Bethany Doerfler

Elimination Diet Effectively Treats Eosinophilic Esophagitis in Adults; Food Reintroduction Identifies Causative Factors

BACKGROUND & AIMS Adults with eosinophilic esophagitis (EoE) typically present with dysphagia and food impaction. A 6-food elimination diet (SFED) is effective in children with EoE. We assessed the effects of the SFED followed by food reintroduction on the histologic response, symptoms, and quality of life in adults with EoE. METHODS At the start of the study, 50 adults with EoE underwent esophagogastroduodenoscopies (EGDs), biopsies, and skin-prick tests for food and aeroallergens. After 6 weeks of SFED, patients underwent repeat EGD and biopsies. Histologic responders, defined by ≤ 5 eosinophils/high-power field (eos/hpf) (n = 32), underwent systematic reintroduction of foods followed by EGD and biopsies (n = 20). Symptom and quality of life scores were determined before and after SFED. RESULTS Common symptoms of EoE included dysphagia (96%), food impaction (74%), and heartburn (94%). The mean peak eosinophil counts in the proximal esophagus were 34 eos/hpf and 8 eos/hpf, before and after the SFED, and 44 eos/hpf and 13 eos/hpf in the distal esophagus, respectively (P < .0001). After the SFED, 64% of patients had peak counts ≤ 5 eos/hpf and 70% had peak counts of ≤ 10 eos/hpf. Symptom scores decreased in 94% (P < .0001). After food reintroduction, esophageal eosinophil counts returned to pretreatment values (P < .0001). Based on reintroduction, the foods most frequently associated with EoE were wheat (60% of cases) and milk (50% of cases). Skin-prick testing predicted only 13% of foods associated with EoE. CONCLUSIONS An elimination diet significantly improves symptoms and reduces endoscopic and histopathologic features of EoE in adults. Food reintroduction re-initiated features of EoE in patients, indicating a role for food allergens in its pathogenesis. Foods that activated EoE were identified by systematic reintroduction analysis but not by skin-prick tests.

Preliminary evidence supporting a framework of psychological adjustment to inflammatory bowel disease

Background: Adjustment to chronic disease is a multidimensional construct described as successful adaptation to disease‐specific demands, preservation of psychological well‐being, functional status, and quality of life. Inflammatory bowel disease (IBD) can be particularly challenging due to the unpredictable, relapsing and remitting course of the disease. Methods: All participants were patients being treated in an outpatient gastroenterology clinic at a university medical center. Participants completed a survey of questionnaires assessing illness perceptions, stress, emotional functioning, disease acceptance, coping, disease impact, and disease‐specific and health‐related quality of life. Adjustment was measured as a composite of perceived disability, psychological functioning, and disease‐specific and health‐related quality of life. Results: Participants were 38 adults with a diagnosis of either Crohns disease (45%) or ulcerative colitis (55%). We observed that our defined adjustment variables were strongly correlated with disease characteristics (r = 0.33–0.80, all P < 0.05), an emotional representation of illness (r = 0.44–0.58, P < 0.01), disease acceptance (r = 0.34–0.74, P < 0.05), coping (r = 0.33–0.60, P < 0.05), and frequency of gastroenterologist visits (r = 0.39–0.70, P < 0.05). Better adjustment was associated with greater bowel and systemic health, increased activities engagement and symptom tolerance, less pain, less perceived stress, and fewer gastroenterologist visits. All adjustment variables were highly correlated (r = 0.40–0.84, P < 0.05) and demonstrated a cohesive composite. Conclusions: The framework presented and results of this study underscore the importance of considering complementary pathways of disease management including cognitive, emotional, and behavioral factors beyond the traditional medical and psychological (depression and anxiety) components. (Inflamm Bowel Dis 2010)

Optimizing management of Crohn's disease within a project management framework: results of a pilot study.

Background: Psychotherapy for Crohns disease (CD) has focused on patients with psychological distress. Another approach to optimize management of CD is to target patients who do not exhibit psychological distress but engage in behaviors that undermine treatment efficacy / increase risk for flare. We sought to determine the feasibility/acceptability and estimate the effects of a program framed around Project Management (PM) principles on CD outcomes. Methods: Twenty‐eight adults with quiescent CD without a history of psychiatric disorder were randomized to PM (n = 16) or treatment as usual (TAU; n = 12). Baseline and follow‐up measures were Inflammatory Bowel Disease Questionnaire (IBDQ), Medication Adherence Scale (MAS), Perceived Stress Questionnaire (PSQ), and IBD Self‐Efficacy Scale (IBD‐SES). Results: There were significant group × time effects favoring PM on IBDQ‐Total Score (F(1) = 15.2, P = 0.001), IBDQ‐Bowel (F(1) = 6.5, P = 0.02), and IBDQ‐Systemic (F(1) = 9.3, P = 0.007) but not IBDQ‐Emotional (F(1) = 1.9, P = ns) or IBDQ‐Social (F(1) = 2.4, P = ns). There was a significant interaction effect favoring PM with respect to PSQ (F(1) = 8.4, P = 0.01) and IBD‐SES (F(1) = 12.2, P = 0.003). There was no immediate change in MAS (F(1) = 4.3, P = ns). Moderate effect sizes (d > 0.30) were observed for IBDQ total score (d = 0.45), IBDQ bowel health (d = 0.45), and systemic health (d = 0.37). Effect sizes for PSQ (d = 0.13) and IBDSES (d = 0.17) were smaller. Conclusions: Behavioral programs that appeal to patients who may not seek psychotherapy for negative health behaviors may improve quality of life and potentially disease course and outcomes. (Inflamm Bowel Dis 2011)

Low-carbohydrate, high-protein diets revisited.

Purpose of review There has been continued interest in the physiological, nutritional and clinical aspects of low-carbohydrate diets. This review will discuss the effects on appetite regulation, metabolic parameters, body weight and body composition, the role of glycemic index and glycemic load, as well as long-term outcomes. Recent findings Low-carbohydrate, high-protein diets appear to improve satiety through their actions on measures of adiposity and gut peptides that influence appetite and caloric intake. Specific macronutrients such as low glycemic index carbohydrates and dietary protein impact appetite, calorie intake and metabolic parameters independent of weight loss. Long-term data, however, continue to support that total weight loss among low-carbohydrate dieters is not significantly different from low-fat dieters. The long-term safety of low-carbohydrate, high-protein diets on cardiovascular disease risk remains undetermined. Summary Low-carbohydrate, high-protein diets may be an effective choice for weight loss, enhanced satiety and improved metabolic parameters.

Practical approach to implementing dietary therapy in adults with eosinophilic esophagitis: the Chicago experience.

Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated esophageal disease characterized by esophageal dysfunction and esophageal mucosal eosinophilia. Diet therapy is effective in the treatment of EoE in both children and adults. The role of food allergens is well established in the pathogenesis and treatment of eosinophilic esophagitis. Empiric elimination with a six-food elimination diet (avoiding milk, wheat, egg, soy, peanuts/tree nuts, and fish/shellfish) demonstrates remission in over 70% of adults with this disease. Dietary therapy in adult EoE is becoming more accepted by both patients and clinicians. Dietary therapy can be effectively implemented in clinical practice with appropriate dietary education, patient resources, and close communication with physician and clinical staff. The ability to identify specific food triggers to help tailor dietary therapy for long-term management allows for a return to consumption of most table foods. Furthermore, the diet approach avoids the need for chronic topical corticosteroid use and possible long-term side effects of these medications. The decision to proceed with dietary therapy should be decided by patient preference and available resources. A collaborative and multidisciplinary approach including gastroenterologists, allergists, nurses, and dietitians is essential in the success of this approach.

877 Prospective Trial of Four Food Elimination Diet Demonstrates Comparable Effectiveness in the Treatment of Adult and Pediatric Eosinophilic Esophagitis

DI-metrics derived from FLIP data acquisition of simultaneous cross-sectional area and distention pressure. The line plot of the smallest CSA versus intrabag pressure for an EoE patient is illustrated to highlight the metrics of distensibility: distensibility slope (DS), distensibility plateau (DP) and plateau onset pressure (POP). Note the insets of the realtime FLIP data approximating the POP at approximately 22 mmHg and the distensibility along the DP at 58 mmHg. There is little overall change in the smallest esophageal CSA along the length of the esophageal body despite a change in pressure once the plateau is reached.

Development and validation of the brief esophageal dysphagia questionnaire

Esophageal dysphagia is common in gastroenterology practice and has multiple etiologies. A complication for some patients with dysphagia is food impaction. A valid and reliable questionnaire to rapidly evaluate esophageal dysphagia and impaction symptoms can aid the gastroenterologist in gathering information to inform treatment approach and further evaluation, including endoscopy.

S1861 A Prospective Clinical Trial of Six Food Elimination Diet or Elemental Diet in the Treatment of Adults with Eosinophilic Gastroenteritis

Background: Eosinophilic gastroenteritis (EG) is a rare disorder whose pathogenesis is poorly understood. To date there are no reports of dietary elimination in adults with EG. Aim: To evaluate the effectiveness of therapy with six food elimination diet (SFED) or elemental diet (ED) in adults with EG. Methods: Adults with a histologic diagnosis of EG were treated with either SFED or ED for 6 wks. All pts were off steroid or immunomodulators prior to inclusion and during the study period and were ruled out for H pylori and other infections. Pts met with a dietician for counseling and compliance. After 6 wks, pts had repeat EGD with biopsies in the proximal/distal esophagus, stomach and duodenum. Response was defined as peak count < 5 eos/hpf in the esophagus and <10 eos/hpf in gastric or duodenal specimens. If pts did not respond to SFED, they were offered 6 wks of ED. Results: 9 pts (6M) have been included to date. Average age was 35yrs (27-49) with median duration of symptoms of 13.5yrs (0.25-37). All pts had gastric involvement and 3/9 and 6/9 pts also had duodenal and esophageal eosinophilia, respectively. Common symptoms were abdominal pain (7), diarrhea (4), weight loss (4), dysphagia (4) nausea/vomiting (3) and fatigue (3). Complications of EG included anemia (4), malnutrition (2), osteoporosis (2) non-healing ulcer disease (1) and duodenal stricture (1). 89% of pts were atopic and 44% had history of food allergies. Skin prick testing for aero and food allergens were positive in 100% of the 77% of pts tested. Endoscopic findings were gastric erythema (100%) and nodularity (56%), duodenal erythema (22%) and nodularity (11%). All pts with dysphagia had features consistent with eosinophilic esophagitis (EoE) including rings (75%) furrows (75%), small caliber (50%), and stricture (25%). Diagnosis of EG preceded EoE in 50% of EG+EoE pts by an average of 10 yrs. No pts with pre-existing EoE progressed to EG. 89% of pts had peripheral eosinophilia (absolute eosinophil counts 1100-3900k/ul). IgE levels were high in 4/6 pts tested. 7/9 pts were initially treated with SFED and 2 pts with ED. 4/7 pts on SFED and 2/2 pts on ED had resolution of symptoms, histologic and peripheral eosinophilia. The remaining 3 pts on SFED had symptomatic but not histologic improvement, therefore are now undergoing ED. Conclusions: (1) Dietary elimination is effective in reducing symptoms, histologic and peripheral eosinophilia in 4/7 EG adults on SFED and 2/2 on ED implicating food allergens in the etiopathogenesis. (2) Further trials of dietary elimination in adults with EG are warranted.

Medical Nutrition Therapy for Patients With Advanced Systemic Sclerosis (MNT PASS) A Pilot Intervention Study

Background: The objective of this study was to demonstrate the feasibility and associations with short-term outcomes of a medical nutrition therapy (MNT) intervention in patients with systemic scleroderma (SSc). Materials and Methods: Eighteen patients with SSc, gastrointestinal (GI) involvement, and unintentional weight loss were consented and recruited for a 6-week MNT intervention, in addition to their usual medical management. MNT emphasized increased calorie and protein intake, modified textures, and lifestyle modifications. Symptoms, anthropometrics, diet (24-hour recall), and body composition (dual-energy x-ray absorptiometry) were assessed pre- and postintervention. Sarcopenia was defined as appendicular lean height (ALH) for women <5.45 kg/m2 and for men <7.26 kg/m2. Descriptive, parametric, and nonparametric statistics were conducted. Results: Participants (n = 18) were predominantly white (78%), female (89%), malnourished (83%), and 51.3 ± 11.0 years of age with a body mass index of 22.6 ± 6.7 kg/m2. Significant decreases in nutrition symptom scores (12.8 vs 7.6, P < .05) and improvements in ALH (5.6 ± 0.8 vs 5.8 ± 0.8 kg/m2, respectively; P = .05) occurred pre- vs postintervention, respectively (n = 14). Sarcopenia was observed in 54% of participants at baseline and 39% at follow-up (P = .02). Caloric intake (1400 vs 1577 kcal/d, P = .12) and macronutrient distribution (ie, % fat, protein, carbohydrate) did not change significantly pre- vs postintervention, respectively. Conclusions: Individually tailored MNT can improve symptom burden and potentially ALH in patients with SSc involving the GI tract. This study underscores the clinical potential of multidisciplinary patient management and the need for larger nutrition intervention trials of longer duration in these patients.

Assessing Adherence and Barriers to Long-Term Elimination Diet Therapy in Adults with Eosinophilic Esophagitis

BackgroundThe six-food elimination diet (SFED) is an effective treatment approach for eosinophilic esophagitis (EoE), but it can be challenging and affect patients’ quality of life.AimAssess patients’ long-term adherence to SFED and potential factors influencing adherence.MethodsEoE patients were recruited online via multiple platforms. Patients were classified as reaching the maintenance stage if they responded to SFED and identified specific trigger foods by reintroduction. Maintenance stage patients were categorized into those actively following the elimination diet (ACTIVE) and those no longer on their prescribed diet (FORMER). Participants completed a study-specific questionnaire assessing patient experiences related to SFED use.ResultsForty-two participants were identified as having reached the SFED’s maintenance stage. 57% (24/42) of the maintenance stage patients were ACTIVE users. FORMER users rated the SFED’s effectiveness at treating symptoms (5.45 ± 3.96, 10 max.) lower than ACTIVE users (8.29 ± 2.76, p = .02). A greater percentage of FORMER users (100%) agreed social situations create challenges in following the diet compared to ACTIVE users (67%, p < .05). Anxiety related to SFED was also higher among FORMER users (64%) compared to ACTIVE users (21%, p < .01). Both ACTIVE (95.8%) and FORMER (81.8%, NSS) users would recommend the elimination diet to other EoE patients.ConclusionsUnderstanding SFED adherence is multifactorial and complex. Factors influencing SFED adherence during long-term maintenance with diet therapy include diet effectiveness, social situations, and diet-related anxiety. Despite a lower than expected long-term adherence to maintenance of an elimination diet, the majority would recommend diet therapy as a treatment to other EoE patients.