Elimination Diets for Eosinophilic Oesophagitis

The immune system overreacts to proteins in common foods, most often cow’s milk, wheat, egg and soy, and to a lesser extent nuts, fish and shellfish. This is not a classic fast “allergy” with hives, and skin or blood allergy tests do not reliably show which food is responsible. The only way to find your triggers is to remove foods, check by endoscopy that the inflammation settled, and then re-introduce foods one at a time.

EoE is now a leading cause of difficulty swallowing and food getting stuck in children and young adults, and is recognised more often in people who also have asthma, eczema, hay fever or food allergy. It affects men more than women. Rates in the Gulf region are less well documented, but it is increasingly diagnosed.

Milk and wheat are everywhere in Saudi cuisine: laban, yoghurt, labneh, cheese, ghee, cream, gahwa with milk or cardamom cream, bread (tamees, saj, samoon), samboosa, harees, jareesh, freekeh, kunafa and many sweets. When removing milk, check ghee and butter (usually milk-derived) and rice dishes cooked with them, and sweets such as muhallabiya. When removing wheat, check vermicelli rice, sauces thickened with flour and marinades. Safe staples include plain rice, grilled meat and chicken (if milk and wheat are not used in marinades), vegetables, dates, fruit, olive oil, and tahini (check sesame tolerance). During Ramadan, discuss timing of swallowed steroids and of the diet with your team; fasting is usually possible, but food impaction risk is higher with large, rushed iftar meals, so chew carefully and eat slowly. Ask your hospital for a dietitian and allergy clinic referral.

Diagnosis needs an endoscopy with biopsies from the oesophagus showing a high count of eosinophils (15 or more per high-power field is the usual threshold), together with symptoms. Because symptoms do not match inflammation well, endoscopy with biopsies is repeated about 6 to 12 weeks after each major diet or drug change to see whether the diet worked. Your team may also exclude other causes, including reflux and coeliac disease.

Safe eating habits reduce the risk of food getting stuck while the gullet heals.

• Cut food into small pieces, chew each mouthful thoroughly, and sip fluid between bites.

• Eat without rushing; do not talk, drink alcohol or lie down while eating; sit upright for 30 minutes after.

• Prepare moist, softer textures (stewed meat, sauces, well-cooked rice) if foods get stuck, but do not use this to hide ongoing inflammation.

• Keep a food and symptom diary during the diet and reintroduction.

• Keep every scheduled endoscopy: no symptoms does not always mean no inflammation.

Elimination diets should be planned with a dietitian experienced in EoE (and an allergist when relevant), with endoscopy and biopsy at each step. Do not do this alone, and do not give a child a restricted diet without supervision.

• Step 1, choose a plan with your team: a one-food (milk), two-food (milk and wheat), four-food (milk, wheat, egg, soy), six-food (add tree nuts and peanuts, fish and shellfish), or elemental (amino-acid formula) approach. Many teams use a step-up approach (start with 2 foods, add more only if the biopsy is still inflamed) to spare people unnecessary restriction; a step-down approach (start with 6 foods) is faster but harder.

• Step 2, strict elimination for about 6 to 8 weeks. Remove the foods completely, including traces in sauces, sweets, processed foods and restaurant dishes; read every label, including for milk (casein, whey, ghee, butter, cream, yoghurt, laban, cheese), wheat (bread, pasta, freekeh, bulgur, couscous, flour in sauces), egg (mayonnaise, cakes), soy (soy sauce, soy oil in some products), peanuts and tree nuts (sweets, pastes), fish and shellfish. Replace calories, protein, calcium and vitamins with safe alternatives.

• Step 3, endoscopy with biopsies after the elimination period. If inflammation has settled, you move to reintroduction; if not, you either add further eliminations (step-up) or change treatment.

• Step 4, reintroduce one food (or food group) at a time, typically keeping each in the diet for several weeks (many teams use about 6 to 8 weeks, or a short period if trials are dosed daily), then repeat the endoscopy and biopsy. If inflammation returns, that food is a trigger and is avoided; if it stays calm, the food stays in. Common order starts with the least likely trigger, often fish and shellfish, then nuts, soy, egg, wheat and finally milk, which is the most frequent culprit. Your team will choose the sequence for you.

• Step 5, long-term: keep avoiding only proven triggers (often one or two foods) and keep periodic endoscopic follow-up. Do not reintroduce a trigger food “to test” without agreeing a plan.

• Nutrition cautions: dairy-free diets can lack calcium, vitamin D, protein and iodine; wheat-free diets can lack fibre and B vitamins; six-food diets are hard in children and can affect growth. Use calcium-fortified alternatives, ask about supplements, and monitor weight and growth. Milk-free means all animal milks: goat and sheep milk carry the same risk because their proteins are very similar, and camel milk has not been well studied in EoE, so avoid them unless your team says otherwise.

• Do not choose which foods to cut based on skin prick or blood allergy tests alone; they are poor guides in EoE. If you have a true immediate allergy (hives, swelling, wheeze), follow your allergist’s advice in addition.

Diet is one of three first-line options with acid-suppressing and topical steroid medicines. The best choice depends on your life, your age and your preferences.

Medicines are an alternative or complement to diet. Your specialist chooses between them with you.

• Proton pump inhibitors (acid-reducing tablets) can calm EoE in a proportion of patients and are often tried first.

• Swallowed topical steroids (such as budesonide or fluticasone prepared for swallowing, not inhaling) coat the gullet with little body-wide effect; they are taken after eating and followed by no food or drink for a short time as advised.

• A biologic medicine, dupilumab, is approved for EoE in some countries and may be considered for those who do not respond; ask whether it is available and appropriate for you.

• Medicine can be combined with diet. Stopping medicine can allow the condition to return, so do not stop without discussing it.

Endoscopy guides all treatment, and dilation is used for scarring.

• Endoscopy with biopsies confirms the diagnosis and checks the response after each diet or drug step.

• Oesophageal dilation stretches a narrowed gullet in those with scarring; it relieves swallowing but does not treat the inflammation.

• Food impaction that does not pass needs urgent endoscopic removal.

Evidence base: AGA/Joint Task Force on Allergy-Immunology guideline on EoE (2020), the international consensus (AGREE, 2018), the joint UEG/EAACI guideline on EoE (2017, updated 2024), ESPGHAN/NASPGHAN paediatric guidance, and systematic reviews of elimination diets. Elemental (amino-acid formula) diets achieve histological remission in roughly 90 percent in studies but are hard to maintain. Empiric six-food elimination (milk, wheat, egg, soy, tree nuts and peanuts, fish and shellfish) achieves remission in roughly two-thirds of patients in pooled data; step-up approaches that start with two foods (milk, wheat) or four foods (milk, wheat, egg, soy) and add steps only if needed reach remission in a large share with fewer endoscopies avoided than for six foods; milk elimination alone helps a meaningful minority. The most common single trigger is cow’s milk, followed by wheat. Allergy test-directed diets (skin prick or blood tests) have not been effective and the AGA/JTF guideline recommends against them. The AGA/JTF guideline suggests dietary elimination as one option alongside topical steroids and proton pump inhibitors, leaving the choice to the patient. Uncertain: the best sequence and long-term outcomes of diet therapy are still being studied, and results can differ in different populations.

EoE is chronic and tends to return when triggers are eaten again, but treated well it is controllable and the risk of scarring falls. With diet, many people end up avoiding just one or two foods long-term. Others prefer or need medicines; both routes are valid, and you can combine them.

• Is diet, medicine or both the best first treatment for me?

• Which elimination plan should we start with, and how many endoscopies will I need?

• How do I keep enough calcium, protein and vitamins on the diet?

• Which foods may I reintroduce first, and when?

• What should I do if food gets stuck?

This guide comes from the Saudi Gastroenterology Association (SGA) patient library, prepared by the Approved for publication by SGA; individual clinician review is ongoing. Last reviewed: 2026-04-24. It is for education and does not replace your doctor's advice.