Elimination Diet for
Eosinophilic Esophagitis
Personalized weekly menus based on Step-Up approach and updated scientific evidence ACG 2025
What is Eosinophilic Esophagitis?
Eosinophilic esophagitis (EoE) is an allergic disease mainly caused by foods, which leads to chronic inflammation of the esophagus. It is a common condition that can appear in both childhood and adulthood.
Complete information: Everything about Eosinophilic Esophagitis and why it's increasingly diagnosed
Main Symptoms
- In young children: food refusal, heartburn, vomiting or abdominal pain
- In teenagers and adults: difficulty swallowing, food impaction with solids (especially meat)
Diagnosis
Performed through endoscopy with biopsies to confirm eosinophilic inflammation of the esophagus (≥15 eosinophils/field).
Step-Up Approach: The Most Modern Strategy
Why Step-Up?
The "Step-Up" approach represents the most modern and efficient strategy to identify triggering foods. Instead of starting by eliminating many foods, we start with the minimum necessary (milk only) and escalate only if there is no response.
ACG 2025 Scientific Evidence
The ACG 2025 guideline reinforces the step-up approach citing two randomized trials demonstrating similar remission rates between less restrictive and more restrictive diets:
- • Adults: 1FED vs 6FED → 34% vs 40% (p=0.58) - no significant difference
- • Children: 1FED vs 4FED → 44% vs 41% (p=1.0) - virtually identical rates
Conclusion: Starting with the least restrictive diet reduces endoscopic procedures by 20% and shortens trigger identification time, without compromising efficacy.
Reference: Dellon ES, et al. Am J Gastroenterol. 2025;120(1):31-59
Important Considerations
- • Endoscopy with biopsies is necessary at 8 weeks after starting each diet
- • DO NOT combine topical corticosteroids and diets simultaneously
- • Diet is NOT the best option for patients with severe esophageal strictures or severe symptoms
- • Collaboration with specialized dietitian is recommended
Step 1: Select Your Diet Level
We recommend starting with 1FED (milk only) and escalating only if there is no response. Consult with your specialist to determine the best level for you.
1FED
35-45% efficacyEliminates only MILK from mammals (cow, goat, sheep) and all dairy products
✨ Recommended as first option (ACG 2025)
2FED
40-45% efficacyEliminates MILK + WHEAT/GLUTEN (wheat, barley, rye, oats, spelt, kamut, triticale)
Second option if 1FED doesn't work
4FED
40-50% efficacy
Eliminates MILK + WHEAT + EGG + SOY
✓ Legumes (lentils, chickpeas, beans) ARE allowed
6FED
40-70% efficacy
Eliminates MILK + WHEAT + EGG + SOY + TREE NUTS (including peanuts) + FISH/SEAFOOD
✓ Legumes (lentils, chickpeas) ARE allowed
IMPORTANT about LEGUMES and SOY
According to ACG 2025 guidelines, there is frequent confusion about these foods:
- • SOY: Specifically eliminated in 4FED and 6FED (as independent category)
- • LEGUMES (lentils, chickpeas, beans): NOT eliminated in any standard diet (1FED, 2FED, 4FED, 6FED)
- • PEANUTS: Although botanically legumes, they are eliminated in 6FED along with tree nuts
- • Expanded European variant: Some European protocols add legumes to 6FED, but this is NOT the ACG standard
Scientific References
- 1. Dellon ES, Muir AB, Katzka DA, et al. ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol. 2025;120(1):31-59. doi:10.14309/ajg.0000000000003194
- 2. Kliewer KL, Abonia JP, Aceves SS, et al. One-Food Versus 4-Food Elimination Diet for Pediatric Eosinophilic Esophagitis: A Multisite Randomized Trial. J Allergy Clin Immunol. 2025;155(2):520-532. doi:10.1016/j.jaci.2024.08.023
- 3. Hirano I, Chan ES, Rank MA, et al. AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis. Gastroenterology. 2020;158(6):1776-1786. doi:10.1053/j.gastro.2020.02.038
- 4. Molina-Infante J, Arias Á, Alcedo J, et al. Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: The 2-4-6 study. J Allergy Clin Immunol. 2018;141(4):1365-1372. doi:10.1016/j.jaci.2017.08.038
- 5. Arias A, González-Cervera J, Tenias JM, Lucendo AJ. Efficacy of Dietary Interventions for Inducing Histologic Remission in Patients With Eosinophilic Esophagitis: A Systematic Review and Meta-Analysis. Gastroenterology. 2014;146(7):1639-48. doi:10.1053/j.gastro.2014.02.006
