Understanding the Eosinophilic Esophagitis (EoE) Diet
Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease of the esophagus, the tube connecting the mouth to the stomach. A key treatment for EoE is identifying and eliminating specific food triggers that cause inflammation. Unlike immediate IgE-mediated food allergies, EoE reactions are often delayed and do not show up on standard allergy tests, making an elimination diet supervised by a doctor and dietitian the most reliable method for identifying triggers. The most common approach involves the Six-Food Elimination Diet (6FED), which removes the six most common food allergens from the diet for a period of time.
The Six Most Common Trigger Foods
Dietary therapy for EoE focuses on eliminating the six food groups most likely to trigger inflammation. While milk and wheat are the most frequent offenders, soy, eggs, nuts, and seafood can also cause a reaction.
1. Milk and Dairy Products: This is the most common food trigger for EoE in both children and adults. All milk products derived from cows, goats, and sheep should be avoided, including:
- Cow's milk (all forms: A2, full fat, skim, low fat)
- Cheese, including cheese powder and cottage cheese
- Butter and butter fat
- Yogurt, kefir, and cultured milk
- Casein and whey, which are milk proteins often used as ingredients in processed foods
2. Wheat: The second most common trigger, wheat elimination requires strict avoidance of all products containing wheat, including hidden sources.
- Breads, pasta, crackers, and other baked goods
- Couscous, semolina, and durum
- Wheat flours, bran, and germ
- Foods containing malt, some caramel colorings, and hydrolyzed vegetable protein (HVP)
3. Eggs: Eggs are a common trigger and are found in many products beyond just their whole form.
- Whole eggs (scrambled, boiled, fried)
- Ingredients derived from eggs, like albumin, ovomucoid, and lysozyme
- Baked goods, sauces, and pasta that contain egg
4. Soy and Legumes: Soy is a frequent trigger for EoE, and a thorough elimination includes many soy-based products.
- Edamame, miso, and tofu
- Soy milk, soy cheese, and soy yogurt
- Soy sauce and tempeh
- Textured Vegetable Protein (TVP)
5. Peanuts and Tree Nuts: While less common triggers, nuts can still cause an EoE reaction.
- All tree nuts (cashews, almonds, walnuts, pistachios) and peanuts
- Nut butters and natural nut extracts
- Cold-pressed nut oils
6. Fish and Shellfish: This includes finned fish, crustaceans, and mollusks.
- All varieties of finned fish
- Crustaceans (shrimp, crab, lobster)
- Mollusks (scallops, clams, oysters)
The Elimination and Reintroduction Process
An EoE elimination diet is not meant to be a permanent solution but a tool for identifying your specific triggers.
- Initial Elimination: Under medical guidance, you will remove one or more of the trigger food groups for 4 to 12 weeks. This allows inflammation to subside.
- Endoscopy: A follow-up endoscopy with a biopsy is performed to check for improvements in the esophagus.
- Food Challenge: If inflammation has resolved, you will reintroduce one food group at a time over several weeks.
- Repeat Endoscopy: After each food challenge, another endoscopy is performed to see if that food caused a relapse of inflammation.
Comparison of Common EoE Elimination Diets
| Diet Type | Foods Eliminated | Typical Remission Rate | Pros | Cons |
|---|---|---|---|---|
| One-Food (1FED) | Dairy | 44–70% | Less restrictive, easier adherence, fewer endoscopies | May not identify all triggers if dairy isn't the sole culprit |
| Two-Food (2FED) | Dairy, Wheat | 43% | Targets the two most common triggers, more effective than 1FED for some | Still misses other potential triggers; may require more elimination steps |
| Four-Food (4FED) | Dairy, Wheat, Egg, Soy | 52–70% | Targets four of the most likely triggers, higher success rate initially | More restrictive, greater nutritional risk, requires more endoscopies |
| Six-Food (6FED) | Dairy, Wheat, Egg, Soy, Nuts, Fish/Shellfish | Up to 74% in children, 70% in adults | Highest initial success rate for eliminating inflammation | Very restrictive, challenging to adhere to, higher risk of nutritional deficiencies |
Life After Elimination: What to Do Next
Once your specific food triggers are identified, managing your EoE involves continued avoidance of those foods. Working with a registered dietitian is crucial to ensure you maintain a nutritionally complete diet and find suitable substitutions for the foods you must eliminate permanently. This might involve replacing dairy products with fortified alternatives or using wheat-free grains. Continuous monitoring with your healthcare team is essential to ensure long-term remission and good nutritional status.
Conclusion
For those with EoE, understanding what foods to avoid is the first step toward effective management. The most common offenders are milk, wheat, soy, and eggs, but a personalized elimination and reintroduction process is necessary to identify individual triggers. This structured dietary approach, guided by medical professionals, allows for targeted, long-term dietary changes while minimizing unnecessary food restrictions and ensuring proper nutrition. Consistent label-reading and careful eating habits are vital for success in controlling EoE symptoms and maintaining esophageal health.
