What to Know About Elimination Diets for Eosinophilic Esophagitis

An elimination diet can be challenging, time-consuming, and expensive. In the end, though, it may reveal exactly what’s triggering your symptoms.

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eoe elimination diet
To figure out what foods may be triggering EoE, it’s best to take it one step at a time.Getty Images; Everyday Health

For people with eosinophilic esophagitis (EoE), a chronic immunologic disease, the simple act of eating isn’t always a piece of cake. In response to an allergen — usually one or more foods — the lining of the esophagus can become so inflamed and constricted that food can’t move smoothly through it. Symptoms include discomfort, dysphagia (trouble swallowing), acid reflux, and even impaction (when food becomes stuck).

Medications for EoE include proton pump inhibitors, topical steroids taken orally, and a biologic. But there’s another way to ward off those symptoms: identifying triggers and then avoiding them with an elimination diet.

This approach can be time-consuming and challenging — it involves multiple steps, frequent endoscopies, and a good deal of time. “We do not have a test we can give to somebody in an easy manner to figure out what food groups they’re allergic to,” says Bryan Sauer, MD, associate professor of gastroenterology and hepatology at the University of Virginia in Charlottesville. “It has to be a trial-and-error process.”

Despite these drawbacks, research shows that, for people with EoE, an elimination diet can be worth the trouble. A meta-analysis published in May 2021 in Nutrients found 71.3 percent of adults who tried a six-food elimination diet (SFED) were able to home in on their triggers and manage their symptoms by avoiding the allergens.

How an Elimination Diet Works

The concept is simple. If you were to embark on an SFED, for example, the process would likely look something like this:

  • Step 1: Cut out the six specific food groups most often associated with food allergies — milk, eggs, wheat, soy/legumes, fish/shellfish, and peanuts/tree nuts.
  • Step 2: After six to eight weeks, undergo an endoscopy and a biopsy of the lining of the esophagus to get a baseline measurement of inflammation and other signs of EoE.
  • Step 3: Slowly reintroduce one food group back into the diet.
  • Step 4: After two to four weeks, have another biopsy or an upper endoscopy (an esophagogastroduodenoscopy, or EGD), to look for signs of inflammation. If there are none, the food likely is not a trigger and you can keep it in your regular diet.

Going forward, you’ll repeat steps 3 through 4 until you’ve tested all six food groups. There’s no question it can be tedious. “With the SFED, there are over 60 different combinations of food you could have as triggers, so we have to do it very systematically,” explains Dr. Sauer.

Note that the SFED is becoming less the norm. More and more doctors are having patients with EoE do a four-food diet and some even start the trigger hunt by eliminating only dairy first. Even so, you’ll still want to reintroduce the foods in stages, since “many people with EoE have more than one dietary trigger,” adds Sameer Berry, MD, chief medical officer of Oshi Health, a virtual specialty care clinic for digestive health. “Don’t assume all other foods are safe once one trigger has been discovered.”

“You truly have to be all in during the diet,” adds Sauer. “You have to be as close to 100 percent compliant as you can — packing your own lunches, not eating out much or at all, and making other sacrifices.”

Trigger(s) Identified! Now What?

Once your triggers are identified, you should try to avoid them as much as you can. “It’s best to think of this reaction as an allergy, rather than an intolerance,” says Dr. Berry.

But breaking the diet “won’t necessarily cause rip-roaring inflammation and close off your esophagus,” says Sauer. “We understand there are times folks are going to have a holiday from their diet. Once we figure out the triggers, it’s about a balance of maintaining adherence and your quality of life. You should not feel ashamed if you ‘cheat.’”

It’s also vital to work closely with your healthcare team to find ways to effectively avoid your triggers without creating nutritional deficiencies or feeling deprived. A nutritionist or dietitian, for example, can help you with meal-planning, grocery shopping, food substitutions, and navigating restaurant menus. Your doctor and other providers also can provide emotional support when things get overwhelming, says Berry.

Making Elimination Diets More Palatable

There are no shortcuts when it comes to an elimination diet, although experts have tried less grueling variations of the SFED. Again, one of these involves eliminating only four food groups — dairy, wheat, eggs, and soy/legumes. In fact, a study published in January 2022 in Frontiers in Pediatrics reported this was effective for 64 percent of children and 54 percent of adults.

There is also a promising alternative to endoscopies and biopsies — using a cytosponge to collect cells from the lining of esophagus. This approach involves swallowing a sponge contained in a capsule attached to a string that remains outside of the mouth?????. As the sponge is pulled back up out of the esophagus, it collects tissue that can be examined under the microscope for the presence of eosinophils and inflammation.

“It’s significantly less expensive because you don’t have to miss a day of work or need a driver to take you home,” says Sauer. “It’s not the most comfortable 10 minutes of your life, but it’s well tolerated overall and a great option for many.”

Note that it isn’t productive to attempt an elimination diet on your own, without the benefit of regular endoscopies and biopsies. There is rarely an instant correlation between eating a trigger food and the appearance of symptoms. It can take a few days or longer for inflammation to occur and even then, you may not be aware of it.

“A lot of people don’t have symptoms for months even though they may have significant active inflammation — it has to narrow the esophagus enough to have food stuck or slowing down when they eat it,” notes Sauer.

On the whole, an elimination diet is not an easy journey — but it can make an enormous difference in the overall health and quality of life for someone with EoE who has the patience to see it through and be willing to avoid food triggers.

What’s more, simply going through the first couple of steps typically spurs fast results and lasting remission. “We’ll often start people on a four- or six-food elimination diet and by six weeks, when we do the endoscopy, there’s no inflammation,” says Sauer. “It’s just a matter of weeks, and people start to feel a lot better.”