Nutrition Diet: What foods should you avoid if you have EoE?

Research indicates a strong connection between food allergies and Eosinophilic Esophagitis (EoE), with common food proteins driving the esophageal inflammation. A primary treatment involves identifying and eliminating these dietary triggers, making it crucial to understand what foods should you avoid if you have EoE.

Quick Summary

Managing EoE involves identifying and avoiding specific food triggers that cause inflammation in the esophagus. The most common triggers are addressed through an elimination diet, removing foods like dairy, wheat, soy, eggs, nuts, and fish/shellfish. A doctor and dietitian can help pinpoint individual triggers through systematic reintroduction.

Key Points

• Consult a Professional: Always work with a doctor and dietitian to manage EoE through a food elimination diet to ensure adequate nutrition and safe identification of triggers.

• Start with the Six: The six-food elimination diet (6FED) is the most common approach and removes dairy, wheat, soy, egg, nuts, and seafood.

• Dairy and Wheat are Most Common: These two food groups are the most frequent triggers for EoE inflammation.

• Watch for Hidden Allergens: Many processed foods contain hidden ingredients from the common EoE trigger groups, so read all food labels carefully.

• Use the Reintroduction Phase Carefully: Systematic reintroduction of foods is the only reliable way to pinpoint specific triggers, and endoscopic monitoring is often necessary.

• Customize Your Diet: Depending on the individual, a less restrictive diet, like a two-food elimination diet, might be an effective starting point.

Understanding Eosinophilic Esophagitis (EoE)

Eosinophilic Esophagitis (EoE) is a chronic immune system disease characterized by the buildup of eosinophils, a type of white blood cell, in the esophagus. This inflammation can lead to difficulty swallowing, food impaction, and chest pain. For many individuals, EoE is triggered by an allergic-type reaction to certain foods, which can be identified and managed through a food elimination diet. The most common approach is the Six-Food Elimination Diet (6FED), though other variations exist, like the two- and four-food elimination diets. Successfully identifying and removing these trigger foods can significantly reduce inflammation and improve symptoms.

The Six Primary Food Triggers to Consider

The 6FED is a comprehensive strategy that targets the most common food allergens responsible for EoE symptoms. It involves removing six major food groups and then systematically reintroducing them to identify the specific culprits. Consulting with a healthcare professional, such as a gastroenterologist and a registered dietitian, is essential for a safe and effective process.

1. Dairy Products

Dairy is widely recognized as one of the most common EoE food triggers, particularly for children. The proteins in cow's milk, such as casein and whey, are often the cause of the inflammatory response. Avoiding dairy requires vigilance, as milk proteins are found in a vast array of products. This includes obvious items like:

• Milk
• Cheese
• Yogurt
• Butter
• Ice cream

However, it also requires checking for hidden ingredients in processed foods, including protein powders, soups, and snack foods. For those needing to eliminate dairy, fortified plant-based milk alternatives like rice, oat, or soy milk are often recommended.

2. Wheat

Wheat is another major trigger for EoE, often cited as the second most common after dairy. For some individuals, the reaction is to wheat itself, while for others, the culprit may be gluten, a protein found in wheat, barley, and rye. It is important to remove all wheat-containing products during the elimination phase, such as:

• Bread and baked goods
• Pasta
• Cereals
• Couscous

For those on a wheat-free diet, suitable alternatives include grains and flours made from rice, corn, or quinoa. Opting for products specifically labeled gluten-free is a safe bet, as regular oats can sometimes be cross-contaminated with wheat.

3. Eggs

Eggs are a well-known allergen and a significant trigger for EoE symptoms in some individuals. The proteins in both the egg white and yolk can cause esophageal inflammation. Eggs are used in many foods, so it's vital to check ingredient lists carefully. Obvious sources to avoid include:

• Scrambled, fried, or poached eggs
• Omelets
• Mayonnaise
• Some salad dressings

When baking or cooking, a variety of egg substitutes can be used, such as ground flaxseed mixed with water or mashed banana.

4. Soy

Soy is a common allergen that can cause or contribute to EoE inflammation. It is important to avoid a wide range of soy-based products, including:

• Edamame and soybeans
• Soy milk
• Tofu and tempeh
• Soy sauce and tamari

Like other allergens, soy can be hidden in processed items like protein bars, soups, and cereals. Some individuals with EoE may tolerate highly processed soy ingredients like soy lecithin or refined soy oil, but it is best to discuss this with a healthcare provider.

5. Nuts and Peanuts

Although less common triggers than dairy and wheat, nuts and peanuts are included in the 6FED due to their potential to cause severe allergic reactions. Peanuts are legumes but are often grouped with tree nuts like almonds, walnuts, and cashews. Avoiding this category means cutting out:

• Peanuts and tree nuts
• Nut butters
• Nut meals and flours

Seed-based alternatives like sunflower seed butter or tahini can provide healthy fats and nutrients during this period.

6. Fish and Shellfish

Fish and shellfish are included in the broadest elimination diets, though they are less frequent triggers for EoE. This includes finned fish (e.g., salmon, tuna) and shellfish (e.g., shrimp, crab, lobster, oysters). Be mindful of hidden ingredients like fish sauce or oyster sauce. For those who need a seafood alternative, lean poultry or certain legumes can be used.

Comparison of EoE Elimination Diets

Different elimination diet protocols exist to help manage EoE. Your doctor and dietitian will determine the best starting point based on individual circumstances.

Diet Type	Foods Eliminated	Typical Duration	Histologic Remission Rate*	Notes
One-Food Elimination Diet (1FED)	Dairy (Cow's Milk)	6-8 Weeks	~34-40% in Adults	Simplest starting point; may be effective alone or requires stepping up to more restrictive diets.
Two-Food Elimination Diet (2FED)	Dairy and Wheat	8-12 Weeks	~40% in Adults	Common starting point; addresses the two most frequent triggers.
Four-Food Elimination Diet (4FED)	Dairy, Wheat, Egg, Soy	8-12 Weeks	~54% in Adults	More restrictive, targeting the most common triggers after dairy and wheat.
Six-Food Elimination Diet (6FED)	Dairy, Wheat, Egg, Soy, Nuts, Fish/Shellfish	6-8 Weeks	~70% in Adults	Most comprehensive and historically most successful, addressing all major trigger categories.

*Remission rates can vary based on the specific study and population (adults vs. children).

The Reintroduction Process

After a period of successful elimination and symptom improvement, foods are gradually reintroduced one at a time to identify the specific trigger(s). The process typically involves:

1. Introduce one food group (e.g., dairy) and consume it regularly for 2 to 6 weeks.
2. Monitor symptoms carefully and record any changes in a food diary.
3. Perform an endoscopy with biopsy at the end of the reintroduction period to check for the return of esophageal inflammation.
4. If the food is safe, you can continue to eat it and move on to the next food group. If it causes symptoms, it is considered a trigger and should be avoided long-term.

Conclusion

Understanding what foods should you avoid if you have EoE is the first step toward effective management. Since food triggers are highly individual, a structured elimination diet under the supervision of a healthcare team is crucial. The 6FED offers the most comprehensive approach, targeting dairy, wheat, soy, eggs, nuts, and fish/shellfish. However, simpler elimination diets focusing on one or two food groups may also be effective for some individuals. By carefully navigating the elimination and reintroduction process, patients can identify their specific triggers and regain control over their symptoms. For more detailed information on dietary approaches for EoE, consider consulting resources like the National Institutes of Health.

Frequently Asked Questions

What is the most common food trigger for EoE?

Cow's milk and other dairy products are the most frequently identified food triggers for Eosinophilic Esophagitis.

How long does a food elimination diet for EoE last?

The initial elimination phase typically lasts for six to twelve weeks. The reintroduction phase follows, with each food group being reintroduced for two to six weeks at a time.

Are there different types of elimination diets for EoE?

Yes, there are several approaches, including the Six-Food Elimination Diet (6FED), Four-Food Elimination Diet (4FED), and Two-Food Elimination Diet (2FED), which progressively eliminate fewer food groups.

Can EoE symptoms improve without a full six-food elimination diet?

Yes, some studies show that eliminating fewer food groups, such as just dairy, can lead to remission in some adults. A healthcare provider can help determine the best plan.

Why is endoscopy used during the diet process?

Endoscopy with a biopsy is the most accurate way to check for inflammation and determine if a specific food has caused a reaction, as EoE symptoms can be delayed.

Can a person on an EoE diet accidentally consume a trigger food?

Yes, cross-contamination is a risk. It's important to be cautious at buffets, salad bars, and when ordering at restaurants. Dedicated cooking surfaces and utensils can help prevent this.

Do I need to avoid all nuts if I have EoE?

While nuts are part of the 6FED, they are less common triggers than dairy or wheat. Whether you need to avoid them long-term depends on the results of the reintroduction phase, guided by your doctor.