Eosinophilic Esophagitis (EOE) is a disease that causes inflammation of the esophagus. The esophagus is the muscular tube that connects your mouth to your stomach.
The most common symptom of severe cases of Eosinophilic Esophagitis (EOE) is swallowing problems, such as when food gets stuck, chest pain, heartburn, and vomiting right after eating or at night. Food may get stuck in the esophagus because it inflames due to an allergic reaction to food.
Other symptoms include difficulty breathing or swallowing, dysphonia (distorted voice), muscle weakness, abdominal pain, weight loss, and fatigue. Severe cases of Eosinophilic Esophagitis (EOE) may result in weight loss. Before embarking on the six food elimination diet to treat this condition, make sure to have a discussion with a doctor or a qualified dietitian.
What Is The 6 Food Elimination Diet?
The 6 Food elimination diet is a diet that eliminates the six most common foods that trigger eosinophils. These foods are wheat, soy, cow’s milk, eggs, fish, and peanuts/nuts. If you eliminate these foods from your diet, then you could rule out an allergy to this food as the cause of your symptoms. During the six weeks on this elimination diet, all other foods can be eaten except those mentioned above (7).
How To Do The 6 Food Elimination Diet Plan?
By following this diet plan you will eliminate all foods in the 6 food elimination diet list from your menu for a month, without exception.
First Phase: Eliminating Foods
During this initial phase, you have to restrict yourself from eating any foods that are on the elimination diet list. If you eat any of the 6 major food allergens, you have to start this phase over again (5).
During this time you’ll need to read food labels and dine out with caution to ensure you’re not accidentally eating any meals that contain the food allergens. You should also track how your symptoms are changing.
Sticking to the diet is easier if everything you eat comes from your own kitchen. To make it work out in restaurants, make sure that you know all the ingredients used in food preparation. Speak up and tell them about your food allergies if you’re concerned. Tell them that you could have EOE and are testing foods to see if they work for you.
After four weeks if there is no change in your symptoms then you’ll have to follow up with your healthcare provider as it means you may have been misdiagnosed with EOE.
Second Phase: Reintroduction Of Foods
However, if your symptoms have improved after the 4 weeks it means that you might have removed the culprit food allergen. Now, you’ll reintroduce each food one at a time while observing your symptoms.
Any changes after reintroducing a food should be noted down. Some signs to look out for include reflux, cramping, vomiting, or difficulty swallowing (1).
Add one new food per week and eat at least 1 serving per day for 3 days. No reaction means it’s considered safe. Move on to the next food, leaving the safe one out of your diet until you’ve tested all foods (1).
Third Phase: Maintenance Diet – Allowed Foods
Once you have determined which triggers are behind your symptoms, you’ll have to avoid them as much as possible. Some of the triggers may have been your favorite foods, but you’ll need to find your limit to avoid any further symptoms or discomfort (1).
What Can You Eat On The 6 Food Elimination Diet?
The six foods to eliminate are usually cooked in restaurants or your everyday home and can be found in many if not the majority of food people eat on a regular basis. Figuring out what to eat on the 6 food elimination diet can be especially frustrating.
Here is how to transform basic recipes into 6 food elimination diet recipes that will improve the quality of what you’re eating.
Wheat is in many foods. Many people are allergic to wheat for a variety of reasons but do not know it because their symptoms are so varied and often blamed on other causes or confounding factors like stress, smoking, excess alcohol, ibuprofen use, etc.
Primary EOE is an allergy to the wheat protein named gluten. In this situation, the immune system can destroy part of the esophagus due to its reaction to this food allergen as it passes by the area in the digestion of swallowed material passing through the organ. This can occur in children or adults, it is just more frequent in infants and young children who are not yet eating solid food (6).
This allergy often results from one or both parents having a wheat sensitivity themselves which is then passed on to their child either by exposure or heredity. Along with this inherited tendency, allergies to other foods (cow’s milk, soy) and environmental factors also play a role. In patients who have no family history of celiac disease the trigger often involves an infection caused by bacteria H-pylori trapped in mucous layers of the stomach (leading to bacterial overgrowth) (6).
When you eliminate wheat on the 6 food elimination diet, this cuts the immune reaction to this protein nearly in half and often improves symptoms significantly. You’ll avoid whole wheat bread, pasta, crackers, or cereals (6). You can swap wheat with these grains: quinoa, buckwheat, gluten-free oats, brown rice, and millet.
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The soybean plant creates a protein called Bowman-Birk that acts as an opioid to protect against pests in the bean pods. When you ingest soy, your immune system reacts to this toxin by creating antibodies (IgE) which activate mast cells causing the production of histamines, prostaglandins, and inflammation (3).
This inflammatory cascade causes esophageal tissue damage similar to wheat gluten reactions discussed above (2). You definitely want to avoid it at all costs while following the elimination diet, however, soy is difficult to match in taste and you may struggle to find an appropriate substitute for your 6 food elimination diet menu. Try this – don’t consume soy milk, tofu, or soybeans/edamame. Instead, eat chickpeas, coconut milk, clive juice, or plum vinegar
The protein casein in cow’s milk is also a major cause of EOE. It contains the same amino acid sequence as gluten and casein protein from soybeans. When you’re on the elimination diet, you should avoid cheese and all foods that contain dairy. This includes yogurt and ice cream. Good substitutes that you can use to avoid cow’s milk but maintain similar nutritional value are fortified rice milk, fortified hemp milk, and flax milk (5).
The protein in eggs can trigger EOE. On an elimination diet you should avoid eggs in any form (this includes both egg whites and yolks) (5). Replacing eggs in recipes is a little challenging, but here are some ideal substitutes:
Flaxseed Flour Substitute For 1 Egg
- 1 Tablespoon Flaxseed Flour
- 3 Tablespoons Water
Stir until egg-like
Agar Agar Substitute For 1 Egg
- 1 Tablespoon Agar Agar
- 3 Tablespoons Water
- Chia Seed Substitute for 1 Egg
- 1 Tablespoon Chia Seed
- 1/3 Cup Water
Stir and set for 15 minutes.
Applesauce Substitute For 1 Egg
- 1/4 Cup Applesauce (unsweetened)
- Ripe Bananas Substitute for 1 Egg
- 1/2 Cup Mashed Bananas
- Mashed Potatoes Substitute for 1 Egg
- 2 Tablespoons Mashed Potatoes (White or Sweet)
The gut reacts to certain proteins in the fish causing allergies that cause inflammatory cells to build up the lining of the esophagus and throat leading to inflammation of tissues. Removing fish from the diet for a few weeks, a month, or more can reduce symptoms (5).
While on this diet, don’t eat fish of any kind including canned tuna. You’re unlikely to find an exact fish substitute for your die, but you can eat chicken or beef as an alternative animal-based protein source. You can also increase your consumption of flaxseed and canola oil to get Omega-3 fatty acids.
These foods have an allergic reaction on the esophagus that patients with EOE suffer from. The throat and esophagus swell up after eating peanuts/nuts causing severe pain, nausea, vomiting, and other symptoms (2).
Items to avoid: Peanut butter, peanut oil, almonds, cashews, pistachios, hazelnuts/filberts, and seeds including sunflower seeds. Avoid all chocolate products that contain nuts (chocolate candy bars). Also, avoid corn nuts or anything made from corn coated in a nutshell (corn chip) (5).
It’s difficult to find substitutes for nuts especially when it comes to taste. If you are looking to replace the nutritional value, you can use seeds that include: chia, flax, and hemp.
Foods with strong flavorings such as bacon and cheese are often used for flavor when preparing food at home. These flavors often come from natural sources like cow’s milk or cream but some restaurants or commercial food vendors may use peanut or nut-based flavoring. You can ask your server if the restaurant uses natural flavorings and not peanut/nut-based flavorings. Always ask questions if you are unsure of what’s on the plate in front of you.
What Are The Pros And Cons Of The 6 Food Elimination Diet?
This diet is mostly beneficial, and when prescribed by a doctor it’s an effective method of treating symptoms. However, you might face a few challenges during and after its implementation.
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Benefits Of The 6 Food Elimination Diet
While on the 6 food elimination diet, there are some benefits that you can gain from the process.
Relief From Symptoms
Eliminating potential food allergens from your diet seems counter-intuitive but it could help when trying to find which foods are triggering esophageal inflammation. Because you’re eating so few items, your digestive system has less exposure to irritants and allergens than usual. This reduces your symptoms if they’re caused by food allergies, sensitivities, or intolerances (because now you’ve removed those specific substances) (2).
Reduced Prescription Medication Use
Many patients suffer from acid reflux (GERD), which requires medication use like proton pump inhibitors (PPIs) or H2-blockers. The 6 food elimination diet removes some of those triggers reducing your dependency on medicine.
Learn What Specific Foods Trigger Your EOE Symptoms
By being on this diet for a period of time, you can see which foods are triggering your symptoms and how much they trigger them. This will help you determine the causes of your EOE and make changes to what you eat in the future when you’re off the elimination diet.
Risks Of The 6 Food Elimination Diet
There are also some risks associated with this type of diet but overall they are relatively minor. If the elimination diet is done under the guidance of a doctor or dietitian, these risks are almost non-existent.
Not Eating Enough Protein And Fat Can Result In Weight Loss
If you’re not eating a lot of foods from the fish, egg, nuts, or dairy groups, then it’s possible to become deficient in protein or fat. The body has an instinctual need for these essential nutrients so if they cannot be consumed through food at all, your body might try to obtain them from alternative means (i.e., breaking down muscle tissues).
You Might Lose Muscle Mass
Fat loss can occur if you aren’t consuming enough dietary protein and fat but muscle loss will not occur as long as adequate protein and fat levels are met by either consuming other foods or taking supplements (4).
You May Not Adhere To Long-Term Diet Restrictions
Following all the food restrictions is difficult because soybeans, dairy products, eggs, corn (including popcorn), fish/shellfish, peanuts/nuts, and so on make up a large portion of most Americans’ diets.
Taking gluten out becomes challenging with all the hidden ingredients that contain gluten like soy sauce and condiments. You’ll have to sample all sorts of foods to figure out what works and doesn’t work for you.
Some people who are on this diet for a prolonged period of time might become more lax with what they eat after being off the diet for a few weeks/months. Giving up foods that you love isn’t easy, and you might be tempted to have a taste. This could result in some form of recurrent esophageal inflammation because you’ve reintroduced trigger foods.
The Bottom Line
The 6 food elimination diet is an effective way of identifying foods that may be the cause of your EOE symptoms. This will give you a guideline for what to avoid long-term after the diet is over and keep your esophagus healthy.
If you suffer from EOE, speak with your doctor or dietitian first to see if this type of diet is right for you. Since there are risks involved, it’s important to make sure that you’re doing it correctly under medical supervision.
This article is intended for general informational purposes only and does not address individual circumstances. It is not a substitute for professional advice or help and should not be relied on to make decisions of any kind. Any action you take upon the information presented in this article is strictly at your own risk and responsibility!
- 6-Food Elimination for Eosinophilic Esophagitis (EOE) (n.d., oregonclinic.com)
- Allergic Components of Eosinophilic Esophagitis (2019, nih.gov)
- Bowman-Birk inhibitor and genistein among soy compounds that synergistically inhibit nitric oxide and prostaglandin E2 pathways in lipopolysaccharide-induced macrophage (2008, pubmed.gov)
- Dietary Protein and Muscle Mass: Translating Science to Application and Health Benefit (2019, nih.gov)
- Elimination Diet for Eosinophilic Esophagitis (n.d., mingi.com)
- Should wheat, barley, rye and/or gluten be avoided in a six food elimination diet? (2015, nih.gov)
- Use of dietary strategies in treating eosinophilic esophagitis (2017, n.d., mayoclinic.org)