Transcript: Vrinda Bhardwaj, MD, on Elemental and Elimination Diets for Treating EGID in Children

Rebecca Mashaw:  Hello everyone and welcome to another installment of Podcasts360, your go‑to resource for medical news and chemical updates. I'm your moderator, Rebecca Mashaw, with Gastroenterology Consultant.

Today we're here with Dr. Vrinda Bhardwaj. She's the director of the eosinophilic gastrointestinal disorders program and the director of endoscopy services at Children's Hospital Los Angeles.

She's going to talk to us today about some recent research that she and her colleagues published on the use of elemental and elimination diets and treating eosinophilic gastrointestinal diseases. Thank you so much for being here today, Dr. Bhardwaj.

In your published review, you state that elemental and elimination diets are highly effective therapies for treating eosinophilic gastrointestinal diseases. Would you begin by explaining the features of these diets and how they are administered and followed?

Vrinda Bhardwaj:  The paper that we are describing today and discussing is a collaborative work that I've done with the allergy team and the dietitian team at Children's LA. I would like to first mention that a crucial factor of picking what diet you will give to a patient has to be acceptable to the patient.

Let's first start about elemental diet. This involves drinking or intaking absolutely broken down formulae. If you consider a regular formula like a house, this is one brick, and it runs through the GI tract. It is shown to cause remission in this condition, and also allow the child to get the nutrition that is necessary.

Data, depending on what you're looking at, can show up to 90% remission in disease and this is a great choice in younger children because they are already consuming formulae or breast milk, so it's not much different for them to get on to a broken-down formula.

Having said that, the more simpler ingredients we go to on a formula, it loses its taste, flavor, and palatability can be a challenge. Occasionally, children require a feeding tube to be able to get this formulae.

The next diet we're going to talk about is the elimination diet, which, looking at the data, can show a 70 to 80% remission rate. The premise of this diet is that certain foods are considered to be triggers in the EGID population. By EGID, that’s just the short term that I'm going to use for eosinophilic gastrointestinal disease for the rest of our discussion.

What we do with this diet is, we start removing from the diet certain culprit or trigger agents which are dietary in nature, and we can achieve remission in a proportion of these patients. This diet can range from six-food elimination to four-food elimination, to now some data supporting even one-food elimination. These are popularly called S‑fed, F‑fed or O‑fed. F‑fed I would like to mention is milk, soy, fish, nuts, wheat, and eggs that are removed.

Classically, endoscopies are performed when the elimination happens or reintroduction happens, and we see what could be identified as a trigger agent. In some children were able to find this diet works best for them, because you can narrow it down to the trigger. For some it doesn't; at times you keep them on the S‑fed and stay with the remission.

Rebecca Mashaw:  Thanks for that great overview of these diets. Can you give us an overview of these diseases? Are they common in children or do they also occur in adults? And what kinds of symptoms do these patients present with?

Vrinda Bhardwaj:  That's a great question to discuss. These conditions are marked by an increase in cells called eosinophils, a marker of allergies and eosinophilic disease. They can be innocent bystanders, too. What I mean by that is that this condition is a clinical pathologic diagnosis. What that means is you have to have the clinical features, and they should correlate with what you're finding on the endoscopy and getting mucosal biopsies from.

In simpler terms, I would segregate this entity in terms like EOE, or eosinophilic esophagitis, which tends to affect the esophagus, and non‑EOE EGID, where you can have distal disease in the GI tract, starting anywhere from gastritis, duodenitis, enteritis, colitis, and the combination of these.

This distinction is important because the response to therapy changes and the behavior of these conditions change. Classic symptoms that we can see with EOE also differ in what age range your patient is. It can start from just vomiting to growth failure. In about the age range of elementary to early high school children we can notice dysphagia, which is painless typically,  a sensation that you could say “I feel like there is a rock or a lump in my throat. I tend to cut up my food, I eat like a bird, and I need water sometimes to slip food down.” Those are classic features.

With the EGID, which is non‑EOE EGID where there is distal gastrointestinal involvement, those tend to typically present more with abdominal pain, diarrhea, occasionally rectal bleeding, and also growth failure. So these are subtle features.

We're trying to understand is it that these are getting recognized more, or is it truly that the incidence is going up. That's a little bit unclear, because it is comparatively a newer diagnosis, which we've seen within the last decade. It has really grown, because there is some understanding of how to select these patients out and how to work these patients.

You mentioned a little bit about how do we see it in adults. To be very honest, I'm a pediatric gastroenterologist, so I’m not going to dwell into the details of adults because I’m not an expert in that.

Having said that, those patients tend to present with similar symptoms of abdominal pain and diarrhea that we talked about and the dysphasia which is feeling of food getting stuck in the throat tends to come more from stricture disease, which is long‑standing inflammation, causing narrowing of the food pipe or maybe just a phenotype of the disease in which there is less inflammation and more stenosis and narrowing.

Rebecca Mashaw:  In your review you noted that standardization in the reintroduction phase of these diets is lacking. How does your research shed light on this issue? What do you think contributes to the lack of standardization of care?

Vrinda Bhardwaj:  Standardization is very patient‑dependent. And there are several factors, which determine how standardization can be achieved, and how reintroduction can be performed safely and with a team approach.

First and foremost, I would like to talk about concomitant allergies. Eosinophilic esophagitis can be very usually called asthma or eczema of the food pipe.

Much of these kids tend to have concomitant IgE food‑related or environmental allergies. So just to give you an example, if you want to introduce milk back into the diet, the child has an IgE‑mediated allergy, that might not be the best agent to go back into the diet. Because, even if it is not the trigger for EGID it is a true IgE-mediated allergy and will limit tolerance.

The second feature is that these diets can be very restrictive for patients and there may be a desire for a certain food to be reintroduced into the diet first, which may drive the reintroduction process. So again, it is very patient-selective.

Thirdly I would say, you really need support from a dietitian or a nutritionist because you need constant communication with the family and learning that if you want to exclude milk, what all are the sources in which you can get milk.

Not all institutions or practices have this support. That limits the standardization because you’ve got MDs working with the busy setup and they really might not have the expertise or the time to allow the standardization in reintroduction to happen.

Rebecca Mashaw:  You and your colleagues pointed out in your review that individualization according to patient preferences is very important to the patient's quality of life and age-related issues also have to be considered in food reintroduction. How would you advise clinicians who are trying to balance the need for individualization and the goal of achieving some sort of standardization in this phase of treatment?

Vrinda Bhardwaj:  My and my colleagues advice would be to balance this specifics of reintroduction and handle those best with a very candid conversation with the families ahead of time. Set realistic goals from the get‑go.

That allows you to have more streamlined management further down and understand things that we've just talked about, which are IgE-mediated allergies, if they have any, and if there is a preferential desire to bring in a certain food early on. We tend to really include the wishes of the patient and that team approach, and again having a dietitian really have helped us achieve the goals. This approach really can do wonders.

Rebecca Mashaw: What kind of best practices did you identify for food reintroduction, when patients have achieved remission?

Vrinda Bhardwaj: Goal‑settings, having a team approach, real support and communication during this process from the EGID team, especially having a nutritionist and the dietitian and continued GI support.

One thing one has to keep in mind when there is reintroduction happening of food agents is a planned endoscopic evaluation to assess if there is mucosal remission which is achieved. If you do that, you know that you've safely been able to reintroduce that food agent, that's a safe agent.

It really guides further liberalization of the diet and helps identify cultured food triggers which you may or may not find in a particular child. That systematic approach does help.

Endoscopic evaluations, one is performing transnasal endoscopy and unsedated evaluation. Traditionally, all sedated endoscopies can be seen as a burden on families. There are concerns related to repeated exposure of anesthetic agents. Having that conversation from the get‑go, I think really helps out.

Rebecca Mashaw: What's the next step in your research into this topic?

Vrinda Bhardwaj: Yeah, we're really excited to move forward with this protocol and utilizing it in a larger cohort. That's really our next step. I think having this protocol, taking a standardized approach will allow us to get more data and to further meaningful research.

Rebecca Mashaw: Thanks so much for talking with us today, and we'll look forward to hearing about your continue your research.

Vrinda Bhardwaj: Absolutely, it's been a pleasure. Thanks for having me.