Dietary Therapy in Eosinophilic Esophagitis (EoE): A Practical Approach to Elimination

To provide an overview of current dietary elimination strategies for eosinophilic esophagitis (EoE) and propose a practical, patient-centered approach to guide dietary therapy. Empiric elimination diets, including one- (1FED), two- (2FED), four- (4FED), and six-food (6FED) elimination strategies, have demonstrated varying efficacy, with broader elimination generally associated with higher histologic remission rates. Elemental diets remain the most effective but are often impractical. Allergy testing-directed diets have limited utility due to poor predictive accuracy. Recent data support a step-up approach—beginning with 1FED or 2FED and escalating as needed—as effective and better tolerated. Dietary elimination remains a cornerstone of EoE treatment. A stepwise, empiric approach that minimizes dietary burden while maintaining clinical efficacy is recommended. Personalizing diet therapy based on patient preferences and response can improve adherence and outcomes, and future research should continue refining strategies to balance efficacy, cost, and quality of life.