What foods should I start with for an elimination diet?

Starting Foods for an Elimination Diet

Begin with a two-food elimination diet removing milk and either wheat or egg for 8-12 weeks, as this approach identifies triggers in approximately 43% of patients while minimizing dietary restriction and nutritional risk. 1

Initial Elimination Phase: What to Remove

The most evidence-based starting point eliminates the two most common food triggers:

• Remove cow's milk/dairy products completely - This is the single most common trigger, responsible for 42% of food-related reactions 1
• Remove either wheat OR egg - Wheat accounts for 10.9% and egg for 21.5% of triggers; the combination of milk + wheat works in 37% of cases, while milk + egg works in 33% 1

Foods You CAN Eat During Initial Elimination

During the two-food elimination phase, you may consume:

• All meats and poultry (chicken, turkey, beef, pork, lamb) - prepared without dairy or wheat-based coatings 1
• Fish and shellfish - unless you have known allergies 1
• Rice and rice-based products - as your primary grain source 1
• Potatoes (including cooled potatoes) 1
• Most vegetables - tomatoes, onions, garlic, ginger, cucumber, carrots, spinach, lettuce, red peppers 1
• Most fruits - bananas, apples, avocados, strawberries, melon, citrus 1
• Oils - olive oil and canola oil 1
• Eggs (if not eliminated) or wheat products (if not eliminated) 1

Critical Implementation Requirements

This diet must be supervised by an experienced dietitian - elimination diets carry significant risks including nutritional deficiencies (calcium, iron, B vitamins), growth impairment in children, and weight loss in adults 1

Timeline and Assessment

• Duration: Maintain strict elimination for 8-12 weeks before assessment 1
• Monitoring: Track symptoms throughout, but understand that symptom improvement alone is insufficient - histological assessment is required for conditions like eosinophilic esophagitis 1

Step-Up Approach If Initial Elimination Fails

If the two-food elimination doesn't achieve remission after 8-12 weeks:

• Step up to four-food elimination: Remove milk, wheat, egg, AND soy for another 8-12 weeks 1
• If still unsuccessful, advance to six-food elimination: Remove milk, wheat, egg, soy, fish/shellfish, AND tree nuts/peanuts 1

The six-food elimination diet shows 72.1% histological response rates but requires significantly more restriction and multiple endoscopies 1

Common Pitfalls to Avoid

• Hidden dairy sources: Check labels for whey, casein, lactose in processed foods 1
• Cross-contamination: Wheat can contaminate other grains during processing 2
• Inadequate duration: Don't assess results before 8 weeks - earlier evaluation leads to false negatives 1
• Nutritional deficiency: Dairy elimination removes major calcium, vitamin D, and protein sources; wheat elimination removes iron, fiber, and B vitamins - supplementation may be necessary 1
• Long-term restriction without reintroduction: Strict elimination should not continue indefinitely; systematic food reintroduction is essential to identify specific triggers 3

Food Reintroduction Protocol

After achieving remission on elimination diet:

• Reintroduce one food at a time for 8-12 weeks 1
• Monitor symptoms and obtain repeat assessment after each reintroduction 1
• Most patients have only 1-2 food triggers - 69% have single trigger, 24% have two triggers 4

Special Considerations

This approach is specifically validated for eosinophilic esophagitis - the evidence provided primarily addresses this condition 1. For other conditions like irritable bowel syndrome, a low-FODMAP diet may be more appropriate 3. For atopic dermatitis, elimination diets should only be pursued with documented, clinically relevant food allergies, not based on suspicious history alone 1.