What is the 4 food elimination diet?

First developed to treat eosinophilic esophagitis (EoE), the 4 food elimination diet is a diagnostic tool that removes four of the most common food allergens from the diet for a set period. It is often a less restrictive and potentially more tolerable alternative to the six-food elimination diet.

Quick Summary

The 4 food elimination diet (4FED) involves temporarily removing milk, wheat, soy, and eggs to identify food triggers for symptoms like those of Eosinophilic Esophagitis (EoE), followed by a reintroduction phase.

Key Points

• Purpose: The 4 food elimination diet (4FED) is a diagnostic tool primarily used to identify food triggers for Eosinophilic Esophagitis (EoE).

• Core Four Foods: The diet eliminates cow's milk/dairy, wheat, eggs, and soy due to their high potential as triggers.

• Two Phases: It consists of a strict elimination phase (typically 8-12 weeks) followed by a systematic reintroduction phase to pinpoint triggers.

• Professional Supervision: Due to the risk of nutritional deficiencies and the need for accurate diagnosis, this diet should only be undertaken with medical supervision, often involving a dietitian.

• Less Restrictive: The 4FED is considered a less restrictive and potentially more manageable alternative to the more comprehensive six-food elimination diet (6FED).

• Food Labels are Crucial: Success depends heavily on meticulously reading food labels to avoid hidden sources of the eliminated foods in processed products.

Understanding the 4 Food Elimination Diet (4FED)

The 4 food elimination diet, or 4FED, is a medical and diagnostic dietary protocol used primarily to identify specific food triggers for inflammatory conditions, most notably Eosinophilic Esophagitis (EoE). It is a focused, short-term dietary strategy, not a long-term treatment plan. The core of the 4FED involves strictly eliminating the four most common food triggers: milk (dairy), wheat, soy, and egg. This temporary restriction aims to allow the body's immune system to calm down and symptoms to improve, after which foods are systematically reintroduced.

The Core Four: Foods to Avoid

Adherence to the 4FED requires a thorough understanding of all sources of milk, wheat, soy, and egg. These ingredients can often be hidden in processed and pre-packaged foods. Diligent label reading is crucial for success.

• Milk (Dairy): This includes all cow's milk products and potentially goat's or sheep's milk due to cross-reactivity. All forms of cheese, yogurt, butter, cream, and whey are excluded.
• Wheat: This means avoiding all wheat-based products, including bread, pasta, couscous, and bulgur. It also extends to gluten-containing grains unless specified otherwise by a doctor.
• Egg: Eggs, whether whole or in ingredients like albumin and ovalbumin, must be avoided. This also includes many baked goods, sauces like mayonnaise, and some packaged foods.
• Soy: All soy products, such as tofu, edamame, miso, and soy milk, are off the table. However, refined soy oil and soy lecithin are often permitted, but checking with a specialist is essential.

The Two Phases of the 4FED Protocol

The 4FED is typically divided into two main phases, both of which should be undertaken with the guidance of a healthcare professional, like a dietitian.

1. The Elimination Phase: This is the initial period, usually lasting 8 to 12 weeks, where all four food groups are completely removed from the diet. The goal is to see if symptoms (such as dysphagia, abdominal pain, or vomiting) improve and if inflammation reduces. For EoE patients, this is often confirmed with an endoscopy and biopsy. During this phase, individuals must maintain a food and symptom diary to track their body's response.
2. The Reintroduction Phase: If symptoms improve during the elimination phase, the food groups are systematically reintroduced, one at a time, to identify the specific trigger(s). Each food is introduced for several weeks, with symptoms monitored closely. If a reaction occurs, that food is identified as a trigger. An endoscopy may be performed after each reintroduction to confirm the effect on inflammation.

What to Eat on a 4FED

Despite the strict exclusions, a wide variety of foods are allowed, and finding substitutions is key.

• Protein: Plain meat, poultry, and fish that are not breaded or marinated with restricted ingredients. Legumes such as chickpeas and lentils are also safe alternatives for soy.
• Grains and Starches: A range of non-wheat grains and starches are permitted, such as rice, quinoa, corn, oats (certified gluten-free to avoid cross-contamination), potatoes, and buckwheat.
• Fruits and Vegetables: All plain fruits and vegetables are included and can be a vibrant part of the diet.
• Dairy Alternatives: Plant-based milks like almond, coconut, or rice milk can be used, ensuring they are fortified for nutrients like calcium. Look for dairy-free yogurts and cheeses made from nuts or coconuts.
• Egg Replacers: For baking, flaxseed eggs (ground flaxseed mixed with water), mashed banana, or apple puree can be used.

Challenges and Considerations

While effective for many, the 4FED can be challenging. Some key factors to consider include:

• Nutritional Adequacy: Removing major food groups can lead to deficiencies in key vitamins and minerals like calcium, vitamin D, and B vitamins. Consultation with a dietitian is vital to ensure proper supplementation.
• Quality of Life: The highly restrictive nature of the diet can impact social life and lead to increased anxiety and stress, especially in children and their families.
• Adherence: Maintaining the diet for several weeks requires significant planning, meal preparation, and label reading.

Comparison: 4FED vs. 6FED

The 4FED is a less restrictive alternative to the 6-food elimination diet (6FED), which was traditionally used for EoE. The key difference lies in the number of food groups eliminated.

Feature	4-Food Elimination Diet (4FED)	6-Food Elimination Diet (6FED)
Foods Eliminated	Milk, Wheat, Soy, Egg	Milk, Wheat, Soy, Egg, Peanuts/Tree Nuts, Fish/Shellfish
Primary Use	EoE diagnosis and management	Historical standard for EoE, still used in some cases
Effectiveness (EoE)	Studies show remission in over 60% of children	Induces remission in a higher percentage of patients, but is more restrictive
Adherence	Better adherence due to less restriction	Higher dropout rate due to more food exclusions
Nutritional Risk	Moderate risk of nutrient deficiencies if not managed	Higher risk of deficiencies due to more restrictions
Food Variety	Greater variety of foods and substitutions available	Limited food variety, making meal planning more complex

Conclusion

The 4 food elimination diet serves as an important diagnostic tool for identifying food triggers in conditions like EoE. By removing milk, wheat, soy, and eggs for a short period and then reintroducing them systematically, it helps pinpoint the culprits causing inflammation and symptoms. While less restrictive and often easier to follow than the 6FED, it still requires careful planning, label-reading, and medical supervision to prevent nutritional deficiencies and manage the challenges associated with a restricted diet. Anyone considering the 4FED should consult with a healthcare provider and a registered dietitian to ensure it is the right approach for their specific situation and to navigate the process safely and effectively.

References

• National Institutes of Health (NIH) Study on 4FED efficacy in children with EoE: https://pmc.ncbi.nlm.nih.gov/articles/PMC6448398/
• ASCIA Dietary Guide - Four Food Elimination Diet (4FED) for EoE: https://www.allergy.org.au/patients/food-other-adverse-reactions/eoe-4fed

Frequently Asked Questions

What is the main purpose of the 4 food elimination diet?

The main purpose of the 4 food elimination diet (4FED) is to identify which specific foods are causing inflammatory reactions or other symptoms in a person, particularly those with Eosinophilic Esophagitis (EoE).

Which four foods are eliminated on the 4FED?

The four foods eliminated on the 4FED are cow's milk (and other dairy products), wheat, eggs, and soy.

How long does the elimination phase of the 4FED last?

The elimination phase of the 4FED typically lasts for 8 to 12 weeks, during which the four food groups are strictly avoided.

Is the 4FED a permanent diet?

No, the 4FED is not intended to be a permanent diet. It is a temporary diagnostic tool. After identifying the trigger foods, those specific foods are avoided long-term while the well-tolerated foods are added back into the diet.

What are the risks of following the 4FED?

The main risks include potential nutritional deficiencies (such as calcium and vitamin D) due to the removal of major food groups and the psychological strain of adhering to a restrictive diet. Professional supervision can help mitigate these risks.

What is the difference between the 4FED and 6FED?

The 4FED removes milk, wheat, egg, and soy. The 6FED is more restrictive, also removing peanuts, tree nuts, fish, and shellfish. The 4FED is often trialed first for better adherence.

Can children follow the 4 food elimination diet?

Yes, children can follow the 4FED, especially for EoE diagnosis. However, it must be done under strict medical supervision to ensure proper nutrition, growth, and development, and to manage the reintroduction phase safely.