Treatment of eosinophilic oesophagitis with diet

Most people with EoE are allergic to more than one food, and EoE is therefore regarded as a special type of food allergy. Eliminating all foods that cause an allergic reaction in your oesophagus could improve or resolve inflammation and other adverse changes by significantly reducing the number of eosinophils. There may also be an associated improvement in your symptoms without the need for medication.

The most common foods that cause EoE are dairy products, wheat, eggs, soy, nuts and fish/seafood. These need to be removed and then reintroduced, one by one, to find out which food(s) cause these adverse changes to your oesophagus. Then they are permanently eliminated from your diet. This approach can be highly effective but slow. You will need an endoscopy once all the foods are removed and then again after each food is reintroduced to see the effects on your oesophagus. For those people who are vegetarian, vegan or pescatarian, management of EoE by diet changes can be difficult as you may have to stop eating foods that are your staples, leaving you with limited alternatives.

Ideally, using a dietary approach as a treatment for EoE is managed by a registered dietitian who has a good understanding of EoE.

eosinophilic esophagitis EoE - dietary restrictionseosinophilic esophagitis EoE - dietary restrictions

Eliminating foods that may cause EoE can improve symptoms.


How effective are amino acid-based nutrient solutions in the treatment of EoE?

Amino acid-based nutrient solution is a special nutritional liquid that the person with EoE (normally a child) takes to ensure their diet is free of any allergy-triggering proteins. The nutrient solution consists of amino acids, which are the basic building blocks of proteins, as well as certain other nutrients – nothing more. Amino acid solutions are produced industrially.

The amino acid-based liquid diet has been found to be effective in reducing inflammation in more than 90% of people with EoE.8 It ensures that remission is established after four to six weeks and the diet provides adequate nutrition. After that time, normal solid foods are reintroduced, starting with the least allergenic (vegetables and fruit) and moving on gradually, one at a time, to the most allergenic (dairy products, wheat, eggs, soy, nuts, and fish/seafood).

How do you take amino acid-based nutrient solutions?

Adults can manage this diet at home if they can tolerate the taste, which is often described as unpleasant. Children/adolescents who need an amino acid-based diet usually do not tolerate the taste and the solution is given via a feeding tube during an in-patient stay in hospital.

What are the side effects/limitations of an amino acid-based solution diet?

Most adults find this diet to be extremely restrictive because you are not permitted to eat anything else in the first four to six weeks while the inflammation in the oesophagus is decreasing. Adults seldom choose this diet.


How effective is an elimination diet in the treatment of EoE?

There are two basic types of elimination diets. One, commonly referred to as a ‘directed’ elimination diet is based on the results from an initial skin prick or patch allergy test. The other is the more often prescribed empirical or ‘non-directed’ elimination diet.

A diet based on allergy testing will not result in an improvement of symptoms for most people as these tests are generally not specific enough to identify EoE-causing allergens and rarely achieve their objective.

The empirical, ‘non-directed’ elimination diet is therefore probably the best choice for people with EoE. The one used most often and most effectively in both children and adults is the six-food elimination diet (SFED). In one study, inflammation of the oesophagus was successfully reduced (defined as a significant reduction in eosinophil numbers in the oesophageal mucosa) with an improvement in symptoms in more than 70% of people following this diet.9


How do elimination diets work?

The SFED involves the complete elimination of the six foods which are the mostly like to cause an allergic reaction (dairy products, wheat, eggs, soy, nuts and fish/seafood) from the diet and then waiting six to eight weeks. At this time, you will have an endoscopy to confirm (by biopsy) that there has been a significant reduction in eosinophil numbers/inflammation in the lining of the oesophagus (the mucosa).

Once this is confirmed, one food group is re-introduced at a time. You will have another endoscopy and another biopsy two to four weeks later to see if there has been a significant increase in eosinophil numbers/inflammation. If there has been an increase, then that food is considered to be allergenic (causing an allergic reaction) and it is permanently removed from your diet. Once it has been removed (known as a ‘wash-out’), you wait another four to eight weeks to allow the eosinophil count/inflammation to decline.

If there is no significant increase in eosinophil numbers in the oesophagus, then the food is most unlikely to be allergenic and you can keep eating this specific food. A new food will then be reintroduced without delay, with another endoscopy and biopsy performed two to four weeks later. This process is repeated until each food is confirmed allergenic or not. For some people with EoE, many foods are allergenic .10

To help you adapt to your diet, seeing a dietitian with knowledge in EoE is helpful in achieving the best possible outcomes. Over several visits, they can offer suggestions and advice on how to avoid foods which are determined to be allergenic to you.

As an alternative to the SFED diet, you might be given the so-called ‘step-up’ elimination diet to reduce the number of endoscopies you would otherwise need by about 20%. At first, only two food groups (usually dairy and wheat, the most likely to be allergenic) are eliminated and then reintroduced using the same procedure described above. However, this doesn’t mean the other four foods are not allergenic and ultimately you might need an SFED to ensure this procedure is as wide-ranging as possible. Even then, there are foods not included in the SFED that could cause allergic reactions in some people with EoE.

What are the limitations of elimination diets?

It can take up to a year to identify the foods that cause an allergic reaction and some people need up to eight endoscopic examinations to get a definite result. When you’re on an empirical elimination diet, it’s important to make several appointments with a dietitian for advice and support. Being on such a strict diet for a very long time can have a negative impact on your quality of life.