Should You Try an Elimination Diet for Eosinophilic Esophagitis?

Eosinophilic esophagitis — a chronic allergic condition that causes inflammation in your esophagus — may be triggered by certain foods.

Should you try an eosinophilic esophagitis elimination diet?

Gastroenterologist  Claire Beveridge, MD, explains how cutting out certain foods can help determine your problematic ones.

Can an elimination diet help eosinophilic esophagitis?

Yes. While environmental allergens (like pollen) can trigger eosinophilic esophagitis (EoE), certain foods may also trigger your EoE to be active. Symptoms related to EoE can be chest pain, heartburn and difficulty swallowing. An elimination diet may help you figure out your specific food triggers.

“About 70% to 80% of people will have their eosinophilic esophagitis controlled by doing a six-food elimination diet,” reports Dr. Beveridge. “Then, if your eosinophilic esophagitis is controlled, we can start reintroducing food groups to identify your food triggers. Most people have one to three food triggers, and the two most common are dairy and wheat.”

Which foods should you eliminate?

If you’re following an elimination diet to determine eosinophilic esophagitis food triggers, Dr. Beveridge says you typically need to eliminate the following six food groups:

• Dairy, including milk, butter, cheese, ice cream and yogurt
• Wheat, like flour, farro, spelt and wheat bran
• Soy, like edamame, miso, soy, tempeh and tofu
• Eggs, including egg noodles, mayonnaise and certain baked goods like bagels
• Tree nuts and peanuts, like walnuts, almonds and pistachios
• Seafood and shellfish, including shrimp, crab, salmon and oysters

How does an eosinophilic esophagitis elimination diet work?

An elimination diet should be followed under the guidance of a healthcare provider.

“The traditional approach is to do the full six-food elimination diet, where you take away all of those food triggers for at least six weeks,” explains Dr. Beveridge.

This is followed by an upper endoscopy. If your EoE is well managed, then you can add in food groups (one to two food groups at a time) every four to six weeks. With each food introduction, your healthcare provider will request an upper endoscopy with a biopsy to see if the eosinophils (a collection of white blood cells that cause inflammation) in your esophagus are controlled.

“If we see that there are elevated eosinophils and inflammation in the esophagus, then that food group is a trigger,” says Dr. Beveridge.

You keep going through this process of reintroducing food groups, as well as undergoing testing, until you’ve evaluated all six food groups.

In some cases, you can introduce multiple food groups at the same time, but Dr. Beveridge says there’s a caveat to this approach. For example, if you reintroduce seafood/shellfish and tree nuts/peanuts together and your test results show inflammation, then you have to separately reintroduce each food group to see which one is causing issues.

In addition, she notes that there are other approaches to the elimination diet. It’s also reasonable to start with a dairy and wheat elimination diet (a two-food elimination diet), as those two food groups are the most common triggers. The goal is to minimize the number of endoscopies and how restrictive the diet may be for you.

Factors to consider

Is an elimination diet right for you? Consider the following:

• An elimination diet may increase your risk of nutritional deficiencies. One potential downside of following an elimination diet is that you may not get enough of the essential vitamins and nutrients you need. Working with a registered dietitian can help you figure out how to get the vitamins and minerals you need while avoiding certain foods.
• It can be hard to follow. Dr. Beveridge says she finds that people who are in college or travel a lot find it difficult to avoid food groups. It can also be challenging for parents of young kids. “Often your diet is the leftovers of what your kids have,” she relates.
• It involves a lot of follow-up appointments and sedated upper endoscopies. Not only will you need to spend time thinking about the foods you eat, but you’ll also need to work closely with your healthcare team to schedule tests and follow-up appointments.
• It can help to keep a food journal. This isn’t necessary, but it can often help keep track of what you’re eating, how you’re feeling and any symptoms you notice.
• A full six-food elimination diet isn’t a long-term diet. A six-food elimination diet is a short-term way to identify any food triggers. If you don’t have any, then you won’t need to avoid any food groups moving forward. If you do find that certain food groups affect your eosinophilic esophagitis, then you should work to strictly avoid that particular food group in your diet. Avoiding your one to three food triggers may be a long-term solution.
• What you pick today doesn’t have to be your forever treatment. Dr. Beveridge says that if an elimination diet becomes challenging, there are equally effective medication alternatives. Also, some people may not be ready to try a diet elimination, but this is an option in the future if you become interested.

Key takeaways

Following an elimination diet for your eosinophilic esophagitis can help identify your food triggers. But it’s not a guarantee.

“An elimination diet may not get your EoE under control because you may have an environmental trigger as well,” clarifies Dr. Beveridge.

It’s vital that you know going in that this diet can be difficult to follow. And once you know what foods to avoid, eliminating a certain food group as you go through life can be a tall task.

“Identifying your food triggers isn’t just about minimizing certain foods, but completely eliminating them,” says Dr. Beveridge. “That’s what can make it really tricky and hard to follow — even a small amount of exposure to your food trigger can lead to inflammation.”