What is the Six-Food Elimination Diet (SFED)?
The Six-Food Elimination Diet, or SFED, is a specialized therapeutic diet primarily used to diagnose and treat eosinophilic esophagitis (EoE) by identifying specific dietary triggers. EoE is a chronic inflammatory condition of the esophagus, caused by an immune reaction to food or environmental allergens, leading to difficulty swallowing and other gastrointestinal symptoms. Unlike general weight-loss plans, the SFED is a medical intervention and should always be undertaken under the supervision of a healthcare professional, such as a gastroenterologist or registered dietitian. It operates on the principle that removing the most common food allergens will allow the esophagus to heal, after which the foods are reintroduced to determine which ones trigger the inflammatory response.
The six food groups targeted for removal are milk/dairy, wheat, soy, eggs, peanuts/tree nuts, and fish/shellfish. These are considered the most likely culprits for causing immune-mediated inflammation. A positive outcome, where inflammation subsides during the elimination phase, suggests that at least one of the restricted foods is a trigger, prompting the second phase of reintroduction.
The Two Phases of the SFED Plan
Following the SFED is a two-step process, requiring strict adherence and careful monitoring to achieve accurate results.
Phase 1: The Elimination Period
This initial phase requires the complete removal of all six food groups from the diet for a period of approximately 4 to 8 weeks. The duration is designed to allow any existing inflammation in the esophagus to calm down and symptoms to subside. For this phase to be successful, it is crucial to avoid all forms of the restricted foods, including hidden ingredients in processed or prepared meals. This necessitates diligent label-reading and a focus on home-cooked meals to minimize the risk of cross-contamination.
- Milk & Dairy: All dairy products, including milk, cheese, yogurt, butter, and whey, must be avoided.
- Wheat: This includes wheat flour, bread, pasta, and any products containing gluten from wheat.
- Soy: Avoid soy milk, tofu, edamame, soy sauce, and any soy-derived ingredients.
- Eggs: Whole eggs and any food containing eggs as an ingredient must be eliminated.
- Peanuts & Tree Nuts: Peanuts, tree nuts (almonds, cashews, walnuts, etc.), and their oils or butters are off-limits.
- Fish & Shellfish: All types of finned fish and shellfish are excluded.
Phase 2: The Reintroduction Process
If symptoms improve during the elimination phase, the reintroduction process can begin. This phase involves systematically adding the eliminated food groups back into the diet one at a time, usually with a follow-up endoscopy to check for inflammation.
- Introduce one food group (e.g., dairy) and consume it for 1-2 weeks while monitoring for symptoms.
- If no reaction occurs, that food is deemed safe and can be incorporated into the diet permanently.
- If symptoms return, the food is identified as a trigger and should be eliminated from the diet long-term.
- After testing one food group, the patient waits for symptoms to clear before testing the next group.
- This process continues until all six groups have been tested, allowing for a personalized dietary plan based on the individual's specific triggers.
What Can You Eat on the SFED?
While the diet is restrictive, many nutritious foods remain available to create varied and satisfying meals.
- Gluten-Free Grains: Brown rice, quinoa, millet, buckwheat, and sorghum are all acceptable.
- Lean Proteins: Chicken, turkey, pork, and beef are allowed, especially grass-fed or organic options.
- Legumes: Beans (excluding soy), lentils, and chickpeas provide excellent protein and fiber.
- Fruits and Vegetables: All fresh, frozen, or canned fruits and vegetables that are not on the restricted list are safe to consume.
- Dairy Substitutes: Coconut milk, oat milk, hemp milk, and flax milk can be used as alternatives to dairy.
- Fats and Oils: Avocado oil, coconut oil, and olive oil are healthy fat sources.
- Seeds: Chia, flax, pumpkin, and sunflower seeds are good additions, along with their respective butters (e.g., sunflower seed butter).
Foods to Avoid During the SFED Elimination Phase
This list includes the six primary food groups to be completely avoided during the initial phase:
- Dairy and Milk Products: Includes all types of milk (cow, goat), cheese, yogurt, ice cream, butter, and whey protein.
- Wheat and Gluten-Containing Grains: All wheat flour, bread, pasta, spelt, kamut, and bulgur must be avoided.
- Soy: Tofu, tempeh, edamame, soy milk, miso, and soy sauce are restricted.
- Eggs: Avoid whole eggs, egg whites, egg yolks, and products containing them.
- Peanuts and Tree Nuts: Peanuts, almonds, walnuts, cashews, pistachios, and all corresponding oils and butters are excluded.
- Fish and Shellfish: All finned fish and shellfish, including shrimp, crab, lobster, and mussels, should not be consumed.
SFED vs. Other Elimination Diets
| Feature | Six-Food Elimination Diet (SFED) | Four-Food Elimination Diet (4FED) | Targeted Elimination Diet (TED) |
|---|---|---|---|
| Eliminated Foods | Dairy, wheat, soy, eggs, peanuts/tree nuts, fish/shellfish | Dairy, wheat, soy, eggs | Foods determined by allergy testing |
| Primary Use | EoE treatment to identify triggers empirically | EoE treatment for potentially higher adherence | EoE treatment based on specific, identified triggers |
| Effectiveness (EoE Remission) | High, with pooled rates around 70% | Slightly lower than SFED, but comparable | Variable, depending on test accuracy |
| Restrictiveness | Very high, eliminating a wide range of foods | Moderately high, targeting common triggers | Varies, depending on test results; can be less restrictive if fewer triggers found |
| Adherence | Can be difficult due to high restrictiveness | Generally easier to adhere to than SFED | Potentially easiest to adhere to, but requires accurate testing |
Conclusion
The Six-Food Elimination Diet (SFED) is a powerful diagnostic and therapeutic tool for individuals with eosinophilic esophagitis, offering a structured, evidence-based pathway to identifying food triggers and reducing esophageal inflammation. While it is a highly restrictive diet that can present significant challenges, its proven success rate makes it a valuable option for those seeking relief from chronic symptoms. Success hinges on strict adherence, careful meal planning, and working closely with a healthcare team throughout both the elimination and reintroduction phases. For a more comprehensive understanding of the SFED and EoE, consider visiting the AGA GI Patient Center. Ultimately, the SFED is a temporary measure that provides a clearer understanding of your body’s unique sensitivities, paving the way for a long-term, personalized diet that supports overall health and well-being.
