The Six-Food Elimination Diet for Eosinophilic Esophagitis Increases Grocery Shopping Cost and Complexity.

The six-food elimination diet (SFED), where dairy, wheat, eggs, soy, nuts, and seafood are avoided, is an effective treatment for eosinophilic esophagitis (EoE). Patient-related costs of this approach, however, are unknown. We aimed to assess the cost of and ease of shopping for an SFED compared to an unrestricted diet. A dietitian with expertise in EoE generated menus meeting dietary requirements for a week's worth of meals for the SFED and an unrestricted diet. We compared prices and the number of missing items for both diets at standard and specialty grocery stores. The average weekly price of the SFED at a standard supermarket was $92.54 compared to $79.84 for an unrestricted diet (p = 0.0001). A patient shopping at a standard grocery store needed a higher proportion of items from a second store compared to an unrestricted diet (32 vs. 3 %, p = 0.0001). The prices of the SFED and unrestricted diet using a specialty supermarket were comparable ($106.47 vs. $105.96, p = 0.81), as was the percentage of items requiring a trip to a second store (6 vs. 2 % items, p = 0.03). Shopping at a specialty grocery store increased weekly grocery costs by $13.93 (p = 0.04) for the SFED and $26.12 (p = 0.03) for the unrestricted diet. In conclusion, for patients shopping at standard grocery stores, the cost of an SFED is higher, and an SFED requires more items from a second store. These differences disappear at specialty grocery stores, but costs were significantly higher. This cost and logistical burden can inform patients when selecting dietary therapy.

Eosinophilic esophagitis and proton pump inhibitors: controversies and implications for clinical practice.

Eosinophilic esophagitis (EoE) is a major cause of dysphagia and food impaction. Recognition and diagnosis of EoE have been increasing rapidly, but the role of proton pump inhibitors (PPIs) for the diagnosis of EoE and treatment of esophageal eosinophilia remains controversial. Initial diagnostic algorithms for EoE relied on a PPI trial to distinguish EoE from gastroesopha-geal reflux disease, a common cause of esophageal eosinophilia. This approach has become complicated by the recent recognition of PPI-responsive esophageal eosinophilia (PPI-REE), a disorder characterized by clinicopathologic features similar to EoE but that resolve with high-dose PPI therapy. The mechanism of PPI action for treatment of esophageal eosinophilia may rely not only on acid suppression but also on novel anti-inflammatory effects of the PPIs themselves. Treatment with PPI therapy is now considered a required step before a formal diagnosis of EoE can be made, and continuing PPI therapy in patients with PPI-REE is a common strategy. However, the role of continuing PPI monotherapy in patients with EoE remains a matter of debate. The decision to do so should hinge on improvement in symptoms and histology as well as the need for ongoing dilation.