Eosinophilic esophagitis (EoE) is a chronic inflammatory condition affecting the esophagus. It’s triggered by an accumulation of immune cells called eosinophils, which respond to certain foods by causing inflammation. Managing EoE often involves dietary modifications, particularly elimination diets, to identify and avoid trigger foods.
Understanding Eosinophilic Esophagitis (EoE)
EoE is an allergic condition characterized by inflammation in the esophagus, the tube connecting the mouth to the stomach. This inflammation results from a buildup of eosinophils, a type of white blood cell, in the esophageal lining. These eosinophils react to certain foods, causing a delayed immune response. Unlike immediate food allergies, EoE reactions can take several days to manifest, making it challenging to pinpoint specific triggers. More than one food may be responsible for the reaction.
Symptoms of EoE
Symptoms of a failed food challenge may range from mild reflux or pains to severe cramps, vomiting, or difficulty swallowing, even food impaction. Any of these changes after reintroducing a food should be written down and considered a reaction.
The Role of Diet in Managing EoE
Adjusting the diet is a common treatment for people with EoE. A healthcare professional may recommend certain diets, including the elemental diet and empirical food elimination diet (FED).
Common Trigger Foods
While triggers can vary, some foods are more commonly associated with EoE reactions:
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- Milk and other dairy products
- Wheat products containing gluten
- Eggs
- Soy and legumes (beans, lentils, green peas, and peanuts)
- Nuts
- Seafood (fish and shellfish)
According to a 2018 study, the most common triggers are cow’s milk, gluten, and egg. Soy, legumes, nuts, and seafood are triggers for some people, although this is rarer.
Elimination Diets: A Key Strategy for Managing EoE
Elimination diets are a cornerstone of EoE management. These diets involve removing suspected trigger foods from the diet and then systematically reintroducing them to identify the specific foods that cause inflammation.
Types of Elimination Diets
Several types of elimination diets are used in EoE management, each with varying degrees of restriction:
- Elemental Diet (Amino Acid-Based Formula - AAF): This diet involves cutting out all foods and instead consuming a formula containing amino acids, which are the building blocks of protein. Elemental Diet (AAF) using AAF to replace all dietary antigens, has been a highly effective treatment for EoE. It can induce quick remission, with a 2020 study showing nearly 94% of patients achieving histologic remission. Research suggests that it is highly effective to induce remission for both adults and children with EoE. AAF is often used to replace all dietary antigens. Transitioning to AAF can be tough due to its distinct taste, but individuals usually adapt. However, it can be challenging for older children or those with feeding disorders due to its restrictive nature.
- Empiric Elimination Diets (FED): FED This diet excludes some known trigger foods. Empiric Elimination Diet involves removing foods based on clinical experience. Based on the recent 2025 ACG guidelines for EoE, the efficiency ranges of various elimination diets are as follows: dairy-only elimination shows an efficacy of 35-45%, dairy and wheat elimination ranges from 40-45%, 4-FED has an efficacy of 40-50%, and a 6-food elimination diet (6-FED) ranges from 40-70%. The first FED, or 6-FED, involved excluding all six most common trigger foods from the previous section above. The 6-FED removes milk, egg, wheat, soy, nuts, and seafood. However, some doctors may recommend starting out with a less restrictive version, such as 4-FED or 2-FED. This only restricts four or two common trigger foods.
- Dairy-Only Elimination: This diet removes only dairy products and shows an efficacy of 35-45%.
- Dairy and Wheat Elimination: This diet removes both dairy and wheat and ranges from 40-45%.
- 4-Food Elimination Diet (4-FED): This diet typically removes milk, egg, wheat, and soy, with an efficacy of 40-50%.
- 6-Food Elimination Diet (6-FED): This diet removes the six most common trigger foods: milk, egg, wheat, soy, nuts, and seafood. It ranges from 40-70%.
Approaches to Identifying Trigger Foods
Two main approaches are used to identify trigger foods:
- Top-Down Method: This approach involves initially cutting out all six trigger foods (6-FED) and then reintroducing each one at a time. After each reintroduction, the doctor recommends an endoscopy to check the effects of the food on a person’s esophagus.
- Step-Up Approach: This approach involves cutting out one or two of the more common triggers, including milk and wheat. If this does not resolve symptoms completely, the doctor may try a 4-FED or 6-FED approach.
A 2023 randomized trial followed 129 people on either a 6-FED or a 1-FED program that excluded only animal milk. The study concluded that cutting out animal milk led to similar remission rates as a 6-FED program. Therefore, removing milk alone from the diet could be an effective initial management strategy for EoE.
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The Importance of a Food Diary
Keeping a food diary can be a valuable tool in identifying trigger foods. A person may record what they eat each day and whether they experience any EoE symptoms. A healthcare professional may also find a person’s food diary useful for identifying trigger foods.
Nutritional Considerations During Elimination Diets
Elimination diets can be restrictive and may lead to nutritional deficiencies if not carefully managed. It is essential to work with a registered dietitian to ensure adequate nutrient intake.
Potential Nutritional Deficiencies
Removing major food groups can lead to deficiencies in essential nutrients. For example, eliminating milk, a major allergen in EoE, can impact protein, calcium, iron, and vitamin D intake. Milk is particularly crucial as it is a major allergen in EoE and provides a complete protein with all essential amino acids, along with vital micronutrients like calcium, iron, and vitamin D. Plant-based milks (PBMs) are a common replacement, but they often lack the protein, fat, and vitamins found in cow’s milk. Soy and pea milks are exceptions but may not be suitable for children with other allergies. PBMs may also contain added sugars, so choosing unsweetened varieties is essential. A 2020 position paper states that when PBMs are used as the primary milk source for older children, their diet should also include alternative sources of protein, calcium, iron, and vitamins B-12 and D; thus, consulting with a dietitian is recommended.
A 2019 study explored the major nutrients in the top allergens and protein was shown to be the top nutrient in milk, egg, soy, nuts and seafood. While other protein sources can be used, they may not always be well accepted, and feeding aversions or inflammation from flare-ups can make it difficult to consume adequate protein.
Working with a Dietitian
Before beginning an elimination diet, it is essential for a dietitian to review the current diet. This helps assess potential risks of nutritional inadequacy, especially as the number of restricted foods increases. The dietitian will evaluate nutrition status, overall feeding behaviors and risks of deficiencies in essential nutrients like protein, calcium, and iron. After analyzing Cole’s diet on a 4-FED, I became aware that his intake of calories, fat, and essential vitamins like B-vitamins, calcium, and iron was insufficient. This was especially concerning as these nutrients are crucial for growth and development. Using supplemental AAF became an important strategy to fill these gaps.
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Addressing Nutritional Gaps
When PBMs are used as the primary milk source for older children, their diet should also include alternative sources of protein, calcium, iron, and vitamins B-12 and D.
Other Treatments for EoE
While dietary changes are crucial, other treatments may be necessary to manage EoE symptoms:
- Medications: Some medications can help reduce certain symptoms of EoE. However, people with EoE may need several treatments or balance dietary approaches with different medications. This may vary between each person depending on their age and other factors.
- Steroids: Steroids may also help reduce inflammation in the esophagus. People may take them through an inhaler or drink them as a liquid. However, a doctor may prescribe steroids in pill form for those whose symptoms are not well controlled with other medications or those experiencing significant weight loss.
The Emotional and Practical Challenges of Managing EoE
Managing EoE and elimination diets is challenging, both emotionally and nutritionally. The emotional toll of restricting food choices, can contribute to disordered eating patterns. Parents of children with EoE must balance restrictive diets with the nutritional needs of growing kids.
Tips for Success
- Careful Planning: From my experience with Cole, careful planning and regular monitoring are essential.
- Professional Support: The journey is not easy, but with support from healthcare professionals and dietitians, families can successfully manage EoE.
- Consultation with Healthcare Professionals: A person needs to speak with a healthcare professional before making any significant dietary changes relating to suspected allergic reactions. A doctor will first need to diagnose EoE and rule out other conditions that may be causing any symptoms. They will then recommend appropriate treatment if necessary.
- Regular Monitoring: Additionally, people who experience regular or severe symptoms of EoE should consult with a physician. This includes individuals who require over-the-counter heartburn medication more than twice each week.
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