What is an elimination diet?

What is an Elimination Diet?

An elimination diet is a structured dietary approach that involves removing specific foods or food groups from a person's diet for a period of time, followed by systematic reintroduction to identify food triggers that may cause symptoms or allergic reactions. 1

Types of Elimination Diets

There are three main types of elimination diets:

1. Single-food exclusion: Removes one specific food from the diet
2. Multiple-food exclusion: Removes several foods simultaneously
3. Few-food diet: Avoids a large number of potential allergens and focuses on foods that can be included rather than those to avoid 2

For eosinophilic esophagitis (EoE) specifically, elimination diets follow a structured approach:

• Two-food elimination diet (TFED): Eliminates milk and wheat/gluten
• Four-food elimination diet (FFED): Eliminates milk, wheat/gluten, egg, and soy/legumes
• Six-food elimination diet (SFED): Eliminates the six most common allergens (milk, wheat, eggs, soy, nuts, and seafood) 1, 3

Implementation Process

The elimination diet process typically involves:

1. Initial elimination phase (8-12 weeks): Complete avoidance of suspected trigger foods
2. Assessment phase: Evaluation of symptom improvement and, in conditions like EoE, histological assessment through endoscopy and biopsies
3. Reintroduction phase: Systematic reintroduction of one food at a time (typically every 8-12 weeks), with monitoring for symptom recurrence 1

Clinical Applications

Elimination diets serve two primary purposes:

• Diagnostic tool: Helps identify specific food triggers for symptoms
• Therapeutic intervention: Manages symptoms by avoiding trigger foods 4

They are commonly used for:

• Food allergies and sensitivities
• Eosinophilic esophagitis (EoE)
• Functional gastrointestinal disorders
• Conditions with refractory symptoms where food triggers are suspected 4

Important Considerations and Pitfalls

• Medical supervision: Elimination diets should be conducted under the supervision of healthcare professionals, particularly dietitians with expertise in nutritional management 1, 2

• Nutritional adequacy: Dietary exclusions must be managed carefully to prevent nutritional deficiencies, especially in growing children 2, 5

• Common pitfalls:

  • Relying solely on symptom improvement without objective assessment
  • Inadequate duration of elimination
  • Poor dietary adherence
  • Delayed assessment of response
  • Using allergy testing alone to identify triggers 1

• Potential risks:

  • Nutritional deficiencies
  • Development of de novo IgE-mediated food allergies upon reintroduction after long-term avoidance
  • Social isolation and psychological impact of dietary restrictions 3

Step-Up Approach for EoE

For conditions like EoE, a step-up approach is recommended:

1. Start with TFED for 8-12 weeks
2. If no remission, proceed to FFED for 8-12 weeks
3. If still no remission, consider SFED or alternative treatments 1

This approach balances effectiveness with quality of life by starting with less restrictive diets before progressing to more extensive elimination if needed.