Read below for more details about the study on the Four Food Elimination Diet for Treatment of Eosinophilic Esophagitis.  The full study can be found here. Here is a table to help find food options on this four food elimination diet.

EoE 4 Food Elimination Study Design This was a US multi-center study (Chicago, New York, Houston and Atlanta) that enrolled 78 children ages 1-18 years of age with confirmed eosinophilic esophagitis. All had upper endoscopies documenting 15 eosinophils per high powered field on esophageal biopsies after being on proton pump inhibitor therapy (e.g. omeprazole, lansoprazole) for 8 weeks. All families were then instructed to remove milk, egg, wheat, and soy from their diet for 8 weeks under the guidance of a dietitian. If there was healing on a follow up endoscopy, then foods were reintroduced into the diet one at a time, in the order soy, egg, wheat, then milk. After 8 weeks of adding in a single food, an endoscopy was performed with biopsies to evaluate response. If 15 eosinophils or greater was seen on endoscopy, then the trigger food was removed and a repeat endoscopy was performed to confirm healing. If there was no increase in eosinophils, the foods remained in the diet and the next food was reintroduced.

Key Study Findings

  • 64% of Patients were healed on 4 Food Elimination Diet
  • Milk was a trigger in 85% of patients
  • 84% of those who were healed on this diet had only 1 or 2 food triggers

Further Details

50 of 78 (64%) Children were in remission on the 4 Food Elimination Diet with significant decreases in their esophageal eosinophil counts.  Upper esophageal biopsies decreased from 43 ± 32 eosinophils counted per high powered filed down to 3 ± 3 eosinophils after the diet.  Lower esophageal biopsies decreased from 55 ± 34 to 4 ± 4 eosinophils per high powered field.

Symptoms also improved for these patients including issues with abdominal pain, low appetite, vomiting, food impactions, choking/gagging on foods, and pocketing foods. Of these 50 patients, 47 began introducing foods back into the scope one at a time with follow-up endoscopies to check for response.

Twenty-five children were able to trial in all 4 foods to identify their food triggers.  Milk was by far the most common trigger in 21 of 25 (84%) patients, followed by wheat (7 of 25; 28%), egg and soy (2 of 25%, 8%) each.  Interestingly, 2 were able to add back in all 4 foods without return of esophagitis.  It was unusual to see more than 2 food triggers with 64% (16 of 25) having one food trigger, and 20% (5 of 25) having two food triggers. Overall, for these 25 responders who trialed in all foods, milk was the only food trigger in 14 of 25 (56%) cases, again emphasizing the large role of cow’s milk plays in the development of EoE.

The study looked to see if there were any factors that could predict who might respond to this diet. They observed that girls, and history of asthma were associated with higher chance of remission. On the other hand positive, serum specific IgE (i.e. “RAST” tests) to the four foods predicted lower likelihood of responding to the diet.

The study did caution that with this diet there is increased risk of poor weight gain and nutritional deficiencies. In fact patients who were on the diet did experience weight loss, but reported catch up weight after reintroduction of foods. Therefore nutritional guidance (e.g. from a dietitian) is important when starting this type of restriction diet.


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