Common Food Triggers for Eosinophilic Esophagitis

Food allergies and eosinophilic esophagitis (EoE) go hand in hand. In short: "EoE is a disease driven by an abnormal immune response to certain foods," says David Gardinier, RD , a registered dietitian with the Cleveland Clinic's Center for Human Nutrition.

EoE is a chronic immune system disease, but it's different from other food allergies , such as immunoglobulin E (IgE) triggered allergies It's also different from food intolerances or sensitivities , which cause discomfort but do not set off an immune response.

In EoE, a certain type of white blood cell, called eosinophils, builds up in the esophagus. When someone has the condition, eating a food they are allergic to triggers an immune response that causes this blood cell build-up. In turn, this build-up can trigger or worsen symptoms of EoE, including difficulty swallowing, heartburn, and food getting stuck in the throat.

The six most common EoE food triggers are:

• Milk
• Wheat
• Soy
• Eggs
• Nuts
• Seafood

But which individual foods, or which combination of foods, is a trigger will be different for everyone.

The most common trigger is dairy, followed by wheat, Gardinier says. Eggs and soy are the next most common, while peanuts, tree nuts, shellfish, and fish are the least likely of those on the list to be triggering EoE. One study found that dairy was such a common trigger for EoE, starting with dairy elimination alone is a good initial treatment for EoE.

Still, there may be other foods at play as well. To determine what your individual triggers are, a doctor will likely prescribe an elimination diet until they have determined which foods cause an immune response.

According to Gardinier, diet therapy for EoE follows a three-phase approach: elimination, reintroduction, and maintenance.

• Elimination: removing one, some or all six common trigger foods for a period of about six weeks.
• Reintroduction: reintroducing these foods one or two at a time to identify which ones seem to trigger EoE to return via endoscopy and which ones are safe.
• Maintenance: avoiding any identified food triggers long term.

How to Avoid EoE Food Triggers

Reading labels and calling ahead to restaurants to determine if they have an allergen-safe menu are ways people with EoE can enjoy meals without worrying about triggering their symptoms.

According to Gardinier, research has not shown that eating large meals triggers an EoE immune response, but eating smaller portions can be a good idea, especially if heartburn or reflux are an issue.

"Larger meals may make it harder for the lower esophageal sphincter to close completely," he says. This allows acid from the stomach to get into the esophagus, or acid reflux.

Emerging research is investigating whether other food groups, such as ultraprocessed food , could also trigger EoE, even if these foods do not contain one of the six major food triggers. Ultraprocessed foods are typically packaged foods made almost entirely from substances synthetically made or extracted from food, including oils, sugars, fats, starches, and proteins.

"It's likely that food processing can open up the possibility that safe historical foods may now be changed enough that they may damage the esophagus and initiate an immune attack," says Russell Hopp, DO , a physician at the Food Hypersensitivity Clinic at Children's Nebraska.

Creating an EoE-Safe Diet That Still Tastes Good

Replacing triggers with equally delicious alternatives - rather than completely going without - is a great way to craft meals that taste good but won't set off an immune response.

Some EoE diet swaps Gardinier recommends are:

• Coconut milk, gluten free oat milk, or hemp milk instead of dairy or almond milk for a dairy or nut allergy
• Coconut aminos instead of soy sauce for a soy allergy
• Sunflower butter instead of peanut or almond butter for a nut allergy
• Sunflower seeds and pumpkin seeds to replace nuts and tree nuts
• Corn, rice, or quinoa pasta instead of wheat pasta
• Gluten free rice, corn, or oat cereals instead of wheat cereal

"In general, most cultural cuisine can be adapted to fit an EoE elimination diet," Gardinier says, adding that one of the easiest cuisines to adapt to an EoE-friendly diet is Mexican due to its use of rice, corn, beans, vegetables, and meat.

Filipino, Pacific Islander, and Indian cuisines are also often easy to adapt, he says.

The Takeaway

Managing EoE primarily involves identifying and avoiding specific food triggers that cause an immune response in the esophagus. The most common culprits include milk, wheat, soy, eggs, nuts, and seafood. Diet therapy typically follows a three-phase approach: elimination, reintroduction, and maintenance, to pinpoint individual triggers. Repeat endoscopies are needed to see if EoE returns with specific food introduction. Work with you doctor to make adaptations to your diet by swapping out trigger foods with safe, flavorful alternatives. With careful planning and label reading, individuals with EoE can maintain a diverse and tasty diet while avoiding their specific food triggers.

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Sources

1. EOE. American Partnership for Eosinophilic Disorders . 2023.
2. Molina-Infante J et al. New Approaches to Diet Therapy for Eosinophilic Esophagitis. Current Opinion in Gastroenterology . July 2023.
3. Kliewer K et al. One Food Versus Six Food Elimination Diet Therapy for Treatment of Eosinophilic Esophagitis: A Multicenter Randomized Clinical Trial. The Lancet Gastroenterology and Hepatology . February 2023.
4. Carussi L et al. Food Allergy: Cause or Consequence of Pediatric Eosinophilic Eophagitis? Potential Implications of Ultraprocessed Foods in Prevention and Management. Frontiers in Allergy . June 2023.