Is Milk Elimination Enough? A Systematic Review and Meta-Analysis of One-Food Elimination Diet in Eosinophilic Esophagitis.

BACKGROUND/OBJECTIVES: Dietary management, particularly through food elimination, has emerged as an effective therapeutic strategy for eosinophilic esophagitis (EoE). In this context, a one-food elimination diet (1-FED) targeting cow's milk has been proposed as a targeted and less restrictive alternative to broader elimination approaches. The aim of this systematic review and meta-analysis was to systematically assess the effectiveness of 1-FED in achieving histological remission and to compare its efficacy with broader elimination diets in patients with EoE. METHODS: A systematic review of the literature was conducted across five databases (PubMed, Scopus, CINAHL, MEDLINE, and ClinicalTrials.gov). The primary endpoint was histological remission (<15 eosinophils/HPF). Comparative studies were pooled using a random-effects meta-analysis. RESULTS: Eight studies met the eligibility criteria for the systematic review, of which seven were included in the meta-analysis. Overall, 156 of 306 patients achieved histological remission following 1-FED, corresponding to a pooled remission rate of 51% (95% CI: 43-60%). Histological remission rates ranged from approximately 34% to 65% across individual studies. Compared with broader elimination diets, 1-FED showed no significant difference in histological remission (OR 1.00, 95% CI 0.64-1.58; p = 0.99). CONCLUSIONS: Compared to multi-food elimination diets, 1-FED requires a less restrictive dietary pattern, which may offer practical advantages for treatment adherence in routine clinical practice, although this was not systematically or objectively measured in the included studies. The findings lend preliminary support to a step-up dietary strategy, in which 1-FED may be considered as an initial intervention and broader elimination diets are reserved for patients who fail to achieve remission.