Eosinophilic Esophagitis (EoE)
Eosinophilic esophagitis or EoE is a chronic inflammatory disorder of the esophagus where there are too many special white blood cells called eosinophils. EoE is triggered by allergens in foods and likely also environmental allergens that are breathed in or swallowed. One option for long term treatment of EoE includes changing your diet.
Symptoms
Symptoms in adults include:
Trouble swallowing
Food impaction
Reflux
Symptoms in children include:
Trouble swallowing
Nausea and vomiting
Pain in abdomen
Diet Treatment for EOE
EoE is a different kind of allergic reaction that cannot be diagnosed with a blood or skin test. If you want to find out which food may be causing your EoE, an elimination diet may be suggested. This type of diet removes likely food triggers to improve symptoms. Then, possible triggers are added back, in a special order to see which one/s worsen your EoE. A dietitian can help counsel you on diet treatment for EoE. They can help make sure your diet is complete and offer many tips to make the diet process easier.
Two-Food Elimination Diet
A two-food elimination diet is now the most common diet used to find your EoE triggers. This replaces the previously used, six food elimination diet and is much less restrictive.
Two-Food Elimination Diet Steps
Remove the top two most common food allergens out of your diet for 8- 10 weeks. All milk products and wheat (and/or gluten).
An EGD test will then be performed (with a biopsy) to retest the esophagus for narrowing and/or
inflammation. The eosinophils from your biopsy are counted under a microscope. Your symptoms may or
may not improve.If you are found to be “in remission”, you can then bring foods back into the diet, one at a time, as a “challenge.” You will have an EGD after each challenge (within 4-6 weeks). See the complete process on the last page.
Recent research shows a 1 food elimination (milk products) may be the only elimination needed.
Additional Eliminations
If the Two-Food Elimination Diet does not identify your trigger or allergy, additional eliminations may be suggested.
Additional allergens may include eggs, soy, nuts/tree nuts, and fish/shellfish. You, your
doctor, and dietitian will work together to decide which foods to remove and the timeline.Keep in mind additional eliminations will require additional EGDs.
Typically, 8-10 weeks is required for each elimination before an EGD is performed. After each challenge, 4-6 weeks will be required before an EGD can be performed.
Two-Food Elimination Diet List
Chicken
Turkey
Fish/Shellfish
Pork
Beef
Lamb
Eggs
Tofu/Tempeh
Beans, lentils
Rice (brown, wild, white)
Potato (russet, red, sweet)
Quinoa
Millet
Buckwheat
Some gluten-free labeled foods (those without milk)
Gluten-free oats
Fruits and vegetables (all)
Nuts (all)
Seeds
Oils (sunflower, canola, olive, avocado)
Coffee and tea
Sparkling water
Almond, coconut, flax, or soy milk
Nutrition Tips
Always read food labels. Foods must say whether they contain the top food allergens. This is found in a “Contains Statement” (i.e. “Contains wheat and milk”). Some food labels have a “May Contain” statement. In this case, you may call the manufacturer to find out more. When in doubt, avoid the product.
Avoid cross-contact. This happens when a food comes into contact with another food. Reduce this chance of this by washing your hands often, avoiding bulk bins, and taking special care in the kitchen (like using a separate toaster for your bread).
Risk of cross contact is high at restaurants. It may be best to avoid restaurants while on this
diet.
Some hidden places you may find these ingredients include sauces, marinades, seasoning, condiments, broth, imitation meats, soy sauce, candy, packaged fruits and nuts, alcohol, supplements. Be sure to check ALL food labels.
Aim for the best diet variety that you can. This will help you get all the vitamins and minerals
your body needs to function.
A hypoallergenic daily multivitamin may be suggested by your dietitian for this diet.
Make sure it does not contain the top two food allergens. A calcium supplement may also be
suggested if you are not consuming calcium fortified foods or drinks.
Resources
www.foodallergy.org www.apfed.org
Eosinophilic esophagitis (EoE) - AGA GI Patient Center (gastro.org)
Allergen Free cookbooks (search “multiple allergy cookbooks” on Amazon/your local library).
Common Foods and Ingredients of Food Allergens
These are the most common allergens and should be clearly labeled by law on all products.
Milk
Foods to avoid:
Butter
Cheese
Cream
Custard
Half and half
Cow’s milk
Pudding
Sour cream
Yogurt
Milk ingredients to avoid:
Casein
Diacetyl
Lactalbumin
Lactose
Lactulose
Recaldent
Rennet casei
Tagatose
Whey
Wheat
Wheat foods to avoid:
Bread
Couscous
Crackers
Many flours
Pasta
Pizza crusts
Instead purchase gluten/wheat free items made from potato, rice, corn, tapioca.
Wheat ingredients to avoid:
Bulgar
Durum
Einkorn
Emmer
Farina
Farro
Kamut
Matzoh
Semolina
Spelt
Triticale
Two-Food Elimination Diet Process
EoE diagnosed
Failed trial of PPI (Proton Pump Inhibitor)
Trial Steroid Therapy or Consider Diet
Elimination of 2 most common food allergens
EGD after 8-10 weeks
a. If esophagus has a good appearance AND your biopsy is clear, proceed with #6 (if not, please discuss “next steps with your doctor and dietitian).Introduce wheat/gluten products
EGD after 4-6 weeks
Introduce milk products
EGD after 4-6 weeks
Who to Call
If you are a UW Health patient and have more questions, please contact UW Health at one of the phone numbers listed below.
Nutrition clinics for UW Hospital and Clinics (UWHC) and American Family Children’s Hospital (AFCH)
(608) 890-5500
Nutrition clinics for UW Medical Foundation (UWMF)
(608) 287-2770
You can also visit our website at:
www.uwhealth.org/nutrition.