Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: The 2-4-6 study

J Allergy Clin Immunol. 2018 Apr;141(4):1365-1372. doi: 10.1016/j.jaci.2017.08.038. Epub 2017 Oct 23.


Background: Numerous dietary restrictions and endoscopies limit the implementation of empiric elimination diets in patients with eosinophilic esophagitis (EoE). Milk and wheat/gluten are the most common food triggers.

Objective: We sought to assess the effectiveness of a step-up dietary strategy for EoE.

Methods: We performed a prospective study conducted in 14 centers. Patients underwent a 6-week 2-food-group elimination diet (TFGED; milk and gluten-containing cereals). Remission was defined by symptom improvement and less than 15 eosinophils/high-power field. Nonresponders were gradually offered a 4-food-group elimination diet (FFGED; TFGED plus egg and legumes) and a 6-food-group elimination diet (SFGED; FFGED plus nuts and fish/seafood). In responders eliminated food groups were reintroduced individually, followed by endoscopy.

Results: One hundred thirty patients (25 pediatric patients) were enrolled, with 97 completing all phases of the study. A TFGED achieved EoE remission in 56 (43%) patients, with no differences between ages. Food triggers in TFGED responders were milk (52%), gluten-containing grains (16%), and both (28%). EoE induced only by milk was present in 18% and 33% of adults and children, respectively. Remission rates with FFGEDs and SFGEDs were 60% and 79%, with increasing food triggers, especially after an SFGED. Overall, 55 (91.6%) of 60 of the TFGED/FFGED responders had 1 or 2 food triggers. Compared with the initial SFGED, a step-up strategy reduced endoscopic procedures and diagnostic process time by 20%.

Conclusions: A TFGED diet achieves EoE remission in 43% of children and adults. A step-up approach results in early identification of a majority of responders to an empiric diet with few food triggers, avoiding unnecessary dietary restrictions, saving endoscopies, and shortening the diagnostic process.

Keywords: Eosinophilic esophagitis; diet; milk; six-food elimination; wheat.

Publication types

  • Clinical Trial
  • Multicenter Study

MeSH terms

  • Adult
  • Eosinophilic Esophagitis / diagnosis
  • Eosinophilic Esophagitis / diet therapy*
  • Eosinophilic Esophagitis / etiology
  • Female
  • Food Hypersensitivity / complications
  • Food Hypersensitivity / diagnosis
  • Food Hypersensitivity / diet therapy*
  • Humans
  • Male
  • Prospective Studies
  • Risk Factors
  • Treatment Outcome