Best Diet Plan for Eosinophilic Esophagitis (EoE) – Ayurveda and Modern Perspective

Dietary Guidelines for Eosinophilic Esophagitis – Modern Point of View

1. Elemental Diet

What is an Elemental Diet?

The special type of medical nutrition plan is one where all kinds of nutrients, like protein, fats, and carbohydrates, are completely broken down into their simplest forms. Proteins are broken down into amino acids so that no intact protein remains and no allergic reactions occur. In the same way, fats are converted into simple fatty acids or medium-chain triglycerides, and carbohydrates are changed into simple sugars like glucose or maltodextrin.

What is Used in this Diet?

This diet uses amino acid-based formulas and excludes all regular foods, effectively removing all potential allergens. It has the highest rate of remission but can be difficult to maintain due to taste and cost.

Why is it Used in EOE?

In EOE, the immune system reacts to certain food proteins, and this elemental diet contains no whole protein, so it removes all possible food allergens.

Studies show that it can put up to 90% of EOE patients into remission.

Reference: Votto M, De Filippo M, Lenti MV, Rossi CM, Di Sabatino A, Marseglia GL, Licari A. Diet Therapy in Eosinophilic Esophagitis. Focus on a Personalized Approach. Front Pediatric. 2022 Jan 20; 9: 820192. doi: 10. 3389/ fped. 2021. 820192. PMID: 35127602; PMCID: PMC 8812465.

What Does it Include?

Commercial formulas: e.g., Neocate, EleCare, PurAmino (for children) and Vivonex TEN (for adults). It can be taken as the only source of food (full elemental diet) or along with a few safe foods (partial elemental diet).

Challenges

• Taste can be unpleasant and sometimes needs a feeding tube in children.
• It is difficult to follow long-term due to the social and emotional impact.
• Expensive.
• Usually used for short periods, i.e., 6– 8 weeks, then foods are slowly reintroduced.

Ayurvedic Perspective

• An elemental diet is like Laghu (light), easily digestible Ahara.
• Comparable to Peya, Vilepi, Manda, i.e., thin rice gruels, soups, porridges, given in conditions where gut rest is needed.
• Supports Agni (digestive fire) without burdening digestion.

2. Six-Food Elimination Diet (SFED)

What is SFED?

The SFED is the Six-Food Elimination Diet, in which the six most common food allergens that trigger EoE are removed. The six foods that are removed or eliminated are Milk, Wheat, Soy, Eggs, Nuts or Peanuts, and Seafood or Shellfish. It is developed as an empirical approach, not based on allergy tests, because most EoE triggers are non-IgE mediated. By this, SFED clinical remission rates are approximately 52–74% in both adults and children.

What to Avoid in SFED

• Milk or dairy products like cow’s milk, goat’s milk, cheese, yogurt, butter, ghee, paneer, cream, and ice cream.
• Wheat or gluten-like breads, chappati (Atta), pasta, various biscuits, cakes, pastries, and noodles can be taken, but make sure to be gluten-free.
• Soy or legume-based products like soy milk, soy sauce, tofu, soy flour, and textured soy protein.
• Eggs in various forms, like boiled, fried, omelets, mayonnaise, cakes, or baked goods containing eggs.
• Nuts or Peanuts and their products like peanut butter, almonds, cashews, walnuts, pistachios, nut oils, etc.
• Seafood like shellfish, prawns, shrimp, crab, lobster, mussels, fish sauces, etc.

What to Include in SFED

The following foods can be used safely unless proven individually reactive.

Grains: Rice, millet, quinoa, corn, oats (it must be certified gluten-free), buckwheat, etc.

Fruits: All fresh fruits like banana, apple, pear, papaya, mango, berries, grapes, pomegranate, etc. can be included.

Vegetables: All varieties of vegetables like spinach, carrot, pumpkin, beans, beetroot, cabbage, broccoli, etc.

Protein sources: Chicken, lamb, turkey. Some patients can tolerate lentils or chickpeas if not soy or peanut sensitive, but legumes may need careful checking before use.

Dairy substitutes: As dairy substitutes, oat milk, rice milk, and coconut milk can be used; it is better to avoid soy and almond milk.

Fats or Oils: Olive oil, sunflower oil, rice bran oil, coconut oil.

Snacks: Puffed rice, roasted makhana, fruit chaat, and vegetable sticks with hummus, if tolerated, can be taken.

Phases and Duration of SFED

Elimination Phase

Duration: 4–8 weeks, and mostly recommended for 6–8 weeks. All six allergenic food groups are removed from the diet for this period before any reintroduction begins.

Reintroduction Phase

Duration: Typically, 6–12 weeks. Foods are reintroduced by one group at a time, commonly at weekly or biweekly intervals, with monitoring for symptoms and, in some cases, endoscopy for EoE.

Challenges of SFED

• Restrictive diet.
• Label reading, meal planning, and cooking from scratch are essential skills needed to follow this diet properly.

• Nutritional risks include calcium deficiency without dairy and protein limitation if legumes are restricted.
• Needs a dietitian’s guidance and regular follow-up.
• The cost and effort may be higher compared to an unrestricted diet.

3. Four-Food Elimination Diet (FFED / 4FED)

The four-food elimination diet is also known as 4FED, a simplified elimination protocol as compared to SFED and is used mainly for eosinophilic esophagitis (EoE) and similar food-triggered conditions. The aim of 4FED is also to reduce common dietary triggers while making the process less restrictive as compared to the SFED.

What to Avoid in 4FED

• Milk and all dairy products, including cheese, yogurt, butter, etc.
• Wheat and all wheat-containing foods or products like bread, pasta, pastries, etc.
• Eggs in all forms and ingredients are like bakery products.
• Soy and soy-based products like soy sauce, tofu, and processed foods with soy.

What to Include in 4FED

• All fruits and vegetables.
• Non-wheat grains like corn, quinoa, rice, and millet. Oats can also be included if gluten-free.
• Meat, poultry, fish, and shellfish are only tolerated.
• Legumes except soybeans and soy products.
• Nuts and seeds can be included if you are not allergic to them. 
• Healthy fats such as olive oil, avocado oil, etc.

Phases and Duration

Elimination Phase: Avoidance of all four groups of food mentioned above for 6- 8 weeks strictly, sometimes longer for persistent symptoms.

Reintroduction Phase: Each food is added back one at a time, typically over several weeks, like soy, then egg, then wheat, and then milk, and so on. During this time, monitoring symptoms or conducting an endoscopy for EoE is also necessary.

Challenges

• Risk of various nutritional deficiencies, especially protein and calcium, can occur if not planned well, in the phases and duration.
• Hidden sources of eliminated foods in processed products, like eggs or milk in baked goods, can be harmful or may hinder results.
• Social and practical difficulties while attending gatherings, eating out, or traveling.
• Label reading, meal planning, and cooking from scratch are essential skills needed to follow this diet properly.

4. Two-Food Elimination Diet (2FED)

It is a simplified restriction diet that is used in EOE and only restricts two food types from the diet, i.e., Milk and wheat. It is usually attempted first to minimize restriction and is assessed for effectiveness before moving to a more intensive elimination, like 4FED or SFED.

5. One-Food Elimination Diet

This diet excludes only milk and milk products. Recent studies show that for some adults with EoE, removing just animal milk can be as effective as multi-food elimination, simplifying dietary management.

6. Allergy Test Directed Diets for Eosinophilic Esophagitis (EoE)

Allergy test-directed diets use results from various allergy tests to guide which foods to eliminate in the individual and what to include, as per condition and nutrition required, aiming to reduce esophageal inflammation triggered by specific allergens in the body of the individual.

To maintain nutritional adequacy, focus on nutrient-rich, whole foods.

Foods to Avoid

• Foods that are identified as positive for allergen sensitization by skin prick tests (SPT), atopy patch tests (APT), or specific serum IgE tests must be avoided as further triggers.  
• Common triggers for EoE include Milk and milk products. Wheat, eggs, soy, nuts, and seafood should also be avoided if positive on testing.  
• Avoid all forms of allergenic foods, including hidden ingredients in various processed foods.  

Foods to Include

• To maintain nutritional adequacy, focus on nutrient-rich, whole foods.
• Not all foods are flagged as allergens by testing.  
• Plain meats, fish if not allergenic, poultry, fruits, vegetables, gluten-free grains if wheat is allergenic, legumes if not allergenic, nuts or seeds if not allergenic can be included. 
• Dairy alternatives or soy alternatives may be included if not sensitized.  

Efficacy and Challenges

• Allergy-test-directed diets show about 65–70% effectiveness in reducing EoE inflammation, similar to SFED, 4FED, etc., elimination diet.
• False positives or false negatives can occur due to cross-reactivity or limitations of tests, especially in adults.  
• Testing based on SPT, APT, and serum IgE combined gives better predictive value than individual tests alone.  

7. Step-Up Diet in Eosinophilic Esophagitis (EoE)

Based on the 2025 ACG Guidelines

Publication: January 2025, American Journal of Gastroenterology

First-line therapies for EoE:

• Proton pump inhibitors (PPIs)
• Swallowed topical corticosteroids
• Dietary elimination

Major Update: Recommends a step-up elimination strategy rather than starting directly with the restrictive Six-Food Elimination Diet (SFED) or elimination diet.

Goal: Maximize remission while preserving nutrition, adherence, and quality of life.

What Is the Step-Up Diet?

It is a personalized, gradual dietary elimination approach starting with the least restrictive diet. In this, instead of removing 6 or 4 food types from the diet, individuals start with the least restriction.

Progressive Escalation

• If remission isn’t achieved, additional food groups are removed step by step.
• If remission occurs early, then stop there, and there is no need for extra restrictions.

 Why Does It Matters?

• Easier for patients to sustain
• Nutritional safety prevents unnecessary deficiencies.
• Fewer endoscopies are performed as each escalation requires biopsy, but many patients respond early.
• Personalized diet so that cultural and lifestyle eating patterns can be maintained.

How to Start a Step-up Diet?

Foods to Exclude

• Step 1: Milk and dairy products like cheese, yogurt, butter, cream, etc.
• Step 2: Dairy and wheat (its products, bread, pasta, baked products, etc.)
• Step 3: Dairy, wheat, eggs, soy (tofu, soy milk, soy protein, etc.)
• Step 4: Eliminate nuts and seafood.

Foods to Include

• Fruits and vegetables: All fresh, unprocessed, organic varieties of fruits and vegetables.
• Gluten-free grains: Rice, quinoa, millet, corn, gluten-free oats, etc.
• Protein sources: Poultry, lamb, turkey, beef, etc.
• Legumes: Lentils, beans, unless soy is eliminated from the diet.
• Healthy fats: Olive oil, seeds, but avoid nuts if eliminated from diet.
• Dairy alternatives: Rice milk, oat milk, coconut milk, but avoid soy or almond milk if eliminated from diet.

Monitoring and Assessment of Step-Up Diet

Each phase: 6 to 12 weeks

Assessment: Endoscopy with biopsy as histology is the gold standard, and symptoms alone are unreliable.

If Remission is Achieved: Maintain the current step long-term or reintroduce foods one by one with monitoring to identify exact triggers.

Key Benefits of Step-Up Diet

• Avoids over-restriction
• Protects nutrition and growth, especially in children.
• Aligns with patient lifestyle
• Reduces the burden of invasive procedures

8. Mediterranean Diet with Modification

Although not a first-line treatment for EoE, the Mediterranean diet emphasizes plant-based foods, whole grains, and healthy fats. This diet can be adapted as a supportive approach for EoE, which especially focuses on anti-inflammatory, nutrient-dense whole food use while avoiding suspected and known triggers. 

What is the Mediterranean Diet?

The Mediterranean diet is plant-based, the interest in which began in the 1950s. This diet is based on the traditional cuisines of the countries that border the Mediterranean Sea, such as Greece, Italy, etc.

The Mediterranean diet is recommended mainly for heart disease, but it gives wonderful results for gastrointestinal disease. According to a recent study published in Gastroenterology, the Mediterranean diet will improve inflammation, symptoms, and quality of life.

What to Include in the Mediterranean Diet for Eosinophilic Esophagitis (EoE)?

• Whole grains that are gluten-free, like quinoa, brown rice, millet, and even oats if gluten-free.
• Various Legumes like lentils, chickpeas, beans. Avoid soy if you are allergic.
• Fresh vegetables like leafy greens, tomatoes, peppers, cucumbers, broccoli, eggplant, zucchini, etc.
• Fresh fruits like berries, citrus, apples, pears, grapes, melons, etc.
• Nuts and seeds like walnuts, flaxseeds, and chia seeds can be used if not allergic.
• Healthy fats like extra virgin olive oil as a primary fat source, avocado oil, etc., can be used.
• Fatty fish rich in omega-3 fatty acids, such as salmon, sardines, and mackerel, can be taken if well tolerated.
• Herbs and spices like basil, oregano, rosemary, and turmeric, which exhibit anti-inflammatory properties, can be used.

What to Avoid in the Mediterranean Diet for Eosinophilic Esophagitis (EoE)?

• Dairy products, especially when milk or milk products are identified as a trigger.
• Wheat and gluten-containing grains should be avoided if a wheat allergy or sensitivity exists.
• Soy products if allergic like soy sauce, tofu, soy milk, etc.
• Eggs can be avoided if identified as a trigger.
• Seafood, whether it is a personal allergen or trigger, should be avoided.
• Highly processed foods, refined sugars, and excessive red or processed meats should be avoided.
• Foods that worsen the inflammation with additives, preservatives, or artificial colorings should be avoided.

9. Anti-Inflammatory Diet

An anti-inflammatory diet contains food that minimizes your chances of having inflammation. Anti-inflammatory foods help to lower the chances of having flare-ups of EoE. This diet is rich in antioxidants and helps to cope with external factors like stress, smoking, etc., which increase the free radicals in the body.

What is Included in an Anti-inflammatory Diet?

An anti-inflammatory diet contains various types of fruits, vegetables, lean protein, whole grains, spices, omega-3-rich foods, etc. 

The DASH diet and even the Mediterranean diet are examples of anti-inflammatory diets. The standard DASH diet can’t be used in EoE, but the modified DASH diet can be used in the case of EoE, as it lowers systemic inflammation. It can be used as a nutritional background diet layered with the elimination principle for EoE.

Also Read:- Eosinophilic Esophagitis Treatment – Natural and Ayurvedic