What is the 6 food elimination diet for esophagitis?

Affecting a significant number of individuals, eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease of the esophagus. The 6 food elimination diet is a common and effective dietary therapy used to identify and remove food triggers that cause this inflammation.

Quick Summary

A comprehensive overview of the 6 food elimination diet for eosinophilic esophagitis (EoE), detailing its purpose, the six common allergens removed, the phases of elimination and reintroduction, and what to expect during the process. The diet helps identify individual food triggers causing esophageal inflammation.

Key Points

• Identify Food Triggers: The 6 food elimination diet is a method to systematically identify food allergies causing eosinophilic esophagitis (EoE) by removing the six most common triggers.

• Elimination Phase: For 6-8 weeks, all dairy, wheat, soy, eggs, nuts, and fish/shellfish are completely removed from the diet to allow the esophagus to heal.

• Reintroduction Phase: After successful elimination, food groups are reintroduced one by one, with an endoscopy performed after each to test for renewed inflammation.

• Medical Supervision: The entire process should be monitored by a healthcare team, including a gastroenterologist and a registered dietitian, to ensure nutritional adequacy.

• Manage Cross-Contamination: Strict avoidance of the six food groups is necessary, which means being careful about cooking methods, restaurants, and processed foods.

• Long-term Management: Once the trigger food(s) are identified, they are permanently removed from the diet, allowing for long-term symptom management.

• Alternative Diets: For some patients, less restrictive diets (2-food or 4-food elimination) may be an effective starting point, although the SFED has shown high success rates.

What is Eosinophilic Esophagitis (EoE)?

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus, the tube that connects the throat to the stomach. It is characterized by a buildup of white blood cells called eosinophils in the esophageal lining, which can cause symptoms such as difficulty swallowing (dysphagia), chest pain, and food getting stuck in the esophagus (food impaction). This condition is often triggered by an allergic reaction to certain foods, though environmental allergens can also play a role. Identifying these specific food triggers is crucial for effective management of the disease.

The Six Foods Targeted in the Elimination Diet

The 6 food elimination diet (SFED) is a therapeutic strategy that removes the most common food allergens from a patient's diet. Research shows this approach can be very effective, with studies reporting a high success rate in reducing symptoms and healing the esophagus. The six food groups eliminated are:

• Dairy: This includes all products derived from cow's milk, such as milk, cheese, yogurt, and butter. Dairy is one of the most common triggers for EoE.
• Wheat: Found in bread, pasta, cereals, and many processed foods, wheat contains gluten, which can trigger an inflammatory response. Gluten-free alternatives must be used.
• Soy: A common allergen, soy and its derivatives are found in a wide variety of foods, from soy milk and tofu to processed meats and protein bars.
• Eggs: The protein in eggs, particularly the egg white, can trigger inflammation. This includes not just whole eggs but also egg-containing products like mayonnaise and baked goods.
• Nuts (Peanuts and Tree Nuts): This category includes peanuts (a legume), and tree nuts such as almonds, cashews, and walnuts. Nut butters, flours, and oils are also eliminated.
• Fish and Shellfish: All types of fish (e.g., salmon, tuna) and shellfish (e.g., shrimp, crab, lobster) are removed from the diet. This includes sauces and flavorings derived from them.

How the 6 Food Elimination Diet is Administered

The SFED process is typically overseen by a healthcare team, including a gastroenterologist and a registered dietitian, and involves two main phases: elimination and reintroduction.

Phase 1: Elimination (6-8 Weeks)

During this phase, all six food groups are completely removed from the diet for a period of 6 to 8 weeks. Strict avoidance is essential for this phase to be effective, as even trace amounts of a trigger food can cause inflammation. Patients are encouraged to cook at home to ensure no cross-contamination occurs. At the end of this phase, an endoscopy with biopsies is performed to assess whether the inflammation has subsided.

Phase 2: Reintroduction

If the initial endoscopy shows significant improvement, the reintroduction phase begins. This process involves adding one food group back into the diet at a time, usually for a period of 2 to 6 weeks. After each reintroduction, another endoscopy is performed to check for renewed inflammation.

Reintroduction Schedule

1. Reintroduce Dairy: Add dairy products back into the diet and consume regularly. After the trial period, an endoscopy is performed.
2. Reintroduce Wheat: If dairy was not a trigger, wheat is added next. A new endoscopy is done after the trial period.
3. Continue with Remaining Foods: Soy, eggs, nuts, and fish/shellfish are reintroduced in a similar fashion, with an endoscopy following each food group.

This systematic approach allows doctors to pinpoint the exact food or foods causing the allergic reaction. Once the trigger is identified, those specific foods are permanently eliminated from the diet, while safe foods can be reintroduced.

SFED vs. Other Dietary Approaches

While the SFED is a common and effective method, other dietary approaches exist for managing EoE.

Feature	6 Food Elimination Diet (SFED)	Elemental Diet	Targeted Elimination Diet	Step-Up/Step-Down Diet
Method	Empirically removes the top 6 most common food allergens.	A formula-based diet, removing all food allergens completely.	Eliminates specific allergens based on prior allergy test results.	Starts with a smaller number of eliminated foods (e.g., 2 or 4) and adds more if needed.
Complexity	Highly restrictive and challenging to maintain. Requires careful meal planning.	Simplest in theory, but restrictive and unpalatable for many.	Less restrictive than SFED if testing is accurate, but test reliability is a concern.	Offers a less restrictive starting point, but may progress to more exclusions.
Effectiveness	High success rate, around 70% in many studies.	The most effective dietary approach, with success rates of 95-98%.	Dependent on the accuracy of allergy testing, which is often unreliable for EoE.	Effectiveness varies depending on the number of eliminated foods.
Prognosis	Effectively identifies and removes food triggers for long-term management.	Allows the esophagus to heal completely, but can be difficult to sustain long-term.	Can be effective if triggers are accurately identified.	Less restrictive but may not resolve symptoms if the initial elimination is insufficient.

Managing the Diet and Ensuring Nutritional Adequacy

Following a highly restrictive diet like the SFED requires careful planning to ensure adequate nutrition. Consulting with a registered dietitian is strongly recommended. They can help identify suitable substitutes and create a balanced meal plan. Many alternatives are available for the eliminated food groups, such as plant-based milks, gluten-free grains, and seed butters. Additionally, focusing on whole foods like fruits, vegetables, and compliant proteins can ensure a nutritionally complete diet.

The Importance of Avoiding Cross-Contamination

Cross-contamination is a significant risk, especially when dining out or eating with others. Patients on the SFED must be diligent in ensuring their food is not prepared with or near any of the six forbidden food groups. This includes avoiding buffets, salad bars, and shared cooking oils. Asking restaurants about their food handling practices is crucial for patient safety.

Conclusion

The 6 food elimination diet is a cornerstone of dietary management for eosinophilic esophagitis, offering a systematic way to identify and remove the foods that trigger inflammation. While challenging due to its restrictive nature, the diet's high success rate in resolving symptoms makes it a valuable therapeutic tool. Working closely with healthcare professionals, patients can navigate the elimination and reintroduction phases to achieve long-term remission and improve their quality of life. For further reading, an excellent resource on the management of EoE can be found on the AGA GI Patient Center website.

Potential Challenges and Considerations

Despite its effectiveness, the SFED presents significant challenges. The restrictiveness can lead to a reduced quality of life, and the need for multiple endoscopies during the reintroduction phase can be invasive. It's crucial for patients to have strong support from their healthcare team and family to adhere to the diet. The psychological burden of dietary restrictions should also be addressed.

Newer Research and Alternatives

Recent studies have explored less restrictive alternatives, such as the single-food or two-food elimination diets, which have shown comparable efficacy for some patients. This suggests a more individualized, step-up approach might be suitable for certain cases, starting with eliminating the most common triggers, like milk and wheat, before progressing to the full SFED. The decision should always be made in consultation with a medical professional.

Supporting Your Journey

Successful adherence to the 6 food elimination diet relies heavily on planning and support. Utilizing recipes that are free of the top 6 allergens, and becoming an expert at reading food labels, are essential skills. Online resources and support groups can also provide valuable tips and encouragement from others on a similar journey.

Frequently Asked Questions

What are the six foods eliminated on the diet?

The six food groups removed during the diet are dairy, wheat, soy, eggs, peanuts and tree nuts, and fish and shellfish.

How long does the elimination phase of the diet last?

The elimination phase typically lasts between six and eight weeks, during which all six food groups are completely avoided.

Is an endoscopy necessary for this diet?

Yes, endoscopies are performed before, during, and after the reintroduction phases to monitor the level of eosinophils and confirm the presence or absence of inflammation in the esophagus.

Can I do the reintroduction phase on my own?

It is not recommended to manage the reintroduction phase alone. This phase must be carefully managed by a healthcare team, as an endoscopy is the only reliable way to detect silent inflammation from a reintroduced food.

What if I accidentally eat one of the trigger foods?

Accidental exposure can cause a recurrence of inflammation. It is important to inform your healthcare provider, who may need to adjust the schedule or perform another endoscopy.

What happens after I identify my trigger foods?

Once the specific triggers are identified, they are permanently eliminated from your diet, allowing you to reintroduce the non-triggering foods and manage your EoE symptoms long-term.

Is the 6 food elimination diet suitable for children?

Yes, the 6 food elimination diet is a common treatment for children with eosinophilic esophagitis and is implemented under strict medical supervision.

What are some safe alternatives to eat on the diet?

Safe alternatives include coconut or rice milk for dairy, gluten-free grains like rice and quinoa for wheat, and seed butters for nuts.

Can I eat at restaurants during this diet?

Eating out is challenging due to the risk of cross-contamination. It's best to prepare meals at home and inform restaurants of your strict dietary needs if you must dine out.