Efficacy of Dietary Therapy for Eosinophilic Esophagitis in Children and Adults: An Updated Systematic Review and Meta-Analysis

Abstract

Background: Several dietary approaches have been used to induce remission in patients with eosinophilic esophagitis (EoE), yielding varied results.

Methods: We searched the MEDLINE, EMBASE, and Scopus databases up to May 2024 to identify studies including dietary interventions for EoE used as monotherapy. Summary estimates with 95% CIs for achieving <15 eosinophils/HPF were calculated for each approach. Fixed or random effects models were used depending on heterogeneity (I²); publication bias risks were assessed using funnel plot analyses. Subgroup analyses results were compared using meta-regression.

Results: Forty-three studies with 2825 patients were included in quantitative summaries. The overall rate of histologic remission was 60.6% (95% CI, 54.6-66.5%). Effectiveness rates were 94.5% (95% CI, 92.3-96.4%) for elemental diets, 63.9% (95% CI, 58.5-69.2%) for six-food elimination diets, 54.7% (95% CI, 45.7-63.6%) for four-food elimination diets, 44.3% (95% CI, 36.1-52.8%) for two-food elimination diets, 46.4% (95% CI, 40-52.9%) for one-food elimination diets, and 39.5% (95% CI, 30.3-49.2%) for allergy testing-directed food elimination diets. Overall, superior efficacy was noted in children than in adults and in retrospective compared to prospective studies.

Conclusion: Diet therapy remains an effective therapeutic asset for pediatric and adult patients with EoE, with increasing efficacy noted as the levels of dietary restriction increase.

Keywords: cohort studies; dietary treatment; eosinophilic esophagitis; histological remission; meta-analysis; pediatric.

Figure 1

PRISMA flow diagram of study selection process.

Figure 2

Risk of bias of observational studies included in the systematic review according to the Cochrane ROBINS-I tool. (A), ‘Traffic light’ plots of the domain-level judgments for each individual result [6,7,8,9,11,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,51,52,53,54,55,56,57,58]. (B), Weighted bar plots of the distribution of risk of bias judgements within each bias domain.

Figure 3

Risk of bias of randomized controlled trials included in the systematic review according to the Cochrane RoB 2 tool. (A), ‘Traffic light’ plots of the domain-level judgments for each individual result [12,50,59]. (B), Weighted bar plots of the distribution of risk of bias judgements within each bias domain.

Figure 4

Overall combined effects of elemental diet for inducing histologic remission of EoE. Percentage of patients with <15 eos/HPF after dietary intervention was extracted from each article/abstract and 95% CIs were calculated using the exact binomial method. A random-effects model was used to calculate the overall effect size. The I² of 39.8% indicates that intra-study differences (heterogeneity) account for only 39.8% of the variability in the overall effect size [23,24,25,27,28,29,31,32,33,37,38,44].

Figure 5

Efficacy of six-food elimination diet (A) [6,7,8,12,25,28,34,35,36,37,40,42,43,45,46,48,49,51,52,53,54,57], four-food elimination diet (B) [8,9,43,49,51,59,60] and one-food elimination diet (C) [11,12,29,38,47,49,59] in inducing histologic remission (<15 eos/HPF) in EoE patients.

Figure 6

Overall effect size of allergy testing-directed food elimination for inducing histologic remission of eosinophilic esophagitis [24,26,27,28,29,30,31,32,36,37,39,41,43,46,55,56].