For people with eosinophilic esophagitis (EoE), a chronic immunologic disease, eating and diet aren’t always a piece of cake. In response to an allergen — usually one or more food groups — 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 an injectable biologic drug. But there’s another way to improve symptoms: Identify food triggers through an EoE elimination diet and then avoid those foods.

This approach can be long 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, an associate professor of gastroenterology at the University of Virginia in Charlottesville. “It has to be a trial-and-error process.”

Despite these drawbacks, for people with EoE, an elimination diet can be worth the trouble. Researchers are finding that a step-up approach is best: The two-food-group EoE elimination diet, which excludes milk and gluten-containing cereals, resulted in remission in about 43 percent of people with EoE in one study. If that approach isn’t successful, the four-food-group EoE elimination diet (which also eliminates soy and egg) and six-food-group EoE elimination diet (which also eliminates peanuts, tree nuts, and fish and shellfish; aka SFGED) can be used. Overall remission rates in that same study reached up to 79 percent with the SFGED.

How an EoE Elimination Diet Works

If you were to partner with your medical team to embark on an EoE elimination diet, the process would look something like this.

Step 1 Cut out the specified food groups (either two, four, or six food groups — or even one only). Keep a food and symptom journal to monitor how it goes.
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. Continue to keep a food and symptom journal to track how you’re doing.
Step 4 After two to four weeks, have another biopsy or an upper endoscopy (an esophagogastroduodenoscopy) to look for signs of inflammation. If there is no evidence of inflammation, the food likely is not a trigger, which means you can keep it in your regular diet.

Going forward, you’ll repeat steps 3 and 4 until you’ve tested all the food groups and, hopefully, identified a trigger.

There’s no question it can be tedious. “With the SFGED, there are more than 60 different food combinations you could have as triggers, so we have to do it very systematically,” Dr. Sauer explains.

That said, the SFGED is becoming less the norm. Some doctors even start the trigger hunt by first eliminating just dairy. Research shows that the elimination of cow’s milk protein can lead to EoE remission in more than 50 percent of pediatric patients, making it a practical first-line dietary intervention.

Even so, “Many people with EoE have more than one dietary trigger,” says Sameer Berry, MD, a gastroenterologist at NYU Langone Health in New York City. “Don’t assume all other foods are safe once one trigger has been discovered.”

Not to mention, “You truly have to be all-in during the diet,” says 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.”

So it’s important to work with your doctor to come up with the right elimination diet approach for you.

How to Avoid Your EoE Diet Triggers

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 important to avoid accidental cross-contamination, which is when your allergens may be accidentally and unknowingly introduced into other foods. Some ways to avoid this include:

Avoid buffets, salad bars, and hot bars, where serving utensils may be mixed.
Avoid fried foods at restaurants, because the oil may also be used to fry other foods containing your allergens.
Avoid bulk condiments or containers at restaurants where allergens may mix.
Let your family, friends, and any restaurant you visit know if you have a food allergy so they can provide food you can eat and take extra care to handle your food safely.
Bring your own snacks and supplies to social events in case there aren’t any safe foods you can eat.

It’s also vital to work closely with your healthcare team to find ways to avoid your triggers effectively without creating nutritional deficiencies or feeling deprived. Calcium and vitamin D deficiencies, for example, are common among people with EoE who follow elimination diets.

A registered dietitian-nutritionist (RD or RDN) can help you with identifying and avoiding foods that may contain potential triggers, meal planning, grocery shopping, food substitutions, navigating restaurant menus, and avoiding nutritional deficiencies. Your doctor and other providers can also be a source of emotional support when things get overwhelming, says Berry.

Don’t Try the EoE Elimination Diet Without Help

It isn’t productive to attempt an EoE elimination diet on your own, without the necessary repeat endoscopies and biopsies to confirm whether the food is a trigger or not. There is rarely an instant correlation between eating a trigger food and the onset 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 get stuck or slow down when they eat it,” Sauer says.

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 of someone with EoE who has the patience to see it through and the willingness to avoid food triggers going forward.

What’s more, simply following the first couple of steps typically spurs fast results and lasting remission. Often, says Sauer, “It’s just a matter of weeks, and people start to feel a lot better.”

The Takeaway

An eosinophilic esophagitis (EoE) elimination diet involves removing and reintroducing specific food groups to identify potential triggers, and undergoing endoscopies and biopsies to confirm or rule out diet triggers.
Research shows an EoE elimination diet can help you reach remission.
Work closely with a registered dietitian-nutritionist (RDN) to manage your dietary restrictions while avoiding potential nutritional deficiencies.
It’s best not to attempt an elimination diet alone; rather, try to rely on an RDN or your healthcare team to accurately identify triggers and foods that may contain potential triggers, and avoid the risk of missed esophageal inflammation, which can develop subtly over time.

Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy. We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.

Resources

Eosinophilic Esophagitis. MedlinePlus. May 16, 2024.
Molina-Infante J et al. Step-Up Empiric Elimination Diet for Pediatric and Adult Eosinophilic Esophagitis: The 2-4-6 Study. Journal of Allergy and Clinical Immunology. April 2018.
Haller E et al. Six-Food Elimination Diet (SFED). American Gastroenterological Association. March 2021.
Wechsler JB et al. A Single-Food Milk Elimination Diet Is Effective for Treatment of Eosinophilic Esophagitis in Children. Clinical Gastroenterology and Hepatology. August 2022.
Visaggi P et al. Food elimination diets in eosinophilic esophagitis: Practical tips in current management and future directions. Best Practice & Research Clinical Gastroenterology. February-March 2023.

Ira Daniel Breite, MD

Medical Reviewer

Castle Connolly Top Doctor

Ira Daniel Breite, MD, is a board-certified internist and gastroenterologist. He is an associate professor at the Icahn School of Medicine at Mount Sinai, where he also sees patients and helps run an ambulatory surgery center.

Dr. Breite divides his time between technical procedures, reading about new topics, and helping patients with some of their most intimate problems. He finds the deepest fulfillment in the long-term relationships he develops and is thrilled when a patient with irritable bowel syndrome or inflammatory bowel disease improves on the regimen he worked with them to create.

Breite went to Albert Einstein College of Medicine for medical school, followed by a residency at NYU and Bellevue Hospital and a gastroenterology fellowship at Memorial Sloan Kettering Cancer Center. Working in city hospitals helped him become resourceful and taught him how to interact with people from different backgrounds.

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Johanna Neeson

Author

Johanna Neeson is an associate editor at Everyday Health with an extensive background in health and wellness journalism. In previous editorial roles at Reader's Digest and national healthcare societies, her work has spanned pediatrics, dermatology, gastroenterology, redox biology, and general health content. Her bylined and ghostwritten articles have appeared in MedPage Today, Parents Magazine, Romper, PopSugar, Mr. Dad, Fatherly, Family Circle, Health eCareers, and BabyCenter, among others.

A Maine native, Johanna now lives in New York City and is overwhelmingly passionate about sci-fi and '90s British theater.