Eosinophilic Esophagitis (EoE) Diet: A Detailed Beginner’s Guide

Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus — the tube that connects your throat and stomach.

Various substances in food can trigger an immune response that causes the condition in susceptible people.

Eliminating foods that trigger the immune response can decrease the risk of health complications and eating problems that are commonly associated with EoE.

This article explains what an elimination EoE diet is and how to follow it to improve your symptoms.

EoE diet

What is eosinophilic esophagitis (EoE)?

EoE is an inflammatory disease that affects the esophagus.

It was once thought to be a component of gastroesophageal reflux disease (GERD), a condition that occurs when stomach contents back up to your esophagus (1).

Children with EoE may experience feeding problems, vomiting, and stomach pain, while adolescents and adults are more likely to experience dysphagia (difficulty swallowing) and food impaction, which occurs when food becomes stuck in the esophagus (1).

The mean age of diagnosis in children is 6 to 7 years and in the second to fourth decades of life in adults (2).

Compared with women, men are three times more likely to have EoE.

While the exact cause of EoE has yet to be determined, genetics and the presence of coexisting conditions like celiac disease and Crohn’s disease are associated with its development.

EoE elimination diet

An elimination diet is generally the first line of treatment for EoE since it’s considered a food-triggered condition, like congenital sucrase-isomaltase deficiency (CSID) (3).

Because skin and immunoglobulin E blood tests are unreliable for identifying food triggers with EoE, the six-food elimination diet has been widely studied as a treatment option (4).

This diet eliminates the six most commonly identified EoE trigger foods including wheat, milk, soy, nuts, eggs, and seafood, and then reintroduces them back into the diet one at a time to identify the trigger.

An endoscopy — a procedure that involves inserting a long, flexible tube down your throat and into your esophagus — test can confirm whether a food is a trigger by assessing the presence of inflammation in the esophagus lining before and after an eliminated food is reintroduced.

The 6-food elimination diet has been shown to improve symptoms in up to 74% of children and 64% of adults within 6 weeks (5, 6).

A less restrictive 4-food elimination diet — free of dairy products, wheat, eggs, and soy — has also been shown to improve symptoms in up to 54% of adults with EoE (7).

In the same study, 31% of the nonresponders to the 4-food elimination diet, were successfully treated with the 6-food elimination diet.

However, starting with the 6-food elimination diet may lead to unnecessary dietary restrictions and can be difficult to follow long-term.

In addition to an elimination diet, an elemental diet has also been proven effective for reducing or eliminating symptoms in people with EoE (8).

An elemental diet consists of elemental formulas — which contain nutrients that have been broken down into their simplest form.

One example of an elemental formula product is the Physicians’ Elemental Diet.

Step-up elimination diet for EoE

A step-up elimination diet starts with the elimination of dairy and wheat — the two most common food triggers for EoE (9).

If your symptoms don’t improve after six weeks, eggs and soy are eliminated, and if that fails, nuts and seafood are eliminated.

This diet — known as the 2–4–6 step-up approach — reduces unnecessary dietary restrictions and allows for quicker identification of the food triggers compared with the standard six-food elimination diet (9, 10).

In one study, 43% of children and adults with EoE experienced symptom improvement after eliminating milk and wheat, 19% showed improvement after the step up to the four-food elimination plan, and 29% had improvement after the final step up to the six-food elimination plan (9).

How to do the 2–4–6 step-up approach

The 2–4–6 step-up approach starts with the elimination of the two most common food triggers for EoE.

If the 2-food elimination diet doesn’t improve your symptoms after 6 weeks, 2 more common allergenic foods are eliminated in the 4-food elimination diet for an additional six weeks.

While most people with EoE experience symptom improvement with the 2- or 4-food elimination diet, a more rigid 6-food elimination diet may be needed.

Once you notice improvements in your symptoms, reintroduce each food, one at a time, slowly over several days while you look for symptoms under the care of a health care provider.

If you experience no symptoms after reintroducing a food, you can assume that food is not the culprit and then reintroduce the next food until you find your trigger food.

Keep a journal so you can document which foods you eliminated and what symptoms you experience after reintroducing them into your diet.

2-food elimination diet

The 2-food elimination diet eliminates dairy and wheat, the two most common EoE trigger foods.

Dairy refers to any food from the milk products of animals, such as cows and goats.

Dairy and products that may use some form of dairy as an ingredient include:

  • cream cheese
  • cheese
  • cottage cheese
  • ice cream
  • whipped cream
  • cookies and cakes
  • chocolate
  • sauces and gravies
  • breakfast cereals
  • margarine
  • salad dressings
  • pudding and custard

Wheat is a common ingredient in many foods including:

  • breads
  • breakfast cereals
  • biscuits
  • crackers
  • pancakes
  • wafers
  • cakes
  • pizza
  • pasta
  • pastries
  • imitation crab meat
  • sauces and salad dressings
  • processed meats
  • potato chips
  • hot dogs
  • soups

4-food elimination diet

The 4-food elimination diet eliminates eggs and soy in addition to dairy and wheat.

Avoid eggs and products that may contain eggs such as:

  • breaded and batter-fried foods
  • salad dressings and sauces
  • custards, puddings, and ice cream
  • specialty coffee drinks
  • meatloaf and meatballs
  • pasta
  • marshmallows
  • crackers and chips

Soy foods and foods that may contain soy include:

  • edamame
  • miso
  • soy sauce
  • natto
  • soy milk
  • soy protein
  • tamari
  • tempeh
  • teriyaki sauce
  • textured vegetable protein
  • tofu
  • baked goods
  • canned tuna and meat
  • cereals
  • ice cream
  • processed meats
  • dressings, gravy, and sauces

6-food elimination diet

In addition to dairy, wheat, eggs, and soy, the 6-food elimination diet eliminates nuts and seafood.

Examples of nuts and products that may contain nuts include:

  • peanuts
  • almonds
  • Brazil nuts
  • walnuts
  • hazelnuts
  • macadamia nuts
  • pistachios
  • pecans
  • cashews
  • nut butter
  • cereals and granola
  • cookies and baked goods
  • candy
  • ice cream
  • sauces and salad dressings

Seafood includes both fish and shellfish.

Examples of seafood include:

  • bass
  • cod
  • haddock
  • sardines
  • tuna
  • clams
  • mussels
  • shrimp
  • lobster
  • crab

Other diet tips for EoE

Here are some tips to keep in mind when following an EoE elimination diet:

Read food labels

Always check the food ingredient list of products before buying so you can make sure they don’t contain the ingredient that you’re trying to avoid.

The United States Food and Drug Administration (FDA) requires that most packaged food products that contain a major food allergen identify the allergen on the food label (11).

The nine major food allergens include:

  • milk
  • eggs
  • fish
  • shellfish
  • tree nuts
  • peanuts
  • wheat
  • soy
  • sesame

Dietary supplement labels are also required to declare any major food allergens present.

However, meat, poultry, egg products, alcoholic beverages, prescription drugs, and cosmetics don’t have to list the common food allergens if present.

Consider nutrient shortfalls

The risk for nutrient shortfalls increases with the number of foods you eliminate (12).

The 6-food elimination diet is especially strict and poses the greatest risk of developing a nutrient deficiency.

Therefore, it’s best to start with the 2-food elimination diet before stepping up to the 4- or 6-food elimination diet to prevent unnecessary dietary restrictions and reduce your risk of nutrient deficiencies as directed by your health care provider.

You may need a multivitamin supplement with consultation from a registered dietitian to ensure you’re not falling short in one or more nutrients.

Avoid cross-contact

For an elimination diet to be effective, you must ensure that you or the person preparing your food avoid cross-contact, which occurs when an allergen-free food is exposed to an allergen-containing food.

Avoid using the same kitchen equipment to prepare allergen-free foods that are also used to make allergen-containing food, and have separate condiments to avoid cross-contact from utensils.

The bottom line

EoE is a chronic inflammatory disease of the esophagus.

Following a 2–4–6 step-up approach elimination diet can help you identify food triggers so you can avoid them and reduce your symptoms.

When trying an elimination diet, remember to closely read the food labels, consider nutrient shortfalls in your diet, and avoid cross-contact.

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