What is an EoE Diet?
An EoE diet is a therapeutic strategy used to manage Eosinophilic Esophagitis, a chronic immune-mediated disease characterized by a buildup of white blood cells called eosinophils in the lining of the esophagus. This inflammation can lead to swelling, scarring, and difficulty swallowing (dysphagia). Unlike immediate IgE-mediated food allergies, the reactions in EoE are delayed, making it challenging to identify the triggers without a structured process. The goal of an EoE diet plan is to systematically remove common food triggers to allow the esophagus to heal and then reintroduce them one by one under medical supervision to pinpoint the specific culprits. This process is different from typical allergy testing (like skin prick tests), which is not reliable for identifying EoE triggers. Because of the complexity and the need to maintain nutritional balance, an EoE diet is best undertaken with the guidance of a gastroenterologist and a registered dietitian.
Types of Empiric Elimination Diets
Empiric elimination diets are based on removing the most common food allergens, as identified by research, rather than on allergy test results. There are several levels of restriction, from the most comprehensive to the least. The choice of diet often depends on a patient's symptoms, age, and ability to adhere to a restrictive plan, often following a 'step-up' approach.
The Six-Food Elimination Diet (6FED)
This is the most well-known and comprehensive empiric elimination diet. It requires the removal of the six most common food allergens associated with EoE: milk, wheat, soy, egg, peanuts/tree nuts, and fish/shellfish. This approach has shown high effectiveness rates, with studies indicating significant reductions in eosinophil counts and symptom improvement in many patients. Due to its highly restrictive nature, it can be challenging to follow and may impact a patient's social life.
The Four-Food Elimination Diet (4FED)
As a less restrictive alternative, the 4FED removes milk, wheat, egg, and soy. Research has shown this can also be effective, particularly in children. This diet may be a more manageable starting point for some patients before considering the broader 6FED.
The Two-Food Elimination Diet (2FED)
Focusing on the top two most common triggers, milk and wheat, the 2FED offers a less restrictive starting point. Recent research has demonstrated that this can be a reasonable first-line therapy for many adults. The risk of removing unnecessary foods is lower, but it may be less effective for those with other food triggers.
The One-Food Elimination Diet (1FED)
Given that milk is the most common trigger for EoE, some patients start with just a milk elimination diet. This is the least restrictive option and serves as an initial step. If a patient does not respond to this, they may proceed to a more restrictive diet.
The Elemental Diet
This is the most restrictive approach, involving the exclusive consumption of an amino acid-based formula with no whole foods. It has the highest success rate but is generally reserved for severe or refractory cases due to its poor palatability, cost, and significant impact on quality of life.
The EoE Elimination and Reintroduction Process
The process of an EoE diet is structured in two main phases, requiring careful tracking and medical monitoring through endoscopies.
Phase 1: Elimination
- Remove the designated food groups (e.g., all six foods) from the diet completely for a period of 4 to 6 weeks.
- It is crucial to avoid even small amounts of these foods, which requires meticulous label reading and careful dining out.
- Patients keep a food and symptom journal to track progress.
- At the end of this phase, a repeat endoscopy with biopsy is performed to assess if inflammation has subsided.
Phase 2: Reintroduction
- If remission is achieved, foods are systematically reintroduced one at a time.
- Each food group is reintroduced for a set period (e.g., 4 to 6 weeks) while closely monitoring symptoms.
- An endoscopy is performed after each food reintroduction to check for the return of inflammation.
- This process helps identify which specific foods trigger EoE in that individual. Foods causing a reaction are then avoided long-term.
A Comparison of EoE Diet Plans
| Diet Type | Foods Eliminated Initially | Initial Effectiveness | Number of Endoscopies | Restrictiveness | Adherence Difficulty |
|---|---|---|---|---|---|
| One-Food (1FED) | Milk | Moderate (~50%) | 2 (Diagnosis, Follow-up) | Low | Low |
| Two-Food (2FED) | Milk, Wheat | Moderate (~40%) | 4 (Diagnosis, After elim, After each reintro) | Low-Medium | Low-Medium |
| Four-Food (4FED) | Milk, Wheat, Egg, Soy | Moderate (~50%) | 6 (Diagnosis, After elim, After each reintro) | Medium | Medium |
| Six-Food (6FED) | Milk, Wheat, Soy, Egg, Nuts, Seafood | High (~60-70%) | 8+ (Diagnosis, After elim, After each reintro) | High | High |
| Elemental Diet | All whole foods | Very High (~90%) | Variable | Extreme | Extreme |
What to Eat on an EoE Diet
During the elimination phase of a 6FED, a patient might eat from the following safe food groups:
- Grains: Rice, quinoa, millet, buckwheat, corn.
- Proteins: Beef, pork, poultry (chicken, turkey, lamb), legumes (beans, lentils) (excluding soy), pea protein.
- Fruits and Vegetables: All fresh, frozen, or canned fruits and vegetables.
- Fats and Oils: Olive oil, coconut oil, avocado oil.
- Dairy Alternatives: Coconut milk, oat milk, hemp milk.
- Snacks and Treats: Seed-based bars, fresh fruit, rice cakes.
Navigating Challenges and Ensuring Success
Adhering to a restrictive diet like the 6FED can be challenging due to its complexity and the prevalence of trigger foods in processed items. Working closely with an experienced dietitian is critical to ensure nutritional adequacy and provide guidance on reading food labels and preventing cross-contamination. The step-up approach (starting with 1 or 2 foods and adding more eliminations if needed) is designed to minimize unnecessary dietary restrictions and the number of endoscopies required. It is also important to remember that EoE can sometimes have environmental triggers, which a diet will not resolve, or that a combination of dietary and medical therapy may be needed.
Conclusion
The EoE diet plan is a highly effective, evidence-based approach for managing Eosinophilic Esophagitis by identifying and eliminating food triggers. From the less restrictive step-up diets (1FED, 2FED) to the more comprehensive 6FED, and the highly effective elemental diet, a tailored strategy can be developed with a healthcare team. While demanding, this process offers a path to long-term remission by controlling the underlying inflammatory cause of EoE and reducing the need for medications, ultimately improving a patient's quality of life.
