Eosinophilic Esophagitis (EoE) and the Six Food Elimination Diet


Posted 5.15.15 | Christine Graham-Garo

Eosinophilic Esophagitis (EoE) is a condition that is continuing to get more and more attention in the medical community, which means the public is learning more about it too. Unfortunately though, the management options for EoE are not black and white. EoE may be managed either with medication, which has known long-term side effects, or nutrition therapy, which has been shown extremely effective, but may be difficult to follow for some families.

Medications used to manage EoE are all steroids, and at this point no medication has FDA approval for EoE. Steroids have been shown to be effective in managing EoE for more than half of patients. However, steroids may not be the best long-term solution for everyone. Many families who choose to use steroids may mix the medication recommended by their physician with Neocate Nutra. This is because Neocate Nutra thickens, so can help to coat the esophagus with the steroid. This use of Neocate Nutra was even studied by a medical team and you can read about their published research here.

As EoE is a chronic condition, management with nutrition therapy is often discussed and preferred by many families over steroids. Here are nutritional therapy options for EoE:

  • Elemental Diet – A diet consisting almost exclusively of amino acid-based (or elemental) products
  • Elimination Diets – The removal of allergens from the diet.
    1. Tailored Elimination – Elimination of specific allergens based on allergy testing
    2. Six Food Elimination – Elimination of 6 top allergens based on the most common allergens seen in EoE patients

The Six Food Elimination Diet

The 6 Food Elimination diet has been gaining in popularity because it bypasses extensive food allergen testing needed for the Tailored Elimination diet. As you may know, allergy tests (skin prick tests and blood tests) are not perfect. There are often false positives which can make the treatment plan more complicated and time consuming, and some allergens may be missed ('false negatives'). So what the 6 Food Elimination diet proposes is that, off-the-bat, patients eliminate the top 6 allergens seen in EoE patients. The top allergens are milk, soy, eggs, wheat, peanuts/tree nuts, and seafood. One study1 confirms there is a 74% success rate when using this type of nutrition therapy for EoE. (As a point of reference, an Elemental Diet shows a 95-98% success rate based on multiple studies.) Researcers are also looking into 4 Food Elimination diets.

Advantages and Disadvantages to consider

The advantages of using the 6 Food Elimination diet approach are that you can still eat solid foods. It also eliminates the need for extensive skin and blood tests to check for food allergies. Important disadvantages to this diet therapy are that it may unnecessarily remove foods from the diet, and many process foods are out, meaning the diet often involves a lot of preparation and careful reading of ingredient lists. Eliminating so many foods can increase the risk of patients being deficient in one or more nutrients. Also, as many of you may know, it is hard just to remove milk and soy from your diet. Try eliminating SIX different allergens that are found in many foods while maintaining your nutritional status! For this reason, many medical teams that manage patients with EoE encourage their patients to supplement the 6 Food Elimination diet with a nutritionally dense, hypoallergenic elemental product, such as Neocate®. This can help ensure the patient is getting all the protein, vitamins and minerals they need per day while ensuring that no allergic reactions will occur with the elemental products. It is vital that EoE patients are monitored by a dietitian. The dietitian will help calculate how much of the elemental product the patient will need per day and also make sure the nutritional status of the patient is maintained.

Again, since research has found a 74% success rate for the 6 Food Elimination diet, it's possible that symptoms will persist after starting the 6 Food Elimination diet. If this happens, your medical team can help you decide the next best step, which may include a careful review of your diet, possibly eliminating more foods, or starting with a more “allergen safe” diet therapy such as an Elemental diet. After a few weeks on the Elemental diet, most teams will work with you to start reintroducing solid foods to figure out which ones may be contributing to your symptoms.

I hope this helped to shed some light on this nutritional therapy options for EoE. Every person will have their own treatment plan that works for them. Is anyone following an elimination diet now? How is it going for you? Have any tips you can share that may help others manage an elimination diet?

-Christine

1 Kagawalla AF et al, Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic esophagitis. Clin Gastroenterol Hepatol 2006:4(9):363-8

Read Comments (30)

  • 2012-08-08 | Roger Dudley

    Is it those foods only or foods that are based on those foods?i.e cheese?.Thanks

  • 2012-08-08 | Rob McCandlish, RDN

    Hi Roger,

    Great question. Generally, it’s those foods and any products that have ingredients derived from those foods. That’s because they can still contain the proteins, which are the root trigger for EoE symptoms. Here’s the link to our YouTube video that explains elimination diets in a nutshell:

    http://www.youtube.com/watch?v=zxkHkWR7U0c

    As always, we’d suggest checking with your healthcare team, in case they have specific recommendations.
    ~Rob

  • 2013-04-04 | Melanie Hohman

    My son has severe food allergies, and while I was nursing him, we gave him Neocate which was extremely helpful.  It provided him where I couldn’t.  We then opened an allergy-friendly bakery called Sensitive Sweets in California.  We make custom cakes for children who are allergic to several foods, like my Bradley.

  • 2013-04-16 | Christine Graham-Garo

    Dear Melanie,
    So happy to hear that Neocate helped your son. It is soo amazing you started the bakery. What a great idea!  Do you have a website for the business? We would love to know more about it.
    Christine
    PS. I really like the name of the bakery!

  • 2013-04-22 | Cecily R Bornemann

    My dr. just told me today that I need to be on this elimination diet.  It seems hard and I looked at everything I have in my house and I have a lot of things with Soy and Wheat in them.  Is there a website that you know of that offers meal planning for this diet?  I do have a dietician but I haven’t heard back from her about her helping me do this.

  • 2013-04-29 | kenny h.

    Maybe you guys can help me out or point me ibm the right direction. My niece has some health issues. The Dr. Say she has eoe. They have put her on med and she quite taking them cause of the suicidal effects of the med. They recently put her on this diet but its not working. She constantly in pain good days she’s on a 6 pain level. Does this sound like this condition? They really haven’t giving her a 100% diagnosis of EOE.

  • 2013-05-06 | Christine Graham-Garo

    Dear Cecily,
    Try starting here: https://web.emmes.com/study/cofar/EducationProgram.htm

    This webstie offers nice tools to help you get started. As far as a meal plan, I do not know where to find an apporpriate one. Usually working with your dietitian, he/she can construct one for you that fits your family’s preferences and lifestyle. Hopefully working with your RD will help with this. Best wishes!
    Christine

  • 2013-05-06 | Christine Graham-Garo

    Dear Kenny,
    I would refer to your doctor for this. Have they scoped/taken a biopsy of her esophagus. That is usually the very first step to get a proper diagnosis of EoE. I would also recommend you see a Registered Dieitian for the elimination diet as they can help with the diet plan to ensure the allergens are being removed properly while maintaining nutrition status. The condiditon usually has symptoms of chest pain, vomiting, ect. See this website to learn more: http://www.aaaai.org/conditions-and-treatments/related-conditions/eosinophilic-esophagitis.aspx 
    I wish your family the best. I hope they get a solid diagnosis soon.
    Kindest wishes,
    Christine

  • 2013-09-12 | Sarah N

    Hi, My daughter was recently diagnosed with EoE after an endoscopy.  Although skin allergy tests showed no known allergies, her GI suggested eliminating dairy anyway.  It helped a lot!!!  She cannot have any dairy or milk proteins whatsoever or she has stomach pain within a few days.  She is much better but not completely well.  It looks like we are going to have to do this elimination diet or at the very least, trial and error with another category like soy or eggs or wheat.  Those seem more likely based on the stats.  We are willing to try anything so she gets well for good.  This has been a difficult process but at least now we know she has EoE and that’s a start.

  • 2013-09-24 | Christine Graham-Garo

    Dear Sarah,
    Glad to hear taking out the milk has helped her feel better. Hopefully the elimination diet will go smoothly. It makes it much easier for everyone when there is an actual diagnosis. Then you can plan better and have a set goal to work towards!  Best wishes for your whole family. As always, if there are any questions about the diet or any of our products, feel free to call us at 1-800-Neocate. We are happy to help!
    Christine

  • 2015-08-21 | Jen

    Is it possible they just have an allergy to ONE of the six things or do you really have to eliminate all of them?

  • 2015-08-24 | Nutrition Specialist

    Hi Jen,
      Great question! Yes, it’s very possible that they only have an allergy to one of the foods, although many people with EoE are allergic to more than one food. It can be hard to know which foods they’ll react to though, which is why the Six Food Elimination Diet (SFED) is used. Researchers have studied a less-restrictive Four Food Elimination Diet with similar success, and some teams have tried a Milk-only Elimination Diet, which worked for a high percentage of the participants. Every team that manages patients with EoE has a slightly different approach, and they usually offer different options, then help families decide which approach will work best for them.
      Rob

  • 2015-08-26 | Tim

    My daughter was diagnosed with EoE and is away at college. We are looking for a list of food products that fit in the 6 food elimination diet.

  • 2015-08-27 | Nutrition Specialist

    Tim,
      Thanks for your question. Unfortunately we haven’t developed any lists like that. The best thing would be to work with a Registered Dietitian Nutritionist (RD/RDN) who works with EoE patients. Most teams that work with EoE patients have an RD on staff or can refer you to one in the community. RDs are the teams’ experts at counseling how to manage the 6 Food Elimination Diet. It can be a challenge for college students, but it can definitely be done!
      Best of luck,
    Rob

  • 2015-09-09 | Jacqueline

    Hello, my 15yr old son has had EOE for over a year now. He had food allergy testing and we found out he was allergic to most foods including chicken, beef, pork, turkey and finned fish. Not to mention all the other foods that came up as positive. He followed the elimination diet, slowly introduced foods and seemed to be better. Now it has flared up again and is the worse it’s ever been. Needless to say, he is back on the diet again. What I am noticing is stress seems to make it worse. Has anyone notice this with themselves or their children?

  • 2015-09-10 | Nutrition Specialist

    Hi Jacqueline,
      We’re sorry to hear your son is having such a tough time, after all he’s been through. We’ve heard that some patients have worsening symptoms during certain seasons (especially spring) or a change in environment, due to environmental allergens. It seems reasonable that emotional stress could contribute to EoE symptoms, but we’re not sure! Can any other families weigh in? Have any of you seen worsening of EoE symptoms with increasing stress?

  • 2015-09-22 | Ashley

    This is for Tim, who commented above looking for a list of foods for his college student. This looks like it could be helpful. Not sure how valid it is, but it is a start to some ideas?

    http://bit.ly/MNGastroElimDiet

  • 2015-09-24 | Nutrition Specialist

    Great find, Ashley. Thanks for sharing!
      Rob

  • 2016-11-03 | Jacqueline

    Hi.. My 3 year old daughter had an upper endoscopy & we found out that she have EoE. I am really trying to find out what all foods should we avoid & what can she have. She love milk. she would rather have milk than food. At this point I’ll try anything.. Any suggestions?

  • 2016-11-04 | Nutrition Specialist

    Hi Jacqueline,
      Thanks for your message - I’m glad your daughter has a diagnosis, but EoE leads to lots of questions! At this point in your journey, the best thing to do is talk to her healthcare team. They can explain approaches that involve different diets, drugs, or even a combination. They should help you decide which approach will work best for your family right now. Since you mention diet, ask them to refer you to a registered dietitian for help, and together they can advise what foods to avoid at first (there is no single “correct” list of foods to avoid) and maybe even suggest a Neocate formula that she could have in place of milk, which is the #1 food that children with EoE are allergic to.
      Feel free to give us a call at 800.NEOCATE - we’re not experts, but we can help you come up with a list of questions to ask the healthcare team. And good luck to you!
      Rob

  • 2016-11-21 | Sue

    Hello

    My 17 year old daughter was just diagnosed with EoE four months ago.  They have her taking splenda and pulmacort slurry everyday.  We would like to have her stop taking the splenda and we have read that neocate nutra is recommended by some doctors as a splenda replacement.  She has been skin tested and has had blood tests done and has allergies to trees, grasses, molds, dust mites and dogs but not to foods except peanuts and sesame which we already knew about. Her allergies seem to be almost all environmental.

  • 2016-11-21 | Nutrition Specialist

    Hi Sue,
      We’re glad to hear that you’re interested in Neocate Nutra! Give us a call (800.636.2283) or send us an email (.(JavaScript must be enabled to view this email address)) if you have any questions for us or if there is anything we can do to help. Hopefully your daughter has been able to have good control of her symptoms, considering all of the environmental allergens she has!
      Kind regards,
    Rob

  • 2016-12-21 | Martina

    Hello. My daughter (14 y.o.) was dg with EoE in July’16. She was recovering from anorexia, and what they thought was recovering process (lots of regurgitation even after she wanted to eat) and painful gas before belching turned out to be EoE (her 1st scope). She did steroid treatment which brought number of eosinophils down significantly (she had over 100 per highfield), but her esophagus was still swollen and inflamed (2nd scope after 10 wks on steroid). Environmental skin test didn’t show anything leading, and I had a blood work done through naturopath which showed high delayed reaction to more foods but mostly dairy and rice(!). Being off these food for month before 2nd scope didn’t improve the inflammation. She was put on Neocate Splash, and having that as a sole nutrition for past 5 weeks, she had her 3rd scope today, and her esophagus looked healthy. Waiting for biopsy now. I wasn’t given much direction with the 6 food elimination diet, gastro doc just told me what to avoid - those 6 allergens. My question is, do I avoid rice too since it showed high on her blood test? I do not want to waste any possible food she can eat. That blood test showed normal reaction to eggs and peanuts, and borderline soy and wheat. Also, she still has painful gas before belching (might be due to slow gastric motility which was dg in July also). I don’t even know what to watch for when I start introducing the allergens bc most of her symptoms happen inside her. Any thoughts please? Thank you!

  • 2016-12-22 | Nutrition Specialist

    Martina,
      Sorry to hear you and your daughter have been through so much! We can’t give direct answers to your question, since we can’t give medical advice. However, here are a few pointers to guide discussions with your healthcare team:
      1) Consider seeing a board certified allergist. There are many types of allergy tests out there, some much less reliable and reputable than others. I worry that the test the naturopath ordered may not be as reliable, which could mean that she would be avoiding rice for no reason. Allergy testing for EoE is especially challenging, so you should really involve an expert.
      2) EoE, especially when an elimination diet is involved, is a key condition for which it’s best to involve a registered dietitian nutritionist. There are some who specialize in working with EoE patients. The dietitian can help explain what foods and ingredients to avoid and help ensure that nutritional gaps in the diet are filled.
      3) The teams that do best at managing patients with EoE include a gastroenterologist, allergist, and dietitian. They often work together to ensure the child receives the best care, and they often have their own protocols for introducing foods from the 6 food elimination diet back into the diet in a structured way. This helps to ensure you know exactly which foods are truly allergenic.
      If you’d like us to see if we can put you in touch with a dietitian and/or allergist in your area, we’d be happy to help. Hang in there and best of luck to you!
      Rob

  • 2017-03-07 | Rasha Farouz

    Yes please, we live in the Washington DC AREA, in Sterling, VA. PLS recommend best dietitian expert in EOE. GREATLY appreciated. My nephew was recently diagnose. 14 yol. Thanks!

  • 2017-03-09 | Robert McCandlish

    Hi Rasha,
      So sorry to hear that your family has the new diagnosis, but I’m glad you’re looking for resources in your community! The American Partnership For Eosinophilic Disorders will be your best bet for finding a healthcare team - http://apfed.org/find-support-treatment/ (Try clicking on Pediatric Gastroenterology in the list on the left). You might also try Children’s National Medical Center.
      To find a dietitian, you can check with your nephew’s pediatric gastroenterologist. Alternatively, you can search the database to see if one is available in the area with the specialty of food allergy/intolerance - http://www.eatright.org/find-an-expert
      Best of luck to you!
    Rob

  • 2017-03-26 | Trish

    My husband has been diagnosed with EOE and we are starting the Elimination diet.  We are looking for recipes to help us as we’re not even sure exactly what to buy for dinner. We also have our meals planned out for the week as we’re both working and have a son. Any help would be greatly appreciated.

  • 2017-04-03 | Nutrition Specialist

    Hi Trish,
      So sorry to hear about your husband’s diagnosis. You can find a few recipes that incorporate Neocate products (to help supplement key nutrients on an elimination diet) on this page http://bit.ly/NeocateGuides
      You also might want to see if there are any support groups in you or look for other ways to connect with other families through APFED - http://apfed.org
      Hang in there, and best of luck to you!
    Rob

  • 2017-06-30 | Amber

    Can someone following an elemental diet for EoE still consume chicken, beef, pork, or turkey (not one of the top 8 food allergies).  Do they need to restrict these foods because they are not broken down amino acids?  When are these foods typically added back into the diet?

  • 2017-07-05 | Nutrition Specialist

    Great questions Amber!
        No, to follow the true elemental diet that has been studied for EoE, meats would not be consumed. In the elemental diet for EoE, the idea is to eliminate almost all foods to have the best chance of recovery, and to then have the best chance of identifying which foods are allergens, and any food can be an allergen. Many teams that specialize in EoE may allow certain fruits and/or fruit juices, because those are less likely to be identified as food allergens. However, that’s not to say that there haven’t been some EoE patients allergic to certain fruits and vegetables!
        When foods are added back to the diet depends on the EoE center or team you work with. They often wait around 6-8 weeks before repeating the endoscopy to ensure there has been improvement and then adding one or a limited number of foods back at a time. There is often a period of 4-8 weeks between new foods or food groups, which means it can take a while to identify all of the “safe” foods and all of the allergens.
        The Six Food Elimination Diet (SFED) for EoE eliminates the top 8 allergens (milk, soy, egg, wheat, tree nuts + peanuts, and fish + shellfish), but meats would still be allowed unless the EoE team removes them based on allergy testing. This diet has been found to be successful for about 75% of EoE patients (compared to about 95-98% success with the elemental diet for EoE). If successful, it takes less time to add foods back into the diet. Many EoE teams will supplement a patient on the SFED with an amino acid-based formula like Neocate to ensure they’re still getting adequate nutrition.
        Hope this helps!
    Rob

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