Eosinophilic esophagitis (EoE) is a chronic, allergic inflammatory disease affecting the esophagus. It's characterized by an accumulation of eosinophils, a type of white blood cell, in the esophageal lining, leading to symptoms like difficulty swallowing (dysphagia), food impaction, chest pain, and heartburn. Identifying and eliminating specific food triggers is a cornerstone of EoE management. The six-food elimination diet (SFED) is a frequently employed dietary therapy in patients with EoE.
Understanding Eosinophilic Esophagitis (EoE)
Eosinophilic esophagitis (EoE) is a chronic immune and allergic condition in which eating certain foods can trigger inflammation and damage in the esophagus. Eosinophilic gastrointestinal disorders (EGIDs) can happen when there are high levels of eosinophils in one or more parts of the digestive system. These disorders occur when a type of white blood cell involved in allergic reactions, the eosinophil, builds up in the esophagus or other part of the digestive tract.
The Role of Elimination Diets in Managing EoE
Avoiding specific food groups is a fundamental aspect of treating EoE, but it can take a little time and effort to identify which foods you need to cut. An elimination diet will help you identify the food allergens that may cause symptoms such as impaction, reflux, and chronic cough. By identifying and temporarily removing common allergens from your diet, you can pinpoint the culprits and start feeling better.
In an elimination diet, you avoid certain foods for a few weeks, then reintroduce them one at a time and watch for symptoms. After a period of avoiding these foods, you’ll add them back in one at a time, paying close attention to your symptoms. This process should help determine which foods are safe and which should remain off-limits. There are several types of elimination diets designed for managing EoE, typically categorized by the number of foods eliminated, such as six-food, four-food, and two-food elimination diets.
The Six-Food Elimination Diet (SFED): An Overview
The Six Food Elimination Diet (SFED) is a therapeutic dietary approach designed to help individuals with eosinophilic esophagitis (EoE) identify food triggers by removing the six most common allergenic foods from the diet. Research has shown that it helps about 70 percent of people with EoE by removing six common food triggers: dairy (cow’s milk), eggs, wheat, soy, fish, and nuts. This can significantly reduce the signs and symptoms of EoE.
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Instead of taking away foods based on allergy testing results, you will stop eating common allergy-causing foods (milk, eggs, wheat, soy, peanuts/tree nuts, fish/shellfish). The six-food elimination diet involves removing all of those food groups from the diet for six to eight weeks, then reintroducing one or two foods at a time to see how your body responds.
- Effectiveness: This type of diet has shown success in about 70% of patients. Results obtained from two studies conducted in Chicago and Spain show that about 70 percent of patients showed symptomatic and histologic response after eliminating specific allergens from their diets.
Note: While the 6FED diet can be effective in identifying food triggers and improving the quality of life for people with EGIDS, it can also be incredibly challenging. The limited food options can make it difficult to meet nutritional needs, leading to potential deficiencies if not carefully managed.
Foods Eliminated in the SFED
The six food groups eliminated in this diet are known to contribute to a majority of food-triggered immune responses in individuals with EoE. By fully removing them for a period of 4 to 6 weeks, you allow inflammation in the esophagus to calm and create a clearer baseline from which to begin reintroducing foods.
The six foods to avoid in an elimination diet:
- Dairy Products
- Wheat
- Eggs
- Soy
- Nuts and Peanuts
- Fish and Shellfish
Alternatives to the SFED
If removing six foods at the same time feels too challenging at first, or if you are already on a restrictive dietary plan such as a vegan or ketogenic diet, you may want to consider doing an EoE elimination diet that removes fewer foods.
Read also: Satisfy Your Cravings with Whole Foods
Four-Food Elimination Diet
The four-food elimination diet removes four common trigger foods: dairy, soy, wheat, and eggs. This diet usually lasts for eight to 12 weeks and follows the same protocols as the six-food elimination diet, including endoscopy checkups.
Two-Food Elimination Diet
The two-food elimination diet excludes only dairy and wheat for eight to 12 weeks. It is often the starting point for adults and children who are trying an elimination diet for the first time.
Recent research shows the 1FED can be as effective as the 6FED diet as first-line therapy for Eosinophilic Oesophagitis (EoE). Eliminating animal milk alone is much easier and more sustainable than eliminating multiple foods.
Implementing the Six-Food Elimination Diet: A Step-by-Step Guide
A 100% elimination of these foods is essential for 4 to 6 weeks to allow the esophagus to heal and symptoms to improve. Plan a time to start the diet when you know you can be successful.
Phase 1: Elimination (4 to 6 weeks)
Remove all six major allergenic foods completely. 100% avoidance is essential to allow symptoms to subside and inflammation to calm.
Read also: Healthy Eating on the Run
Phase 2: Reintroduction (6 weeks)
Once symptoms improve, reintroduce one food group per week while carefully tracking symptoms. Reintroduce each food for 3 days, then remove it for 4 days to watch for delayed reactions. If your EoE is not active following dietary elimination, then serial food reintroduction can start to identify what foods are causing your allergy.
Step 1: Consultation and Planning
Work with your healthcare team to identify which foods might be causing symptoms. Now it is time to meet with a GI-expert dietitian. You’ll work with your allergist, gastroenterology specialist, or dietitian to remove certain foods from your diet.
Step 2: Strict Elimination
Remove all 6 foods from your diet for 4-6 weeks without any exceptions. Start with 4 to 6 weeks of strict elimination. This diet may feel like a big shift, but it can uncover the root of long-standing symptoms and bring profound relief when followed carefully.
Step 3: Food Reintroduction
If your symptoms have improved, start the challenge phase with ONE of the foods you stopped eating at a time. Your doctor may perform endoscopies, in which they take a biopsy, or obtain tissue samples from your esophagus, to determine whether the reintroduced foods are causing damage.
Introduce ONE new food per week. Add 1 serving of the food in the morning.
Step 4: Monitoring and Documentation
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.
Foods to Avoid and What to Eat During SFED
You can still enjoy a variety of nourishing, flavorful foods while avoiding the top allergens.
Dairy Products
Dairy is one of the most common triggers for EoE symptoms. In fact, when it comes to the development of EoE, it’s the primary cause of symptom recurrence in children. The proteins in cow’s milk, casein and whey, can provoke an allergic reaction in sensitive people, leading to inflammation of the esophagus. Some people may also have reactions to other types of animal milk.
Dairy products include:
- Milk
- Cheese
- Yogurt
- Butter
- Ice cream
Casein and whey are also common in products such as protein powders and cheese-flavored snacks. One good way to avoid dairy products is to switch to plant-based milk such as almond, oat, or coconut milk and vegan versions of yogurt or ice cream. However, this also depends on which elimination diet you or your child is trying.
Wheat
Wheat and wheat flours contain gluten, a protein that can trigger EoE symptoms for some people. It’s a common cause of EoE, which is why it’s one of the first food groups to be removed in an EoE elimination diet.
You can find wheat flours in bread, pasta, cereals, couscous, and many processed foods. It includes products made from common wheat, as well as spelt, durum, and semolina. Many packaged foods also include wheat flours, so it’s important to read food labels. If gluten is the issue, it’s also important to avoid foods that say they contain trace amounts of gluten. You should always choose oats that are specifically labeled as gluten-free, since oats often have cross-contamination with wheat. Thankfully, there are many wheat-free goods available these days, like gluten-free bread.
Eggs
Eggs are a well-known allergen that can trigger EoE symptoms. The proteins in eggs, particularly in the whites, can cause inflammation in the esophagus.
This means avoiding chicken eggs, as well as products that contain eggs, including mayonnaise, many baked goods, and some sauces. If you’re doing your own baking, you may be able to swap banana or applesauce for eggs. You can also use flaxseed as an egg substitute.
- Eggs (yolks, whites, dried, powdered, and solids)
- Egg substitites
Soy
Soy is another common allergen that is often included in EoE elimination diets. Soy proteins can be inflammatory, leading to esophageal discomfort and other symptoms.
Soybeans and soy products include:
- Tofu
- Soy milk
- Edamame
- Soy sauce
Many processed foods, such as protein bars, soups, cookies, breakfast cereals, and processed meats, contain soy or soy derivatives, so it’s vital to check the label. Soy lecithin and processed soy oil may not cause a reaction in most people with EoE, but check with your allergist before trying it.
- *Highly refined soybean oils found in vegetable oil do not usually contain soy protein and are allowed on SFED. Cold pressed and expeller pressed oils can be sources of soy protein and should be avoided.
Nuts and Peanuts
Nuts are a common allergen and can be a significant trigger for EoE symptoms. Both tree nuts and peanuts contain proteins that can cause severe allergic reactions in sensitive individuals. Dairy and wheat are the food groups most often recommended to avoid during an elimination diet.
Tree nuts include almonds, walnuts, and cashews. Peanuts are technically legumes, but they are often grouped with nuts. Avoid peanut butter and other nut butters. Seeds are a good substitute for nuts. You could also try seed-based butters, such as sunflower seed butter.
Fish and Shellfish
Seafood and shellfish are potent allergens. They are frequently associated with EoE triggers, which is why they are included in the six-food elimination diet. The proteins in these foods can lead to an allergic response, causing esophageal inflammation.
This category encompasses fish like salmon, tuna, and cod, as well as shellfish such as:
- Shrimp
- Crab
- Lobster
- Oysters
To swap seafood out of recipes, try replacing it with lean poultry or mushrooms.
- All fish
- All crustacea (shrimp, crab, lobster)
- All mollusks (oysters, clams, mussels, scallops)
Remember that finned fish and shellfish are not related.
Label Reading
There are three ways dairy may be indicated on a label.
- As a separate statement after the ingredient list.
Monitoring Progress and Long-Term Management
Current guidelines recommend performing endoscopic biopsy to obtain four to six tissue samples from the esophageal mucosa to confirm diagnosis. Your doctor may perform endoscopies, in which they take a biopsy, or obtain tissue samples from your esophagus, to determine whether the reintroduced foods are causing damage. Treatment of EoE is directed at reducing inflammation and reversing esophageal fibrosis that develops as a result of long-term inflammatory activity.
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