EoE food Collins M.H. et patients with eosinophilic esophagitis: an Allergy Clin Immunol. 2007; Full Text Full Text PDF PubMed Scopus Google Scholar, J.M. B. C. et in children with eosinophilic Clin Immunol. Google Scholar, S. et not food in adult patients with eosinophilic A prospective study using Pharmacol Ther. 2016; PubMed Scopus Google Scholar, J.D. K. Katzka D.A. et al.Efficacy of in dietary therapy of eosinophilic esophagitis: a Dis Sci. PubMed Scopus Google Scholar of inflammation these be patients are overly restrictive diets based on are to identify food these are and not available for in A.M. et in eosinophilic oesophagitis.Aliment Pharmacol Ther. 2022; PubMed Scopus (3) Google Scholar, M.J. I. et to esophageal food in adult patients with eosinophilic esophagitis.Gastroenterology. Full Text Full Text PDF PubMed Scopus Google Scholar, E.S. R. et approach to dietary elimination in eosinophilic esophagitis.Clin Gastroenterol. 2019; PubMed Scopus Google Scholar Despite the perceived of dietary therapy for this approach is in to patient for the of less restrictive and of pharmacologic with EoE report high of diets and the diet to R. Hirano I. Doerfler B. et adherence and barriers to long-term elimination diet therapy in adults with eosinophilic Dis Sci. PubMed Scopus Google Scholar treatment for EoE and with providers knowledge or not support diet treatment as an J.W. et patients with eosinophilic esophagitis not with a of 2022; PubMed Scopus Google J.W. et and outcomes of in eosinophilic Dis Sci. PubMed Scopus Google Scholar studies show that to medications diet for diet as less lack access to dietitian and that patients are not in or to to food J.W. Kliewer K. Katzka D.A. et al.Provider beliefs, practices, and perceived barriers to dietary elimination therapy in eosinophilic esophagitis.Am J Gastroenterol. 2022; 117: 2071-2074Crossref PubMed Scopus (5) Google S. M. et and adherence to clinical for diagnosis and management of eosinophilic esophagitis 2020; Scopus Google Scholar, J. S. Eosinophilic esophagitis: of adult and pediatric Dis Sci. PubMed Scopus Google Scholar, A.F. Dellon E.S. Practice for the and treatment of eosinophilic oesophagitis.Aliment Pharmacol Ther. PubMed Scopus Google Scholar, J.W. et of eosinophilic esophagitis is often with and not of a of 2019; PubMed Scopus Google Scholar pharmacologic therapies offer relative ease of and are of include and esophageal and there be and long-term from chronic and proton pump E.S. Katzka D.A. Collins M.H. et and efficacy of budesonide therapy in patients with eosinophilic esophagitis.Clin Gastroenterol Hepatol. 2019; Full Text Full Text PDF PubMed Scopus Google Scholar, Yang The and of long-term of proton pump review and from the American 2017; Full Text Full Text PDF PubMed Scopus Google Scholar, M. J.W. in eosinophilic esophagitis: a of topical of 2022; 117: Google Scholar the of dupilumab is include complications of and and E.S. Rothenberg M.E. Collins M.H. et al.Dupilumab in adults and adolescents with eosinophilic esophagitis.N Engl J Med. 2022; 387: 2317-2330Crossref PubMed Scopus (35) Google T. L.A. et in dupilumab clinical trials in a J Clin 2019; PubMed Scopus Google Scholar, N. C. et al.Dupilumab in patients with a systematic 2022; PubMed Scopus Google Scholar, T. E. et phase trials of dupilumab in Engl J Med. 2016; PubMed Scopus Google Scholar The cost of topical corticosteroids can be as a of budesonide is to cost and in a cost the cost per accessed: therapy for eosinophilic 2014; Google Scholar budesonide offer but include in and S. Dellon E.S. et in of budesonide for eosinophilic esophagitis.Am J Gastroenterol. PubMed Scopus Google Scholar, C.C. et with fluticasone improves the clinical, and histologic of eosinophilic PubMed Scopus Google Scholar, C.C. Fan C. Koutlas N. et budesonide is effective and a response in eosinophilic J Gastroenterol PubMed Google Scholar show that 6-food elimination diet is less and topical budesonide and C.C. D. Eluri S. et of topical steroids with dietary elimination for treatment of eosinophilic esophagitis.Clin Gastroenterol Hepatol. 2017; 15: Full Text Full Text PDF PubMed Scopus Google Scholar the and of dupilumab an of treatment for to be for this therapy patients long-term The of dietary therapy is to disease remission by specific foods that the 2 response in the esophageal This to identify food the the elimination a of foods to disease remission by at with in eosinophilia, endoscopic the reintroduction food in to EoE food that active and (3) the long-term of the food As this strict of or reintroduction of food patient and partnering with a dietitian is to in of the diet and long-term symptoms are often with disease symptoms not be to treatment E. Straumann A. Coslovsky M. et in endoscopic and histologic remission in adults with eosinophilic esophagitis.Gastroenterology. 2016; Full Text Full Text PDF PubMed Scopus Google Scholar on symptoms in to food elimination or reintroduction is and can in of food and prolonged dietary be that foods are not the foods that cause symptoms to commonly with is the for response to therapy and is recommended at a in including elimination and reintroduction to identify of food et approach to eosinophilic esophagitis: American for 2022; Full Text Full Text PDF PubMed Scopus Google Scholar phase of the diet and to food can be in the of several food or restrictive diets diet include the 4-food elimination diet elimination diet and elimination diet The most and of these is the of milk and and response of in both children and A.F. Sentongo T.A. Ritz S. et al.Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic esophagitis.Clin Gastroenterol Hepatol. 2006; 4: 1097-1102Abstract Full Text Full Text PDF PubMed Scopus (601) Google N. Yang G.Y. Doerfler B. et al.Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors.Gastroenterology. 2012; 142: 1451-1459Abstract Full Text Full Text PDF PubMed Scopus (504) Google A.J. 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: 797-804Abstract Full Text Full Text PDF PubMed Scopus (321) Google Scholar the EoE the less restrictive of the of milk and or milk offer less food reintroduction and endoscopies to identify N. Doerfler B. Schwartz S. et al.Prospective trial of four food elimination diet demonstrates comparable effectiveness in the treatment of adult and pediatric eosinophilic esophagitis.Gastroenterology. 2013; 144S-154Abstract Full Text PDF Google J. Arias A. Barrio J. et al.Four-food group elimination diet for adult eosinophilic esophagitis: a prospective multicenter study.J Allergy Clin Immunol. 2014; 134: 1093-1099Abstract Full Text Full Text PDF PubMed Scopus (189) Google A.F. Wechsler J.B. Amsden K. et al.Efficacy of a 4-food elimination diet for children with eosinophilic esophagitis.Clin Gastroenterol Hepatol. 2017; 15: 1698-1707Abstract Full Text Full Text PDF PubMed Scopus (131) Google J.B. Schwartz S. Ross J.N. et al.Cow's milk elimination for treatment of eosinophilic esophagitis: a prospective pediatric study.Gastroenterology. 2017; 152S-855Abstract Full Text PDF Google Scholar the is response to the elimination a with less restrictive diets or and the diet to the or there is patients to the most and of endoscopies to identify the J. Arias A. J. et elimination diet for pediatric and adult eosinophilic esophagitis: the study.J Allergy Clin Immunol. Full Text Full Text PDF PubMed Scopus Google Scholar The most food for EoE are milk to and to and to of patients dietary therapy dietary J. Arias A. J. et elimination diet for pediatric and adult eosinophilic esophagitis: the study.J Allergy Clin Immunol. Full Text Full Text PDF PubMed Scopus Google T. A. et to the dietary elimination for treatment of eosinophilic esophagitis.Clin Gastroenterol Hepatol. Full Text Full Text PDF PubMed Scopus Google Scholar a study of adult patients dietary therapy with the of patients food this a for long-term A. Doerfler B. A. et outcomes of the six-food elimination diet and food reintroduction in a of adults with eosinophilic esophagitis.Am J Gastroenterol. 2022; 117: PubMed Scopus (5) Google of Elimination Diet of systematic reintroduction of foods to identify specific to A. Gonzalez-Cervera J. Tenias J.M. et al.Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic esophagitis: a systematic review and meta-analysis.Gastroenterology. 2014; 146: 1639-1648Abstract Full Text Full Text PDF PubMed Scopus (386) Google J. Arias A. Barrio J. et al.Four-food group elimination diet for adult eosinophilic esophagitis: a prospective multicenter study.J Allergy Clin Immunol. 2014; 134: 1093-1099Abstract Full Text Full Text PDF PubMed Scopus (189) Google A.F. Wechsler J.B. Amsden K. et al.Efficacy of a 4-food elimination diet for children with eosinophilic esophagitis.Clin Gastroenterol Hepatol. 2017; 15: 1698-1707Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 15Wechsler J.B. Schwartz S. Ross J.N. et al.Cow's milk elimination for treatment of eosinophilic esophagitis: a prospective pediatric study.Gastroenterology. 2017; 152S-855Abstract Full Text PDF Google Scholar, 16Mayerhofer C. Kavallar A.M. Aldrian D. et al.Efficacy of elimination diets in eosinophilic esophagitis: a systematic review and meta-analysis.Clin Gastroenterol Hepatol. 2023; (Jan 31 [E-pub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (3) Google J. Arias A. J. et elimination diet for pediatric and adult eosinophilic esophagitis: the study.J Allergy Clin Immunol. Full Text Full Text PDF PubMed Scopus Google Scholar, A. Doerfler B. A. et outcomes of the six-food elimination diet and food reintroduction in a of adults with eosinophilic esophagitis.Am J Gastroenterol. 2022; 117: PubMed Scopus (5) Google Scholar, K. S. D. et al.Efficacy of and 4-food elimination diets for pediatric eosinophilic esophagitis in a randomized study.Gastroenterology. 2019; Full Text PDF Google Scholar, Gonsalves Dellon E.S. et six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a Gastroenterol Hepatol. 2023; [E-pub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus Google of the elimination histologic remission for elimination restrictive of the elimination of diet remission from Molina-Infante et less on quality of of life be patient remission on quality of of life be patient restrictive on quality of of life be patient remission on quality of of life be patient of systematic reintroduction of foods to identify specific to from Molina-Infante et J. Arias A. 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Elimination diets for eosinophilic esophagitis: the Clin Immunol. 2020; PubMed Scopus Google Scholar to diet as an effective and alternative to work with the patient to these in a therapy that is with patient and not in and with a dietitian is for pediatric patients on dietary therapy specific for and for and and in a for EoE Dietary patient and to dietary therapy and/or and life to to for and to a strict and toward to and for frequent and high for eosinophilic in a for a Dietary to an initial to the with and for disease the dietary and elimination providers the elimination diet to the providers identify a dietitian or to barriers to diet adherence be starting the diet high for to patients be time and of endoscopies to dietary with the of vs patients on dietary therapy with to to the elimination and food reintroduction restrictive or of be on diet patients on prolonged and overly restrictive the of dietary therapy be the risk of A of not using dietary therapy but the of dietary for eosinophilic in a eosinophilic eosinophilic As a of EoE dietary an elimination approach dietary of or food A.M. Venter C. Dietary therapy for eosinophilic esophagitis: elimination and Allergy Immunol. PubMed Scopus Google Scholar of the patients be on to specific food include nutrition to and the of an EoE food is a strict of the food group and of is recommended the initial of diet to identify the specific EoE triggers. A diet to risk of Venter C. A.M. et and/or be in a 6-food elimination Allergy Clin Immunol. 2016; Full Text Full Text PDF PubMed Scopus Google Scholar such as the and can and adherence this restrictive phase B. Hirano I. et approach to dietary therapy in adults with eosinophilic esophagitis: the 2015; PubMed Scopus Google Scholar As the of an EoE food active disease is not patients are recommended to on the elimination phase for at is to the response to therapy. disease remission is in a patient reintroduction of foods can guidance to identify specific be that patients require prolonged elimination to disease remission and from an of dietary elimination response not yet response but eosinophilia, and endoscopic is or dietary is the initial to A. Doerfler B. A. et outcomes of the six-food elimination diet and food reintroduction in a of adults with eosinophilic esophagitis.Am J Gastroenterol. 2022; 117: PubMed Scopus (5) Google Dellon E. of dietary elimination for eosinophilic esophagitis be to PubMed Google Scholar The most for to the elimination phase include or inadvertent dietary nonadherence, and or of food triggers. are to remission with the initial elimination, a to or adherence be the are to that the presence of disease the response to M. E. et of on response to therapy in children with eosinophilic Allergy Immunol. 2017; Full Text Full Text PDF PubMed Scopus Google Scholar, J. M. et of esophageal eosinophilia in children with eosinophilic esophagitis and Allergy Immunol. 2015; Full Text Full Text PDF PubMed Scopus Google Scholar, C.C. et of eosinophilic esophagitis histologic in adults and children of Allergy Immunol. 2019; Full Text Full Text PDF PubMed Scopus Google Scholar As a with an to the of and can be no or are patients be with an to food on a less restrictive diet to the on the or to the from the or the elimination phase for an in a study of adults the response with a at diet elimination, this for A. Doerfler B. A. et outcomes of the six-food elimination diet and food reintroduction in a of adults with eosinophilic esophagitis.Am J Gastroenterol. 2022; 117: PubMed Scopus (5) Google Scholar This and to in restrictive diets the to include or to between the patient and and dietitian

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