Food Elimination Diet for Eosinophilic Esophagitis (EoE)

What is 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
  

Why are foods I eat important with 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, we suggest an elimination diet. This type of diet removes likely food triggers to improve the symptoms. Then, triggers are added back in a special order to see which ones cause 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.

What is the Six Food Elimination Diet?
This is one of the diets used to find EoE food triggers. This diet is best for finding triggers but takes longer than the other options.

Six Food Elimination Diet

1. Take the top 6 most common food allergens out of your diet for 6-8 weeks (milk products, eggs, wheat, soy, peanut/tree nuts, and fish/shellfish).

2. We then perform an EGD test with biopsy to retest the esophagus for narrowing or inflammation. Your symptoms may or may not improve.

3. You can then bring foods back into the diet, one or two at a time, as a one month “challenge.” You will have an EGD after each challenge. See the complete process on page 4.
   

The “Step Up” Approach
If the Six Food Elimination Diet is not the best fit for you, try the “Step Up” approach. It is shorter and still works well.

1. Take out the 2 most common EoE food triggers (milk and wheat) for 6-8 weeks.

2. Complete the EGD. If your results are still high, then “step up” to a 4-food elimination (milk, wheat, eggs, and soy).

3. Repeat the EGD. If still your results are still too high, “step up” to the full six food elimination diet.

4. If at any step of the diet, your EGD shows that your EoE responds well, then you will only add back in the foods you took out. For instance, if you are better after taking out only milk and wheat, you will only challenge milk and wheat.
   

What can I eat? (Below is list for the Six Food Elimination Diet)

• Chicken

• Beef

• Game meats

• Turkey

• Lamb

• Pork

• Beans, lentils

• Chickpeas

• Rice (brown, wild, white)

• Potato (russet, red, sweet)

• Quinoa

• Millet

• Buckwheat

• Some gluten-free labeled foods

• Gluten-free oats

• Fruits and vegetables

• Seeds

• Oils (sunflower, canola, olive)

• Most coffee and tea

• Rice or coconut milk

• Vinegar

• Foods with allowed ingredients

• Most people allergic to soy can safely eat soy lecithin and soybean oil
  

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 eggs”). 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.

We suggest a hypoallergenic daily multivitamin for this diet. Make sure it does not contain the top six food allergens. We also suggest a calcium supplement if you are not eating calcium fortified foods or drinks.

Aim for the best diet variety that you can. This will help you get all the vitamins and minerals your body needs to function.

Avoid cross contamination. This happens when a food comes into contact with another food. Reduce the 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 contamination is high at restaurants. It may be best to avoid restaurants while on this diet.

Resources

www.foodallergy.org

www.apfed.org

Allergen Free cookbooks

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 casein

• Tagatose

• Whey
  

Eggs

Foods to avoid:

• Eggs

• Eggnog

• Mayo

• Meringue

• Surimi

• Egg substitutes

• Beware of baked goods, puddings
  

Ingredients to avoid:

• Albumin

• Lysozyme

• Ovalbumin

• Lecithin

• Globulin

• Ovovitellin
  

Wheat

Wheat foods to avoid:

• Bread

• Couscous

• Crackers

• Most flours

• Pasta

• Pizza crusts
  

Instead purchase gluten/wheat free items made from potato, rice, tapioca

Wheat ingredients to avoid:

• Bulgar

• Durum

• Einkorn

• Emmer

• Farina

• Kamut

• Matzoh

• Semolina

• Spelt

• Triticale
  

Soy

Soy foods to avoid:

• Edamame

• Miso

• Natto

• Shoyu

• Soybean

• Soy sauce

• Tamari

• Tempeh

• Tofu

• Quorn
  

Soy ingredients to avoid:

• Soy

• Soy flour

• Soy fiber

• Soy protein

• Textured vegetable protein

• May be in vegetable gums, starches and broths
  

Nuts and Tree Nuts

Nut foods to avoid:

• All nuts (seeds are okay)

• Lychee
  

Nut ingredients to avoid:

• Nut meal

• Nut meat

• Nut milk

• Nut extracts

• Nut paste

• Peanut oil
  

Seafood and Shellfish

Seafood and shellfish to avoid:

• All fish

• Krill

• Barnacle

• Crab, crayfish

• Lobster

• Shrimp, prawns
  

• Fish ingredients to avoid:

• Check imitation fish

• Fish stock, sauce

• Seafood flavoring

• Surimi

• Bouillabaisse
  

The Six Food Elimination Diet Process

1. EoE diagnosed

2. Failed trial of PPI (Proton Pump Inhibitor)

3. Trial Steroid Therapy or Consider Diet

4. Elimination of 6 most common food allergens

5. EGD after 6-8 weeks

6. Introduce 1-2 least likely offending food groups (usually seafood and nuts)

7. EGD after 4 weeks

8. Introduce 1-2 more offending food groups (usually soy and eggs)

9. EGD after 4 weeks

10. Introduce wheat products

11. EGD after 4 weeks

12. Introduce milk products

13. EGD after 4 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. You can also visit our website at www.uwhealth.org/nutrition.

Nutrition clinics for UW Hospital and Clinics (UWHC) and American Family Children’s Hospital (AFCH) can be reached at: (608) 890-5500.

Nutrition clinics for UW Medical Foundation (UWMF) can be reached at: (608) 287-2770.